Scaling-up harm reduction services for prevention of HIV among people who inject drugs (PWID)

Joint Action on HIV and co-infection prevention and harm reductionHA-REACT

Mika Salminen, Professor

Malta, 30 January 2017

> 5 3 to <51 to <3

< 1

Not included or not reporting

Liechtenstein

Luxembourg Malta

Non-visible countries

HIV diagnoses acquired through injecting drug use, 2014, EU/EEA

Rate per 100 000 population

Source: ECDC/WHO (2015). HIV/AIDS Surveillance in Europe, 2014

HIV prevalence among people who inject drugs; Europe, 2008–2009

4

10 < 50%

≥ 50%

Not included, not reporting, or not known

5 < 10%

Source: EMCDDA and Reitox National Focal Points (EMCDDA countries: EU, Croatia, Turkey and Norway); Mathers et al., Lancet 2008 (other countries). Colour indicates midpoint of national data, or if not available, local data. Data for EMCDDA countries are mostly from 2008–2009. When data were not available for 2008–2009, older data were used.EMCDDA data are sub-national for Turkey, UK, France, Slovakia, Netherlands, Belgium, Poland, Bulgaria, Spain, Sweden, Ireland, Latvia, Germany, Lithuania, Romania, Estonia. For non-EMCDDA countries, this information is not available.

0 < 5 %

8.2.2017 5

The stairs of change in health promotion (Puska & McAlister 1982)

6. Community Organisation / Policy change

5. Environmental support

4. Social support

3. Practical skills

2. Persuasion

1. Knowledge

8.2.2017 6

Policy change in mid 1990-ies in Finland: from naïve to pragmatic public health based drug policy

• Abandonment of a naïve/heroic approach in favour of a pragmatic/humble policy

• Development of Low threshold health service centers (LTHSC) tailored to the needs of the target group (IDU)

• Governmental policy programmes, 1998, 2000 and 2004-7

• Law on infectious diseases: mandatory requirement for municipal harm reduction, incl. NSP

• Framework of the LTHSC operational parameters

– Anonymity service without any kind of identification

– Reachability of the location and the services

– User-friendly atmosphere – Dialogue with the users – Practical approach to the

operation – ideological and moral Non-

judgementality – Realistic hierarchy of goals

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Growth of the LTHSC network• First Low Threshold Health Service

Centre opened 1997

• Since expanded to > 35 municipalities

• Service mix:– Health advice – Exchange of injection equipment– Vaccinations– Low threshold testing– Food and – Smallscale outpatient services– Outreach and peer-peer work

• Referrals to:– Maintenance and substitution

therapy for opiate users– Detoxification services– other social- and health services

• Municipal responsibility!

• Close cooperation with NGO-sector

8.2.2017 9

Effectiveness indicators evaluated

Impact indicators• Changes in prevalence and incidence

of blood-borne infections (i.e. HBV, HCV, HIV)

• Sustaining low prevalence of HIV among IDU

• Absense of negative effects (i.e. increases in drug use, recruitment of younger users)

Targets set in 2004-2007 governmental policy

• Improving scenario: reduction in HIV-incidence to less than 30 cases among IDU/year

Coverage & operational indicators• Numbers and proportion of IDU

reached• Regional coverage• Numbers of equipment exchanged in

relation to estimated need• % returned equipment• HBV and HAV Vaccination coverage• Acceptance of services• Awareness of infection status

Economical indicators (cost/ benefit)• Crude scenario-type estimates

8.2.2017 10

Coverage

• Numbers and proportion of IDU reached

• Regional coverage

• Equipment exchanged and estimated need

• Return rate for equipment

• Hepatitis vaccination coverage

• Acceptance of services

• Awareness of own infection status

Coverage in 2006 estimated at 70.8 % (target > 60 %)

Partly met: full coverage of major cities, partial or spotty coverage of small municipalities, total coverage 2.3 population (target: cover all regions where need exists)Half of calculated need met (target: no re-use)

> 98 % (target 90 %)

Regional coverage > 90 % (target > 75 %)

High among target group

Annual testing rate 10-15 % (target > 10 % within system)

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Policy indicatorsThree scenarios of IDU HIV epidemic

evolution in government drug policy programme 2004 – 2007

1. Worsening situation> 100 cases annually2. Unchanged30 – 50 cases annually3. Improved situation

< 30 annual HIV cases

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Cost effectiveness• Current direct additional

total national costs of LTHSC services are estimated to be less than 5M €

• Given a median estimate of approximately 15.000 users, annual additional cost per IDU is 670 €

• In contrast, annual healthcare cost due to HIV-infection can be up to 10000 €

• Suggests cost-effectiveness

Modelling the Direct Cost of the HIV/Aids Epidemic Mean PLWHA lifetime 13 years, stdev 10 y,

Cost level 10 k€/PLWHA/year

€0

€20

€40

€60

€80

€100

€120

€140

€160

1990 2000 2010 2020 2030 2040

Mill

ions

Years modelled

Ann

ual u

ndis

coun

ted

cost

(€)

€0

€500

€1,000

€1,500

€2,000

€2,500

€3,000

Mill

ions

Cum

ulat

ive

undi

scou

nted

cos

t (€)

Annual cost, 100 cases/y

Annual cost, 500 cases/y

Cumulative cost, 100 cases/y

Cumulative cost, 500 cases/y

8.2.2017 13

Correlation of service increase and annuallyreported cases of HIV infection

0

20

40

60

80

100

Ann

ual H

IV ra

te

0

1125000

2250000

3375000

4500000

Equ

ipm

ent e

xang

e

8.2.2017 14

Comparison of outcomesAnnual incidence of HIV-infection

newly reported cases/million population

0

200

400

600

800

1000

1200

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Inci

denc

e (lo

g-sc

ale)

Incidence - ExampleIncidence - Finland

Objectives of HA-REACT Joint Action

Zero new HIV, reduced HCV and TB among PWID in the EU by 2020

Improved prevention and treatment of blood-borne infections and TB in priority regions and priority groups in the European Union

PurposeImproved capacity to respond to HIV and co-infection risks and provide harm reduction with specific focus on people who inject drugs (PWID) in the EU

Direct beneficiaries: professionals working with PWIDUltimate beneficiaries: people who inject drugs

ECDC & EMCDDA joint guidance

– Comprehensive Guidance document

• Based on evidence and fully referenced

– Two part evidence assessment 1. Needle and syringe programmes and other

interventions for preventing hepatitis C, HIV and injecting risk behaviour

2. Drug treatment for preventing hepatitis C, HIV and injecting risk behaviour

16

Seven interventions, one aim: no infections

Seven key recommended interventions

• INJECTION EQUIPMENT: Provision of and legal access to clean drug injection equipment, including sufficient supply of sterile needles and syringes, free of charge, as part of a combined multi-component approach, implemented through harm-reduction, counselling and treatment programmes

• VACCINATION: hepatitis A and B, tetanus, influenza vaccines, and, in particular for HIV-positive individuals, pneumococcal vaccine

• DRUG DEPENDENCE TREATMENT: Opioid substitution treatment and other effective forms of drug treatment

• TESTING: Voluntary diagnostic testing with informed consent for HIV, HCV, (HBV for unvaccinated) and other infections including TB should be routinely offered and linked to referral to treatment

17

INFECTIOUS DISEASE TREATMENT: Antiviral treatment based on clinical indications for those who are HIV, HBV or HCV-infected. Anti-tuberculosis treatment for active TB cases. TB prophylactic therapy should be considered for latent TB cases.

HEALTH PROMOTION: health promotion focused on safer injecting behaviour; sexual health including condom use; and disease prevention, testing and treatment

TARGETED DELIVERY OF SERVICES: Services should be combined and organised and delivered according to user needs and local conditions; this includes the provision of services through fixed sites offering drug treatment, harm reduction, counselling and testing, and referrals to general primary health and specialist medical services.

COMBINE THESE KEY INTERVENTIONS TO ENHANCE PREVENTION SYNERGY AND EFFECTIVENESS

Activity basics

Budget: approx. 3,75 million EUR

co-funding by EC – 80%

Duration: October 2015 – September 2018

Coordination: National Institute for Health and

Welfare (THL), Finland

Partners: 23 partners from 18 countries

EU Priority groups

Comprehensive prevention service package

Integrated, comprehensive public health serviceapproach with an emphasis on capacity development

8.2.2017 Mika Salminen/Outi Karvonen 19

Coordi-nation

Dissemination

Evalu-ation

Selectedpartner countries

for capacitydevelopment

Direct supportfrom the project

funds

Partners with existing

comprehensiveservices packages

and/orexperience in overcoming

structural barriersand issues of sustainability

EU PriorityRegions

Direct support

Training and bench-

marking

Focusing the action: use of ECDC and EMCDDA objectiveselection criteria

8.2.2017 Mika Salminen/Outi Karvonen 20

AT BE BG HR CY CZ DK EE FI FR DE EL HU IS IE IT LV LT LU MT NL NO PL PT RO SK SI ES SE UK

HIV trendHIV case reports and prevalence (15% weight; no increase in case reports or prevalence=0; increase in one=1; increase in both=2; high without an increase=1)

0 0 2 0 0 0 0 1 0 0 0 1 0 0 0 0 2 1 0 0 0 0 0 0 2 0 0 0 0 0

Transmission riskprevalence of injecting drug use, changes in injecting risk behaviour (HCV prevalence and trends) (10% weight; no changes=0; moderate increase in one criteria=1; increase in >1 criteria=2)

0 0 2 0 1 2 0 2 2 2 0 0 0 2 0 0 0 0

OST coverage% estimated problem opiate user population receiving OST (cut-off 30%) (25% weight; OST coverage >30%=0; no data=1; OST coverage <30%=2)

0 1 1 0 0 0 1 1 1 0 0 0 2 1 0 0 2 2 0 0 0 0 2 1 1 2 0 0 1 0

NSP coverageNumber of syringes given out per PWID per year (cut-off 100 syringes) (25% weight; NSP coverage >100=0; no data=1; NSP coverage<100=2)

1 2 1 0 2 0 1 0 0 1 1 2 2 1 1 1 2 1 0 1 1 0 1 1 2 2 1 0 1 1

Taking part in the Joint Action x x x x x x x x x x x x x x x x x x x x

Scores (maximum 2) 0,3 0,8 1 0 0,6 0 0,5 0,6 0,3 0,3 0,3 0,9 1,2 0,5 0,3 0,3 1,5 0,9 0 0,3 0,3 0 0,8 0,5 1,3 1 0,3 0 0,5 0,3Ranking of those participating in the JA (1=greatest need/opportunity to improve harm reduction situation) 6 3 8 5 2 1 4 6

NO ALERT – no evidence for increase in case reports or HIV/HCV prevalence and/or transmission risk and/or low intervention coverageCONCERN - Subnational increase in HIV/HCV prevalence and/or transmission risk or consistent but non-significant rise at national level.ALERT – evidence for significant increase in case reports or HIV/HCV prevalence and/or increase in transmission risk and/or low intervention coverage.Information unknown/not reported to EMCDDA/ECDC.

Table 1: Indicators of HIV trend, transmission risk and prevention coverage

HA-REACT Work Packages

WP1. Coordination

WP2. Dissemination

WP3. Evaluation

WP4. Testing and linkage to care

WP5. Scaling up harm reduction

WP6. Harm reduction and continuity of care in prisons

WP7. Integrated care

WP8 Sustainability and long-term funding

Starting activities• 1st Steering Committee in

Luxembourg, 8-9 December 2015

• Kick-off in Vilnius, 14 January 2016

• 1st Advisory Board and 2nd Steering Committee in Vilnius, 15 Jan 2016

• 3rd Steering Committee in Berlin on 12 May

• Logical Framework Approach workshops during spring 2016 in Budapest, Riga, Vilnius, Prague

Recent and next activities• October 6-7, 2016, Berlin (Germany)

Study tour for prison staff from Czech Republic• October 2016, Madrid and Barcelona (Spain)

Study visits for participants from Latvia (WP5)• October 26, 2016, Budapest (Hungary)

HA-REACT Sustainable Funding meeting• November 2-3, 2016, Riga (Latvia):

HA-REACT Partnership Forum in Riga, • November 4, 2016, Riga (Latvia):

2nd Advisory Board• November 4, 2016, Riga (Latvia):

4th Steering Committee• November 15-17, 2016, Latvia

Training on HIV/HCV testing• December 13-15, 2016, Hungary

Training on HIV/HCV testing• January 31, 2017, Malta

CHAFEA Symposium (in connection with HepHIV conference)• March 7-9, 2017, Warsaw

International training seminar on OST and harm reduction in prisons

• April 5-6, 2017, Vilnius (Lithuania)International workshop on models of careMeeting on sustainable funding

Thank you !

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