Access to Antiretroviral Therapy for HIV-Positive Drug Users : Breaking Another Myth

1. Access to Antiretroviral Therapy for HIV-Positive Drug Users:Breaking Another Myth Konstantin Lezhentsev, MD Program Manager, IHRD-Budapest

2. Why Myth? Starting from 1999 one of the main obstacles for ARV in developing countries was the statement about “the impossibility of following the complicated course of therapy”. “they lack the feeling of time because they have no watch…” UN Special Session on HIV/AIDS, 2001

3. 2001 – Expanding the ARV Scale in Africa 90% adherence to antiretroviral therapy has been achieved taking into account: - good organization of the medicine-distribution system - the involvement of NGOs as consultants - proper adjustment of the ARV combination

4. IDUs – Special Category of Patients • Chaotic way of life • Poverty • Double stigmatization in the society • Discrimination in health care institutions • Fear of the police • Prison • The health system unready to work with this group in other than specialized institutions

5. IDUs – Special Category of Patients Even in countries where ARV is fully available, the number of IDUs in treatment is limited Research by Strathdee et al. showed that only 40% IDUs eligible to therapy are receiving HAART (Vancouver, 1997) Research by Wood et al. underlined the increase in the number of IDUs covered but still 30% do not receive any treatment (Vancouver, 2001)

6. Main Principles of Organizing an HIV-Service for IDUs • Availability. Services must be geographically close to the patient (their house or the place they visit most frequently) and they must be part of the general health care system. • Service integration (“one-stop shop” principle). Concentration of the maximum possible range of services in one place. • Gradual increase of the complexity of medical measures. Except for emergency cases. • DOT- and half-DOT methods. • Link to harm reduction programs (outreach, syringe exchange). Training consultants among users based on the peer-to-peer principle.

8. Service Availability • Territorial availability. Location in the vicinity of the residence place (district out-patient clinic). • Services must be part of the general health care system. • Connection with specialized clinics must be provided.

9. One-Stop Shop Principle – Availability of the Maximum Range of Services in One Place • Narcological aid integration (first of all, methadone therapy) • Psychiatric and psychological help • General medical aid (links to specialized institutions and emergency services) • Mutual support group and NGO consultants • Links to social services/employment

10. Specials Needs of IDUs • Narcological aid • Psychiatric help • Specificity of opportunistic infections (bacterial pneumonias) • Co-infection with hepatitis C • Methadone and ARV interaction • ARV and “street drugs” interaction

11. Hepatitis C • 60-90% co-infected with hepatitis С/HIV • Side effects аlfa-2b-IFN+ribavirin (side effects; complexintroduction) – need for pegged IFN • Possible IFN and NRTI interaction • Impact on the course of the HIV-infection (GB subtype, hepatitisG-V)

12. Methadone maintenance treatment has been admitted to be the most efficient approach for developing adherence to treatment and for social and medical rehabilitation of patients.

13. Efficiency Enhancements for Joint Met/ARV Programs • Methadone treatment must be accompanied by consulting (psychologist, social worker, employment assistance, family psychologist) • Methadone treatment must be provided “on site” (locally). 76% adherence versus 4% (Umbricht-Schneiter study) • ARV and methadone interaction: Efavirentz, Nevirapin, Nelfinavir, Kaletra – 60%; 50%; 37%; 36% reduction.

14. Gradual Increase of the Complexity of Medical Measures. • Start from simple measures (prevention of opportunistic infections) • Establishing contact with the patient, solving associated problems (social and medical ones, work for developing the adherence) • Start ARV treatment

15. DOT- and Half-DOT Methods: Directly Observed Treatment Possibilities: • Providing therapy and efficiency of treatment • Support of the patient during the most difficult period – beginning of the therapy • Effective monitoring and assessment of the treatment process Problems: • Unlike TB, this therapy is life-long • Lack of medicines for 1 dose: only Didanosin, Nevirapin, Efavirentz and Tenofovir. • Half-DOT – one dose taken on one’s own (56% adherence within 12 months)

16. Links to Harm Reduction Programs • Access to user groups • Training consultants among outreach workers • Using SEP for organizing voluntary consulting and HIV testing • Using SEP for organizing the spread of ARV (experience of Yale University AIDS Program, New Haven, Connecticut)

17. Conclusions • ARV therapy standards must take account of the peculiarities of such a category of patients as IDUs • Methadone must be a part of the standard HIV-service for drug users living with HIV and must be included in the list of essential medical preparations, WHO. • Taking into consideration the isolated position of the narcological service and HIV-service, it is necessary to integrate these directions for ensuring the use of the “one-stop shop” principle (as a pilot project) • The experience of harm reduction must be used to maximum for providing access to this category of patients both for “DTK” and for providing treatment and care as well as for training “peer-to-peer” consultants and supervising the ARV patients.

18. Individualization of the ARV therapy by using new methods of spreading medicines, using combined preparations with one-time doses taken as well as cooperation with harm reduction programs and methadone treatment programs are fundamental for ensuring efficient availability of Highly Active Antiretroviral Therapy for drug users