harm reduction in asia - amfar...• harm reduction programme supported by the global fund and adb...
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HARM REDUCTION IN ASIA
Adeeba Kamarulzaman
University of Malaya, Kuala Lumpur
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*Mathers et al., 2008. The global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review.
The Lancet: IN PRESS
No estimate of HIV prevalence
0% ‐
<7.5%
7.5% ‐
<15%
15% and greater
Prevalence of HIV among IDUs: 2007
• DU identified in 148 countries
• 15.9 million PWID
• Accounts for 30% of all new infections outside Sub-Saharan Africa
• Up to 3.3 million PWID living with HIV IDU
Reference Group to the United Nations on HIV and Injecting Drug Use Lancet 2008
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Estimated number of people who inject drugs in selected Asian Countries
China 541,184Indonesia 219,130Malaysia 205,000India 164,820Thailand 160,528Vietnam 135,305Pakistan 130,460Myanmar 75,000Bangladesh 30,000Nepal 22,050Cambodia 1,750Lao PDR Not knownTotal 1,685,227
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HIV prevalence among people who inject drugs
UNRTF 2008
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HIV prevalence in incarcerated settings
• Vietnam - 28.4% of the estimated 88,000 prisoners
• Indonesia - 20.0% of 100,000 prisoners• China and Malaysia - 4.0 % • Vietnam - 40 – 50% among residents in
drug rehabilitation centres
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Progress of Harm Reduction in Asia
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Harm Reduction in Philippines• Has three identified sites with people who inject drugs
• Harm reduction programme supported by the Global Fund and ADB – implemented mainly by NGOs – Needles and syringes continue to be distributed discreetly in
identified sites, with support from GF Rounds 3 and 5 AIDS Project
– NGOs refer IDUs to treatment hubs for treatment, care and support
• Outreach work and outreach post supported by ADB in one site
• Government drafting the national guidelines on HR
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•National Strategic Plan for drug use and HIV/AIDS, 2008 2010
•NSP operational since 2004
•Outreach programmes
•Govt authorisation to commence MMT through Ministry of Health
Cambodia
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China• First NSP in Yunnan province and Guangxi Zhuang AR
in 1999;
• Since 2001, the State Council has officially advocated needle social marketing;
• National policy guidelines on NSP in 2002;
• Almost 800 NSP in 17 Provinces by September 2008• 50,000 accessing NSP
• 515 MMT clinics by end of 2007 in 22 Provinces• 100,000 on MMT
• Wu, Sullivan et al. (2007) Evolution of China's response to HIV/AIDS, The Lancet. 369:679‐690• Mesquita, F et al. (2008, submitted) Accelerating Harm Reduction
interventions to confront the HIV epidemic in the Western
Pacific and Asia: the role of WHO (WPRO), Harm Reduction Journal.• WHO Report, Towards Universal Access, Geneva, 2 of June 2008.
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Methadone Maintenance Clinic inKunming - China
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Malaysia
• National response since 2005 after evaluation of the
non achievement of the Millennium Goals.
• Mainly a Public Health Based approach, combined with
NGOs for NSP
• Comprehensive approach - NSP, MMT and CST
• Currently 74 MMT clinics, started in prisons in 2008
• 6 NSP covering 3600 IDUs by the end of 2007.
• National Government supports the response
• Mesquita, F et al. (2008, submitted) Accelerating Harm Reduction
interventions to confront the HIV epidemic in the Western
Pacific and Asia: the role of WHO (WPRO), Harm Reduction Journal.
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• 22 000 on opiate substitution treatment
• 11 NSP sites ‐
> 1.3 M needles and syringes distributed as of
June 2008
• Pre‐release prison methadone project
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Indonesia• Strong political commitment
• Costed National Action Plans
• ST: – 7 methadone clinics (4 in Hospital, 2 in Puskesmas, 1
in prison)– Around 1700 on MMT and Buprenorphine
• NSP:
– 130 NSP sites
• ARV: Required for IDU – limited access/availability
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Vietnam
• Public Health Based approach
• 42 Provinces in Vietnam conducting HR activities• 60,000 IDU accessing NSP with a total of 11
million syringes distributed• In April 2008 Vietnam announced its first MMT
clinic– Currently ~ 500 on MMT
• ARV for IDUs has good coverage, thanks to PEPFAR
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Deputy First Minister of Vietnam Addressing the National HR Conf.
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India• Political commitment:
– No established policy on Harm Reduction.
• Enabling environment:
– Drug use remains a criminal offence.
– Methadone classified as narcotic and not used.
– The legality of NSP under the NDPS Act is
unclear.
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India• OST: Buprenorphine.
– NGO interventions in Delhi, Chennai, Kolkata and Mumbai
– 4,000 on Buorenorphine
• NSP: – 122 government supported NGO targeted intervention
sites which include NSP .
• ARV:
– Affordability generally limited.
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Thailand• Political commitment:
– No concrete political commitment to HR strategies - law enforcement
approach dominates.
• Enabling environment: – A National Strategy for collaboration between public health and law
enforcement required.
• Policy environment: – Incarceration for drug possession. No effort to address legal/policy
issues.
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Thailand
• ST: Methadone only free in Bangkok – very hard to access in other provinces. No methadone in prison settings.
• NSP: Small scale (needle distribution almost totally underground)2 official NSP - less than 500 clinets
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Factors that Hamper Progress of Harm Reduction in Asia
• Legislative and policy barriers to harm reduction
• High level of stigma and discrimination
• Overlap between SW and injecting drug use
• Limited government capacity and infrastructure
to develop, scale up and monitor harm,
reduction programmes
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Factors that Hamper Progress of Harm Reduction in Asia
• Disproportionately low allocation of national
AIDS budget for HIV prevention and harm
reduction among IDU
• Absence, or limited availability of research,
surveillance and M&E data for planning,
implementation and scaling‐up
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What Role for TREAT Asia
• Advocacy– Policy– Access to OST, ARV, HCV therapy
• Capacity Building– Healthcare workers– Community
• Operational Research– Integration of prevention and treatment
– Integrating ARV/OST/TB/HCV
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What Role for TREAT Asia
• Clinical Research• Coinfections
–
HIV/HCV/Tuberculosis
– Hepatotoxicity– Drug‐drug interaction
• HAART‐TB treatment
• HAART‐OST• HAART‐HCV treatment
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Acknowledgements
• Anna Bergenstrom
–
UN Regional Task Force on HIV & IDU
• Fabio Mesquita
–
WPRO
• David Jacka
–
WHO, Vietnam