harm reduction atma jaya

35
HIV, harm reduction and the right to the highest attainable standard of health Adeeba Kamarulzaman

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Page 1: Harm reduction   atma jaya

HIV, harm reduction and the right to the highest attainable

standard of health

Adeeba Kamarulzaman

Page 2: Harm reduction   atma jaya

Estimated numbers of IDUs and regional prevalence of HIV in people who inject drugs, 2010

* No countries have a prevalence of 5% to <10% Copyright, The Lancet

16 million people in 148 countries inject drugs

3.3 – 6 million people inject drugs and are HIV+ve

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3

Global HIV situation

• HIV now accounts for 1: 6 global deaths• World beyond Sub Saharan Africa (SSA)

now accounts for 30% new HIV• IDUs account for 30% new HIV beyond

SSA;• 10% global new HIV• Sometimes HIV in IDUs rapid spread

general population

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4

Controlling HIV among IDUs

• Best results if implemented:– Early – To scale

• But global implementation– Very poor - < 5% - 12 needles/IDU/year– Increasing rapidly

Page 5: Harm reduction   atma jaya

Current Response

Where 3 programmes work together, at all levels:Negative consequences of drug use can be reducedLong term problem of drug use can itself be addressed

Supply ReductionSupply Reduction

Demand Reduction

Harm Reduction

Page 6: Harm reduction   atma jaya

Principles of Harm Reduction

• Emphasis on achieving short-term pragmatic goals based on a hierarchy of risk

• A focus on reducing the harms to the individual and society associated with drug use

• Use of multiple strategies to achieve goals

• Involvement of current drug users in the planning and implementation of programs.

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Harm Reduction Hierarchy

• Reduce the sharing of injecting equipment• Reduce the incidence of injecting• Reduce the use of street drugs• Reduce the use of prescribed drugs• Increase abstinence

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Comprehensive Package of HIV Prevention and Treatment Services to IDU

• Needle and syringe programmes • Opioid substitution therapy • Voluntary HIV counselling and testing • Anti-retroviral therapy • Prevention and treatment of STI • Condom programming • Targeted information, education and communication • Hepatitis diagnosis, treatment and vaccination • Tuberculosis prevention, diagnosis and treatment 

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Effective HIV prevention for IDUs – the evidence base

International Journal of Drug Policy. Vol.16,suppl. 1 (2005)

• Outreach• Evidence from 40 studies • Needle et al, Effectiveness of community-based outreach in preventing

HIV/AIDS among injecting drug users

• Sterile needle and syringe programmes (NSP)• Evidence from 50+ studies• Wodak A and Cooney A, Effectiveness of sterile needle and syringe

programmes

• Substitution treatment (ST)• Farrell M, Gowing L, Marsden J, Ling W, Ali R, Effectiveness of drug

dependence treatment in HIV prevention

• Information, education and communication (IEC)• Aggleton P et al, HIV/AIDS and injecting drug use: Information, education

and communication

• Sexual risk behaviour of IDUs• Des Jarlais DC, Semaan S, Interventions to reduce the sexual risk behaviour

of injecting drug users

Page 10: Harm reduction   atma jaya

Models of Operation

3 basic types of needle and syringe program:

• Fixed site – a specific place that injectors can come to collect and dispose of injecting equipment

• Mobile services – using a van or bus, usually with a regular route and regular hours of stopping in several locations

• Outreach/backpack – in which workers travel through the streets distributing clean needles and syringes and collecting used injecting equipment for safe disposal

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Do outreach-based interventions reduce HIV risk behaviours—drug using, injecting

equipment use and sexual

• Effective in reaching out-of-treatment IDUs and providing the means for effective behaviour change (> 40 studies) (Coyle, Needle, & Normand, 1998)

• Significant and strong post-intervention reductions in:– cessation of IDU (10 of 11 studies);– injecting frequency (17 of 18 studies); – multi-person reuse of syringes (18 of 22 studies); – use of other injecting equipment (9 of 13 studies);

• India - self reported reductions in HIV-related risk behaviours Kumar, Mudaliar, and Daniels (1998) 

R Needle IJDP 2005

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Evidence of Effectiveness of Needle Syringe Program

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Effectiveness of NSPs• 45 studies from 1989 to 2002• 6 out of 10 studies, which evaluated HIV

seroconversion or seropositivity as outcomes, found that NSP use was protective

• 33 studies - HIV risk behaviour : 23 were positive

• Efficacy of individual NSPs reported in at least 10 different countries, including several resource-poor countries

Wodak, Cooney IJDP 2005

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HIV seroprevalence in cities with and without NSPs

Hurley Lancet 1997

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Effectiveness of NSPs Return of Investment 2 - Australia

Over the last decade (2000-2009) NSPs have directly averted:

• 32,050 new HIV infections• 96,667 new HCV infections

This investment yielded:• Healthcare costs saved of $1.28 billion• Approximately 140,000 DALYs gained• Net financial cost-saving of $1.03 billion 

 

Page 17: Harm reduction   atma jaya

Effectiveness of NSPs Return of Investment 2 - Australia

• For every $1 invested in NSPs, > $4 were returned in healthcare cost-savings in the short-term (10 years)

• If patient/client costs and productivity gains and losses are included in the analysis– then the net present value of NSPs is $5.85bn

– for every $1 invested in NSPs (2000-2009), $27 is returned in cost savings. This return increases considerably over a longer time horizon

• NSPs are very cost-effective compared to other common public health interventions.

 

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Evidence of Effectiveness of Drug Dependence Treatment in HIV

Prevention

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Effectiveness of Drug Dependence Treatment

Cochrane Systematic Review

• Effectiveness:

– seroprevalence in IDUs– rates of seroconversion

• most emphasis on treatment effect on:

– injecting drug use – sharing injecting equipment– number of sexual partners– unprotected sexual activity

Gowing et al Cochrane Rev 2008

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Summary of findings from Individual studies - HIV

• Seroprevalence (2 studies)– methadone and buprenorphine may help prevent

HIV diffusion

• HIV Seroconversion (3 studies) if in treatment (e.g. 3.5% vs 22% in 18 mth -Metzger 1993)

Gowing et al Cochrane Rev 2008

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Summary of drug treatment findings

**** Increasing methadone and buprenorphine doses

Retention increases, heroin use decreases

*** most effective methadone programs - doses of >60mg/day- maintenance oriented

*** most effective burprenophine programs-doses of > 12-16mg-maintenance orientated

Gowing et al Cochrane Rev 2008

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Summary of drug treatment findings - MMT

**** Maintenance agonist treatment substantially reduces heroin use

**** Maintenance agonist treatment is more effective than no treatment

or placebo in:- reducing rates of imprisonment, - reducing heroin use, - retaining clients in treatment, - employment/return to education

Gowing et al Cochrane Rev 2008

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Summary of drug treatment findings – residential treatment

** High early drop-out from residential rehab. (>40% drop-out in the first month)

** >3 months treatment required

** Completion of residential rehabilitation- reduced drug use and criminal behaviour- legal employment increased

* Good outcomes predicted by tx progress in addition to time in treatment

Gowing et al Cochrane Rev 2008

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Intervention coverage – crucial,

but often inadequate

Coverage of target population is critical for

HIV prevention

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COVERAGE

IDU population No. of NSP

IDUs in contact

% IDUs contact

Syringes distributed

(year)

% all injections with a syringe from a NSP*

135 000 9 (110)

5500 4% 750 000 1.3 %

* assuming 400 injections per IDU/year

NSP Coverage in Malaysia

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Coverage of substitution treatment is poor in much of the world

Malaysia

• ~ 7000 receiving MMT through national program

• 20 000 receiving methadone/bupenorphrine/bup-naloxone through the private system

90% + methadone is consumed in developed countries (2003)

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What sort of delivery system is required

• Needs integrated health care system• Public Health Strategy to achieve

maximum coverage• Primary care training in delivery of

treatment • Family Practice Approach• Prisons based care linked to community

ongoing treatment

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Harm Reduction IS Effective What Are the Obstacles?

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What Are The Obstacles?Political will – lack of are there votes in harm reduction?

Denial national immunity myths

Legal restriction laws against outreach, needle distribution, ST drugs classed as ‘narcotics

Prejudice – medical, political, societal HR, ST ‘condones drug use’,

Lack of concern and compassion drug users ‘have selves to blame’, ‘God’s punishment’

Disinformation campaigns misuse of science

Reliance on law enforcement… …rather than public health

Imbalance between prevention and care

too much emphasis on, excitement about, clinical issues

Page 30: Harm reduction   atma jaya

Harm Reduction is a Western Concept

Asian countries adopting Harm Reduction• Malaysia• Iran• Indonesia• Bangladesh• China• Vietnam• Nepal• Cambodia• India

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Harm Reduction is Against Islamic Principles

• The injunctions of the Shariah (Islamic law) are stipulated to preserve the faith, life, intellect, progeny and wealth of mankind which are threatened by drug use and HIV/AIDS

• In Islam life and good health must be protected and promoted in all circumstances and this includes prevention and treatment of any illness and disease

• In this regard, the numerous harms associated with drug addiction, a chronic medical condition should be prevented through measures that have been scientifically proven

• Islam also believes that every disease has a treatment known or discoverable by further scientific research.

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Harm Reduction is Against Islamic Principles

• The principle of injury in Islam (Darar) asserts that no one should be hurt or cause hurt to others, la darara wa la dirar.

• Drug addiction and HIV/AIDS hurt patients and their family in their life and health

• The law requires that any injury should be mitigated to the extent possible. A legal dictum in Islam gives the provision that “a lesser harm may be tolerated in order to eliminate a greater harm”; al-darar al-ashadd yuzalu bi al-darar al-akhaff.

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Harm Reduction is Against Islamic Principles

• In Islam public interest takes precedence over personal interest

• A relevant legal dictum in the context of harm reduction is that “a particular harm may be tolerated in order to prevent harm to the general public”. This means that whenever a conflict between personal and public interests arises, harm to the former may be tolerated so as to protect the latter

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Harm reduction 20 years of experience

Human rightsPublic health Two strands,shared ethos

Evidence basedAssessment based PragmaticTargetedRealistic goals

Rights to:Life and securityHealth protectionMedical care Protection against hurts from community and state

Ethos:Facilitative

Non-coercive

Non-punitive

Cooperative

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