Transcript Global Areas of Drug User

Injecting Drug Users: A Global
Problem
Roger Detels, M.D., M.S.
Global Areas of Drug UserTransmitted HIV
• Europe
• North America (U.S., Canada)
• South America
• Southeast Asia (Thailand, Myanmar, Vietnam,
northeast India, Indonesia)
• China (originally Yunnan, now all provinces;
highest in Yunnan, Guangxi and Xinjiang)
Golden triangle in southeast Asia
05.15.2013
Major heroin-producing locations
05.15.2013
Global Injecting Drug Use Statistics (2008)
Number of countries with documented injectors: 148
Areas lacking statistics: Africa, Middle East, western
South America
Prevalence estimates possible: 61 countries
Estimated number of injectors worldwide: 15.9 million
Estimated number of HIV-positive injectors
worldwide: 3.0 million
Countries with most injectors: China, USA, Russia
Prevalence of injecting drug use
Mathers BM, et al. Global epidemiology of injecting drug use and HIV among people who inject
drugs: a systematic review. Lancet 372:1742, 2008.
Prevalence of HIV infection among injecting drug users
Mathers BM, et al. Global epidemiology of injecting drug use and HIV among people who inject
drugs: a systematic review. Lancet 372:1744, 2008.
Role of Drug Use in Spread of HIV in Asia
Relationship of Drug Use to
HIV Spread to Other Groups
• Rapid spread (Thailand, Myanmar, NE
India)
• Initially slow spread among older addicts,
followed by rapid spread in younger
addicts (Vietnam)
• More recent increase in female injectors
(Vietnam, China)
• Spread to “bridge” populations
Characteristics of Drug
Users in Asia
• Remain as a member of the family
• Remain as a member of the community
• High failure rate for rehabilitation centers
(90+%)
• Increasing number of drug replacement and
needle exchange programs
• Recent increase in other drugs for injecting
• Increasing non-injection (club) drug use,
especially among MSM
Trends in HIV prevalence (%) among IDUs in three sites in India. Sources: Sarkar et al. (1993), Joseph (1996),
Tamil Nadu State AIDS Control Society Report on Sentinel Surveillance (2005), Panda et al. (2002a), and West
Bengal State AIDS Prevention and Control Society, Sentinel surveillance reports, 1994-2003. Note: The
prevalence data for Manipur before 1994 are not based on sentinel surveillance data
Panda S and Sharma M. Needle syringe acquisition… Substance Use & Misuse 41:953-977, 2006
Prevalence of HCV among IDUs in South Asia
Panda S and Sharma M. Needle syringe acquisition… Substance Use & Misuse 41:953-977, 2006
Drug Use Intervention Strategies
•Needle exchange programs
•Drug replacement programs (e.g. methadone)
•Cognitive behavioral therapy (identify and
address triggers and situations)
•Contingency management: reward (i.e., pay) for
negative urine tests
•Community intervention
Comparative equipment-sharing behavior by locations with and without outreach-based
interventions in Bangladesh (2002). (From Panda et al., 2002a). Source: Panda et al., 2002
Panda S and Sharma M. Needle syringe acquisition… Substance Use & Misuse 41:953-977, 2006
There are currently an estimated 740,000 people living with HIV in China.
http://www.avert.org/aidschina.htm
Wu et al., Community-based trial to prevent drug use in Yunnan, China. Am J Publ
Hlth 92:1952-1957, 2002.
Intervention Methodology (1)
Study sites: Longchuan, southern Yunnan
Selection of intervention and control areas:
19 villages matched on prevalence of drug
use and HIV, number of drug users,
geographically separated
Theoretical framework: behavioral change
model, Bandura’s social learning theory
Wu et al., Community-based trial to prevent drug use in Yunnan, China. Am J Publ
Hlth 92:1952-1957, 2002.
Intervention Methodology (2)
Intervention strategies
• Recruitment of official and informal leaders and
police
• Multiple approach: school, family, community, clinic
• Activities
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Workshops
Games and videos with anti-drug messages
Literacy classes
Agriculture classes
School programs
Visits to detox centers
Establishment of youth centers
Youth work core
Skits
Community-based Intervention to Reduce Drug Use
Non-drugusing youths
Non-injecting
drug users
Injecting
drug users
Injecting & sharing
equip. drug users
Intervention points
Intervention activities:
Comprehensive
intervention
activities on
drug/HIV
prevention in
villages
Introduce farming
skills into villages
to assist drug/AIDS
prevention; youth
corps, youth center
Evening class and
and entertainment
to assist drug/AIDS
prevention
Integrating drug/
AIDS prevention
into school
curriculum
Evaluation of Intervention
Comparison of incidence of drug initiation
• Retrospective cohort, October 1995-Feb 1997
• Retrospective cohort, May 1997-Sept 1998
Data collected
• Demographics
• Initiation of drug use, injecting-sharing
• Sexual behavior
Response rate: intervention villages 91%, control
villages 88%
Significant Incidence Changes in New Male
Drug Users in Intervention and Control Villages
Variable
Attributable
Risk Reduction
Incidence
Reduction Ratio*
P-value
All males 15-49
yrs
-99%
2.7
<0.05
Males 15-19 yrs
-479%
>216§
<0.001
Single
-301%
>291§
<0.001
Dai ethnicity
-61%
>60§
<0.001
Jingpo ethnicity
-301%
>196§
<0.001
Illiterate
-616%
>61
<0.001
*Incidence change in intervention group/Incidence change in control group
§Change at baseline set at -0.01 (incidence increased in control area)
Conclusion
Community intervention can be useful
for preventing initiation of drug use, but
not for preventing progression to
injection use
Has the intervention been
sustained?
Yes
Requirements for Successful Needle
Exchange Programs
•Local political and community support
•Cooperation of security officials; e.g., police
•Dissemination of knowledge of availability to injecting
population
•Magnitude/scale sufficient to reduce community reservoir of
infectious syringes/needles
•Supportive, empathetic staff
•Ready availability; e.g., “dial-a-needle”
•Supportive services; e.g., counseling, referral, etc.
•Recognition and support for exchange program staff
Requirements for Successful Drug
Replacement Programs
• Political and community support
• Police non-interference/support
• Committed, rewarded staff
• No entry restrictions to program
• Sufficient dosing
• Drug monitoring
• Supportive services; e.g., counseling, referral, etc.
• Outcomes – abstinence, reduction?
• Measuring impact appropriately; what is the correct denominator?