Adeeba Kamarulzaman

“The treatment not like what they give to normal people, there’s a difference. Like touching you… they feel reluctant to touch. When the doctor tells them to draw blood…ah…they will think twice. They will ask us whether you can draw your own blood or not. If they touched also, immediately they go and wash their hands. [It] is happening everyday. You can go to the ward and see”

(Male, 40yrs, Drug user) [11]

“In hospital, what I can see … people … nurse or attendant or other members of society. They know about AIDS and HIV. They know but they are not convinced. They are not convinced about what they have learned.”

(Male, 32yrs, Drug User) [11]

Quotes from a focus group discussion with HIV-positive drug users in Malaysia on stigma and discrimination in health care settings.

Asia currently faces an escalating HIV/AIDS epidemic with more than 8.3 million people living with HIV in the region at the end of 2005. [1]

In many parts of Asia, HIV epidemics have been largely driven by injection drug use, and transmission among sex workers and their clients. HIV rates of greater than 20% among injecting drug users have been recorded in many countries, including Indonesia, Malaysia, Myanmar, Thailand, and Vietnam. [2]

In response to the escalating epidemics, several countries in the region have recently embarked on harm reduction efforts for injecting drug users that include opiate substitution therapy and needle and syringe exchange programmes. In many instances these responses have come somewhat too little and too late. Given that transmission of HIV has firmly taken roots in many parts of Asia through injecting drug use, it is no surprise that injecting drug users account for a large number of those living with HIV in Asia. In Indonesia, for example, 51% of all newly reported HIV infections up to March 2006 occurred among IDUs, whilst in China, it is estimated that over half of new HIV infections are occurring among the country’s estimated 1.14 million registered drug users. [3, 4]

In Malaysia drug users account for 65% of all reported HIV cases that to December 2006 have totaled 76389. [5]

Despite recent global initiatives that have increased the number of people receiving antiretroviral therapy in the region by almost threefold, injecting drug users remain disproportionately less likely to have access to these medications. In Malaysia, for example, injecting drug users comprise the majority of HIV-positive people, but they comprised only 25% of those receiving ARV by end of 2006 (an increase from 7% in 2003). Some of the major obstacles to access to antiretrovirals for injecting drug users include legal policies surrounding drug use, inadequate health infrastructure, cost, and pervasive stigma and discrimination, which hinder drug users from coming forward for treatment.

In many parts of Asia, continued criminalisation of drug use means that the management of “treatment and rehabilitation” of drug users is in the domain of law enforcement rather than health practitioners. Many HIV-positive patients go without access to antiretrovirals because of mandatory internment in detoxification and rehabilitation centres where there is often little access to basic medical care. In some countries, where access to antiretrovirals in the community has increased, continued criminalisation of drug users has led to periods of treatment interruption for HIV-positive IDUs when they are imprisoned, as there is no provision for access to antiretroviral therapy in prisons or in mandatory rehabilitation. This raises the risk for development of antiretroviral resistance.

In Asia, an inadequate health infrastructure and lack of people with the relevant skills and training to provide treatment are major obstacle to access to antiretrovirals, particularly for injecting drug users. The shortage of health professionals with the capacity to respond to Asia’s growing HIV epidemic was highlighted in a special TREAT Asia report in 2004. The report noted that “an acute shortage of healthcare workers trained to deliver these lifesaving drugs has emerged as a critical gap in providing safe and effective treatment. Most Asian nations have far too few doctors trained to administer complicated ARV regimens. The discrepancy in physician preparedness ranges from one doctor per 24 HIV-positive people in Japan to one doctor per nearly 11,250 HIV-positive people in Vietnam”. [6]

The complexity of managing HIV-positive drug users, who often present with multiple medical problems, makes it crucial that health professionals are adequately trained. High rates of co-infection with hepatitis C and tuberculosis increase the risk for antiretroviral-associated toxicities as well as complex drug-drug interactions. These pose a significant challenge in managing HIV-positive drug users.

The rate of HCV co-infection in HIV-positive IDUs has been reported to be between 60-90%. [7] Patients with HCV coinfection may experience increased rates of hepatotoxicity during antiretroviral therapy compared to patients without HCV.

One of the most widely available ARVs in the region, nevirapine (widely included in several Fixed Dose Combinations) is associated with a higher incidence of rash and life-threatening hepatotoxicity. In many countries in Asia, second line regimes consisting of protease inhibitors or newer classes of antiretroviral agents simply do not exist. The options are severely limited for patients who are unable to tolerate NNRTI based regimens. In a recent analysis of Asian patients enrolled into a large observational database (TAHOD), approximately one in four of the TAHOD patients started their ARV treatment with d4T/3TC/NVP. The rate of treatment change among these patients commencing antiretroviral therapy with d4T/3TC/NVP was 22.3 per 100 person-years. In this study, 12% and 15% of patients stopped this initial regime due to rash and hepatotoxicity, respectively. More disturbingly after d4T/3TC/NVP was stopped, nearly 40% of patients ceased antiretroviral treatment entirely (it was not clear whether they had other options). [8]

In addition to co-infection with hepatitis C, IDUs have an increased risk for tuberculosis. Recent reports from the region have recorded HIV prevalence in TB patients of 12 percent in Cambodia and Thailand, 11 percent in Myanmar, and 4 percent in Vietnam. Simultaneous treatment of TB and HIV is fraught with difficulties. The number of medications increases the risk for drug interactions, toxicities, and poor adherence to treatment. In fact, adverse event rates as high as 54% have been reported. [9] Drug-drug interactions between antiretroviral agents and anti-tuberculosis medications, as well as those with opiate substitution treatment further add to the complexities of managing these patients. These factors can potentially lead to microbiological and/or virological treatment failure. When patients commence HAART in tandem with TB treatment, they are at increased for immune reconstitution syndrome. This is a particular problem for IDUs, since they frequently have latent or undiagnosed tuberculosis infection and present late for medical care.

Adherence to treatment is a crucial factor in the success of antiretroviral treatment. Whilst the common perception is that drug users do not adhere to antiretroviral treatment, confounding effects of chaotic social circumstances, poverty, homelessness, unemployment, psychiatric co-morbidity and incarceration, increase the risk for non-adherence. Several studies, mostly in developed country settings, have shown that with appropriate support, including provision of opiate substitution therapy, good adherence and treatment outcomes can be achieved, comparable to non-IDU HIV-positive populations. However, in many Asian countries, implementation of opiate substitution therapy is just beginning and coverage is inadequate in many instances. Separation of ARV treatment provision from substance abuse treatment, which is often provided by psychiatrists compared to HIV physicians, is a further obstacle to be overcome. Adequate training must be provided about the possible interactions between HAART, opiate substitution treatment, and other drugs frequently used by IDUs. For instance, two of the most commonly used antiretroviral drugs in the region, nevirapine and efavirenz result in marked reductions in methadone levels which may precipitate symptomatic opiate withdrawal in a significant number of individuals. In turn, this may in turn cause the patient to discontinue HIV treatment, methadone treatment or both. Clinicians therefore must be aware of these drug-drug interactions and make adjustments to the doses accordingly.

Integrated treatment for substance abuse, general medical care, HIV and psychiatric treatment and psychosocial support in non-traditional health care settings such as hospitals and clinics is a model of care that should be examined and extensively developed in the region. HIV-positive IDUs often experience stigma and discrimination when they attend medical facilities, and are therefore reluctant to seek health care. Models of care that need further evaluation include community based directly administered antiretroviral therapy (DAART) conducted in home settings or through mobile outreach programmes. Alternatively, integrating HIV treatment with tuberculosis, hepatitis and other infectious disease treatment, mental health care, harm reduction services, and drug treatment into existing primary health care facilities provides a one-stop centre that may improve HIV prevention and treatment efforts. [10]

Finally, scaling up antiretroviral and opiate substitution treatment must be accompanied by a commitment to improve social support services, in order to help integrate people back into society, with their families, and into job training and placements. Building the capacity of health care professionals will not be adequate. Peer support, peer-based treatment education, patient advocacy, case management and social services are other crucial services that must be developed for a comprehensive and successful management of HIV-positive drug users.

Adeeba Kamarulzaman is President of the Malaysian AIDS Council and works at University Malaya Medical Centre.

References
1. UNAIDS: AIDS Epidemic Update: Special report on HIV/AIDS. December 2006.
2. UNAIDS (2005). Joint UNAIDS statement on HIV prevention and care strategies for drug users Geneva.
3. Ministry of Health of Indonesia, Report on HIV/AIDS cases to March of 2006, Jakarta.
4. Tang YL, Zhao D, Zhao C et al. Opiate addiction in China: current situation and treatments. Addiction, 2006, 101(5): 657-665.
5. Ministry of Health Malaysia. Annual HIV/AIDS Surveillance Report 2006
6. TREAT Asia Special Report: Expanded availability of HIV/AIDS drugs in Asia creates urgent need for trained doctors. July 2004. amfAR.
7. Matthews GV, Dore GJ. The natural history of HIV and HCV coinfection in delivering HIV care and treatment for people who use drugs: lessons from research and practice. International Harm Reduction Program. Open Society Institute. 2006.
8. Zhou J, Paton NI , Ditangco R et al on behalf of the TREAT Asia HIV Observational Database. Experience with the use of a first-line regimen of stavudine, lamivudine and nevirapine in patients in the TREAT Asia HIV Observational Database. HIV Medicine (2007), 8, 8–16.
9. du Cros P, Kamarulzaman A. HIV and tuberculosis coinfection. In Delivering HIV Care and Treatment for People Who Use Drugs: Lessons from Research and Practice. International Harm Reduction Program. Open Society Institute. 2006.
10. Altice FL, Bruce RD. Directly administered antiretroviral therapy for injecting drug users. Delivering HIV Care and Treatment for People Who Use Drugs: Lessons from Research and Practice. International Harm Reduction Program. Open Society Institute. 2006.
11. SN Zulkifli, MH Soo Lee, WY Low, YL Wong, Study on the impact of HIV on people living with HIV, their families and community in Malaysia. Project Report.