Transcript HIV prevention among IDUs

Monitoring of the implementation
of UNGASS Commitments:
HIV Prevention among IDUs
by
Karl L. Dehne, UNAIDS, Vienna
Senior Advisor on HIV and Drug Use
March 2003 slide number 1
Presentation overview

UNGASS on HIV/AIDS commitments regarding IDUs

Original behavioural IDU indicator

Proposed (supplementary) service coverage indicator

First round results

Advantages and disadvantages of the two indicators

Conclusions
March 2003 slide number 2
UNGASS ON HIV/AIDS
DECLARATION OF COMMITMENT TARGETS
 Reduce by 2003, HIV incidence for groups
with high/increasing rates of infection
 Develop/strengthen, by 2003, national
strategies to promote health of groups with
high rates of HIV infection, e.g. injecting
drug users
 Ensure, by 2005, a wide range of prevention
programmes, including efforts to reduce
drug use related harm
March 2003 slide number 3
10 Areas of Commitment

Leadership
Prevention
Care, support and treatment
Human rights
Reducing vulnerability

Orphans








Social and economic
impact
Research and
development
Conflicts and disasters
Resources
IDU commitment interpreted as “prevention”
March 2003 slide number 4
Behavioural indicator (1)
• Definition:
• Percentage of injecting drug users who have adopted safe
behaviours (avoided equipment sharing last 30 days and used
condom on last intercourse).
• Purpose
• To assess progress in preventing IDU associated HIV
transmission
• Applicability
• Countries where injecting drug use is a significant mode of
HIV transmission
• Frequency
• Biennial
March 2003 slide number 5
Safe injecting and sexual practices (2)
• Method of measurement:
• Cluster sample or targeted snowball sample survey (BSS
style)
• Sequence of 4 questions (injected? shared? had sex? Used
condoms?)
• Score of those replying yes for denominator (1+3) and
numerator (2+4)
• Interpretation:
• Gaining access to IDUs a challenge (especially where there
are no services!), survey data rarely representative nationally
• Extent of IDU related HIV epidemic also dependent on size of
vulnerable population
March 2003 slide number 6
Coverage indicator (1)
• Definition:
• Percentage of injecting drug users reached during last month with
either (outreach) prevention services or drug dependence
treatment, either longer-term drug-free or substitution therapy.
• Purpose
• To assess progress in the implementation of programmes and
services for the prevention of HIV transmission associated with
injecting drug use
• Applicability
• Countries where injecting drug use is a significant mode of HIV
transmission
• Frequency
• Biennial
March 2003 slide number 7
Coverage indicator (2)
• Measurement
•
•
Denominator (estimated number of regular IDUs):
• Multipliers, as many as possible
• If possible, other methods (e.g. capture-recapture)
• Extrapolate from cities, regions/provinces
• In reality, often multiplier “guesstimate
Numerator
• Inventory of outreach projects and treatment sites
• Service statistics (No. of individual clients last month)
• Interpretation
•
Denominator data will have a considerable margin of error:
best available estimates
•
Different types of services (outreach with provision of advice,
counselling only, needle-syringe programmes, various types
of treatment) all be weighted the same
March 2003 slide number 8
Coverage indicator, definitions (1)
• Outreach
•
•
Any designated programme activity through which injecting drug
users have contact (face-to-face interaction) with service providers,
including, for example, outreach workers, trust points, counselling
centres or clinics, mobile services, etc., and are provided with one of
the following
•
Information on HIV/AIDS
•
Counselling on safer injecting methods
•
Clean needles, syringes and condoms
Outreach can be conducted by professional health care workers as
well as by volunteer peer workers (current or ex-drug users).
Outreach does not include activities, where there is no face-to-face
contact between service provider and drug injector, e.g. media
campaigns
March 2003 slide number 9
Supplemental IDU indicator, definitions (2)
• Substitution treatment
•
Any activity, in which daily* and for a longer period of time (more than
6 months) a substitute for opiates is provided; most common
substitution therapies include methadone maintenance and provision
of buprenorphine. Note that drug-assisted detoxification is not
considered substitution therapy
• Drug-free dependence treatment
•
Any residential treatment lasting more than four weeks with the goal
of total abstinence, including for instance, therapeutic communities;
any longer-term (designed for 6 months and more) drug -free
outpatient treatment, in which the individual has had contacted at
least once during the last 30 days
• For the purpose of estimating the numerator, detoxificationonly in whatever form is not considered treatment
March 2003 slide number 10
Some preliminary results

20 countries approached, in extra effort to obtain
IDU UNGASS indicator results

Coverage indicator results obtained from 9
countries (plus some in-official results)

Behavioural indicator results obtained from 3
countries
March 2003 slide number 11
IDU Service Coverage
in Selected Countries
COUNTRY
Belarus
Estimated No. of
IDUs
% IDUs reached with
prevention services
in last month
50,000
1.8
Brazil
800,000
10.5
China*
400,000
5.0
Indonesia
160,000
1.5
Iran*
135,000
0.6
Nepal
20,000
21.9
Pakistan
60,000
0.4
Romania
30,000
2.2
Viet Nam
84,000
62.7
*reported by UN staff
March 2003 slide number 12
Other important countries
Coverage indicator results not reported
COUNTRY
Estimated No. of
IDUs
% IDUs reached with
prevention services
Ukraine
540,000
10-15
Russian Federation
1.5-2.5 million
< 10
India
0.5-1.6 million
?
March 2003 slide number 13
Behavioural indicator results
COUNTRY
Ukraine
Kazakstan
Surinam
March 2003 slide number 14
No. of IDUs
sampled
600
% IDUs reporting
safe behaviours
65
1365
14.5
9
0
Summary of differences and
commonalities

Impact (like young people’s behaviour) versus
service coverage (like MTCT)

Both composite (IDU & sexual behaviours and
different type of services respectively), requiring
analysis by individual component

Both would require aggregation or extrapolation
from local sites to national level
March 2003 slide number 15
Differences & commonalities (2)

Measurement of both indicators requires extra
efforts beyond existing data compilation in most
countries, but…..

Promotion of coverage indicator measurement
process may be more beneficial for program
development (e.g. inventories, intersectoral
consultations on IDU population size) than series
of behavioural surveys

Political commitment versus commitment of IDUs
March 2003 slide number 16
Additional interpretation issues

Behavioral indicator:
– Safe behaviours: only those reached?
Consistent over time? Definition of sharing
– Unsafe behaviours: risk of blaming the
addicted

Coverage indicator
– Official underestimates of No. of IDUs
– Quality of services
– Definition of treatment (e.g. Vietnam)
March 2003 slide number 17
Issues related to current patterns of
IDU epidemics and responses

IDU population size crucial (and important
vulnerability factor)

Drug dependency tends to make a significant
“spontaneous” reduction in risk behaviours, in the
absence of face-to-face service contacts, unlikely,
and ….

… prevention service currently coverage low (care
service coverage virtually non-existent)
March 2003 slide number 18
Conclusion

Prevention service coverage indicator currently
most appropriate

Behavioural and/or HIV prevalence indicator to be
used in addition, where either
– epidemic is recent, or
– service coverage is significant and likely to
have an impact
March 2003 slide number 19