hiv in people who use drugs adeeba kamarulzaman university of malaya kuala lumpur, malaysia
TRANSCRIPT
HIV in People Who Use Drugs
Adeeba KamarulzamanUniversity 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• Antiretroviral treatment for people who use drugs• Can We Do Better?
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
Degenhardt, et al (2013). The Lancet, 380, 1564-1574UNAIDS Global AIDS Report 2012.
• Overall, illicit drugs caused 1% of global disease burden• 8th largest contributor to disability (YLDs) among males• In countries where HIV incidence is increasing, 70% - 80% of HIV
cases are among PWIDs
Interventions to prevent HIV and Hepatitis C in people who inject drugs: A review of reviews to assess evidence of effectiveness
Intervention Outcome Summary of studies
Evidence Statement
Needle andsyringeprogrammes (NSP)
Injecting risk behaviour (IRB)
43 studies Sufficient evidence to support theeffectiveness
HIV 16 studies Tentative evidence to support theeffectiveness
Opiate Substitution Treatment (OST)
IRB 35 studies Sufficient evidence to support theeffectiveness
HIV 8 studies Sufficient evidence to support theeffectiveness
McArthur G et al. Int J Drug Policy Jan 2014
• 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
Van der Knaap et al, March 2013
Harm Reduction: Coverage
Opioid Substitution TherapyGlobally, for every 100 PWID,only 8 are receiving OST (range less than 1 to 61)
Needle and Syringe ExchangeGlobally, 2 needles per PWIDper month (range less than 1
to more than 200)
• 72 countries have OST• 86 countries with IDU have no OST
• 82 countries have NSP• 76 countries with IDU have no NSP
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
Transformation of Compulsory Drug Detention Centers into Voluntary Evidence Based Treatment & Care Centers• July 2011• 36 000 PWID • 6500 receiving MMT
Mistreatment of Drug Users and "Undesirables" in Cambodia’s Drug Detention CentersDECEMBER 9, 2013
Unmet Needs & Challenges
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)
(EuroHIV 2007, UNAIDS report on the global AIDS epidemic. 2010)
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 2010El-Bassel, et al., Curr HIV/AIDS Rep 2014Meyer, et al, J Women Health 2012
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%)
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
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. Stoicescu Injecting drug use among
under 18s: A snapshot of available data, London: Harm Reduction International 2013.
MSM & Drug Use
Lancet September 2013
Countries with published MSM drug use data use data
Bourne IHRA 2013
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
• Polydrug use is common – alcohol, biggest contributor– especially stimulants eg ecstasy, cocaine, amphetamines or
ketamine• Prevalence of IDU (heroin) generally very low, but….
Bourne, IHRA 2013
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
Any Alcohol Use Disorder
Hazardous Drinking
Harmful Drinking
Dependent Drinking
Rela
tive
Haz
ard
1.21
1.23 1.26
1.71
1.43
1.25
1.49
1.82
2.28
1.86
2.57 3.
29
2.11
1.76
2.27 3.
00
1.53
1.44
1.46
1.78
Ludford K, PLoS One, 2013
Alcohol and Drug Use Independently Correlate with HIV Risks Among Peruvian MSM
Drug Use Drug Use Drug Use
Drug use, and drugs injected, are changingLooking 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.
Harm Reduction for People Who Use DrugsContext is Key
Prison and People Who Use Drugs
Geography and ImprisonmentTo
tal P
rison
Pop
ulat
ion
In 1971 President Nixon declared a War on Drugs
Lifetime prevalence (%) of illicit drug use among prisoners in European countries
EMCDDA 2012
Incarceration: High Risk Environment for HIV Transmission Among HIV+s in Ukraine
Any IDU Syringe Sharing Among PWIDs
0102030405060708090
10088.4
53.656.4
74.1
58.1
23.6
30d PreincarcerationDuring IncarcerationPost-Release
Perc
ent
Only 19.4% received
ART
Izenberg et al, IJDP, In Press
Mean number of people sharing among injectors = 4.4 (0-30)
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)
AIDS-Related Mortality Achieves Parity in Prisons and the General Population
0
10
20
30
40
AID
S-R
elat
ed D
eath
sR
elat
ive
to A
ll D
eath
s (%
)
1995
State inmates
General population34.2%
10.2%
2008
3.5% 3.4%
Maruschak LM. Bur Justice Stat Bull. December 2009.
HAART(1996)
Independent Correlates of Sustained Retention in HIV Care
Covariate AOR 95% CI P
Male gender 2.10 1.42, 3.11 <0.01
Having an HIV provider (pre-incarceration) 1.67 1.09, 2.56 0.02
Discharge planning (within jail) 1.50 1.06, 2.12 0.02
Disease management session (within jail) 2.25 1.51, 3.36 <0.01
Needs assessment (post-release) 1.59 1.06, 2.37 0.02
HIV-related education (post-release) 2.03 1.37, 2.99 <0.01
Transportation assistance (post-release) 1.54 1.0, 2.22 0.02
Althoff, AIDS Behav, 2013
Evidence-Based Strategies to Reduce HIV Transmission Among PWUDs
NSP
MAT
HIVC&T
PrEP
Primary & Secondary Secondary Only
ART
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
Engagement in Care Among PWIDs in Baltimore, ALIVE Cohort, 1998-2011
Fully
Ret
aine
d (3
0.5%
)
Conti
nuou
sly
on A
RT (1
7.3%
)
Sust
aine
d VL
<400
(8.0
%)
Westergaard, AIDS 2013
Engagement in Care Among PWIDs in Baltimore, ALIVE Cohort, 1998-2011
Poor Retention in Care
• Active drug injection
• Incarceration• No health insurance• No usual site of care• Lack of consistency in HIV
care provider
Poor Viral Suppression
• Active drug injection• Alcohol use• Crack cocaine use• Incarceration
• Lack of consistency in HIV care provider
• Decreasing CD4 countWestergaard, AIDS 2013
HIV Care Cascade: Select Countries in Central Asia
McNairy et al. Journal on Drug and Alcohol Dependence, 2013
Provider and clinic-level correlates of deferring ART for people who inject drugs
Westergaard RP, J Int AIDS Soc, 2012
Altice FL et al, JAIDS, 2011
Integrating Buprenorphine Into HIV Clinical Care Settings
Prescribed ART Viral Suppression
Organization of Healthcare Delivery for HIV+ PWIDs Matters (Ukraine)
Bachireddy C, Drug Alcohol Depend, 2013
Strategies to overcome healthcare disparities for HIV–infected people who use drugs at each step of continuum of HIV care:
Roadmap of Findings
Diagnosis of HIV
Entry into HIV Care
Retention in HIV Care
ART Initiation
ART Adherence
• Targeted out-reach programs• Opt-out testing• On site rapid testing – drug
treatment programs, CJS• Peer driven interventions• Intensive case management• Nurse support interventions• Community outreach program
• Evidence based drug treatment• Integration of clinical/social services• SBIRT
• Evidence based drug treatment• Public health campaigns• Targeted outreach• CME for providers
• Evidence based drug treatment• DAART• Access to treatment for comorbid conditions
and social services
VIRAL SUPPRESSIONMeyer et al CID 2013
Economic evidence for interventions with PWID
Dutta et al. The Global HIV Epidemics among People Who Inject Drugs, World Bank 2013
Cost Effectiveness of the Harm Reduction Program in Malaysia
Incremental Cost Effectiveness Ratio (ICER)Scenario Year 2006 – 2013 2013 - 2023 2006-2050
NSP vs no intervention
QALY gained 28,591 316,852 1,819,945
USD per QALY gained Cost-effective Cost-effective Cost-effective
Combined MMT and NSP vs NSP
only
QALY gained 22,974 76,674 344,864
USD per QALY gained 7,396
Cost-effective4,832
Cost-effective4,446
Cost-effective
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)
GDP per capita in 2012 was approximately USD10,000
H Naning et al, IAS 2013
Global heroin supply increased by 380% from 1980-2010Price of heroin in Europe decreased by 79%
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. HIV AIDS
0
100
200
300
400
500
600
700
800
900
1000
Incidence of HIV and AIDS among drug users, 2000-2008
20002008
Kent. B Journal Crim 2012
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
General Patients HIV+ Patients PWID Patients MSM Patients0
10
20
30
40
50
60
70
80
9080.3
59.4
39.933.3
73.2
51.2
35.732.1
Medical Students (N=486)Dental Students (N=658)
Mea
n Sc
ore
P=0.001 P=0.001 P=0.001 P=NS
The Future HIV Healthcare Providers: Stigma & Healthcare Students in Malaysia
P<0.0001
P<0.0001
P<0.0001
Jin et al, AIDS Care 2014
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
Rick Altice, Yale University
Nabila El-Bassel, Columbia University
Howie Lim, Ezra Akbar, Bertlin Ng, Britton Gibson, H Naning CERiAChris Beyrer JHUDamon Barrett, Catherine Cook Harm Reduction InternationalDavid Wilson, Louisa Degenhardt University of NSWKen Mayer Fenway Institute, Harvard Medical School Tim Hunt, Wafaa el Sadr Columbia University
Ministry of Education/University Malaya High Impact Research GrantThe World Bank
National Institute of Drug Abuse, USA
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