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HIV in People Who Use Drugs

HIV in People Who Use Drugs. Adeeba Kamarulzaman University of Malaya Kuala Lumpur, Malaysia. Outline. Global Burden of HIV due to illicit drug use The Global State of Harm Reduction Unmet needs and new challenges Women Adolescents MSM Prison and people who use drugs

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HIV in People Who Use Drugs

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  1. HIV in People Who Use Drugs AdeebaKamarulzaman University of Malaya Kuala Lumpur, Malaysia

  2. Outline • Global Burden of HIV due to illicit drug use • The Global State of Harm Reduction • Unmet needs and new challenges • Women • Adolescents • MSM • Prison and people who use drugs • Antiretroviral treatment for people who use drugs • Can We Do Better?

  3. Injecting drug use as a risk factor for HIV, HCV, HBVDALYs per 100,000 people, age-standardised, 2010 • Overall, illicit drugs caused 1% of global disease burden • 8th largest contributor to disability (YLDs) among males • Overall, illicit drugs caused 1% of global disease burden • 8thlargest contributor to disability (YLDs) among males • In countries where HIV incidence is increasing, 70% - 80% of HIV cases are among PWIDs Degenhardt, et al (2013). The Lancet, 380, 1564-1574 UNAIDS Global AIDS Report 2012.

  4. Interventions to prevent HIV and Hepatitis C in people who inject drugs: A review of reviews to assess evidence of effectiveness McArthur G et al. Int J Drug Policy Jan 2014

  5. Van der Knaap et al, March 2013 • Trends in HIV incidence, injecting and sexual risk behaviour: 1986 to 2011 in the Amsterdam Cohort Study (ACS) • 1298 participants • Total follow-up - 12,921 person-years (PY) • HIV incidence declined from 6.0/100 PY in 1986 to less than 1/100 PY from 1997 onwards (95% [CI] 3.2–11.1) • Both injection and sexual risk behaviour declined significantly over time

  6. Harm Reduction: Coverage Opioid Substitution Therapy Needle and Syringe Exchange Globally, 2 needles per PWID per month (range less than 1 to more than 200) Globally, for every 100 PWID, only 8 are receiving OST (range less than 1 to 61) • 82 countries have NSP • 76 countries with IDU have no NSP • 72 countries have OST • 86 countries with IDU have no OST

  7. What has been achieved in HIV prevention, treatment and care for people who inject drugs, 2010–2012? • China • 30% increase in OST recipients between 2009 and 2011 • Vietnam • significant scale up of NSP, >1000 NSP sites • five-fold increase in the number of clients receiving OST • Russia • number of PWID accessing NSPs decreased by nearly 60%, from around 123,000 (2010) to 49,090 (2011) • Ukraine • increase in number receiving NSP, OST, ARV • USA • reversal of the lifting of the Federal ban on funding NSP • Malaysia • shift from a punitive law-enforcement approach Degenhardt et al IJDP 2013

  8. Mistreatment of Drug Users and "Undesirables" in Cambodia’s Drug Detention Centers DECEMBER 9, 2013 Transformation of Compulsory Drug Detention Centers into Voluntary Evidence Based Treatment & Care Centers July 2011 36 000 PWID 6500 receiving MMT

  9. Unmet Needs & Challenges

  10. Women & Drug Use • Percentage of women among PWID • 4% (Iran) to 45% (North America, Eastern Europe) • Higher HIV prevalence rates in female IDUs • Systematic review of 117 studies in 14 countries with HIV rates > 20% (Des Jarlais, DAD 2012) • Studies in 9 European countries (EMCDDA, 2006) • Sex work and women who use drugs • 10% (US) - 55% (Eastern Europe, China) (EuroHIV2007, UNAIDS report on the global AIDS epidemic. 2010)

  11. Gender-Specific Drivers that Increase Vulnerabilities to HIV Structural “risk environments” that drive the HIV epidemic among women who inject drugs: Intimate Partner Violence - 60-80% Gender norms and gender imbalances in the drug culture Lack of woman-specific drug treatment and services Strathdee,et al., Lancet 2010 El-Bassel, et al., Curr HIV/AIDS Rep 2014 Meyer, et al, J Women Health 2012

  12. Female and Transgender Sex Workers in Malaysia: Sex, Drugs and … • RDS of F/TG SWs in Kuala Lumpur (underway) • Preliminary findings (N=114 of planned 450) • HIV: 21% • 12 HIV cases in TGs (35%), 12 in FSW (15%) • 54% unaware of being HIV+ • Drug/alcohol use (past 30 days) • Amphetamines (62%) • Opioids (35%) • Alcohol (25%) • Injection drug use (16%) • High prevalence of physical and sexual abuse • Interactions with police (89%) • High self-reported condom use (82%)

  13. Adolescents and Injection Drug Use Low ages of initiation across regions. • In some countries significant proportions of people who inject drugs are adolescents • Nepal, 20% • High rates of needle-sharing • Jakarta 15-19 age group – 50% needle sharing • Poor access to services A global population size estimate for people who inject drugs under the age of 18 is unavailable

  14. Ukraine: No. of adolescents who inject drugs versus access to harm reduction services See: O. Balakireva et al Population Size Estimate of Most-At-Risk Children and Youth in the 10–19 Age Group, Kyiv: Unicef, 2011 and D. Barrett, N. Hunt and C. StoicescuInjecting drug use among under 18s: A snapshot of available data, London: Harm Reduction International 2013.

  15. MSM & Drug Use Lancet September 2013

  16. Countries with published MSM drug use datause data Bourne IHRA 2013

  17. MSM and drug use • Use of drugs vary widely • Episodic • Prevalence of use higher • further marginalised or minority groups, eg ethnic minority gay men in the USA • younger men • living in large urban centres • Polydruguse is common • alcohol, biggest contributor • especially stimulants egecstasy, cocaine, amphetamines or ketamine • Prevalence of IDU (heroin) generally very low, but…. Bourne, IHRA 2013

  18. Alcohol and Drug Use Independently Correlate with HIV Risks Among Peruvian MSM 3.29 2.57 3.00 2.28 2.27 2.11 1.86 1.82 1.76 1.71 1.53 1.49 1.43 1.46 1.44 1.78 1.25 1.26 1.21 1.23 Drug Use Drug Use Drug Use Ludford K, PLoS One, 2013

  19. Drug use, and drugs injected, are changing • Looking at those only using ‘Club drugs’, • Mephedrone • Methamphetamine • Ketamine • GHB • ecstasy • The proportion currently injecting has doubled from: • 5%(N=531) in 2011-12 to • 10%(N=795) in 2012-13. Data Sources: NTDMS / NTA; Shooting Up report 2013.

  20. Harm Reduction for People Who Use DrugsContext is Key

  21. Prison and People Who Use Drugs

  22. Geography and Imprisonment Total Prison Population In 1971 President Nixon declared a War on Drugs

  23. Lifetime prevalence (%) of illicit drug use among prisoners in European countries EMCDDA 2012

  24. Incarceration: High Risk Environment for HIV Transmission Among HIV+s in Ukraine Mean number of people sharing among injectors = 4.4 (0-30) Izenberg et al, IJDP, In Press

  25. Results: • N=125 • Men (90%), age <40 years (62%), 72% had injected drugs • Median CD4 - 337 cells/μL, • 19 (15.2%) receiving ARV. • Prevalence of undiagnosed active PTB (15/125; 12%) • Associated with longer duration of drug use • (AOR 1.14, 95% CI 1.03-1.26, for each year of drug use)

  26. AIDS-Related Mortality Achieves Parity in Prisons and the General Population State inmates General population 34.2% HAART (1996) AIDS-Related Deaths Relative to All Deaths (%) 10.2% 3.4% 3.5% 2008 1995 Maruschak LM. Bur Justice Stat Bull. December 2009.

  27. Independent Correlates of Sustained Retention in HIV Care Althoff, AIDS Behav, 2013

  28. Evidence-Based Strategies to Reduce HIV Transmission Among PWUDs Primary & Secondary Secondary Only NSP HIVC&T ART MAT PrEP

  29. Treatment as Prevention Can Work Among PWIDs, but ….. • Ecological studies in Vancouver and Baltimore • documented reduced transmission among PWIDs where community VL has decreased • The HIV Continuum of Care for PWUDs is not equal to their non-drug using counterparts • HIV diagnosis • Linkage to care • Retention in care • Receipt of ART • ART adherence • Viral Suppression Differs based on local context and funding priorities

  30. Engagement in Care Among PWIDs in Baltimore, ALIVE Cohort, 1998-2011 Fully Retained (30.5%) Continuously on ART (17.3%) Sustained VL<400 (8.0%) Westergaard, AIDS 2013

  31. Engagement in Care Among PWIDs in Baltimore, ALIVE Cohort, 1998-2011 Poor Retention in Care Poor Viral Suppression Active drug injection Alcohol use Crack cocaine use Incarceration Lack of consistency in HIV care provider Decreasing CD4 count • Active drug injection • Incarceration • No health insurance • No usual site of care • Lack of consistency in HIV care provider Westergaard, AIDS 2013

  32. HIV Care Cascade: Select Countries in Central Asia McNairy et al. Journal on Drug and Alcohol Dependence, 2013

  33. Provider and clinic-level correlates of deferring ART for people who inject drugs Westergaard RP, J Int AIDS Soc, 2012

  34. Integrating Buprenorphine Into HIV Clinical Care Settings Prescribed ART Viral Suppression Altice FL et al, JAIDS, 2011

  35. Organization of Healthcare Delivery for HIV+ PWIDs Matters (Ukraine) Bachireddy C, Drug Alcohol Depend, 2013

  36. Strategies to overcome healthcare disparities for HIV–infected people who use drugs at each step of continuum of HIV care: Roadmap of Findings • Targeted out-reach programs • Opt-out testing • On site rapid testing – drug treatment programs, CJS Diagnosis of HIV Entry into HIV Care • Peer driven interventions • Intensive case management • Nurse support interventions • Community outreach program Retention in HIV Care • Evidence based drug treatment • Integration of clinical/social services • SBIRT • Evidence based drug treatment • Public health campaigns • Targeted outreach • CME for providers ART Initiation ART Adherence • Evidence based drug treatment • DAART • Access to treatment for comorbid conditions and social services VIRAL SUPPRESSION Meyer et al CID 2013

  37. Economic evidence for interventions with PWID Dutta et al. The Global HIV Epidemics among People Who Inject Drugs, World Bank 2013

  38. Cost Effectiveness of the Harm Reduction Program in Malaysia GDP per capita in 2012 was approximately USD10,000 CE threshold : <GDP per capita (highly cost effective); 1-3 x GDP per capita (cost effective); > 3 x GDP per capita (not cost effective). (WHO Commission on Macroeconomics and Health, 2001) H Naning et al, IAS 2013

  39. Global heroin supply increased by 380% from 1980-2010 Price of heroin in Europe decreased by 79%

  40. Eliminating laws prohibiting OST and scaling up NSP and OST to 80% coverage could prevent 29% of new HIV infections among IDUs in Nairobi by 2015

  41. The Prototype: The Case of Portugal • Decriminalisation of personal possession of all illicit drugs since 2001. • Continued prosecution of dealers and traffickers. • Expansion of treatment and harm reduction. • Introduction of guaranteed minimum income. Kent. B Journal Crim 2012

  42. Confronting Stigma & Addiction • Opioid use disorder as a medical illness is still overshadowed by its misconception as a moral weakness or a wilful choice • Separation of opioid use disorder treatment from the rest of health care insufficient attention to other substance use, mental health, and physical health conditions • Language mirrors and perpetuates the stigma. Often assign judgmental, pejorative terms. • Criminal justice system Olse & Sharstein, JAMA Feb 2014

  43. The Future HIV Healthcare Providers: Stigma & Healthcare Students in Malaysia P<0.0001 P<0.0001 P<0.0001 P=0.001 P=0.001 P=0.001 P=NS Jin et al, AIDS Care 2014

  44. What Do We Do Next? • No one size of prevention fits all • tailor approaches to local and group context • Combination (biomedical, behavioral) and multilevel intervention (e.g., individual, relationship, community, societal) • Integrate treatment • Address stigma and discrimination • begin with the medical and scientific community • Drug Policy Reform

  45. Rick Altice, Yale University Nabila El-Bassel, Columbia University Howie Lim, Ezra Akbar, Bertlin Ng, Britton Gibson, H NaningCERiA Chris Beyrer JHU Damon Barrett, Catherine Cook Harm Reduction International David Wilson, Louisa Degenhardt University of NSW Ken Mayer Fenway Institute, Harvard Medical School Tim Hunt, Wafaa el Sadr Columbia University Ministry of Education/University Malaya High Impact Research Grant The World Bank National Institute of Drug Abuse, USA

  46. Science can be a catalyst for the realization of human rights And human rights can accelerate the translation of scientific knowledge into practice and policy Richard Horton KL 2011

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