Professional Documents
Culture Documents
Basic principles for treatment and psychosocial support of drug dependent people living
with HIV/AIDS.
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Content
Acknowledgements 2
Foreword 3
The Principles in Brief 5
Introduction 7
Principle 1
Human rights of drug dependent people with HIV/AIDS 10
Principle 2
Evidence-base for treatment, care and psychosocial support 13
Principle 3
Appropriate treatment and psychosocial support 16
Principle 4
Equitable access to HIV/AIDS care and treatment including
antiretroviral therapy (ART) 19
Principle 5
Supportive environments to enable and facilitate treatment,
care and psychosocial support 21
Principle 6
Client participation 23
Principle 7
Participation of community and other stakeholders 25
Conclusion 27
Key documents 28
1
Acknowledgements
The project was initially managed by Inon Schenker under the coor-
dination of Maristela Monteiro, and the original text was prepared by
Edna Oppenheimer. The revision of the document was co-ordinated
by Isidore Obot of the Department of Mental Health and Substance
Abuse (NMH/MSD) and Andreas Reis of the Department of Ethics,
Trade, Human Rights and Health Law (SDE/ETH) under overall supervi-
sion of Vladimir Poznyak (NMH/MSD) and Alex Capron (SDE/ETH),
and in cooperation with Andrew Ball of the Department of HIV/AIDS
(HTM/HIV). Administrative support was provided by Tess Narciso and
Mylène Schreiber.
Financial support for this project was provided by the Joint United
Nations Programme on HIV/AIDS (UNAIDS).
2
Foreword
Over the past two decades, HIV infection has been added to the serious
risks of injection drug use, and the diffusion of HIV associated with drug
injecting not only creates medical and social problems for the millions
of injecting drug users worldwide but for society at large. Yet many drug
dependent people living with HIV/AIDS do not enjoy equitable access to
HIV/AIDS treatment, care and support services for HIV/AIDS as a result of
stigma and discrimination, of their own reluctance to seek treatment, and
of the unavailability of HIV/AIDS treatment in programmes for injecting
drug users.
Dr Kevin M. De Cock
Director, HIV/AIDS
3
4
The Principles in Brief
Principle 1
Human rights of drug dependent people with HIV/AIDS
Principle 2
Evidence-base for treatment, care and psychosocial support
Principle 3
Appropriate treatment and psychosocial support
5
Principle 4
Equitable access to HIV/AIDS care and treatment including
antiretroviral therapy (ART)
Past or present drug use should not pose a barrier to equitable access
to all available state-of-the-art HIV/AIDS treatment and care, including
anti-retroviral therapy and psychosocial support. Drug dependent
people should be accorded the same treatment, care and psychosocial
support as the rest of the HIV-positive population in their country, and
their exclusion from such care is medically and ethically indefensible.
Principle 5
Supportive environments to enable and facilitate treatment, care
and psychosocial support
Restrictive policies that can impede access to effective treatment
and care of individuals suffering from substance dependence and
HIV/AIDS are detrimental both to the health and well-being of drug
dependent people living with HIV/AIDS and to the larger community.
Supportive environments will maximize the efficacy of the treatment
and care such people receive by removing the obstacles that impede
appropriate interventions and by creating the conditions, both
national and local, that foster good practice and maximize the avail-
ability, acceptability and accessibility of treatment and care.
Principle 6
Client participation
Drug dependent people with HIV/AIDS should not be just passive
recipients of treatment but should fully participate in the planning,
delivery, evaluation and monitoring of services.
Principle 7
Participation of community and other stakeholders
Community and non-government organizations should be active
participants in, and advocates for, the development and implementa-
tion of treatment, care and psychosocial support for drug dependent
people living with HIV/AIDS.
6
Introduction
Despite the large numbers of drug dependent people living with HIV/
AIDS, there is considerable evidence that they do not enjoy equitable
access to treatment and support services. Drug dependent people
living with HIV/AIDS are stigmatized and discriminated against,
resulting in their receiving inadequate services for both substance
dependence and for HIV/AIDS. Individuals who report past or current
injection drug use have less access to anti-retroviral medication and
other HIV/AIDS treatment and care than others who are not sub-
stance-dependent.
7
Many drug dependent individuals are reluctant to seek any kind of
treatment for a variety of reasons:
• some do not wish to identify themselves as drug users because
they fear incarceration or being pressured to stop using drugs;
• some do not perceive themselves as “sick” and in need of treat-
ment or do not believe treatment would be effective;
• some are not interested or willing to approach drug treatment
agencies and programmes or to stop drug use;
• some cannot afford the cost of treatment or the travel to reach
services;
• some are discouraged from seeking help by the long waiting time
to enter treatment in countries where the demand for treatment
greatly exceeds treatment availability (particularly for agonist
pharmacotherapy of opioid dependence).
For those drug dependent people living with HIV/AIDS, the situation
is even more challenging. Differences in national healthcare and drug
control policies and in financial and human resources contribute to a
varied global landscape, but in general, the following scenarios pertain:
• In developing and transitional countries, scarcity of financial and
human resources necessitates prioritization of competing health
needs. Drug dependent people living with HIV/AIDS face negative
societal attitudes and stigma and discrimination by healthcare
workers and decision-makers; they are thus rarely seen as a priority
and have limited access to both drug-dependence and HIV/AIDS
treatment. Serious barriers to treatment include: the prohibitive
8
cost of both drug dependence and HIV/AIDS treatment and care;
poor geographical coverage of services; the misinformed notion
that anti-retroviral treatments are unsuitable and inappropriate
for drug users; and the legal and medical barriers to use all avail-
able effective treatment options for drug dependence, as, for
example, agonist maintenance therapy for opioid dependence.
Furthermore, the public health infrastructure is inadequate in
many countries, where physicians and other healthcare workers
lack the training necessary to address substance use disorders
and HIV/AIDS and the physical, psychological and social problems
created and exacerbated by both conditions.
• In developed countries, access to HIV treatment by drug depen-
dent people is often limited by stigma and discrimination and by
the lack of communication between the drug dependence and
HIV/AIDS treatment systems. Many healthcare workers mistak-
enly believe that drug users must be drug-free before they can
be treated for HIV disease. Evidence of inequalities in access to
HIV/AIDS treatment and care include discrimination because of
drug use status past or present, legal status, gender, age, ethnicity,
economic and social instability, as well as the lack of health insur-
ance coverage.
• In all countries in which drug dependent persons are incarcerated
or confined to residential facilities (whether admitted on a volun-
tary or involuntary basis), their ability to access HIV/AIDS treatment
depends on the availability of appropriate treatment programmes
within, or in conjunction with, the facilities in which they reside.
Unfortunately, such settings are often not integrated or linked with
the community-based treatment programmes available to persons
living with HIV/AIDS.
9
Principle 1
Human rights of drug dependent people
with HIV/AIDS
Drug dependent people living with HIV/AIDS should enjoy full human
rights and not be subjected to stigma or discrimination because of
their past or present drug use, HIV status, gender, sexual orientation,
ethnicity, nationality, legal status, or social or economic circumstances.
10
Actions to promote this principle
1 Assess and analyze the human rights situation for drug dependent
people living with HIV/AIDS.
11
8 Develop appropriate and equitable treatment, care and support for
drug dependent people living with HIV/AIDS through a process that
includes client and community participation.
12
Principle 2
Evidence-base for treatment and
psychosocial support
The health and social care provided to drug dependent persons living
with HIV/AIDS should be based on salient evidence. Evidence is essen-
tial for the planning and delivery of ‘good practice’ interventions. Yet
research evidence has not always been taken into consideration when
interventions for substance-dependent people living with HIV/AIDS
have been planned and implemented. A variety of interventions for
drug dependence continue to be routinely offered despite evidence
that they are ineffective (e.g. coerced detoxification in the absence
of follow-up care). By contrast, some treatment options that provide
demonstrable benefits for substance-dependent people are disal-
lowed in some countries (e.g. opioid substitution maintenance thera-
py). Likewise, the frequent exclusion of drug dependent people from
HIV treatment or the insistence that they must be drug-free before
anti-retroviral drugs are prescribed is not supported by research
findings. To ensure good practice, the collection, interpretation and
integration of valid, significant and applicable patient-reported,
clinician-observed and other research-derived evidence should be
an important part of the treatment process. Lack of «conclusive» evi-
dence, based on rigorous research, on the effectiveness of a particular
intervention should not preclude or delay the introduction of such an
intervention if there is adequate evidence that such an intervention
would be beneficial. The introduction of such «evidence-informed»
interventions should be linked with the necessary operational
research and evaluation elements that will help establish a stronger
evidence-base.
13
Components of this principle
2 Audit the services and resources that are available in the country/
community.
14
5 Strengthen capacity of services to undertake operational research,
monitoring and evaluation.
15
Principle 3
Appropriate treatment and
psychosocial support
16
Components of this principle
5 Services for people with drug dependence and HIV/AIDS are sustai-
nable based on the government resource commitments.
17
Actions to promote this principle
18
Principle 4
Equitable access to HIV/AIDS care and
treatment including antiretroviral therapy (ART)
Past or present drug use should not pose a barrier to equitable and
universal access to all available state-of-the-art HIV/AIDS treatment
and care including anti-retroviral therapy and psychosocial support.
Exclusion is indefensible on ethical, human rights, and public health
grounds, especially when a person is in a residential or custodial
programme for drug dependent persons and is therefore not able to
seek access to HIV treatment outside that programme. Drug depend-
ent people should be accorded the same treatment, care and psy-
chosocial support as the rest of the HIV-positive population in their
country.
19
Components of this principle
20
Principle 5
Supportive environments to enable and facili-
tate treatment, care and psychosocial support
21
Actions to promote this principle
8 Ensure that national plans are translated into local multi-sectoral col-
laboration to include the participation of patient families and peers,
and community associations.
22
Principle 6
Client participation
23
Actions to promote this principle
24
Principle 7
Participation of community and other
stakeholders
25
Actions to promote this principle
26
Conclusion
27
Key documents
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29
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30
This guidance document, built on expert advice and developed
in consultation with UNAIDS, articulates the central principles
for treatment and support of HIV-positive injecting drug users.
It is addressed to policy makers, treatment planners, and
service providers, particularly those who deal with substance-
dependent populations, and to patient organizations.
ISBN 92 4 159473 X