The spread of HIV among injecting drug users continues to fuel the HIV epidemic in many countries, particularly in Eastern Europe and Asia. An independent expert group to the United Nations has warned that to control the spread of HIV among injecting drug users countries must pursue evidence-based strategies that are protective of human rights.

The Reference Group to the United Nations on HIV and Injecting Drug Use estimates that there are 16 million injecting drug users worldwide, of whom 3 million are thought to be HIV positive.

The Reference Group recommends the implementation of needle and syringe programmes, opioid substitution therapy, antiretroviral therapy and sexual risk reduction strategies targeting injecting drug users as a matter of priority.

As reported by UNAIDS in its recent Global Report on the HIV/AIDS epidemic, many countries have managed to stabilize or achieve significant declines in rates of new HIV infections. Despite these important gains, however, HIV among injecting drug users continues to fuel the epidemic in many countries, particularly in Eastern Europe and Asia.

To achieve similar success in controlling the rapid spread of HIV among injecting drug users, it is imperative that countries pursue evidence-based strategies that are protective of human rights affirms the Reference Group in a Consensus Statement released today: “Interventions that violate human rights, or are not supported by evidence of their effectiveness in reducing HIV and drug related harms, should not be part of a country’s strategy to respond to HIV among people who use drugs.”

To achieve maximal impact these interventions need to be implemented together and as part of a comprehensive package of interventions to reduce the harms associated with injecting drug use. The Reference Group report that although the number of countries that have introduced these core HIV prevention services is growing, the scale of these programmes in the majority of countries is inadequate to prevent the spread of HIV among injecting drug users.

The Consensus Statement highlights the critical role of law enforcement and criminal justice systems in effectively preventing drug use related HIV transmission through working in partnership with the health sector to optimise access to HIV prevention, treatment and care for people who use drugs. Legislation and police activity should not hinder access to drug treatment services or clean injecting equipment. Effective drug treatment and HIV prevention and care should also be available to people in prison.

Acknowledging the importance of investing in drug treatment services that have been proven to reduce drug use and the risk of HIV, the Reference Group calls for the closure of “detention centres that impose arbitrary confinement and human rights abuses on drug users for ‘drug treatment’ and which offer no evidence-based treatment for drug dependence or HIV”.

Further, the Reference Group calls for “an end to the imprisonment of people who have committed no crime other than drug use or possession for personal use”.

The Consensus Statement was developed by the Reference Group at the request of the United Nations to inform the policy development and priority setting by UN agencies involved in addressing HIV and injecting drug use. The Consensus Statement draws on research examining the effectiveness of interventions to address HIV and injecting drug use and their impact in differing contexts around the world. In this Consensus Statement the Reference Group identifies key regional issues of concern and outlines recommendations for action.

The full report and summary of recommendations can be accessed online.
http://www.idurefgroup.com

The Reference Group to the United Nations on HIV and Injecting Drug Use was established in 2002 and provides independent advice to the United Nations system on matters related to injecting drug use and HIV. The Group consists of experts from around the world and includes researchers, clinicians and representatives from civil society organisations.

The guide is for people with limited experience of HIV and harm reduction programming in a community setting. It is not a comprehensive manual containing everything that is known about successful HIV and harm reduction programming. Instead, it aims to be an accessible and user-friendly guide to thinking through what “good practice” means for community organisations working with people who use drugs. It refers the reader to many other in-depth and technical tools people working in resource-poor settings. HIV and harm reduction programmes and services are well established in Canada, Australia and parts of Europe. But in many developing and transitional countries where HIV and harm reduction programming is urgently needed, there are added challenges of fewer resources and fewer “safety nets” or state welfare systems for people who use drugs. This affects our definitions of what are key services and programmes.

To download the guide:
http://www.aidsalliance.org/publicationsdetails.aspx?id=454

For further information:
http://www.medpagetoday.com/InfectiousDisease/Hepatitis/21823

As the title suggests, the central focus of this report is on the stigmatisation of problem drug users. However, this is not a self-evident term that comes with a common understanding. A pragmatic approach has been to define problem drug use in terms of combinations of particular drugs and modes of use: the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) defines it as “injecting drug use or long-duration/regular use of opioids, cocaine and/or amphetamines”. It is this latter type of definition that has informed this report, but, to the degree that it is dependent on other studies and reports, this report has had to adopt the definitions used in these studies.

For further information:
http://www.ukdpc.org.uk/publications.shtml#Stigma_commentary

PegIntron and ViraferonPeg (peginterferon alfa-2b), from Schering-Plough Europe, to extend the therapeutic indication of combination therapy with ribavirin to include treatment of the paediatric population and to include the treatment of adult patients with compensated cirrhosis. PegIntron and ViraferonPeg were previously indicated for the treatment of adult patients with chronic hepatitis C who have elevated transaminases without liver decompensation and who are positive for serum HCV-RNA or anti-HCV, including naïve patients with clinically stable HIV co- infection. They are also indicated for the treatment of hepatitis C in adult patients who have failed previous treatment with interferon alpha (pegylated or non-pegylated) in combination therapy with ribavirin.

The same extension of indication applies to Rebetol (ribavirin) used in combination with peginterferon alfa-2b from Schering-Plough Europe.

For further information:

http://www.emea.europa.eu/pdfs/human/opinion/PegIntron_60936809en.pdf

and

http://www.emea.europa.eu/pdfs/human/opinion/Rebetol_60935609en.pdf

The flyer covers the following eight main points:

1. Overdose prevention services connect people who use drugs to HIV prevention, drug treatment, primary healthcare and other basic services.
2. Overdose may exacerbate HIV-related disease.
3. HIV treatment programs should make efforts to prevent overdose related to interactions between illegal drugs and antiretrovirals and other prescribed medication.
4. Overdose disproportionately affects HIV-positive injection drug users.
5. Overdose is a significant cause of mortality among people living with HIV.
6. Overdose prevention empowers people who use drugs and who have or are at risk of acquiring HIV.
7. Many of the same policies that increase risk of HIV infection among IDUs also increase the risk of overdose.
8. Overdose is a serious concern among people living with HIV who use drugs.

Download PDF file of this flyer:

http://www.harm-reduction.org/images/stories/library/why_overdose_prevention_matters_for_hiv.pdf

The writers conducted a ‘systematic search of peer-reviewed (Medline, BioMed Central), internet, and grey-literature databases for data published in 2004 or later. A multistage process of data requests and verification was undertaken, involving UN agencies and national experts. National data were obtained for the extent of provision of the following core interventions for IDUs: needle and syringe programmes (NSPs), opioid substitution therapy (OST) and other drug treatment, HIV testing and counselling, antiretroviral therapy (ART), and condom programmes. They calculated national, regional, and global coverage of NSPs, OST, and ART on the basis of available estimates of IDU population sizes’.

They reported ‘By 2009, NSPs had been implemented in 82 countries and OST in 70 countries; both interventions were available in 66 countries. Regional and national coverage varied substantially. Australasia (202 needle–syringes per IDU per year) had by far the greatest rate of needle–syringe distribution; Latin America and the Caribbean (0.3 needle–syringes per IDU per year), Middle East and north Africa (0.5 needle–syringes per IDU per year), and sub-Saharan Africa (0.1 needle–syringes per IDU per year) had the lowest rates.

OST coverage varied from less than or equal to one recipient per 100 IDUs in central Asia, Latin America, and sub-Saharan Africa, to very high levels in western Europe (61 recipients per 100 IDUs). The number of IDUs receiving ART varied from less than one per 100 HIV-positive IDUs (Chile, Kenya, Pakistan, Russia, and Uzbekistan) to more than 100 per 100 HIV-positive IDUs in six European countries. Worldwide, an estimated two needle–syringes (range 1–4) were distributed per IDU per month, there were eight recipients (6–12) of OST per 100 IDUs, and four IDUs (range 2–18) received ART per 100 HIV-positive IDUs’.

Their interpretation of the findings was ‘worldwide coverage of HIV prevention, treatment, and care services in IDU populations is very low. There is an urgent need to improve coverage of these services in this at-risk population’.

Reference

1. Mathers BM et al. HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage. The Lancet, Volume 375, Issue 9719, Pages 1014 – 1028, 20 March 2010. DOI:10.1016/S0140-6736(10)60232-2

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60232-2/abstract

The INCB is overstepping its mandate by condemning the intelligent and informed approach taken by Argentina, Brazil and Mexico, to the demand and use of narcotics and their placing of public health imperatives ahead of dogma driven ideology.

Such statements by INCB contradict UNSG Ban-Ki Moon appeal to “guard against legislation that blocks universal access by criminalizing the lifestyles of vulnerable groups..” (March 28, 2008,) the multiple calls to stop criminalization of drug users by UNAIDS Executive Director Michel Sidibe and by Global Fund Executive Director Michel Kazatchkine, and the fact that countries such as Portugal, the first European country to have abolished all criminal penalties for personal possession of all drugs, has the lowest rate of lifetime marijuana use in people over 15 in the E.U. and a documented decline of lifetime use of any illegal drug among seventh through ninth graders  since drug use and personal possession was decriminalised.

The evidence that law enforcement has failed to prevent the availability of illegal drugs, in communities where there is demand, is now unambiguous. Furthermore, there is no evidence that increasing the ferocity of law enforcement meaningfully reduces the prevalence of drug use. In fact it is important to acknowledge the harmful consequences of punitive drug laws:

• HIV epidemics fuelled by the criminalization of people who use illicit drugs and by prohibitions on the provision of sterile injecting equipment and opioid substitution treatment.
• HIV and Tuberculosis outbreaks among incarcerated and institutionalized drug users as a result of punitive laws and policies.
• The undermining of public health systems when law enforcement drives drug users away from prevention and care services and into environments where the risk of infectious disease transmission and other harms is increased.
• A crisis in criminal justice systems as a result of record incarceration rates in a number of nations, negatively affecting the social functioning of entire communities. While racial disparities in incarceration rates for drug offences are evident in countries all over the world.
• Stigma towards people who use illicit drugs, which reinforces the political popularity of criminalizing drug users and undermines HIV prevention and other health promotion efforts.
• Severe human rights violations, including torture, forced labour, inhuman and degrading treatment, and execution of drug offenders in a number of countries.
• A massive illicit market worth an estimated annual value of US$ 320 billion, the profits of which are entirely outside of government control, fuelling crime, violence and corruption.
• Billions of tax dollars wasted on a “War on Drugs” that does not achieve its stated objectives but instead directly or indirectly contributes to the above harms.

We applaud Argentina, Brazil and Mexico for having the courage to take rational steps to reduce risks, improve health outcomes and mitigate the impact of drug related crime on communities.

See also TNI/WOLA press release at:

http://www.tni.org/pressrelease/un’s-international-narcotics-control-board’s-annual-report-oversteps-mandate-and-interf

Mick Matthews Senior Civil Society Officer the Global Fund

Mauro Guarinieri Civil Society Officer The Global Fund

Vitaly Zhumagaliev Civil Society Officer The Global Fund

This response does not reflect the opinion of the Global Fund to Fight AIDS, TB and Malaria.

My name is Steve Berry, and I’m with Johns Hopkins University. I’m presenting the results of a prospective observational study showing the reasons for hospitalisations in HIV-infected patients after HAART initiation.
We looked at 2,000 people in our centre in Baltimore, Maryland who were previously naïve to antiretrovirals. All of them initiated HAART between 1996 and 2005. We looked at their hospitalisation rates within six months prior to starting HAART, and then looked at all hospitalisations over time in that first year after starting HAART.

What we have done now, which is new from what was presented in October was to look at the reasons for all the hospitalisations, based upon separating them into 18 categories, which are roughly by organ system, and then also looking specifically for immune reconstitution inflammatory syndromes, which was done by chart review, rather than using ICD-9 categories.

The major findings

Number one, was that all-cause hospitalisations remain high for the first 45 days.

However, by 45 to 90 days, and then out through one year after starting HAART, they are statistically less significantly than prior to starting HAART.

Then we looked just at the baseline characteristics of our group. The group is about 66 percent men. The median age for starting HAART was 39. The group was about 75 percent African-American. About 45 percent have injection drug use as a risk factor for HIV infection. The bulk of the people’s HAART initiation events that we studied were actually occurring prior to 2000, with a large number, 54 percent, being 1996 to 1998 – shortly after HAART came out.

When we look at all the categories for reasons for hospitalisation, the top category was actually not AIDS-defining illnesses, but were non-AIDS-defining infections. This included episodes of pneumonia; this was bacterial endocarditis; this was cellulitis – as the top types of infections in that category.

The next category for hospitalisations was AIDS-defining illnesses, where PCP [pneumocystis pneumonia] was top, accounting for 25 percent of those; Cryptococcus was next; candidal esophagitis was next.

Psychiatric illness was actually the third most common reason for hospitalisation in this overall period, accounting for about 11 percent of all admissions. Gastrointestinal and liver causes were next and then endocrine nutritional, metabolic and immunity, as one combined category. The bulk of that was hypovolemia as a reason for admission; then reno- and genito-urinary; and then cardiovascular, to round out the top seven categories for most common reasons for admission.

What we did next was to look, for each of those categories, over time after starting HAART: what happens to admission rate within each of those categories?

So, for the two reasons for admission which were most common-the non-AIDS-defining infections and AIDS-defining illnesses-we see the pattern-which is what we see for all-cause admissions, and what was presented in October-that for the first 45 days, admission rate remains quite high.

Then it seems that, at 45 to 90 days, the real immune recovery has kicked in and is operating, and you see decreases for all these manner of infectious illnesses.

Next, looking at psychiatric reasons for admission, there’s also a statistically significant drop-off. This drop-off occurs immediately after starting HAART, and remains constant out through one year.

When we look at all of those other categories for admission-GI [gastrointestinal], liver, endocrine metabolic, renal and cardiovascular-there doesn’t appear to be any change after starting HAART. Admission rates within those categories remain flat across time.

We did multivariate analysis of admission rates for the top three categories – so, for non-AIDS-defining infections, AIDS-defining illness and psychiatric illness. And here, as you would probably expect, for AIDS-defining illnesses-CD4 count, baseline CD4 count, is the largest driver. But the decay over time is not at all affected in multivariate analysis. Still, after 45 days, you see this decrease in admission rate.

And the greatest risk was  …? I see you had a lot of patients with below 50-cell CD4 count at baseline.

Definitely. In that risk group, there was an incidence rate ratio of infection of over 10, if you had less than 50 cells/mm3, compared to having over 200 cells/mm3 when you started HAART.

And did you track the rise in their CD4 count, and correlate it with hospitalisations?

We didn’t have a chance to do that. We didn’t track that.

Are there plans to do that?

We may look at that. In fact, we may look at that especially, as well, because there’s a lot of interest now in looking at some of these non-AIDS defining illnesses over time, after starting HAART, and even after starting and restarting HAART, looking at cardiovascular events, for example, and risk of heart attacks, in particular. So, using CD4 rebound in that analysis would be something interesting to do.

Could you talk about the psychiatric illnesses? Because it’s not something one thinks about when predicting reasons for hospitalisations for HIV-infected patients.

Sure. I think the first major finding is that they represent a significant burden of illness. Overall, they represent 11% of reasons for admission. They do have that drop-off in admission rate right after starting HAART. What’s interesting here is that we can’t tell from these data whether the decrease in psychiatric admissions actually causes people to start HAART, or whether HAART, and getting better from HIV, leads to a decrease in mental illness. I actually would suspect it’s the former. My suspicion is that people who are getting admitted for depression within the six months prior to starting HAART: a lot of them are getting engaged in care, and they are getting better. As part of that getting engaged in care, their providers are recognizing these patients have low CD4 counts and that HAART is indicated. So then they’re starting HAART. So it’s hard to tell in this case which came first.

One little piece of corroborating evidence is that the drop-off in admission rate for psychiatric illness happens immediately in the first 45 days after starting HAART. I think that makes me suspect that it’s actually improvement in mental illness is preceding the HAART initiation.

And the most likely patient to experience psychiatric hospitalisations?

The most likely patient, we can see here. It’s going to be someone who’s been using injection drugs. Women were also more likely in multivariate analysis to be admitted for psychiatric reasons. Interestingly, younger age, rather than older age, was also significant in multivariate analysis for being admitted for psychiatric reasons.

Have these numbers been corroborated in other studies that you know of? In terms of the psych? Psychiatric illnesses are very interesting. I haven’t really heard that before.

In terms of psychiatric illness itself, I don’t know the literature. But we know that for overall reasons for admission, injection drug users [IDUs], women, African Americans, are all more likely to have admission, and are also more likely to die.

But the difference is very striking here. I mean, for psychiatric illness admissions, it’s really almost double, even between women and IDU.

Well, we do see for non-AIDS-defining infections, there’s also, similarly, a higher risk for women and a higher risk for IDU. It’s logical for IDU, because substance abuse correlates very strongly with depression. In these admissions, overall admissions for psychiatric illness: recurrent major depression was the number one cause; depressive disorder not otherwise classified was the second one; and drug-induced depression was the third one. So I think a lot of what we’re seeing here is comorbid illness with substance abuse and depression.

Do we know what sort of drugs the IDU were using?

Primarily heroin. Cocaine is often combined, injected at the same time.

But actually, this is a good story, as well as a bad story. The good story is that there’s a lot of difference within 45 days.

Exactly. So 45 days is a period that clinicians may want to keep in mind. It represents a period of the time when you really need to be quite concerned. But then after 45 days, making it through that high-risk period, we see great improvements across the board.

Great. What are your next steps?

The next steps for this would be, as mentioned earlier, looking at people who are not naïve to antiretrovirals, looking at people who are starting and stopping HAART, and looking for causes of admission in those groups, maybe paying particular attention to some of the non-AIDS-defining illnesses. Looking at psychiatric illness again, for example, looking at cardiovascular illness, looking at renal illness.

Source: thebody.com

http://www.thebody.com/content/confs/croi2009/art50557.html

References:
1. Berry SA, Gebo KA, Moore RD, Manabe YC. A high risk of hospitalization immediately follows HAART initiation. In: Programme and abstracts of the 48th Annual ICAAC/IDSA 46th Annual Meeting; October 25-28, 2008; Washington, D.C. Abstract H-2292.
2. Berry SA, Manabe YC, Moore RD,. Reasons for Hospitalization that Occurs after HAART Initiation. In: Programm

Researchers used data from the National HIV Behavioral Surveillance System collected from May 2005 to February 2006 in 23 U.S. cities with high AIDS prevalence to assess trends associated with HIV risk behavior, testing and prevention services among injection drug users.

The report found that 31.8% of IDUs had shared needles, 62.6% had unprotected vaginal sex, 71.5% had been tested for HIV, and 27.4% had used an HIV behavioral intervention service. According to the authors, the findings “underscore the need to continue current public health strategies” aimed at preventing HIV transmission and expand efforts to provide “effective behavioral interventions that focus on HIV risks of sharing syringes and other injection equipment and engaging in high-risk sexual behavior”.

Source: kaisernetwork.org [14 April 2009]

http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=1&DR_ID=57988

Link to download report: http://www.cdc.gov/mmwr/PDF/wk/mm5813.pdf

Paisan Suwannawong, a native of Bangkok, has been living with HIV for 18 years. A former injecting drug user and graduate and former staff of Rebirth Drug Treatment Center in Ratchaburi, Thailand, Suwannawong is one of Thailand’s leading harm reduction advocates. He is the co-founder of the Thai Drug Users’ Network (TDN), founding chairman of the Thai Network of People Living with HIV/AIDS (TNP+), and, with award co-recipient Karyn Kaplan, co-founder of the Thai AIDS Treatment Action Group (TTAG) which strives to build leadership and advocacy capacity among people living with or at high risk for HIV. Suwannawong serves as TTAG’s executive director.

Karyn Kaplan, a native of New Jersey, has been involved with fighting the AIDS pandemic in the US and Thailand for over 20 years. In the US she worked with the International Gay and Lesbian Human Rights Commission (IGLHRC), and in Thailand she has campaigned for harm reduction and conducted drug policy advocacy with the Thai Drug Users’ Network (TDN), including helping to secure a historic US $1.3 million grant to drug user groups from the Global Fund to Fight AIDS, TB and Malaria (GFATM) for the country’s first peer-driven harm reduction project in 2003. Kaplan is the co-founder and Director of Policy and Development for the Thai AIDS Treatment Action Group (TTAG) in Bangkok.

“Their outspoken courageousness is undeniable and humbling for all of us,” said Robert Estrin, President of the John M. Lloyd Foundation.

“This award is given with the Foundation’s admiration and respect for all that Paisan and Karyn have accomplished, and with the hope that it will help them to achieve even more success as leaders in the AIDS advocacy community.”

“It is such a huge honour for us to receive this recognition, and you have no idea how much this means to our organisation in terms of its sustainability,” said Karyn Kaplan. Paisan Suwannawong added, “This is an honour not just for us, but for all of the activists working so hard in Thailand to fight AIDS and the discrimination around it.”

Leading AIDS experts applauded the selection of Suwannawong and Kaplan for the second annual John M. Lloyd AIDS Leadership Award.
The John M. Lloyd AIDS Leadership Award was established in 2008 to recognise, support and empower effective leaders in AIDS advocacy. There is no application process for the award – the selection is made by the board of the John M. Lloyd Foundation. The award will be split among Paisan Suwannawong,

Karyn Kaplan and the Thai AIDS Treatment Action Group as an unrestricted gift to help build leadership capacity.

The John M. Lloyd Foundation was established in 1991 by John Musser Lloyd (1948-1991) to seek creative, compassionate, and courageous solutions to the root causes of the AIDS epidemic. Each year, the foundation awards approximately $400,000 in mostly small grants.

Source: www.johnmlloyd.org

Essential requirements include

• active interest in IDU advocacy and access to HIV treatment
• good written English and editorial experience
• self motivation and good ability to work independently
• ability to plan and adhere to publication schedules
• interest in developing working involvement of the editorial board
• interest in supporting and developing new activist writers

This post is part-time and the successful applicant will be able to work remotely, though daily internet access is essential.

For further details please contact Simon Collins with a brief outline of your interest and experience.

simon.collins@i-Base.org.uk

The government’s rash drug war announcement has not been accompanied by appropriate mechanisms in place to guard against history repeating itself. Apart from prosecuting perpetrators of past drug war-related crimes, the Thai government must immediately hold public consultations to discuss the impact, including human, social, political, and health costs, of the Thai drug war approach, and develop policies and laws that uphold human rights, not undermine them. Wholesale repression of the type experienced in 2003 will again result in thousands of inappropriate arrests, deaths, and the disruption of HIV prevention and other services.

Prime Minister Samak Sundaravej must urgently renounce the drug war and all human rights violations that have taken place in its context. Drug suppression efforts need to take place with full respect for due process of law and human rights standards. In addition, Prime Minister Samak should encourage his government to work with civil society organisations including people who use drugs to develop a humane approach to the country’s drug problem, for example through the promulgation of a national harm reduction policy supporting comprehensive harm reduction services integrated into existing health and social policies and programs and the immediate cessation of military-style compulsory drug “treatment.”

Continued rates of HIV infection among drug users in Thailand, and reports of abuses by law enforcement, demonstrate how much is at stake. Rather than being subjected to indiscriminate suppression, people who use drugs must be supported to be actively and meaningfully involved in leading harm reduction work in Thailand.

Efforts to force tens of thousands into prison or drug treatment are ineffective and immoral.

Recommendations from two previous Human Rights Watch (and TTAG) reports still go unheeded. Please review these recommendations, and send letters to the Prime Minister and Interior Minister demanding that they SAY NO TO A THAI DRUG WAR and urgently hold past police officers guilty of abuse and criminal offenses accountable.

Demand that people who use drugs are treated as human beings by the government and receive appropriate, effective health and harm reduction services that meet them where they are at, and prevent government actors from committing human rights violations, in the name of drug demand and supply reduction and national security.

Harm Reduction Saves Lives! NO MORE THAI DRUG WAR!

Address your letters and faxes to:

His Excellency Samak Sundaravej,
Prime Minister of the Kingdom of Thailand,
Government House,
Pitsanulok Road,
Bangkok
10300
THAILAND.

FAX: +66-2-282-5131

Chalerm Yubamrung,
Minister of the Interior,
Ministry of the Interior,
Asdang Road,
Bangkok,
10200
THAILAND.

FAX: +66-2-222-8866

Source: Thai AIDS Treatment Action Group (TTAG) Press Release
February 14, 2008

The Russian Federation is facing one of the most rapidly developing HIV epidemics in the world, and accounts for approximately two-thirds of the cases in Eastern Europe and Central Asia region. As of October 2006, some 350.000 cases of HIV infection had been officially registered – although UNAIDS estimates that the true number is as high as 1.6 million. [1]

As in many countries of Eastern Europe and Central Asia, the HIV epidemic disproportionably affects one of the most marginalised and discriminated communities – injecting drug-users (IDUs) – who represent 87% of total registered cases in Russia. HIV-positive IDUs have the highest mortality rate, mostly due to HIV/TB co-infection, limited access to programmes aimed at scaling up ARV treatment in the country, and a complete lack of effective adherence support services. [2]

Although a full range of services proved to be effective in supporting treatment adherence in injecting drug users are needed, one of the most problematic issues is the complete absence of substitution treatment programs. These are considered illegal across the Russian Federation. The lack of support for Harm Reduction programmes, means that they are still largely unavailable, or are limited to small scale pilot projects.

In October 2003, the board of the Global Fund to Fight AIDS, Tuberculosis and Malaria approved an application for a project to fight HIV/AIDS in Russia, from a consortium of five Russian and international NGOs, with many years of experience in the field.

In June 2004, the Global Fund and Open Health Institute, which is the main recipient of the Global Fund grant, signed an agreement to commence the implementation of the first phase of the project. The project has been given the name GLOBUS – an abbreviation of the Russian for ‘Global Efforts Against HIV/ AIDS in Russia’ and was initially launched in 10 sites: St. Petersburg, Tver, Krasnoyarsk, Nizhniy Novgorod, Kazan (Republic of Tatarstan), Ulan-Ude (Buryatia).

The main mission of GLOBUS is to support and develop effective prevention and to provide treatment, care and support to PLWHA. In particular, GLOBUS sets up ARV treatment projects in selected sites with the main focus on delivering treatment and care to marginalised groups of patients. To this end, Open Health Institute, even on the stage of writing the proposal, was considering intensive technical assistance in presenting best international model of organising comprehensive care for IDUs and adjusting it to the specifics of the Russian Federation. One of the key barriers was illegal status of Substitution Treatment in Russia and little hopes of any access to it in the nearest future.

GLOBUS has developed an overall strategy for launching treatment pilot projects based on the following directions:

• Involvement of leading international and regional experts in HAART programs for IDUs;
• Building strong national team of experts in HAART and adherence support for IDUs;
• Establishing working multidisciplinary teams in each treatment site;
• Integration of Harm Reduction projects into care and treatment delivery.

The International Harm Reduction Development Program (IHRD) of the Open Society Institute (OSI), based on the long-term partnership with Open Health Institute, became one of the main technical assistance implementers in the area of antiretroviral drugs for injecting drug users.

With IHRD support the national technical assistance team has passed the training in the model project ‘Jumpstart’ in New-York. This unique project was implemented by a team from the Columbia Presbyterian Medical Center’s Infectious Diseases Clinic (which serves predominantly poor, Hispanic and Afro-American populations). The team of ‘Jumpstart’ developed an effective and innovative model of adherence support in patients suffering from co-morbidities (including TB, viral hepatitis, psychiatric disorders), drug (mainly crack and cocaine) and alcohol addiction, and social problems (including homelessness and poverty). [3]

Most of the patients also had a history of failed ARV regimens in the past. Jumpstart built their strategy on three main interventions:

• Education of patients about HIV, ARV medicines and goal of HAART;
• Intensive course of adherence provided by trained “peer counsellors”, detailed assessment of potential risks for adherence by the team of social workers and peer counsellors and control over pill dispensing (modified DOTS);
• A multi-disciplinary approach to managing patients, regular counselling and adherence support by the team of medical doctors, nurse, social worker and peer counsellors.

Under the guidance of the leader of ‘Jumpstart’ programme, Dr Jay Dobkin (who is also IHRD consultant on care and treatment with experience of working in Eastern Europe and Central Asia) the group of technical assistants was formed. The critical factor of technical assistance was IHRD support for the position of regional “peer advisor”, an HIV-positive person from the region trained and educated in both organisation of peer support and adherence work as well as in mentoring and educating.

Alecandra Volgina, leader of St.-Petersburg PLWHA community organisation ‘Svecha’ was nominated and selected for this position. This team also included Dr. Vladimir Musatov, medical professional experienced in providing ARV, who also worked in one of the first Harm Reduction projects in Russian Federation.

This team worked out together first model training “Introduction into ARV for multi-disciplinary teams” focusing primary on effective teambuilding, highlighting value of peer counsellors, and ARV delivery to active IDUs.

However, this training is just a first step in the multi-component cycle of technical assistance. IHRD also ensured sustainable on-site technical assistance to the projects through regular Adherence trainings for the new multi-disciplinary teams and regular site visits to the projects. Each visit to the sites takes at least two days and includes two main areas of technical expertise: clinical case discussions and overall problems with organising ARV management (with special focus on adherence work, patient enrolment and peer counsellors performance and equal involvement into care work).

Based on each visit, international and peer advisors developed recommendations for the improvement of adherence work and for overcoming barriers for equal access of active IDUs.

The key barrier remains universal for all people within the Russian Federation: no access to substitution treatment and very limited access to quality rehabilitation support. This barrier does not permit organisations to implement a full range of comprehensive services to the most marginalised and affected group of patients. At the same time, implementation of very simple but crucial services, and effective integration of Harm Reduction projects and their experiences, could play important role in saving life of IDU clients.

One of the sites where such activities have been implemented, as a result of effective collaboration between a technical assistance group, a local Harm Reduction project and AIDS-centre, as well as additional funding attracted to broaden the spectrum of services, is the ARV program in the city of Kazan, Republic of Tatarstan.

The Republic of Tatarstan is located on the eastern frontier of Europe at the confluence of the Volga and the Kama rivers, 800km from Moscow. Tatarstan is one of the most economically developed republics of the Russian Federation and due to historical, geographical, and natural conditions and other important factors, the Republic of Tatarstan has developed as a major scientific, educational, and industrial centre recognised in Russia and worldwide. The city of Kazan, the capital of Tatarstan Republic, was selected as one of the first sites for developing effective ARV treatment projects within the GLOBUS project, and was initially evaluated as one of the potential model sites. First of all, Kazan is characterised with one of the oldest, most effective and powerful Harm Reduction projects and a highly evaluated group of trained peer educators from IDU community. However, the scope of barriers and problems that both the project and technical assistants witnessed when HAART was first launched was typical for the situation in other sites.

In the Republic of Tatarstan, 264 patients had been enrolled in ARV treatment projects by 2005, but only eight of them were active IDUs including five referred from HR programs. Despite the fact that over 70% of all patients registered in AIDS-centre are IDUs, the local AIDS centre had limited access to this group. In addition, drug users had limited information about ARV treatment and were afraid to contact the AIDS centre for fear of being hospitalised or even referred to the police.

The majority of drug users had little knowledge about ARV treatment. They had probably heard horror stories about the side effects and toxicity associated with HAART that are popular within the IDU community. They were also, understandably, afraid of being in treatment clinics and medical institutions that they did not trust. This was often because of past experience of police harassment, which is common in the central districts where AIDS clinics are located.

“Our project was very motivated to work on access to HAART for our clients and we prepared good team of peer counsellors and case managers to focus on adherence support and to maximise treatment outcomes and retention in active drug users … ” said Larysa Badrieva, leader of the Harm Reduction NGO ‘Obnovlenie’ (‘Renewal’), “ … however, we were faced with the fact that most of our clients were reluctant to even come to the AIDS-centre for CD4 monitoring”.

Therefore, the main challenge was to establish maximum proximity of counselling and treatment information by outreach teams, ensure safe and trusted environment for clients and move treatment-related activities (counselling, adherence sessions, blood sampling and medicine pickup) as close as possible to their environment. It is obvious that involvement of the HR project is critical for developing active patient outreach, establishing decentralised and proximal services based on community-centres, drop-in zones and needle-exchange points.

In order to meet this challenge, an IHRD expert team identified an HR community centre, located in the epicentre of drug scene of Kazan, to serve as a proximal service centre on antiretroviral treatment for IDUs. It is important to note that one of the specific barriers for IDUs in Kazan, was the need to get to the AIDS centre, which involved crossing the central bridge usually patrolled by road police. Being caught by the road police as someone registered at the narcology (drug treatment) clinic, automatically means arrest of the vehicle and an administrative fine. As most users use driving as a main source of income for their families, most of them try not to leave the area.

The location of the centre provided a unique opportunity for the clients to get counselling and blood sampling in a safe environment without leaving this district. As a first step, a separate peer-training, based on the STEP model, was provided for the Community Centre team to prepare outreach workers and case managers able to deliver treatment counselling and adherence support.

IHRD provided additional financial support to ‘Renewal’ for follow up technical assistance in terms of treatment education, reconstruction of the community centre building, to buy furniture and to cover salaries for four treatment outreach workers and three case managers. Such focused additional funding for treatment outreach, mobile communication and transportation later became known as an ‘expanded HR integration kit’ and was used by IHRD to support HR projects working on antiretroviral treatment for IDUs in other GLOBUS sites (7 sites) and in Ukraine (5 integration sites for HR/ST/ARV).

The Community centre started active treatment work in September 2006. During the first month they scaled up treatment education sessions and patient outreach and introduced on-site blood sampling for CD4-cell count. However, they first created a safe and friendly environment for the clients. This is the most important factor in motivation of IDUs to look for, and to stay on treatment. After the first 2 months, the number of visitors increased from 70 to 425 and the number of regular clients reached 300.

This community centre became a crucial link in the continuum of care for IDUs and is a clear example of how prevention projects could be effectively integrated into HAART management for marginalised patients. It serves as an entry point to medical care and performs comprehensive services to ensure adherence and effective use of ARVs. The vanguard outreach team provided more than 390 consultations on treatment issues as part of their regular work in outreach, on NEP and in the community centre. The team of case managers provided 30 successful cycles of case management, supporting their clients through a full course of entering into care, clinical and laboratory evaluations, social and drug treatment support, and starting HAART with adherence monitoring. [4]

It is important that, thanks to the effective work of case managers, all clients had regular access to a rehabilitation centre (including free detox service), a PLWHA support group, and social services that played critical role in their motivation for, and adherence to, HAART.

All cases were well documented and serve as a good example on how well-established, peer-based comprehensive approach played vital role in saving clients lives. [5]

Igor, 35 year old active opiate user, who became a client of the community centre commented:

“I would never even think of getting my CD4 cells tested in time and was not able to get to the AIDS centre due to a number of factors. The community centre gave me the chance to get my CD4 tests here. I can pick up my medicines here and the case manager regularly supported me when I was sick, when I was doing cold turkey, and when I could not leave my apartment”.

Igor now has an undetectable viral load and his CD4 cell count has increased to over 500 cells/mm3.

References:

1. UNAIDS: AIDS Epidemic Update: Special report on HIV/AIDS. December 2006.
2. Harm Reduction Developments 2005: Countries with injection-driven epidemics. International Harm Reduction Development Program (IHRD) of the Open Society Institute. New York, 2006.
3. Murphy R, Ferris D, Wnnyiwang MS et al. Intensive intervention and ongoing adherence support yields high success rate in salvage ART. Programme and Abstracts, Infectious Disease Society of America, Annual Meeting, Boston, 2004. Abstract 893, p 199.
4. Expanding harm reduction services in Kazan: Using community centres to improve injecting drug users’ (IDUs) access to HIV care and treatment. Conference abstract: AIDS Impact, Marseille, 2007.
5. Interviews with NGO “Renewal”, January, 2007.

Mortality rates among injection drug users (IDUs) have been historically high and are still significantly higher than the rates for the general population. HIV-positive IDUs have an additional increase in mortality risk.

A paper authored by Roberto Muga and coworkers from the Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, and Department of Statistics and Operations Research, Universitat Polite`cnica de Catalunya, Barcelona, Spain, published in the 1 August 2007 edition of Clinical Infectious Diseases, looked at survival of HIV-positive IDU in the era of HAART.

In this study they evaluated the mortality rates for a cohort of HIV-positive and negative IDUs who were admitted to a substance abuse treatment programme in a tertiary hospital between January 1987 and December 2004. The investigators divided the follow up period into: 1987-1991 (the antiretroviral monotherapy era), 1992-1996 (the dual-combination treatment era and the introduction of methadone maintenance), and 1997-2004 (the era of HAART and established methadone programmes).

The investigators noted that during follow-up, several IDUs who were HIV-negative at admission became HIV-positive. They defined the time of infection by the midpoint of the interval from the last negative test result to the first positive test result. People that seroconverted contributed survival times to both groups of HIV infection: as seronegative subjects, the (right-censored) survival time lasted from admission until HIV infection; as seropositive subjects, the survival time lasted from the duration after admission to HIV infection, until either death or the end of follow-up.

During the study period,1209 IDUs were admitted for the first time to a substance use treatment programme. Twenty-eight (2.3%) of the total study group were excluded from the study cohort because their HIV status was unknown. The calendar periods of admission, for the remaining 1181 IDU included were as follows: 490 (41.5%) for 1987-1991, 393 (33.3%) for 1992-1996 and 298 (25.2%) for 1997-2004.

The majority (81.3%) of patients were men. The mean age was 27.8 (+/- 5.6) years, and the mean duration of injection drug use was 7.6 (+/-5.0) years. The prevalence of HIV infection and hepatitis C virus infections was 59.0% and 92.3%, respectively, and the total duration of follow-up was 10,116 person-years.

The investigators reported that although survival duration for HIV-negative IDUs in 1997–2004 was similar to the duration in earlier periods, the duration for HIV-infected IDUs improved significantly since 1997 (p=0.01). Additionally, among patients admitted in the last period, there was no significant difference between the survival durations for HIV-uninfected and HIV-infected IDUs (HR 0.89; 95%; CI 0.44–1.81).

They found that survival for HIV-positive IDUs improved substantially since 1997, reaching similar rates to those for HIV-negative IDUs who accessed the health care system in the era of HAART and methadone.

They noted that because only one-third of the HIV-positive IDUs in this study received HAART, other factors are likely to have contributed to their improved survival including: access to substitution therapy with methadone, prophylaxis for opportunistic infections, harm reduction interventions, and regular clinical care.

They wrote: “HAART has been proven to be an extremely effective therapy for HIV-infected individuals. We have shown that HIV-infected IDUs who received health care during the period 3 exhibited mortality rates comparable to those for IDUs who were not infected with HIV.”

Ref: Muga R, Langohr K, Tor J et al. Survival of HIV-Infected Injection Drug Users (IDUs) in the Highly Active Antiretroviral Therapy Era, Relative to Sex- and Age-Specific Survival of HIV-Uninfected IDUs. Clinical Infectious Diseases 2007:45, 1 August 2007.

A combined analysis from three prospective US cohorts, published in 6 June issue of AIDS Research Therapy reported that injecting drug use was not related to earlier changing, reducing or switching treatment – discussed as a marker for poorer long-term treatment success – after adjusting for other factors.

The three cohorts – AIDS Link to IntraVenous Exposure (ALIVE), Women’s Interagency HIV Study (WIHS) and Multicentre AIDS Cohort Study (MACS) – were used to select approximately 1400 patients with no history of injecting drug use and compare treatment outcome to just under 850 former or current IDUs. These 1588 patients contributed 2,358 patient-years with 713 events.

The IDU group had a lower nadir CD4 count and higher proportion of patients who were unemployed, on low income, had lower educational level and a higher proportion of Black, non Hispanic patients. Use of treatment and choice of drugs was similar between the two groups.

All three cohorts collect similar follow-up data, and reported similar trends in ARV prescribing (generally with a similar shift from PI- to NNRTI-based therapy over the time of the study (April 1996 – April 2004).

The median time to a first report of discontinuation was 1.1 years vs 2.5 years for people without vs with a history of IDU, and overall the relative hazard (RH) of HAART discontinuation was higher for any IDU use when looking at the whole time period (pre- and post-1999) ([HR1.24 (1.03-148)], However, when looking at the pos-1999 period alone (852 people contributing 382 events over 1,396 person years) this association disappeared in the multivariate analysis [HR = 1.05 (0.81-1.36), after adjusting for previous health, race, income and employment. For patients switching treatment, HR was 0.96 (0.82-1.14) and 1.09 (0.89 – 1.34) in the pre- and post 1999 periods respectively.

Over time, the proportion of patients using the same HAART regimen increased in both group: form 55% in 1997 to 70% by 2004 (in the non-IDU group) vs increasing from 35% to 65% at the same time points in the IDU group.

Similar results were seen when looking at current vs former IDU: in the post-1999 analysis: HR = 1.32 (0.90 – 1.94) vs RH = 1.00 (0.77 – 1.31).

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These results are particularly useful to challenge the common assumption that drug users are not able to be adherent.

Ref: Morris JD, Golub ET, Shruti H et al. Injection drug use and patterns of highly active antiretroviral therapy use: an analysis of ALIVE, WIHS, and MACS cohorts. AIDS Research and Therapy 2007, 4:12 doi:10.1186/1742-6405-4-12.

Although HCV antibody screening is recommended in HIV management guidelines, false negative results can occur in both acute and chronic HCV infection. This has led to recommending wider use of HCV RNA screening in patients with HIV coinfection who have a negative antibody result.

Gabriel Chamie from University of California and colleagues reported an analysis in the February 2007 edition of Clinical Infectious Diseases, on the prevalence of HIV-positive patients who were HCV antibody-negative/PCR-positive, in four US cohorts.

The four cohorts (FRAM, Los Angeles, Iowa and REACH) included around 1800 patients, 37 of whom were Hcv antibody-negative/PCR-positive, and reported a pooled seronegative prevalence of 3.2% (95%CI 2.2-4.3%] Prevalence in individual cohorts ranged from 1.3% (FRAM) to 4.6% (IOWA).

Standard variables in the multivariate analysis included age, ethnicity, sex, alcohol use, history of IDU, ALT, CD4 and viral load. In the combined data, three independently predictive factors of chronic seronegative HCV infection: history of IDU [OR 5.8 (2.7-12.8), p <0.0001], CD4 count <200 cells/mm3 [OR 2.3 (1.1 - 4.8), p= 0.025) and ALT [OR 2.0 per doubling (1.3-3.2, p=0.002], see Table 1. A similar pattern of OR were reported in each of the cohorts, looked at individually. For HCV antibody-negative patients, with a history of IDU and either raised AT or CD4 <200 cells/mm3 a pooled prevalence of 24% was reported for testing HCV RNA-positive.

Table 1: Factors associated with higher rate of antibody-negative HCV infection

ADD TABLE

This is the largest study so far to look at prevalence of HCV antibody-negative/PCR-positive results in HIV-coinfection. Among US blood donors, the prevalence by comparison is estimated to be as low as 1 in 250,000, largely explained by acute HCV infection.

The researchers concluded that HCV PCR testing should be recommended in anitbody-negative, HIV-positive patients, especially those with a history of IDU and either a low CD4 count or a raised ALT.

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This is an important study in that it highlights the issue of antibody negative chronic HCV infection in the context of HIV-co-infection.

The important message here is that in patients with ‘risk factors’ and persistent unexplained hepatic transaminase elevation an HCV-RNA by RT-PCR is mandatory in order to rule out chronic HCV infection.

The BHIVA guidelines on HIV/HCV co-infection (2004) suggest that consideration should be given to HCV RNA testing in patients with a negative HCV-antibody test and unexplained raised hepatic transaminases.

Ref: Chamie G, Bonacini M, Bangsberg DR, et al. Factors associated with seronegative chronic hepatitis C virus infection in HIV infection. Clin Infect Dis. 2007;44:577-583.

Representatives from STIGMA, a non-governmental organisation working to improve treatment options for drug users, were invited to talk to government officials and a meeting with national legislators has been scheduled. The organisers were featured on an hour-long radio talk show broadcasted on 50 stations.

The Jakarta action was part of a national effort, with actions by users groups and harm reduction activists in Banten, Bali, Jakarta, Bandung, and several cities in West and East Java that received local and national press attention. Activist groups spoke out for the scale-up of methadone clinics, more rehabilitative alternatives to jail time, and an end to the criminalization of drug users, and gained the attention of local legislators, health officials, and media.

For more information please contact Nick Bartlett (nicholas.bartlett@ucsf.edu) or Bani Risset (our_stigma@yahoo.com)

Drug abuse is a problem that can be prevented, treated and controlled. While efforts must be stepped up to reduce supply – by helping growers of illicit crops find viable alternatives, and ensuring that law enforcement agencies continue their good work in seizing drugs – the greatest challenge in global drug control is reducing demand. With less demand, there would be less need for supply, and fewer incentives for criminals to traffic drugs.

Combating drug abuse is a collective effort. It requires political leadership and sufficient resources – particularly for more and better drug treatment facilities. It requires engagement of parents and teachers, as well as health care and social workers. It requires the media and criminal justice officials to play their part.

All walks of life must join forces and devote special attention to the vulnerable: to those who are vulnerable to taking drugs because of their personal or family situation, and to those who are vulnerable because they take drugs. Our mission is to enable them to take control of their lives, rather than allowing their lives to be controlled by drugs. That means giving young people sound guidance, employment opportunities, and the chance to be involved in activities that help organise life and give it meaning and value. It means supporting parents’ efforts to provide love and leadership. It means reaching out to marginalised groups and ensuring they receive the care they need to cope with behavioural, psychological or medical problems. It means providing reasons to hope.

For those who are grappling with addiction, effective treatment is essential. Drug abuse is a disease that must be treated on the basis of evidence, not ideology. I urge Member States to devote more attention to early detection; to do more to prevent the spread of disease – particularly HIV and hepatitis – through drug use; to treat all forms of addiction; and to integrate drug treatment into the mainstream of public health and social services.

Drug abuse brings anguish and torment to individuals and their loved ones. It eats away at the fabric of the human being, of the family, of society. It is a subject all of us must take personally. On this International Day against Drug Abuse and Illicit Trafficking, let us ensure there is no place for drugs in our lives or our communities.

Source: UN press release (12 June 2007): Drug abuse can be prevented, treated, controlled with political leadership, sufficient resources, says Secretary General in international day message.

Currently, the exchange of syringes and needles (Harm Reduction) has not been legalised and only a limited number of NGOs are providing services to a limited number of drug users. ARVs are not accessible for drug users in Nepal, People have to quit using drugs to access these services.

The National Association of People Living with HIV/AIDS, Nepal (NAP+N) with wearing t-shirt demanding the Government of Nepal to provide  “Clean Syringes, Methadone and ARVs Now” organised a fundraising program with the banner to support the government as Government of Nepal does not have resources to support the program for Drug User’s.

The fundraising program raised funds in 30 locations along with 40 PLHA organisations and students with the majority of drug user’s living with HIV. The collected resources were to handed to the Government of Nepal by Rajiv Kafle. the President of NAP+N, through Home Ministry but the ministry declined to accept the support. NAP+N will be handing the resources to the ministry through bank.

NAP+N through the press release requested the Government of Nepal to utilise the funds handed by NAP+N in providing Clean Syringe, Methadone and ARV to Drug User’s and allocate sufficient financial resources for comprehensive programs for drug users. Press Release also includes to make public the statistic of drug users in Nepal and the kinds of drugs they use.

International Day Against Drug Abuse and Illicit Trafficking with the slogan “Do Drugs control your life? Your life. Your community. No place for drugs.” was celebrated around the country.

The campaign demanded that the government revealed statistics on drug use in Nepal on the International Day Against Drug Abuse and Illicit Trafficking which has so far been delayed.

Source: NAP+N press release

International Day Against Drug Abuse and Illicit Trafficking
http://www.unodc.org/unodc/event_2007_06_26_1.html