Background
Previous reviews have examined the existence of HIV prevention, treatment, and care services for injecting drug users (IDUs) worldwide, but they did not quantify the scale of coverage. We undertook a systematic review to estimate national, regional, and global coverage of HIV services in IDUs.

Methods
We did a systematic search of peer-reviewed (Medline, BioMed Central), internet, and grey-literature databases for data published in 2004 or later. A multistage process of data requests and verification was undertaken, involving UN agencies and national experts. National data were obtained for the extent of provision of the following core interventions for IDUs: needle and syringe programmes (NSPs), opioid substitution therapy (OST) and other drug treatment, HIV testing and counselling, antiretroviral therapy (ART), and condom programmes. We calculated national, regional, and global coverage of NSPs, OST, and ART on the basis of available estimates of IDU population sizes.

Findings
By 2009, NSPs had been implemented in 82 countries and OST in 70 countries; both interventions were available in 66 countries. Regional and national coverage varied substantially. Australasia (202 needle—syringes per IDU per year) had by far the greatest rate of needle—syringe distribution; Latin America and the Caribbean (0·3 needle—syringes per IDU per year), Middle East and north Africa (0·5 needle—syringes per IDU per year), and sub-Saharan Africa (0·1 needle—syringes per IDU per year) had the lowest rates. OST coverage varied from less than or equal to one recipient per 100 IDUs in central Asia, Latin America, and sub-Saharan Africa, to very high levels in western Europe (61 recipients per 100 IDUs). The number of IDUs receiving ART varied from less than one per 100 HIV-positive IDUs (Chile, Kenya, Pakistan, Russia, and Uzbekistan) to more than 100 per 100 HIV-positive IDUs in six European countries. Worldwide, an estimated two needle—syringes (range 1—4) were distributed per IDU per month, there were eight recipients (6—12) of OST per 100 IDUs, and four IDUs (range 2—18) received ART per 100 HIV-positive IDUs.

Interpretation
Worldwide coverage of HIV prevention, treatment, and care services in IDU populations is very low. There is an urgent need to improve coverage of these services in this at-risk population.

Funding
UN Office on Drugs and Crime; Australian National Drug and Alcohol Research Centre, University of New South Wales; and Australian National Health and Medical Research Council.

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Dr Bradley M Mathers MBChB
Prof Louisa Degenhardt PhD
Hammad Ali MBBS
Lucas Wiessing MSc
Prof Matthew Hickman FFPHM
Prof Richard P Mattick PhD
Bronwyn Myers PhD
Atul Ambekar MD
Prof Steffanie A Strathdee PhD for the 2009 Reference Group to the UN on HIV and Injecting Drug Use

The Lancet,  Volume 375, Issue 9719, Pages 1014 - 1028, 20 March 2010
doi:10.1016/S0140-6736(10)60232-2