A Review of Barriers and Ways Forward
Daniel Wolfe1
M. Patrizia Carrieri2
Donald Shepard3
Paper 3
Treatment and Care for IDUS with HIV
1. Open Society Institute 2. INSERM/ORS PACA 3. Brandeis University
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 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
• 2010 review of IDU access to ART finds data unavailable for 2/3 (66%) of countries
• 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 based often on police or treatment data
Russia China Ukraine Vietnam Malaysia
0%
20%
40%
60%
80%
100%
83.0%
38.5%
60.5%
44.0%
70.0%
IDUs as share of total reported HIV cases
53%
47%
Share of Estimated IDUs with HIV in Low and Middle Income Countries, 2009
IDUs with HIV in Russia, China, Ukraine, Vietnam and Malaysia
IDUs with HIV in all other low- and middle-income coun-tries
“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
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
94973*
1484 6538
330000*
> 60000*
68480
50000
100000
150000
200000
250000
300000
350000
China Vietnam Malaysia
Number in Methadone/Buprenorphine TreatmentNumber in Drug Detention Centers
3 x greater
33 x greater
1.1 x greater
*2008
IDUs in Govt.-funded Methadone v. Detention
• 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 services
• Use of peers for reach and stigma reduction --DAART possible beyond the clinic setting
From the Individual to the Systemic
From Criminality to Care
• End to sharing of registries with police• 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
And especially, my co-authorsM. Patrizia CarrieriDonald Shepard