a comprehensive approach to hiv prevention and treatment in idu

7/30/2019 A Comprehensive Approach To HIV Prevention And Treatment In IDU

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A comprehensive approach

to HIV prevention and treatment

for injecting drug users

Professor Michel D. KazatchkineExecutive Director

The Global Fund to Fight AIDS, Tuberculosis and Malaria

3rd Eastern Europe and Central Asia AIDS Conference

October 29, 2009


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EECA region has


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16 million IDUs globally in ~150 countries

3 million IDUs living with HIV

Injecting drug use accounts for 10% of all new

infections globally, and 30% outside sub-Saharan Africa: probably growing

Generalized epidemics in several countries

started among IDUs

Injecting drug use and the global HIV

epidemic


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The comprehensive package of HIV prevention,

treatment and care interventions for injecting drug usersrecommended by WHO, UNODC, UNAIDS (2009)

1. Needle and syringe programs

2. Drug dependence and opioid substitution therapy

3. HIV counselling and testing

4. Antiretroviral treatment

5. STI prevention and treatment6. Condom programming

7. Targeted information, education and communication

8. Vaccination, diagnosis and treatment of viral hepatitis9. Diagnosis and treatment of TB


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Increase in antiretroviral therapy in low- and middle-

income countries, adults and children

December 2007 December 2008 (WHO, 2009)

36%2 970 000[2.73.3 million]

4 030 000[3.74.4 million]

Total

43%7 00010 000North Africa and the Middle East

39%54 00085 000Europe and Central Asia

35%420 000565 000East, South and South-East Asia

14%390 000445 000Latin America and the Caribbean

39%2 100 0002 925 000Sub-Saharan Africa

Increase

in one

year

Number of

people receiving

ARV therapy

December 2007

Number of people

receiving ARV

therapy

December 2008

Geographical region


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Antiretroviral therapy coverage in low- and middle-income

countries, adults and children, December 2008 (WHO 2009)

42%[4047%]

9 500 000[8.610 mill ion]

4 030 000[3.74.4 million]

Total

14%68 00010 000North Africa and the Middle East

23%370 00085 000Europe and Central Asia

37%1 500 000565 000East, South and South-East Asia

54%820 000445 000Latin America and the Caribbean

44%6 700 0002 925 000Sub-Saharan Africa

Antiretroviral

therapy

coverage

Estimated

number of

people needing

ARV therapy

Estimated number

of people receiving

ARV therapy

Geographical region


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Under-representation of IDUs among

people accessing ART in the region

83.0%

24.0%*

69.0%

50.8%

60.5%

24.0%

79.0%

38.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Russia Azerbaijan Ukraine EECA*

IDUs asshare of totalreported HIVcases

IDUs asshare of totalpeople on

ART

Sources: EHRN, 2008 Annual Form of Federal State Statistical Surveillance #61 Data about Groups of HIV-InfectedPatients, Azerbaijan National AIDS Center, Ukrainian Institute of Public Health Policy, European Centre for the

Epidemiological Monitoring of AIDS (EuroHIV)


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Treatment for IDUs: barriers to access

Vertical, competing systems of care do not link HIV

care and drug dependence treatment

Denial of ART to active injectors

User-unfriendliness of ART services for IDUs

Limited opening hours, lack of confidentiality, lack of trustin medical staff, poor understanding of patient needs

Low treatment literacy among IDUs


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ART-CC Men Women IDUs Non-IDUs

At age 20 42.8 44.2 32.6 44.7

At age 35 31.7 32.5 23.4 33.0

Egger M et al, ART-CC, Lancet 2008

Life expectancy for people on ART

by gender and transmission group


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Antiretroviral treatment for IDUs:

considerations for physicians IDUs have the same right to treatment and care as anyone

else: withholding treatment for a whole class of people is

ethically unacceptable

The physicians role is to create the best conditions forsuccessful treatment outcomes, working with others as

necessary (e.g. peers, counsellors, social workers)

IDUs can be highly adherent to medication and are moreadherent when on substitution therapy

HIV does not manifest differently in IDUs, but it is importantto be alert for and address co-infections (TB, HCV, bacterial)


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Percentage of PLWH co-infected with

HCV in selected countries

0

10

2030

40

50

60

70

80

Neth

erlands

Sweden

Poland

Slov

akia

Bulgaria

Estonia

Ukraine

Kazakh

stan

RussianFe

deration

WHO, EURO, 2008


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Tuberculosis in Europe

Worsening problem in Europe as a whole and

large problem in eastern Europe 0.5m new cases & over 60,000 deaths per year

Estimated 70,000 MDR cases

Low average case detection rate: 51%

Low average treatment success rate 74%

High % of people with HIV co-infected with TB inseveral countries Tajikistan ~ 25%, Armenia ~50%, Azerbaijan ~ 70% (WHO EURO 2008)


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Harm reduction (1)Based on the principle that reducing harm from drugs

is even more important than reducing drug consumption

Information, education, counselling

Needle and syringe programmes (NSP) Drug dependence treatment, including opioid

substitution (OST)

Community development for IDUs

Overdose prevention


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Scientific debate is over

- Evidence is abundant, consistent and compelling

Among the most effective, safe and cost-effective

interventions for HIV prevention

Needed in health services, community-based settings

and closed settings (detention centres, prisons)

Harm reduction (2)


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Political declarations endorsing

harm reduction

United Nations General Assembly Special Sessions onWorld Drug Problem (1998) and on HIV/AIDS (2001,

2006) Millennium Development Goals (2000)

Joint UNAIDS Statement on HIV Prevention and CareStrategies for Drug Users (2005)

WHO (Euro) Resolution R9/RC52 (2002) Dublin and Vilnius Declarations (2004)

2005 G8 communiqu: universal access

UNAIDS PCB 2008

ECOSOC 2009


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Global acceptance of harm reduction

UN and international organizations

WHO, UNAIDS, UNODC, Unicef, World Bank,

Red Cross/Crescent

Adopted by a growing number of countries

70+ include harm reduction in national policy* 77 countries have an NSP*

63 have OST*

All countries in the EU

Opposed by a shrinking minority

*IHRA 2008


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NSP: evidence for efficacy in Eastern

Europe and Central Asia

Russia:

5-city study finds reduction of needle sharingfrom 38% to 11% in 2002 International Journal of Drug Policy, 13, 165-174; Jarlais, D., Grund, J., Zagoretzky, C., Milliken, J., Friedmann, P., Titus, S., Perlis, T.,Bodrova, V., &Zemlianova, E. (2002).

Kyrgyzstan: Percent of clients reusing needles drops from

98% to


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Annual change in HIV prevalence among IDUs at

city level

Prevalence increased 5.9%

annually in 52 cities without NSP

Prevalence decreased 5.8 %

Annually in 29 cities with NSP

Hurley SF, Jolley DJ, Kaldor JM. Effectiveness of needle-exchangeprogramme for prevention of HIV infection.

Lancet 1997, 359 (9068): 1797-800

NSP: evidence for efficacy, 81 cities


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Current coverage and modeled impact in SvetlogorskFrom: Vickermann P et al: J Acquir Immune Defic Syndr 2006;42:355Y361

Modeling of HIV prevalence and impact

depending on NSP coverage in Svetlogorsk,

Russia


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13.3%12.7%11.1%5.7%-9%-% increase per year inRussian Federation

50 67144 71339 66335 69733 76036 345

Total number of new HIV

cases per year in Russian

Federation

6.3%-0.4%10.6%6.7%-4%-% increase per year in10 GLOBUS regions

9 0098 4778 5097 6957 2127 506

Total number of new HIV

cases per year in 10

GLOBUS regions

200820072006200520042003

Annual number of new HIV infections:

Globus regions and Russian Federation, 2003-2008


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NSP: No evidence of adverse effects

No initiation of injecting among people

who have not injected previously

No increase in the duration or

frequency of illicit drug use or druginjection

WHO, UNODC, UNAIDS (2004) Policy Brief: the provision of sterile injecting equipment to reduce HIV transmission

WHO (2004) Evidence for Action Technical Paper: Effectiveness of Sterile Needle and Syringe Programming in Reducing

HIV/AIDS among Injecting Drug Users


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HIV and opioid substitution therapy

OST reduces illicit drug use and associated

HIV risk

OST reduces HIV infection rates in IDUs

OST improves adherence to ART

* Methadone added to WHO EDL in 2005

For patients with HIV and opioid dependence,

WHO recommends

First, stabilize on opioid substitution treatment

(+bactrim and isoniazid, if indicated)

then initiate ART in combination with OST


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Societal outcomes of OST

Improved social integration and employment

Substantial reductions in criminal activities

4 to 7-fold savings from reduced drug-related

crime and criminal justice costs. (May be 12-fold

if healthcare costs are included)

No evidence for increased drug use in community

Sources : WHO/UNODC/UNAIDS position paper: Substitution maintenance therapy in the management of opioid

dependence and HIV/AIDS prevention (WHO, 2004); WHO/UNOC/UNAIDS: Effectiveness of Drug Dependence Treatment

in Preventing HIV among Injecting Drug Users, Geneva 2005


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A Parpieva. Psychological rehabilitation in program of substitution therapy inBishkek in Decreasing Vulernability of Injecting Drug Users in the Kyrgyz

Replublic. Conference Proceedings May 2009 ed. TK Asanov (Osh. 2003) 39


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STI/HIV/AIDS Programme

WHO/Europe

Number of needle syringe programmes per 1000 IDU in

WHO European Region (2007 or latest available)

Median 24.4 syringes distributed per IDU

per year in EECA (WHO 2009): well below

internationally-recommended target of200 syringes /IDU/year needed for impact


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OST: Barriers in EECA

Too few centres; distance

Perpetual pilot status

Reviews by panels of physicians prior to admission Drug user registration systems

Restrictions on dose adjustments

Collateral or informal fees

Inappropriate expulsion for use of illicit opiates

Requirement of documented attempts atabstinence

Lack of mobility / take-home doses

Harassment of service users by law enforcement


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Tension between law enforcement

and public health


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Detox alone is the norm in Russia, where

methadone/bupe are illegal

Russian survey of harm

reduction clients (n=950)in 10 cities, 2007

64% returned to drug

use within two months

Many sedated to point of

near coma during detox

Interest in quitting drugs

decreases with detoxprogram encounters

Oleinik, S. Russian Narcological System Through the Eyes of Patients.

Penza: Social foundation for the support of public health and education AntiAids 2007


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Summary

Increased numbers of people on antiretroviral treatment butcoverage still too low

Significant barriers to access to treatment for IDU includingpoor integration of ART/drug dependence services; stigma,denial of treatment

Overwhelming evidence for harm reduction, increasingacceptance worldwide but coverage in EECA stillunacceptably low, programs not at scale, ideological barriersremain

Continued reliance on detox, law enforcement andcriminalization: minimal deterrents to drug use and mayactually increase HIV

Access to treatment and prevention in prisons still very poor


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HIV is a serious problem in this region

Expanding coverage of evidence-based HIV treatment andprevention should be the major priority for countries in theregion

Know your epidemic: pay close attention to theepidemiology

Include affected communities

Treat drug use primarily as a health problem and allocatefunding accordingly

Base policies on science and human rights

We know what to do lets do it!


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Acknowledgements

Alexey Bobrik

Ian Grubb

Gundo Weiler

Alex Wodak

Daniel Wolfe

Jeff LazarusWHO

UNAIDS

IASThe Global Fund team

a comprehensive approach to hiv prevention and treatment in idu

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