A comprehensive approach to HIV prevention and treatment for injecting drug users

Professor Michel D. Kazatchkine

Executive Director The Global Fund to Fight AIDS, Tuberculosis and Malaria

3rd Eastern Europe and Central Asia AIDS Conference October 29, 2009

EECA region has <5% of the worlds population but a quarter of the worlds IDUs

Injecting drug use and the global HIV epidemic

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 subSaharan Africa: probably growing Generalized epidemics in several countries started among IDUs

The comprehensive package of HIV prevention, treatment and care interventions for injecting drug users recommended by WHO, UNODC, UNAIDS (2009) 1. 2. 3. 4. 5. 6. 7. 8. 9. Needle and syringe programs Drug dependence and opioid substitution therapy HIV counselling and testing Antiretroviral treatment STI prevention and treatment Condom programming Targeted information, education and communication Vaccination, diagnosis and treatment of viral hepatitis Diagnosis and treatment of TB

Increase in antiretroviral therapy in low- and middleincome countries, adults and children December 2007 December 2008 (WHO, 2009)
Geographical region Number of people receiving ARV therapy December 2008 Number of people receiving ARV therapy December 2007 Increase in one year

Sub-Saharan Africa Latin America and the Caribbean East, South and South-East Asia Europe and Central Asia North Africa and the Middle East

2 925 000 445 000 565 000 85 000 10 000

2 100 000 390 000 420 000 54 000 7 000

39% 14% 35% 39% 43%

Total

4 030 000
[3.74.4 million]

2 970 000
[2.73.3 million]

36%

Antiretroviral therapy coverage in low- and middle-income countries, adults and children, December 2008 (WHO 2009)
Geographical region Estimated number of people receiving ARV therapy Estimated number of people needing ARV therapy Antiretroviral therapy coverage

Sub-Saharan Africa Latin America and the Caribbean East, South and South-East Asia Europe and Central Asia North Africa and the Middle East Total

2 925 000 445 000 565 000 85 000 10 000

6 700 000 820 000 1 500 000 370 000 68 000

44% 54% 37% 23% 14%

4 030 000
[3.74.4 million]

9 500 000
[8.610 million]

42%
[4047%]

Under-representation of IDUs among people accessing ART in the region

90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Russia Azerbaijan Ukraine EECA* 24.0%* 24.0% 38.0% 50.8% 83.0% 69.0% 60.5% 79.0%

IDUs as share of total reported HIV cases

IDUs as share of total people on ART

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

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 trust in medical staff, poor understanding of patient needs

Low treatment literacy among IDUs

Life expectancy for people on ART by gender and transmission group

ART-CC
At age 20 At age 35

Men
42.8 31.7

Women
44.2 32.5

IDUs
32.6 23.4

Non-IDUs
44.7 33.0

Egger M et al, ART-CC, Lancet 2008

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 for successful treatment outcomes, working with others as necessary (e.g. peers, counsellors, social workers) IDUs can be highly adherent to medication and are more adherent when on substitution therapy HIV does not manifest differently in IDUs, but it is important to be alert for and address co-infections (TB, HCV, bacterial)

Percentage of PLWH co-infected with HCV in selected countries

80 70 60 50 40 30 20 10 0
s e an ion a ria n nd a i i d n e t at k i n n d a a s a a l o a e r kh er o lov ulg st rl k w P e U za ed E S h S B t Ka n F Ne ia s s u R

WHO, EURO, 2008

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 in several countries
Tajikistan ~ 25%, Armenia ~50%, Azerbaijan ~ 70% (WHO EURO 2008)

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

Harm reduction (2)

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)

Political declarations endorsing harm reduction

United Nations General Assembly Special Sessions on World Drug Problem (1998) and on HIV/AIDS (2001, 2006) Millennium Development Goals (2000) Joint UNAIDS Statement on HIV Prevention and Care Strategies 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

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

NSP: evidence for efficacy in Eastern Europe and Central Asia Russia:
5-city study finds reduction of needle sharing from 38% to 11% in 2002 International Journal of Drug Policy, 13, 165174; 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 <30% after start of NSP; needle sharing drops from 68% to 14% Estebesova, B. The Role of

NGOs in Implementation of the Harm Reduction Programs for Drug Dependency in the Kyrgyz Republic, in Decreasing Vulnerability of Injection Drug Users in the Kyrgyz Republic (2003)

NSP: evidence for efficacy, 81 cities

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-exchange programme for prevention of HIV infection. Lancet 1997, 359 (9068): 1797-800

Modeling of HIV prevalence and impact depending on NSP coverage in Svetlogorsk, Russia

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

Annual number of new HIV infections: Globus regions and Russian Federation, 2003-2008

2003
Total number of new HIV cases per year in 10 GLOBUS regions

2004

2005

2006

2007

2008

7 506

7 212

7 695

8 509

8 477

9 009

% increase per year in 10 GLOBUS regions

Total number of new HIV cases per year in Russian Federation

36 345

-4% 33 760

6.7% 35 697

10.6% 39 663

-0.4% 44 713

6.3% 50 671

% increase per year in Russian Federation

-9%

5.7%

11.1%

12.7%

13.3%

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 drug injection

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

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

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

A Parpieva. Psychological rehabilitation in program of substitution therapy in Bishkek in Decreasing Vulernability of Injecting Drug Users in the Kyrgyz Replublic. Conference Proceedings May 2009 ed. TK Asanov (Osh. 2003) 39

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 of 200 syringes /IDU/year needed for impact

STI/HIV/AIDS Programme WHO/Europe

<1% of IDUs in region have access to MMT or Buprenorphine Source: OSI International Harm Reduction Development Program 2009
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
0 575 4,350 50 735

1,825,000

127,833

375,000

100,000

25,000

Russia

Georgia

Ukraine

Kazakhstan Kyrgyzstan
Total Estimated IDUs

Total on government-funded MMT or buprenorphine

102 OST sites serve 16 000+ IDUs, but 3.4m IDUs in the region (IHRA 2008) Median number of OST sites per 1000 IDUs in the region: 0.4 (WHO 2009)

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 at abstinence Lack of mobility / take-home doses Harassment of service users by law enforcement

Tension between law enforcement and public health

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 detox program encounters
Oleinik, S. Russian Narcological System Through the Eyes of Patients. Penza: Social foundation for the support of public health and education AntiAids 2007

Summary
Increased numbers of people on antiretroviral treatment but coverage still too low Significant barriers to access to treatment for IDU including poor integration of ART/drug dependence services; stigma, denial of treatment Overwhelming evidence for harm reduction, increasing acceptance worldwide but coverage in EECA still unacceptably low, programs not at scale, ideological barriers remain Continued reliance on detox, law enforcement and criminalization: minimal deterrents to drug use and may actually increase HIV Access to treatment and prevention in prisons still very poor

HIV is a serious problem in this region

Expanding coverage of evidence-based HIV treatment and prevention should be the major priority for countries in the region Know your epidemic: pay close attention to the epidemiology Include affected communities Treat drug use primarily as a health problem and allocate funding accordingly Base policies on science and human rights We know what to do lets do it!

Acknowledgements
Alexey Bobrik Ian Grubb Gundo Weiler Alex Wodak Daniel Wolfe Jeff Lazarus WHO UNAIDS IAS The Global Fund team