A Review of Barriers and Ways Forward

Daniel Wolfe1

Patrizia Carrieri2

Donald Shepard3

Paper 3 Treatment and Care for IDUS with HIV

1. Open Society Institute 2. INSERM U912 - ORSPACA 3. Brandeis University

The HIV risk environment • Levels: – Macro – Micro

• Types: – Physical– Social– Economic– Policy

Adapted from Rhodes 1999 and Glass and McAttee 2006

Illustrate how varying levels of environmental influence affect IDUs’ risk behaviours, HIV incidence and attributable risks (Strathdee et al. Lancet 2010)

Impact of Scaling up Combination HIV Interventions: Example from Odessa (Strathdee et al. Lancet 2010)

Reducing unmet need of OST, NSP and ART by 60% could prevent 41% of incident HIV infections

ART for IDUs effective and cost effective

• ART for IDUs successfully initiated in 50 countries• Excellent virologic response, and no greater ART

resistance, with appropriate supports • Methadone and buprenorphine most critical

– DAART, pre-loaded pill boxes, peer support, incentives, case management also help

• ART targeted for IDUs cost-effective; and benefit-cost ratio of drug dependence treatment about 7:1

• Treatment as prevention appears viable (though largely untested) in IDUs

• No reason to exclude active IDUs (WHO protocol; universal access commitments)

Global Progress?

• No global assessment of IDUs on ART compared to their share of HIV since 2004

• Global Fund does not ask countries to disaggregate data on IDUs

• PEPFAR does not collect data on IDUs served, despite legal requirement

• Overall IDU estimates often based on police or treatment data

83.0%

38.5%

60.5%

44.0%

70.0%

0%20%40%60%80%

100%

Russia China Ukraine Vietnam Malaysia

IDUs as share of total reported HIV cases

Share of Estimated IDUs with HIV in Low and Middle Income Countries,

2009

53%

47%

IDUs with HIV in Russia, China, Ukraine, Vietnamand MalaysiaIDUs with HIV in all other low- and middle-income countries

“Mega-Epidemics” offer global snapshot

Share of IDUs as total HIV cases and those on ART, 2008

83.0%

20-30%

38.5%

10.7%

60.5%

24%

44.0%

6.3%*

70.0%

< 25%

0%10%20%30%40%50%60%70%80%90%

Russia China Ukraine Vietnam Malaysia

IDUs as shareof totalreported HIVcases

IDUs as shareof total peopleon ART

*2009

Inequity in ART access

IDUs 67% OF HIV CASES, BUT ONLY 25% OF THOSE ON TX

Share of IDUS reached by methadone or buprenorphine

94,9730

6,5384,634 1,484

205,000135,305375,0002,350,0001,825,000

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Russia China Ukraine Vietnam MalaysiaTotal on government-funded MMT or buprenorphine Total estimated IDUs

OST available to < 2% of IDUs

HEALTH SYSTEM BARRIERS• High threshold treatment—fees, tests,

commissions– Russia: 18 of 19 cities have “treatment commissions”;

10 exclude on grounds of drug use– China: ART free, but charge for lab tests, OI treatments– Malaysia required patients to pay for 3rd drug in combo

(now changed)

• Siloed treatment—TB, HIV, OST– TB clinics won’t treat HIV, HIV clinics won’t treat TB

(Ukraine)– OST unavailable in many maternity clinics or inpatient

wards (China, Ukraine)

• Discrimination in health settings– Explicit bans on treatment for active IDUs– Assumptions (inaccurate) about adherence– Hostile or untrained health workers

“If you are under the influence of narcotics, please—come back tomorrow”

Sign from AIDS center, Ukraine

STRUCTURAL BARRIERS I• IDU registries, with names of those

seeking treatment given to police

• Police harassment of patients (all countries)

• Provider harassment – Arrests and fear chill tx (Ukraine), pain

prescription (all countries), and open discussion (Russia)

• Incarceration and tx interruptions – No OST (or ARV) in pre-trial detention– No OST and little ARV in prison

• Ukraine: 1 in 10 HIV+ prisoners treated • Malaysia: 1 in 15 HIV+ prisoners treated• Russia: food shortages, medication

shortages, unsanitary conditions

STRUCTURAL BARRIERS II

• Drug detention in name of treatment– No medical evaluation– No right of appeal– Forced labor– No treatment– No effectiveness

1484 6538 6848

94973*

> 60000*

330000*

0

50000

100000

150000

200000

250000

300000

350000

China Vietnam Malaysia

Number in Methadone/Buprenorphine Treatment

Number in Drug Detention Centers

3 x greater

33 x greater

1.1 x greater

*2008

IDUs in Govt.-funded Methadone v. Detention

From the Individual to the Systemic• Stronger data—including equity ratio• OST considered part of ART, included in

treatment assessments, and scaled up (take home doses!)

• Integration of TB, HIV, drug treatment, and reproductive health

• Use of peers for reach and stigma reduction --DAART beyond the clinic setting

From Criminality to Care

• End to registries• End to compulsory drug detention • End to imprisonment for drug use/possession

for personal use• End to portrayal of drug users as less than

human, and so deserving of less-than-human rights

Acknowledgements• Johna Hoey• Damien Walker• Azizbek Boltaev• Oleksandr Pokanevych• Anna Shubashvili• Alexei Bobrik• Anya Sarang• Volodymr Kurpita• Konstantin Lezhentsev• China CDC• Pavlo Skala

• Evan Wood• Adeeba Kamarulzaman• Kasia Malinowska-

Sempruch• Chris Beyrer• Adeeba Kamarulzaman• Roxanne Saucier• Pamela Das• American-Austrian

Foundation