dushanbe, 10 02 - hiv prevention & harm reduction

Dr. Jean-Paul C. Grund

UNAIDS Vienna

Key Components of Good HIV/AIDS Policy

Targeting The Drugs-HIV Nexus with Pragmatic Health interventions

The Drugs

and HIV

Nexus

The Micro Risk Environment

of Drug Injecting: Drug Culture

Tradition of Self Preparation of Drugs

Use of Cooking Utensils, Nizhniy Novgorod

Frontloading Cheornaya, Nizhniy Novgorod

Group Injecting, Nizhniy Novgorod

Group Injecting, Nizhniy Novgorod

Group Injecting, Rostov Na Donu

Group Injecting of Heroin, Volgograd

Group Injecting, Volgograd

Drug Use Soviet Style: Do It Yourself!

IDUs’ Relationships with Law Enforcement

IDUs’ Relationships with Law Enforcement

Needle Exchange Programs

Slide:Courtesy of S. Strathdee

Countries with at Least One Existing Needle Exchange Program N= (46)

Global Expansion of Needle Exchange Programs

(December 2000)

NEPs in the Russian Federation

• Recent, explosive epidemic of injection

and blood borne infections

• ~ 1 million IDUs

• At least 42 NEPs

• 58% of NEPs surveyed in Dec 2000 had

opened in the last year

Source: D. Burrows, 2001

N. N.

N = 236

Pskov

N = 201

R-N-D

N = 199

St. Petersb.

N = 221

Volgograd

N = 219

Total

N = 1,076

Daily Injection of at

least one drug (%)

30 Ds. Prior to SEP

Last 30 DaysP

64

64

.7237

25

11

<.0001

52

36

<.0001

66

77

.0031

74

71

.2009

53

53

.0001

Receptive Sequential

Syringe Use (%)

30 Ds. Prior to SEPLast 30 Days

P

41

9

<.0001

26

4

<.0001

39

9

<.0001

48

29

<.0001

37

3

<.0001

38

11

<.0001

Injected @ Anonym.

Injecting Venue (%)

30 Ds. Prior to SEP

Last 30 Days

P

62

47

<.0001

25

9

<.0001

54

28

<.0001

37

19

<.0001

45

33

<.0001

45

28

<.0001

1 Totals may not equal 100% due to rounding or missing data.

Injection-Related HIV Risk Behaviors of Russian

Syringe Exchange Participants1 N = 1,076 Russian syringe exchange program participants reported a strong pattern of risk reduction, associated with participation in the program. In particular substantial and statistically significant decreases in “receptive syringe sharing” were reported.

Single-digit percentages of respondents reportedly engage in receptive syringe sharing for the recent 30 days in four out of five cities.

Drug Use Characteristics of Russian

Syringe Exchange Participants N = 1,076 N. N.

N = 236

Pskov

N = 201

R-N-D

N = 199

St. Petersb.

N = 221

Volgograd

N = 219

Total

N = 1,076

Age First IDU1 (Mean/SD) 19 (4) 21 (5) 21 (5) 18 (3) 19 (4) 20 (4)

Years Injecting1 (%)

< 3 years

3+ – 6 years

6+ – 10 years

>10 years

22

33

33

12

47

31

10

12

18

22

25

35

43

27

16

14

26

41

26

6

30

32

23

15

Drug Injected1,2

(%)

Homemade opiates

Powder Heroin

Amphetamine

83

47

9

15

53

61

84

5

24

6

96

9

21

90

4

42

59

20

Reported Secondary Exchange (%) 40 46 40 43 48 44

1 N differs because results are derived from intake questionnaires that linked with risk assessment questionnaires, only, so that N

for

Nizhny Novgorod = 165; N for Pskov = 153; N for Rostov-na-Donu = 109; N for St. Petersburg = 56; N for Volgograd = 160;

and the total N for the five programs = 643.

2 Percents may sum to > 100; more than one response may apply.

Almost half of Russian Syringe Exchange Participants reported Secondary Exchange (40-48%), whether the program encouraged it or not.

Methadone Maintenance Programs

Why Do We Need Them?

Great Need for New Scientific Treatment Concepts

When Substitution Treatment is Unavailable

Do Methadone Maintenance

Programs Work?

YES! There is evidence from around

the world showing the efficacy of

Methadone Maintenance Programs

Effect of Methadone Treatment

on Level of Heroin Use

Heroin Use in Past 30 Days

407 MM Patients by Current Methadone Dose

0

10

20

30

40

50

60

70

80

90

100

0 1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 90+

Methadone Dose

Percentage Heroin Use

SOURCE: Ball and Ross 1991, p. 248.

Effect of Methadone Treatment

on Injecting Drug Use

and Syringe Sharing

IDU And Needle Sharing Practices Among 507

Methadone Maintenance Patients In Six Programs

DROPOUT SAMPLE

(n=105)

NO IV USE

since

treatment

29%

Needle

Sharing IV

USERS

20%

IV USERS

(no needle

sharing)

51%

SOURCE : J.C. Ball, University of Maryland, Baltimore, 1987.

IN TREATMENT SAMPLE

(n=402)

Needle

Sharing IV

USERS

8%

IV USERS

(no needle

sharing)

29%

NO IV USE

in the past

year

63%

Effect of Methadone Treatment

on HIV Prevalence and Incidence

Absence of HIV Antibodies in Long-term, Socially

Rehabilitated Methadone Maintenance Patients

• Patients Entering MMT Before 1983 (N = 58):

0% HIV+ in 1990

• Out of Treatment IDUs in New York:

55-60% HIV+ in 1990

Source: D. Novick, H. Joseph, et al., Archives of Internal Medicine, Vol 150, Jan. 1990

Eighteen-month HIV Seroconversion By Methadone

Maintenance Treatment Retention

22%

4.4%3.5%

0

10

20

30

In Treatment

(N = 85)

Partial Treatment

(N = 45)

Treatment Status

No Treatment

(N = 55)

Percent of

Seroconversion

Rate

Adapted from Metzger et al., 1993

Effect of Methadone Treatment

on Prevalence of Hepatitis

Increased Methadone Maintenance Census

And Decreased Hepatitis Cases: NYC, 1971-1973

0

10000

20000

30000

40000

1971 1972 1973

3-Year Increase (19,900 Additional Patients)

Patients in

Methadone

Maintenance

Treatment

0

400

800

1200

1600

2000

2400

1971 1972 1973

3-Year Increase (1,500 Fewer Cases)

Reported

Cases of

Serum

Hepatitis

Source: Dole, Joseph, and Des Jarlais, 1981

Effect of Methadone Treatment

on Crime and Incarceration

CRIME BEFORE AND DURING Methadone

Methadone TREATMENT AT 6 PROGRAMS (Ball and Ross, 1991)

Last Addiction Period, "On Street"

264

189

224210

282273

0

50

100

150

200

250

300

A B C D E F

Before Treatment Crime

Crime-

Days Per

Year at

Risk

In Methadone Maintenance Treatment

2715 14

3719 21

0

50

100

150

200

250

300

A B C D E F

In-Treatment Crime

Program: Program:

Red bars = crime days per year when addicted. Blue bars = crime days per year after 6 months

or more in treatment. (N = 491)

Time of Incarceration Before and

During Methadone Treatment

3,4 Days

(8%)

44,3 Days

(100%)

0

5

10

15

20

25

30

35

40

45

Days in prison per year of heroin

addiction

Days in prison in the last 12

months

Days in prison

per year

Reduction of 92% of

time spent in prison

HIV is not the only harm

Harm Reduction and Overdose

Overdose Deaths: Frankfurt/M, 1969-1998

0

20

40

60

80

100

120

140

160

69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99

No. Of ODs under "No Tolerance" Policy No. Of ODs under "Harm Reduction" Policy

State Repression vs. Community Integration

Conclusion: Good AIDS Policy

• Multi-Sectoral Approach: HIV/AIDS policy is a matter of all areas and levels of government and civil society;

• Evidence-Based Interventions;

• Biggest Bang for the Buck: Direct funding to where the Epidemic is and goes;

• Keep Your Priorities Clear;

• Pragmatism is Essential:

“In Essence, a Policy of Harm Reduction

Requires an Approach of Pragmatism

Rather Than Purism – an Acceptance That

It May Sometimes Be Better to Go for a

Probable Silver Than a Possible Gold.” John Strang

Photo Credits

Black & White Photographs:

© John Ranard

Color Photographs:

© Jean-Paul Grund