Transcript Australian perspectives from the 2011 International Harm

International
Overview of PWID,
HIV and Opioid
Substitution
Dr Craig Rodgers
Staff Specialist
Kirketon Road Centre



Now known as Harm Reduction International
International non-governmental organisation
promoting policies and practices that reduce
the harms from all psychoactive substances
A key principle of Harm Reduction
International’s approach is to support the
engagement of people and communities
affected by drugs and alcohol around the
world in policy-making processes
•
•
•
•
Middle East and North Africa Harm Reduction
Association
Formed in June 2007
Supported by WHO, IHRA and Drosos
Foundation
Aim
 to strengthen the role of civil society organizations in
•
harm reduction in the Middle East and North Africa
 to stabilize and decrease prevalence of HIV/AIDS in
the region
Priority countries - Afghanistan, Egypt, Iran and
Pakistan






IDU occurs in at least 158 countries and territories
around the world
Estimated 15.9 million PWID globally (range 11-21
million)
Largest populations in China, USA and Russia
120 countries report HIV in PWID
Approx 3 million PWID living with HIV (range 0.8 – 6.6
million)
8 countries have HIV prevalence in PWID > 40%:
Argentina, Brazil, Estonia, Indonesia, Kenya,
Myanmar, Nepal and Thailand
The Global State of Harm Reduction 2010. Key Issues for broadening the response.
2010. International Harm Reduction Association.
Australia
• PWID: 150,000 (0.4% population)
• HIV prevalence amongst PWID: 1.5%
• NSP:
•
 > 1300 (plus > 2,500 pharmacies)
 Highest rate of NSP distribution with 213 syringes per person per year
 Approx 29 million needles/syringes distributed in 2008
OST:




•
methadone available since 1969
?132 sites treating approx 43,500 individuals
64% clients receive Rx from private prescribers
85% dosing points in pharmacies
Data on IDU and HIV in Pacific Islands and territories largely
unavailable
Problems
 Cost is an significant barrier to OST
 Ageing cohort of PWID
 No new HR initiatives in the past 10 years






1 million PWID (0.2 % population)
460,000 people living with HIV
6 countries with HIV epidemics in PWID:
Afghanistan, Pakistan, Iran, Libya, Bahrain
and Egypt
Hepatitis C prevalence ranges 45-93%
50 % report sharing needles & syringes
Average age first IDU 20-28
Elie Aaraj. Plenary session Mon 4th April




Iran has introduced comprehensive harm
reduction programs
By end 2010 OST had been introduced in
Morocco, Lebanon and Afghanistan
Pakistan has mobilised resources for
introducing OST
Oman has requested assistance to develop
OST site




Estimated PWID: 180,000
HIV prevalence in PWID: 15%
NSP:
 420 – 630
 Distributes approx 41 syringes per person per year
OST since 2008: 680 – 1100 (Buprenorphine, Methadone)
Shabnam Salimi (INCAS):
 Study on female drug use in Iran (40 female drug users –
median age 37yrs)
 87% used heroin, 27% stimulants
 88% smoked heroin rather than injecting
 12% IDU with HIV prevalence 5.5%
 Stigma far worse for female drug users





< 1% prevalence HIV in Morocco (approx
26,000 people)
PWID constituted 13% of Moroccans with HIV
(approx 3300)
Only 4,256 have access to treatment
Methadone program began in June 2010
Only 77 people on program so far




Produces more than 90% of the world’s
heroin ($2 per gram)
Approx 1 million drug users (8% adult
population) – 120,000 heroin users
HIV prevalence in PWID 7% in 2009
Feb 2010: pilot program established to
provide OST for up to 200 patients run by
Medecines du Monde
Higher induction rates because of increased
purity (and residential) – 60-70mg
 Coordinated by Ministry of Health (MoH) and
Ministry of Counter Narcotics (MoCN) which
do not work well together
Problems:
 Need to import methadone and
buprenorphine – results in shortages
 Funding issues







Approx 4 million PWID (¼ of the total population of
PWID)
HIV prevalence frequently above 20-25%
Several countries have much nigher national HIV
prevalence rates amongst PWID – Indonesia,
Myanmar, Nepal, Thailand and Viet Nam (30-50%
PWID likely to have HIV)
15 countries now have some form of NSP
12 countries prescribe OST
Coverage of harm reduction initiatives still too low to
have an impact on HIV epidemic (less than 1/3 PWID
are reached by NSP and < 5% receive OST)
•
•
•
•
•
Estimates suggest that current funding for harm
reduction in the region is only 10% of actual need
Lack of supportive legal and policy frameworks
impedes harm reduction responses
Several states prohibit possession and/or provision of
needles and syringes, methadone or buprenorphine
Imprisonment or detention in compulsory centres
remains the dominant response to drug use
Half the countries in the region retain the death
penalty for drug offences (8 countries have executed
for drug offences in the past 3 years)
•
•
•
•
PWID: 220,000
HIV prevalence among PWID: 42.5% (52%)
NSP: 159
OST:
 Methadone established in 2003 with expansion in
2006 and by 2008 there were 29 programs (15 public
health sector, 10 hospitals, 4 prisons) serving 2700
clients
 Private Buprenorphine treatment
 Possibility of injectable buprenorphine treatment
(Dr James Blogg)
•
•
•
•
Second largest producer of opium poppy
PWID: 75,000
HIV prevalence among PWID: 42.6%
NSP:
 19 NSPs (pharmacies > NGOs > HCWs)
 distributing 3.5 million needles (annual requirement
•
of 27 million)
OST:
 MMT began in 2006
 By 2010 there were 10 MMT sites with approx 820
clients (< 1% that require MMT)



PWID: 40,000 - 160,500 (wide variation)
HIV prevalence among PWID: 42.5%
NSP:
 10 (mainly peer driven, no govt funding, available at
pharmacies)

OST:
 available in up to 147 hospitals and clinics
 Methadone clinics first opened in 1989
 Treatment is free but clients must undergo detox 3
times prior to MMT and treatment has a time limit of
1-2 yrs



PWID: 164,000 (1/3 PWID in Nth East - Manipur,
Nagaland & Mizoram)
HIV prevalence among PWID: 11.15%
NSP:
 220 (Targeted Interventions/TIs – administered by
NGOs)

OST:
 50 (plan to expand to over 300)
 Buprenorphine available since 1993 via TIs (supposed
to lead to detoxification and rehabilitation)
 Methadone pilot program ? July 2010
Viet Nam:
 HIV prevalence in PWID 33%
 380 – 2000 NSPs and 6 OST clinics
China
 HIV prevalence in PWID 12%
 Approx 900 NSPs
 Approx 600 OST clinics
Comprises Central and Eastern Europe
Approx 3.7 million PWID
Russia (1.8 million), Azerbaijan (300,000) and
Ukraine (291,000)
 Highest population prevalences of PWID –
Azerbaijain 5.21%, Georgia 4.19%, Russia 1.78%
and Ukraine 1.16%
 Estimated that 1 million PWID infected with HIV
 Leading cause of death is overdose




NSP provided in all 29 countries/territories
 Coverage: 9 syringes per person per year

24 countries have OST
 mainly pilot programmes
 reach only 1% of PWID




PWID: 13,801
HIV prevalence amongst PWID: 72.1%
NSP:36
OST: 8 clinics (Buprenorphine and
methadone)
PWID: 1.8 million
 HIV prevalence amongst PWID: 37.15% (2003)
 NSP: 70
 Estimated to only reach 7% PWID
 Distributes 7 millions needles per year
 OST: Nil





PWID: 291,000
HIV prevalence amongst PWID: 32.4%
NSP: 985-1323
OST:
 Buprenorphine and methadone
 Up to 5000 people on OST
•
•
•
•
•
Estimated to be approx 1 million PWID
HIV prevalence is generally < 10%
Exception of France (12.2%), Italy (12.1%)
Portugal (15.6%) and Spain (39.7%)
Countries with good HR programs have seen
reductions in drug-related HIV transmission
HR initiatives include: drug consumption
rooms, vending machines, prescription of
OST and heroin





PWID: 83,972
HIV prevalence amongst PWID: 39.7%
NSP: 1271 - 1458
OST: 497 – 2,229
Offer Methadone, Buprenorphine and Heroin
•
•
•
•
•
Most commonly injected drug is cocaine
(heroin in parts of Colombia and Northern
Mexico)
>2 million PWID
580, 500 living with HIV
Vast majority of NSPs operate in Brazil &
Argentina
Only Mexico & Colombia provide OST
(approx 25 and 4 clinics respectively)




PWID: 65,829
HIV prevalence amongst PWID: 49.7%
NSP: 25
OST: Nil



PWID: 540,500
HIV prevalence amongst PWID: 48%
NSP: 150-450
 Coverage is very low
 Estimate that PWID receive < 1 needle/syringe per
year

OST: Nil
United States
• PWID: 1,294,000
• HIV prevalence amongst PWID: 15.5%
• NSP: 186
• OST: 1433 (Bupe/Methadone)
Canada
• PWID: 286,000
• HIV prevalence amongst PWID: 13.4%
• NSP: >775
• OST: Bupe/Methadone and Drug Consumption
Room
Accounts for 67% new HIV infections world wide
Injecting now reported in the majority of the 47
Sub-Saharan states
 Estimated that 221,000 PWID are living with HIV
 HIV prevalence in PWID ranges from 5.5%
(Nigeria) – 42.9% (Kenya)
 Mauritius is the only country with OST and NSP
 OST also available in South Africa, Senegal and
Kenya


However…
•
•
o
o
o
o
Does data from different sources tell the
same story?
IDU data collated and compared from four
2010 global datasets:
UNGASS HIV
Global Fund progress reports
WHO Universal Access progress data
Systemic reviews by the Reference Group to
the UN on HIV and IDU (independent of
government agencies)
Data rarely in agreement
Significant variation between estimates of the
response to HIV and IDU depending on methods
and definitions employed
Need
 Consistency in data collection methods
 Independent scrutiny of data (including official
government data)
 Estimation methods and bias must be
documented


Lastly…





Yajilarra
Director: Melanie Hogan
Producer: Jane Latimer
Shows the determination of 2 women in
Fitzroy Crossing dealing with the alcohol
problems in the community
“Shows what is possible when Indigenous
leaders bring the community together to
build consensus and act upon it”