Transcript Document

HIV Prevention, treatment and
care among
people who inject drugs
Fabienne Hariga, MD, MPH
Senior HIV Adviser, UNODC Vienna
Co-sponsor
CONVENING AGENCY
HIV among
People who
Use Drugs
HIV in
Prison
Settings
Prevalence of HIV among people who inject drugs
12.7 million PWID (0.27 % )
1.7 million PWID living with HIV (13.1% of PWID)
52% with hepatitis C
Source: World Drug report 2014
HIV AND PEOPLE WHO INJECT DRUGS IN PRISONS
JOINT UN RECOMMENDED INTERVENTIONS
Comprehensive Package of interventions for HIV prevention,
treatment and care among people who inject drugs
1.
2.
3.
4.
5.
6.
7.
8.
9.
Needle and syringe programmes (NSPs)
Opioid substitution therapy (OST) and other evidence-based drug
dependence treatment
HIV testing and counselling (HTC)
Antiretroviral therapy (ART)
Prevention and treatment of sexually transmitted infections (STIs)
Condom programmes for people who inject drugs and their sexual
partners
Targeted information, education and communication (IEC) for
people who inject drugs and their sexual partners
Prevention, vaccination, diagnosis and treatment for viral hepatitis
Prevention, diagnosis and treatment of tuberculosis (TB).
Effectiveness of NSP
 Reduction in the rate of HIV transmission (and
HCV)
 Frequency of unsafe injection (risk HIV and HCV)
 No initiation of injecting among people who have
not injected previously
 No increase in the duration or frequency of illicit
drug use or drug injection
 Allow for IEC
 Allow for referral to OST, HTC or ARV and TB
 Reduce number of used syringes discarded in
public areas
 Bleach is not an effective alternative especially for
Hepatitis C
HIV (and hepatitis C or B) is transmitted among
people who inject drugs through sharing
injection equipment
Effectiveness of OST
 Opioid use
 Frequency of injection & unsafe injection (risk HIV
and HCV)
 Risk of overdoses
 Risk of abortion/miscarriage of pregnant opiate
dependent women
 Increase retention in drug dependence treatment
 Adherence to treatment (ARV , TB, Hepatitis C)
 Improve health status and wellbeing
 Social functioning
 Work and productivity and economic status
 Criminal behaviour
 Recidivism
 Violence, drug seeking in prison
Reduction in the rate of HIV transmission (and
HCV)
People living with HIV (millions)
Why a comprehensive approach?
1.2
1
0.8
0.6
0.4
0.2
0
2000
2005
2010
2015
2020
2025
2030
baseline
substitution (only)
needle exhange only
comprehensive harm reductions
Source: Sarkar et al, 2008
Universal Access
• Physically accessible
– geographically distributed
– Hard to reach location
• Affordable
– patients should not have to pay for their treatment
• Equitable and non-discriminatory
– no exclusion criteria except medical ones, e.g.
– OST should not be limited to only those IDUs who are HIV infected or who
have failed on other drug dependence treatment
– No compulsory treatment
• Non-rationed
– supply should be determined by need:
– e.g. needle and syringe programmes with strict limits on the number of
syringes provided to each client are less successful than those that do not
impose such restrictions
HIV incidence
Incidence du VIH à Maurice (2000-oct 2013)
1000
900
800
New HIV Cases
700
600
PWID Incidence Rate
500
400
300
200
100
0
Nicolas Ritter, AFRAVIH 2014
PRINCIPLES
 Prison health is public health
 Linkages with public health and
community programmes
 Human rights based and gender sensitive
 Principle of equivalence
 Medical ethics
 No segregation of PLWH;
 Criminal justice reforms to reduce the prison
population
 Alternatives to imprisonment
 Reduce pre-trial incarceration
 End compulsory detention of drug users
and sex workers for “rehabilitation”
 Prison reforms
 Ensure safe prison conditions
 Prevent violence
 Proper classification
 Conjugal visiting rooms
Harm reduction in prisons
Increase of HIV in Lithuanian prisons in the absence of prevention services
New HIV Infections in Lithuanian prisons
Availability
NSP
No
OST
No
HIV Testing
Yes
ARV Therapy
18%
Harm Reduction
Education
28
30
New HIV Infections in Prisons (#)
Intervention
25
20
10
15
10
5
3
1
2007
2008
0
2006
5 pilot projects
2009
2010
2011
Source: UNODC S. Rotberga, Tallinn, 2011
Decrease of HIV in Spanish prisons in the presence of prevention services
New HIV Infections in Spanish prisons
Availability
NSP
Yes, 30 Prisons
OST
10.2% of inmates
(6,429 in 2010)
HIV Testing
ARV Therapy
Peer Health
Education
12
76.10%
64.6%
(2,668 in 2010)
0.8%
HIV Prevalence in Spanish Prisons (%)
Intervention
0.6%
0.5%
0.4%
0.3%
0.15% 0.17%
0.2%
0.1%
0.0%
100%
0.70%
0.7% 0.60%
0.15%
0.16%
0.09%
0.14%
0.06%
0.08%
0%
in 2010
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Source: Enrique Acín García, M.D., Head of Public Health Department. General Secretariat of Penitentiary Institutions. Ministry of Interior. Spain.
Bottlenecks
Critical enablers
• Supportive legal and policy
framework
• Supportive law enforcement
practices
• Empowerment of people who
use drugs
• Alternatives to imprisonment
including decriminalisation of
drug use
Appropriate funding
New publications:
• Police, HIV and PWID: a
training manual
• Policy brief on HIV and women who inject
drugs
• Handbook on needle and
syringe programmes in
prisons
…Unfortunately, many national drug control
systems rely on sanctions and imprisonment,
rather than evidence-based health care in full
compliance with human rights standards …
… These are major barriers to HIV
and to harm reduction services, including
in prisons and other closed settings…
UNAIDS Programme
Coordinating Board,1
July 2014
Thank
you!
[email protected]
www.unodc.org