Tackling the Dual Epidemics of HIV and Addiction

By Hugo Francisco de SouzaReviewed by Benedette Cuffari, M.Sc.

Introduction
Understanding addiction and its role in HIV transmission
Core addiction prevention strategies
Key HIV prevention strategies related to addiction
Global examples of successful prevention programs
Challenges and barriers to effective prevention
The importance of integrated and multisectoral approaches
Future directions and innovations
Conclusions
References
Further reading

Addiction and HIV fuel one another in a global syndemic, but innovative programs, from Portugal’s reforms to Australia’s NSPs, show that integrated, stigma-free care can halt the cycle and save lives.

Image Credit: Tinnakom jorruang / Shutterstock.com

Introduction

Drug addiction is a growing global health crisis that is often intertwined with the human immunodeficiency virus (HIV) epidemic. Despite widespread efforts that target both substance use and HIV transmission, persistent structural and societal barriers like stigma and limited financial support continue to undermine mitigation efforts. Addressing these challenges requires a nuanced understanding of how multisectoral research, cross-sector collaboration, and innovative approaches have influenced public health responses to date.

Understanding addiction and its role in HIV transmission

Addiction is an umbrella term referring to long-term, relapsing disorders characterized by compulsive engagement in substance use or maladaptive behaviors despite their increasingly harmful consequences. Addiction results in a loss of control over the substance or behavior, which subsequently leads to declining health, relationships, and overall quality of life.⁷

Addiction and HIV remain two of the most pressing global public health challenges, with the World Health Organization (WHO) estimating that over 35 and 39 million people suffer from substance use disorders and HIV, respectively, worldwide.¹ The positive feedback between these two epidemics is particularly alarming, as addiction significantly increases the risk of HIV transmission.⁸

Injection-based drug administration is one of the primary drivers of new HIV infections in many parts of the world, especially communities affected by systemic inequality.⁵ Shared needles and other injecting equipment can carry HIV-infected blood, resulting in rapid transmission among users.

Recent reports published by the United Nations Office on Drugs and Crime (UNODC) suggest that people who inject drugs are 22 times more likely to be living with HIV than the general population.¹ Social determinants such as poverty, criminalization, and stigma further exacerbate vulnerability, as these factors often limit access to healthcare and prevention services.⁹

Core addiction prevention strategies

Harm reduction approaches, such as needle exchange programs and supervised injection sites, form the cornerstone of addiction prevention efforts.³ Needle and syringe exchange programs (NSPs) reduce HIV transmission by providing clean, HIV-free equipment. Supervised injection sites allow safer drug use under medical supervision, thereby preventing both overdoses and infections.

Medication-assisted treatment (MAT) leverages pharmacotherapy, including methadone, naltrexone, and buprenorphine, in combination with counseling, behavioral therapies, and peer support for managing opioid dependence and substance use disorders.^7. Behavioral therapies and community development improve long-term outcomes, whereas policy reforms, such as decriminalization, aim to redirect users from prisons to public health services.

Key HIV prevention strategies related to addiction

Several public health agencies have enacted HIV prevention policies and intervention efforts that target people with substance use disorders. For example, pre-exposure prophylaxis (PrEP) is a once-daily pill that significantly reduces the risk of HIV infection in high-risk populations, including drug users.⁴

Complementary strategies include condom distribution, routine HIV testing, and early care, as well as access to clean and HIV-free equipment. Public health agencies increasingly recommend using integrated models that combine addiction treatment with HIV prevention.^1,5,6

Global examples of successful prevention programs

In Portugal, decriminalization paired with expanded harm reduction services reduced new HIV infections among people who inject drugs by more than 98% between 2000 and 2021, alongside significant reductions in addiction-associated morbidity and mortality.² NSPs in Australia have similarly reduced HIV transmission, with public health professionals estimating that over 25,000 HIV cases have been prevented since the 1980s.¹⁰

Multinational collaborative efforts between governments and public health agencies are instrumental in managing addiction and the global burden of HIV. Between 2002 and 2023, the Joint United Nations Programme on HIV and AIDS (UNAIDS) and the Global Fund delivered over nine billion condoms and nearly five billion sterile syringes worldwide, which significantly reduces transmission risks in vulnerable communities.^1,5

Digital health tools, including wearable devices, telemedicine platforms, and mobile apps, are also emerging as vital connectors and facilitators for public health interventions. In fact, a recent WHO pilot study reported that remote interventions increased HIV testing rates among drug-using populations by 28%.⁵

Challenges and barriers to effective prevention

Despite these successes, several barriers to addiction mitigation and HIV eradication persist. Stigma and discrimination against people who use drugs and those living with HIV remain significant deterrents to intervention-seeking behaviors, as these social factors make patients feel alone and hopeless, which can negatively impact their mental well-being and quality of life (QoL).

The legal systems in many regions exacerbate these conditions by criminalizing drug use, which effectively prevents users from seeking care or undergoing HIV screening.⁶ Funding limitations also prevent program deployment and expansion, particularly in low-resource countries. Cultural and political resistance to harm reduction policies may also restrict the implementation of proven strategies.

Overcoming these barriers requires a shift toward viewing addiction and HIV as intertwined public health concerns, rather than criminal justice issues.⁶ Following examples set by Portugal, Australia, and other nations have the potential to expand societal acceptance of patients living with HIV and addiction, thereby expediting treatment and improving outcomes.

The importance of integrated and multisectoral approaches

Holistic strategies designed to combine addiction treatment with HIV prevention are considered more effective than isolated efforts.⁵ Consequently, future health systems, social services, law enforcement, and community organizations must collaborate to address the complex needs of at-risk populations.

For example, providing stable housing, mental health support, and employment services not only reduces drug use but also strengthens HIV prevention, thereby addressing both public health issues. Multisectoral cooperation ensures the sustainability and scalability of these interventions, which in turn contribute to a safer and healthier tomorrow.

HIV and addiction-associated scientific research can also leverage multidisciplinary inputs. For example, clinical studies can be combined with genome-wide association studies (GWASs) to identify critical and population-wide disease risk associations. Pharmacological interventions can subsequently leverage this data to design personalized treatment plans to ultimately optimize patient outcomes.

Future directions and innovations

Although addiction rates and HIV prevalence remain at historically high levels, ongoing research demonstrates the potential to reverse these trends in the future.¹ At the local level, long-acting injectable PrEP, antiretroviral, and HIV vaccine development have shown promise in improving intervention adherence and holistic health outcomes.⁴

Globally, expanding harm reduction models into regions with emerging epidemics is a key priority. Data-driven interventions that are informed by real-time surveillance and predictive analytics can also be leveraged to more precisely and effectively allocate limited public health resources.^2,4

Conclusions

Case studies from countries such as Portugal and Australia demonstrate the success of holistic, community-based approaches, serving as examples of the benefits of policy implementations aimed at mitigating stigma and discrimination at the national level.

Continued global investment, innovation, and political reform are essential to reduce new infections and improve the lives of millions. By acting together, governments, healthcare providers, communities, and patients can address these dual epidemics to build a healthier and more equitable future.

References

1. Grant, R. M. et al. (2010). Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men. New England Journal of Medicine 363, 2587–2599, DOI: 10.1056/NEJMoa1011205, https://www.nejm.org/doi/full/10.1056/NEJMoa1011205
2. WHO. Global HIV, Hepatitis and STIs Programmes (2022). https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/populations/people-who-inject-drugs Accessed on 13 June 2025.
3. Global Commission on Drug Policy (2018). The World Drug Perception Problem: Countering Prejudices about People Who Use Drugs. https://www.drugsandalcohol.ie/28434/ Accessed on 13 June 2025.
4. UNAIDS. Global HIV & AIDS statistics — Fact sheet | UNAIDS (2023). https://www.unaids.org/en/resources/fact-sheet Accessed on 13 June 2025.
5. Degenhardt, L. et al. (2017). Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review. Lancet Glob Health 5, e1192–e1207. DOI: 10.1016/S2214-109X(17)30375-3, https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30375-3/fulltext
6. Strathdee, S. A. & Beyrer, C. (2015). Threading the Needle — How to Stop the HIV Outbreak in Rural Indiana. New England Journal of Medicine 373, 397–399. DOI: 10.1056/nejmp1507252, https://www.nejm.org/doi/full/10.1056/NEJMp1507252
7. Wodak, A. & Cooney, A. (2006). Do needle syringe programs reduce HIV infection among injecting drug users: A comprehensive review of the international evidence. Subst Use Misuse 41, 777–813. DOI: 10.1080/10826080600669579, https://www.tandfonline.com/doi/full/10.1080/10826080600669579
8. Volkow, N. D., Frieden, T. R., Hyde, P. S. & Cha, S. S. (2014). Medication-Assisted Therapies — Tackling the Opioid-Overdose Epidemic. New England Journal of Medicine 370, 2063–2066. DOI: 10.1056/nejmp1402780, https://www.nejm.org/doi/full/10.1056/NEJMp1402780
9. Hughes, C. E. & Stevens, A. (2010). What Can We Learn From The Portuguese Decriminalization of Illicit Drugs? Br J Criminol 50, 999–1022. DOI: 10.1093/bjc/azq038, https://academic.oup.com/bjc/article-abstract/50/6/999/404023
10. Kwon, J. A. et al. (2012). Estimating the cost-effectiveness of needle-syringe programs in Australia. AIDS 26, 2201–2210. DOI: 10.1097/QAD.0b013e3283578b5d, https://journals.lww.com/aidsonline/abstract/2012/11130/estimating_the_cost_effectiveness_of.9.aspx

Further Reading

• All Addiction Content
• Tremors Following Alcohol Dependency
• Video Game Addiction Symptoms, Diagnosis and Treatment
• Sun Addiction: Evolutionary Survival Advantage?
• What is Heroin Addiction?