How can we tailor the delivery of the TB/HIV package to IDU?

1. How can we tailor the delivery of the TB/HIV package to IDU? David H.-U. Haerry European AIDS Treatment Group(European Community Advisory Board, Policy Working Group)

2. Eastern Europe & Central Asia • 1,4 million HIV infected by end of 2004. • 490’000 women, 210’000 new infections & 60’000 deaths in 2004.

3. Ukraine • Exponential increase of epidemic since 2000 (+7%) – 2002 (+25%). • In 2003, 30% of new infections heterosexual transmission (within IDU subpopulation). • 10 – 15% of TB cases in Ukraine MDR. • TB leading cause of death among PWAs, 50% of AIDS-related deaths are due to TB. • 45’000 patients in need of ARV, 1500 treated (GFATM component).

4. Russia • 70% of all HIV infections registered in Eastern Europe/Central Asia. • Estimated 860’000 PWHAs in Russia, 80% aged 15 – 29, >1/3 women (Dec. 2003). • 1.5 – 3 million Russian IDUs (1 – 2% of population), 30 – 40% use non sterile syringes. • In 2004, 80% of reported HIV cases among IDU. • 70% sexually active. • Sharp increase of pregnant women with HIV.

5. Latvia, Estonia, Lithuania • Latvia: 5-fold increase 1999 – 2002 (2300). • Estonia: 1999 12 new cases, 2003: 840. • Lithuania: 2001 72 new cases, 2002 increase more than 5-fold. Infections mostly due to injecting drug use, sexual transmission is gaining ground.

6. Eastern Europe / Central Asia • 90% of HIV cases caused by injecting drug use. • <1% of HIV-positive IDUs have access to ARV treatment (or medical care in general). • TB patients are 10 times more likely to have MDR-TB than in the rest of the world. • Estonia, Kazakhstan, Latvia, Lithuania, Russia and Uzbekistan: MDR up to 14%. • 79% of MDR-TB cases are "super strains", resistant to at least three of the four main drugs used to cure TB. • Kaliningrad: highest documented HIV prevalence within Russia. 70 – 80% of HIV-infected IDUs have had hepatitis C exposure.

7. Treatment access in the region • 11% of patients in need of ARV are getting treatment. • Due to legal restrictions & discrimination, HIV-positive IDUs have limited or no access to treatment.

8. Problems we are facing • Conflict healthcare priorities - current drug policy. • Double-stigma in society. • Discrimination in medical institutions. • Fear of police harassment. • Unwillingness of medical infrastructure to meet the demands of this patient group.

9. Main barriers for equal access to HAART • No political commitment to meet the requirements of the epidemic. • Repressive drug policies supersede the principles of public health. • High prices for ARV and diagnostic equipment. • No national protocols on HIV treatment and care that meet international standards focusing IDU patients. • Vertical and centralised AIDS-service infrastructure. • Illegal substitution treatment programmes (Russia). • Limited number of ST programmes. • Limited NGO involvement into HIV care and treatment. • Stigma and discrimination within medical institutions.

10. Ukraine – assessment on TB treatment in IDUs Artur Ovsepyan, All-Ukrainian Network of PWHAs, 2005 • AIDS-centres, TB hospitals and drug-addiction clinics in 13 regions of Ukraine. • 40 medical institutions assessed. • 14 have access to opiate analgetics. • 13 have license for storage and prescription of opiate medications, 2 are planning to obtain license. • 2 medical institutions prescribe buprenorphine for ST – Kherson and Odessa drug addiction clinics. • 16 patients received ST with buprenorphine in 2004. • 2540 patients have interrupted TB treatment because of drug-addiction (expelled from hospital because of drug-use). • 420TB patients with HIV co-infection that have interrupted TB treatment because of drug-use.

11. Conclusions (based on assessment) • TB and AIDS-service infrastructure are desintegrated and parallel in Ukraine. • TB and HIV services do not have legal or administrative authority to ensure access to opiates as part of palliative care and ST. • Clear evidence: most IDU patients cannot receive appropriate TB care without access to ST. • Urgent need to overcome these barriersa) to provide required medical care for IDUs b) to overcome of TB/HIV epidemic.

12. Brazil • São Paolo: epicenter of injection-driven epidemic, 50% of all HIV cases in Brazil. • Assessment has shown that 69% of all people on treatment successfully followed treatment procedures. • Decentralized and widely available “user-friendly” network of clinics (up to 300 day clinics across the country). • Development of a harm reduction strategy on national scale. • Effective integration of harm reduction projects in care programs (incl. hepatitis vaccination etc). • Creation of a national drug-user organisation with strong support of health professionals and local authorities.

13. Key factor of Brazilian success • Government commitment to provide universal and equal access to treatment as part of the overall strategy to fight HIV in the country.

14. Recommendation: Need of a comprehensive care programme, including • TB treatment & prevention – isoniacid? • Hepatitis treatment & prevention. • HIV/AIDS treatment & prevention. • Effective harm reduction & substitution programmes, including prison settings. • Access to safe conception methods.

15. Requirements • Support community-based advocacy, education and mobilisation. • Promote international care standards for HIV-TB-Hepatitis co-infection. • Promote reference centres for integrated HIV-TB-Hepatitis care. • Promote substitution programmes as integrated part of the TB/HIV service kit for IDUs (one stop shopping model). • Perform ARV/TB/hepatitis drugs – street drug interaction studies. • Coordinate ARV-TB-hepatitis drug provision at affordable prices; plan first-, second-line and salvage regimens. • Invest in training: health care professionals & patient organisations.

16. Conclusions • IDUs must be identified as a special category of patients with specific needs. • Interaction studies in ARV/TB/Hepatitis treatment – street drug must be performed. • ST access in TB / HIV medical services is a cornerstone of effective HAART and TB treatment for IDUs and a vital factor for overcoming the TB/HIV epidemic in the CIS region.