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Dr. Jean-Paul C. Grund
UNAIDS Vienna
Key Components of Good HIV/AIDS Policy
Targeting The Drugs-HIV Nexus with Pragmatic Health interventions
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The Drugs
and HIV
Nexus
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The Micro Risk Environment
of Drug Injecting: Drug Culture
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Tradition of Self Preparation of Drugs
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Use of Cooking Utensils, Nizhniy Novgorod
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Frontloading Cheornaya, Nizhniy Novgorod
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Group Injecting, Nizhniy Novgorod
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Group Injecting, Nizhniy Novgorod
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Group Injecting, Rostov Na Donu
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Group Injecting of Heroin, Volgograd
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Group Injecting, Volgograd
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Drug Use Soviet Style: Do It Yourself!
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IDUs’ Relationships with Law Enforcement
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IDUs’ Relationships with Law Enforcement
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Needle Exchange Programs
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Slide:Courtesy of S. Strathdee
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Countries with at Least One Existing Needle Exchange Program N= (46)
Global Expansion of Needle Exchange Programs
(December 2000)
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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
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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.
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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.
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Methadone Maintenance Programs
Why Do We Need Them?
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Great Need for New Scientific Treatment Concepts
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When Substitution Treatment is Unavailable
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Do Methadone Maintenance
Programs Work?
YES! There is evidence from around
the world showing the efficacy of
Methadone Maintenance Programs
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Effect of Methadone Treatment
on Level of Heroin Use
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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.
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Effect of Methadone Treatment
on Injecting Drug Use
and Syringe Sharing
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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%
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Effect of Methadone Treatment
on HIV Prevalence and Incidence
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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
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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
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Effect of Methadone Treatment
on Prevalence of Hepatitis
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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
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Effect of Methadone Treatment
on Crime and Incarceration
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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)
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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
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HIV is not the only harm
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Harm Reduction and Overdose
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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
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State Repression vs. Community Integration
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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:
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“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
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Photo Credits
Black & White Photographs:
© John Ranard
Color Photographs:
© Jean-Paul Grund