According to the 2024 World Drug Report published by the United Nations Office on Drugs and Crime, approximately 1.6 million people who inject drugs (PWID) worldwide — or 1 in 8 PWID — are also living with HIV. Recent data suggests India has roughly 850,000 PWID, most of whom are at high risk for acquiring HIV. The spread of opioid use to previously unaffected regions of the country — coupled with a high prevalence of needle sharing, high rates of HIV incidence, and barriers to care — has contributed significantly to negative outcomes for PWID, despite global advances in HIV testing and treatment.

The Johns Hopkins-led PWID Opportunities to Improve, Treat, and Retain (POINTER) study is the latest iteration of efforts that originated nearly two decades ago to address the unique needs of PWID living with HIV in India.

“Early on in my career, I focused on the intersection of HIV and injection drug use,” says POINTER principal investigator Gregory Lucas, M.D., Ph.D., associate professor of medicine in the Johns Hopkins Division of Infectious Diseases. During his medical residency at Johns Hopkins in the mid-1990s, injection drug use accounted for almost 50% of HIV cases in Baltimore, “So there was plenty to do,” he notes.

Eventually, Lucas crossed paths with Sunil Solomon, M.B.B.S., M.P.H., Ph.D., and Shruti Mehta, M.P.H., Ph.D., who were training at the Johns Hopkins Bloomberg School of Public Health at the time and were also working on issues related to drug use in India. Lucas credits their influence with shifting his research interests to PWID living with HIV in that part of the world.

“I came to learn that opioid use is prevalent in India, and that the HIV epidemic was raging in some cities with large populations of people who inject drugs. In partnership with an HIV-focused nongovernmental organization, we conducted a number of observational and interventional studies and service-based interventions across several Indian cities.”

Now on faculty at Johns Hopkins, the three continue this collaboration through the POINTER study: Mehta, professor and Charles Armstrong Chair in Epidemiology at the school of public health, is the study’s co-PI and Solomon, professor and vice chair for research in the Department of Medicine, is chairman and managing trustee of YRGCARE, a nonprofit organization in Chennai that runs one of the study’s trial sites.

Today, poor outcomes for PWID living with HIV in India persist. While government-sponsored HIV clinics are spread throughout the country, and medications to treat HIV are available and free, huge crowds, long wait times, and the fear of social stigma prevent many people from getting tested or seeking treatment at large government clinics. People who initiate treatment often don’t stay in care. As a result, viral suppression is low, and mortality rates attributed to HIV are high among people who use injection drugs.

POINTER seeks to address these challenges by evaluating the effectiveness of decentralized HIV care for PWID, with treatment follow-up and support added to the host of other services offered at harm-reduction clinics.

“What we’re looking at is whether it would help PWID do better if they were offered HIV follow-up in the places where they already go to get harm-reduction services [related to injection drug use, like] buprenorphine, needle exchange, nutritional supplements, and HIV and hepatitis C testing,” Lucas explains.

One group of study participants has been randomized to receive HIV treatment at a government-run clinic, the current standard of care; the other group receives HIV care at a harm-reduction center operated by YRG.

The idea is to offer PWID proven interventions that large, government-run HIV clinics in India can’t provide. These include nonstigmatizing community-based HIV care in smaller clinics focused on addressing the unique needs of people who use injection drugs, and targeted support to help PWID better navigate HIV treatment to achieve and maintain viral suppression.

If POINTER results are favorable, “Our greatest hope is to be able to implement the integrated HIV/PWID care in other cities [in India] with large PWID populations,” Lucas says. He expects to have data available for review in the coming months.

As the study nears completion, Lucas is quick to recognize the team’s partners in India for their essential contributions. Strong relationships with clinicians and care providers at government HIV centers and community harm reduction clinics combined with the dedication of research coordinators Jiban Jyoti Baishya and Ashwini Kedar have helped the team reach their enrollment goal ahead of schedule, retain more than 200 PWID living with HIV in care, and manage the many challenges of a study designed to solve a complex public health issue.