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Organising care for HIV-positive ID-users Experience of Spain

Moving harm reduction policy forward Chisinau Moldova, November 2003. Organising care for HIV-positive ID-users Experience of Spain. Elia Díez, Teresa Brugal Agència de Salut Pública de Barcelona. AIDS cases diagnosed in 2002 per million population WHO European Region. AIDS cases per

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Organising care for HIV-positive ID-users Experience of Spain

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  1. Moving harm reduction policy forwardChisinau Moldova, November 2003 Organising care for HIV-positive ID-users Experience of Spain Elia Díez, Teresa Brugal Agència de Salut Pública de Barcelona

  2. AIDS cases diagnosed in 2002 per million population WHO European Region AIDS cases per million 0 50 + 20 - 49 4 6 5 - 19 6 3 3 < 5 7 23 13 2 Not available 10 18 2 4 2 0.8 33 0.4 26 26 9 0.2 0.2 0 3 0.2 4 1 31 77 71 3 9 8 37 NA 0.2 10 2 2 2 Update at 31 December 2002 9 0.3 0.7 10 10 EuroHIV Data adjusted for reporting delays

  3. AIDS cases diagnosed among homosexual men in 2002, per million population, WHO Eur Region AIDS cases per million 0 20 + 1 5 - 19 0.9 1 - 4 2 0.5 0 3 < 1 0.8 3 1 Not available 4 2 0.1 0.6 0 0.4 9 0 0.4 7 2 0 1 0 0 0.5 6 6 0.7 0 9 0 NA 2 0 0 0.1 0.1 0 0 Update at 31 December 2002 5 0.1 8 0.8 EuroHIV Data adjusted for reporting delays

  4. AIDS cases diagnosed among injecting drug users 2002, per million pop, WHO Eur Region AIDS cases per million 0 20 + 5 - 19 0.7 0.6 0.5 1 - 4 0.7 0.5 0.5 < 1 19 0.5 0 Not available 0.5 0.4 1 2 2 0 4 0 6 1 20 0.2 3 0 0 0 11 0.2 36 0 36 0 2 NA 0 7 0 0.7 0 Update at 31 December 2002 0.2 0.3 0.03 0 2 EuroHIV Data adjusted for reporting delays

  5. AIDS cases diagnosed among heterosexuals in 2002, per million pop, WHO European Region AIDS cases per million 0 20 + 2 5 - 19 5 1 - 4 3 2 2 3 < 1 3 9 1 Not available 1 15 0.4 0.6 0 0.1 16 5 0 11 5 0.04 0.9 1 0 0 12 33 4 1 18 0 NA 1 0 2 1 0.7 2 0 Update at 31 December 2002 2 0.2 3 6 EuroHIV Data adjusted for reporting delays

  6. AIDS incidence per million population, by geographic area, 1986-2002, WHO Eur Region* Cases per million 60 40 West 20 East Centre 0 Update at 31 December 2002 1986 1988 1990 1992 1994 1996 1998 2000 2002 Year of diagnosis EuroHIV Data adjusted for reporting delays * Excluding Netherlands (West), Kazakhstan, Kyrgyzstan, Russian Federation (East): data not available whole period

  7. Centre: low level epidemic* Globally, low level HIV epidemic but Romania: large numbers of young adolescents infected in late 1980s starting to engage in behaviour at risk of transmitting HIV Poland and Serbia & Montenegro: HIV epidemic in IDU in late 1980s although of lower extent than in several countries of the West or in the East Risk factors for epidemic spread of HIV present in all countries Including risk behaviours and economic migration from affected countries of the East EuroHIV * HIV prevalence not consistently >5% in any defined sub-population

  8. East: recent, concentrated* epidemic • Major HIV epidemic among IDU • For the first time in 2002, decreases in HIV diagnoses likely due to saturation of IDU populations • Emergence of a heterosexual HIV epidemic • Closely related to the HIV epidemic among IDU: >50% of HC cases known to have an IDU sex partner • Substantial uncertainty about the extent of HIV spread among HBM • Low numbers of reported homosexual HIV infections probably reflect high social vulnerability rather low HIV transmission among HBM • Inevitable severe futureAIDS epidemic and negative impact of HIV on theTB epidemic • Over 40% of reported AIDS cases have TB as initial AIDS indicative disease EuroHIV * HIV prevalence consistently >5% in at least one defined sub-population and <1% in pregnant women

  9. HIV/AIDS in Spain2003 • AIDS incidence rate: Second place in European ranking • HIV incidence rate: Sharp reduction, 70 per million • People HIV: 110.000-150.000 • People HIV since 1981: 160.000-200.000 • People AIDS: 18.000-22.000 • Deaths HIV/AIDS since 1981: 50.000-60.00

  10. HIV/AIDS in Spain2003/ 2 • Pattern • IDU: 55% • HBM: 20% • Heterosexual risk: 25% • Women / man: ¼ • Children.< 1%

  11. AIDS incidence (new cases). Men. Spain, 2001

  12. AIDS incidence (new cases). Women Spain, 2001

  13. Mean incidence rate 1998-2001. Spain, 2001

  14. Mean incidence rate. Homosexual & bisexual men. 1998-2001. Spain, 2001

  15. Mean incidence rate. IDU. 1998-2001. Spain, 2001

  16. Mean incidence rate. Heterosexual. 1998-2001. Spain, 2001

  17. Proportion of AIDS cases who didn’t know their serostatus until they got the AIDS diagnose. Spain, 1998-2001. %

  18. AIDS in Spain in the 80’s

  19. AIDS incidence by transmission group. Spain, 1981-2003

  20. AIDS in the 80’s • 66% among IDU, followed by HBM • No actions on IDU • 50% of IDU infected by HIV • Secondary transmission heterosexual & perinatal • 1990 more than 100.000 persons infected • Since 1988 until 1998 Spain has had the higher rate in Europe

  21. Who was against harm reduction in the ’80s? • Public opinion • Professionals • Politicians Why we all changed? • Deaths • Illness, costs • Safety • Open scenes • Political agreements

  22. Needle exchange facilities • First great NEP in Basque Country 1990, in chemists (drugstores) • Evolution in Spain • 1991: few • 1996: 451 • 2000: 1175 (most in chemists) • Pesesud 1996-2000 (EC project France, Spain, Italy, Portugal)

  23. Needle exchange. Number of needles exchanged and number of facilities. Barcelona. 1991-2001. Barcelona 1991-99 Barcelona Drug Information System

  24. Methadone Maintenance Programs • Law forbidding methadone in 1985 • Law enabling access to methadone in 1990 • Coverage • 1990: 3000 IDU • 1995: 29.000 • 1999: 78.000

  25. Prison • Needle exchange programs: • first in 1997 in Basauri • in 2001 9 prisons • Methadone

  26. Prostitution • Network • 70 governmental and non govermental entities • Specific groups: • african women • latinoamerican women • transexual • homosexual

  27. Other facilities • Safe injection rooms: 2 • First in Madrid 2000 • Barcelona • Maintenance with heroine • Andalousia

  28. Description Objectives Target diana Method Coverage Interventions & policies implemented among drug usersin order to prevent or reduce consumption risk. Methadone maintenance program Maintenace with agonists to prevent deaths and health hazards Heroine use patientstreated in treatment centers To offer access to methadone maintenance programmes in diffeent settings: treatment centers, prisons, mobil bus, drugstores 60% heroine treatment demands Secondary prevention Risk reduction Needle exchange facility Prevention of risk related to parenteral use Intravenous drug users (IDU) Exchanges facilities in: Drugstores, health agents, primary health care, mobile bus 58% injectors Social & health support program (SAPS) Prevention of risk related to parenteral use and health education Intravenous drug users (IDU) in social exclusion Night center. Health education, needle exchange, social & health care, legal assessement, hygiene, food 90% IDUs vulnerables Social & health support programaddressed to female prostitutes Prevention of risk related to parenteral use and health. Self –care promotion Women prostitutes IDU in vunerable situation Day center. Health education workshops. Health & social care assessment 30% prostitutes Outreach program addressed to extremely excluded population (Programa Can Tunis) Prevention of risk related to parenteral use and health. Self –care promotion.Health education. Basic needs support. Intravenous drug users (IDU) in social social exclusion homeless Mobile day program specialized in health education, needle exchange, health & social care, legal assessment food, hygiene settled in the street where addicts buy drugs 100% area residents

  29. Intervention results

  30. HIV prevalence by injection practice. Barcelona & Madrid. 1995-2002. 50% 44% 39% 37% 28% 28% 20% 19% 17% 0% BCN MAD BCN MAD Injeción 12 ultimos meses Total consumidores 1995 2002

  31. Frequency of heroine use among IDU. Barcelona & Madrid. 1995 & 2002 88.0 82.0 84.0 81.0 70.0 48.0 32.0 20.0 80.0 75.0 67.0 65.0 64.0 49.0 41.0 20.0 BCN MAD BCN MAD BCN MAD BCN MAD Once/few times 12 months 30 days 2002 1995

  32. IDU who have ever used a needle already used. Percentage. Barcelona & Madrid. 1995 & 2002 72.0 61.0 39.0 35.0 17.0 8.0 42.0 39.0 20.0 17.0 13.0 12.0 BCN MAD BCN MAD BCN MAD Once/few times 12 months 30 days 2002 1995

  33. HIV prevalence & incidence rate among users who begin treatment. 1991-2001 Percentage % person per year 50% 6,00 45% 5,00 40% 35% 4,00 30% Incidence rate VIH+ prevalence 25% 3,00 20% 2,00 15% 10% 1,00 5% 0% 0,00 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 HIV prevalence HIV incidence Barcelona Drug Information System

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