HIV a major challenge in Prevention. An overview of addiction and HIVspread, AIDS travels through the fault lines of society.

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1 An overview of addiction and HIVspread, Michael Farrell 1 National Addiction Centre, Kings College London London, United Kingdom AIDS travels through the fault lines of society Jonathon Mann Estimated size of IDU population (1998/2003) Challenge to the Global Community Develop Treatment Systems that can meet the needs of large scale and evolving problems of opioid dependence and other injecting drug use Political and moral values of the social system HIV a major challenge in Prevention Research SERVICE Evidence Provider AND USER VIEW A model for evidence-based clinical decisions (from Hayneset 01,1996) 111 1mEmerging Controlling 1mDownturning Epidemics Epidemics Epidemics 1mComprehensive Harm reduction provision of multiple interventions targeted at injection drug use are a key tool of HIV Prevention and Control m Systematic Reviews by Farrell et al 2003, Gowing et al 2004, Sorenson et al 2000, Marsch et al 1998, Zadic et al 2000, Valdiserri et al 1

2 Aw~.:. t~i<"j 1; BAYERPharmaceuticalProduts HER Drug Addiction: chronic relapsing disease (H"" el ai, 2001; ""LeUa, el ai, 2000; abrie, & McLeUa" 1993; GoI"e', & HeITeCa, 1995) It Drug addiction is a chronic,lifelongrelapsingdisease with frequent medical complications (e.g. HIV, HVC, TB) and a high fatality rate f>. ~< "..,. :;'410 ~ Each detoxificationis followed by 80-95% relapse m long-term stable abstinencerates range between 10-25% m Estimatedheritabilityof drugdependence is about 40%. Personalresponsibilitysimilar to other chronicdiseases, e,g. diabetes. Biologicalsubstratesidentifiedfor drugseeking behaviorand relapse. Pharmacologicalinterventions rather ineffectivein cure of drugaddiction.. Pharmacologicalinterventionsquite effective in care for drugaddiction. Treatmentcompliancesimilarlyprobiematicas in other chronic diseases. (Wim Van den Brink2004) A 33 year follow-up of narcotic addicts l.u",row""0..' a",,,~\~i!fde$~\1i.,,6p.qj,j'io~i~'.ab,"~= I N 581 Ag, 24.5(3.9) (5.4) (5.1) % 2% 5% 7% 4% 48% 12% (4.0) Follow up studies 1MA study in Thailand (Celentano 2002) recruited over 1000 drug users entering treatment in Northern Thailand and followed the group for over 2 years after discharge from inpatient detoxification. Ninety six per cent of users relapsed to heroin use within two years and 82 per cent within six months. The global response: UN support for good treatment WHO/UNODC/UNAIDS position paper: Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention "Substitution maintenance treatment is an effective, safe and cost-effective modality for the management of opioid dependence. Repeated rigorous evaluation has demonstrated that such treatment is a valuable and critical component of the effective management of opioid dependence and the prevention of HIVamong IDUs." HIV infection rates in and out of substitution treatment (Metzger et ai, 1993) Out % In % ~\<I",*,,'" ~~'",*,,'",*,,'",*,,'",*,,'" ~~'" ~~'",*,,'",*,,'" '0",'" Q'" ~'Io'" ~'/,'" ~'" ",,<I>'"""Q'" ~'Io'" ri>'" Q<I>'"1'10'" 2

3 Drug Substitution Treatment Availability of substitution treatment iii Strong evidence for the benefits of oral methadone treatment RCTs +++ REASONABLE EFFECT SIZE fi REDUCES DRUG CRIME.70 fi REDUCES OPIATE CONSUMPTION.35 iii REDUCES INJECTING & RISK TAKING 0.22 iii Now good evidence for buprenorphine and LAAM RCTs ++ (LAAM CURRENTLY UNDER REVIEW) iii Use of injectable diamorphine and other drugs building evidence base for comparative effectiveness. more dicussion on comparative cost effectiveness. "g'o'o' - Ch'o. - C.o.li. lodi. lodooo'" - '.M Ky'gy"'o M.I.y'" - Moldo,. - N.p.1 S'og_. - Th.IIMd - Uk.'oo.?? rm.nk, to Gony S'ro'M Drug Users in Substitution Treatment per 100, IIIAustralia DItaly 0 France l1lichina IIISpain l1liuk [ijcanada IUndia D United States D Germany D Sweden IIINepal IIINetherlands IIIDenmark IIIThailand Numbers (per mil pop) receiving methadone in 15 EU member states Source: EMCDDA, 2001 Evolving treatment programmes WiIt is estimated that there are over 67 treatment centres providing opioid agonist therapies and the overall number of patients in these centres is roughly 7000 patients in total. WiHONG KONG mithailand M:IRAN WiMALAYSIA CHINA...EL. 3

4 Background - HIVspread among IDUs I!iAustralia: early methadone, rapid expansion low incidence of HIV in IDUs -mii European Union: Increase in drug substitution services reduction in AIDS cases related to IOU EasMr"nEurope, Russia and new Independent Republics: New epidemics of HIV in IDUs Background - HIVspread among IDUs Asia Pacific - relatively new problem for some countries need to develop culturally appr opriate services Methamphetamine Epidemic Presents new challenges to treatment a nd research community to define its contribution to risk of HIV spread IiiUnited States of America & Canada - initial evaluator and pioneer of methadone - lack of public funding have limited the comprehensiveness of approaches - substantial containment of HIV in IDUs but still major ongoing problem in US Background - HIVspread among IDUs v South America - Long standing cocaine crack problem substantial contribution to HIV through risk behaviour and aiso less so through transition to injecting iii Africa evolving drug and injecting problem but drowned out by scale of general HIV and social infrastructure problems in many countries II Central & Eastern Europe - Rapidly evolving HIV probiem in IDUs HIV in European IDUs w Generally well contained except for recent increases in Portugal PiSpain, France and Italy experienced major HIV epidemic in IDUs successfully contained through broad prevention strategy including expansion of substitution treatment, Other Major Infections 1MTuberculosis, major problem where established HIV among IOU Pi Hepatitis Cover 90% plus in those with a long history of injecting drug use Substitution in prisons Estimated that over 30 million imprisoned annually IlK Major risk for blood borne virus spread I!i In most countries where measured between one third and half have drug of methadone in prison (Dolan et al) demonstrates role in reduction of blood borne virus, and general improvement, and post release reduction in mortality for those who expansion in Europe in substitution in prisons Ii Huge challenge for Asia pacific region where insitutional incarceration standard response to opioid 90% relapse to heroin use, no 4

5 Drug Overdose and Mortality II!!Mean of 5+ non fatal overdoses using cohorts II!!Mortality 1 to 2% in heroin II!!In methadone treatment down to 0.2% II!!Recent Hser 33 year longitudinal study reports over 50% mortality in cohort II!!Suicide completion rates high and significant contributor to overall suicide 45 :840 ~ 35 ~30 ~ 25 e20 ::15 ~ 10 ~ 5 0 Excessmortalityratiofor differenttimeperiodspost;eleaseby causeof death(singleton,farrell,marsdenet al 2003). [)-ug-relateddeaths0 Notdrug.related \0\ \01. \O~ \0'0 \'0 1.~ <:,'!.,..<:'1.,\o"~ '0"<,~"< 1.~"< ~~"< '0~"<\0,'0 ~"<\0 1.,,;,>,,<\0 Tilliesi1ce release (weeks) The odds of a drug-related death in the first week of release _.n.wom~. ~w 10""''''''''''~''atob''''odat~.Y..«OR1D.6; 96%<: ) Iii70 ""'highw"~", ~""od...w.pop""~ Wh.ng m... w~'d8 'me','.alw"~ at on. Y'" (OR %CI ). Ii 30 'me, hi,h.,"~ ago mal","",",,,01 pop.latlon (S.~.'on. FeooD.' ) II! IN SUMMARY A 8-10 FOLD INCREASED RISK OF MORTALITY IN THE EARLY RELEASE PERIOD Consequences of drug use within correctional settings I!illPressures on prison environment - health services - prison staff - security I!illHIV, hepatitis Band C m:tuberculosis II!!Recidivism - use of drugs is a predictor of recidivism 5

6 Changes in ATS Abuse ( ) Other Changes to be considered ~A.owi" :::.,," m~, ~Are" wiili :::~,,,'" m= 1mChanges in the alcohol industry n Other mood altering drug availability 1MChanges in sexual behaviour around mood altering drugs including alcohol n Reconsideration of role of alcohol and other drugs in high risk taking environments and indiviudals, from a health education perspective HILL CRITERIA LOOKING AT THE CRITERIA H STRENGTH OF ASSOCIATION H CONSISTENCY 1MPLAUSABILITY H!COHERENCE R!EXPERIMENTAL R!SPECIFICITY EVIDENCE OF EFFECT But does this evidence apply in developing countries? I!JThe majority of countries that have developed substitution therapies outside the United States have introduced the programmes as part of a pilot feasibility study where the main assessment has been to determine the capacity of the treatment system to operationalise the treatment within particular cultural settings, and to assess the impact of treatment on those individuals who undergo treatment H HONG KONG** rmbangkok** rmiran rmmalaysia mmchina R! INDONESIA rmvietnam What sort of delivery system is req uired mlneeds integrated health care system mlpublic Health Strategy to achieve maximum coverage HIPrimary care training in delivery of treatment R!Family Practice Approach WiPrisons based care linked to community ongoing treatment 6

7 Direct Observed Therapy. Enables implementation of Anti TB Therapy. Enables delivery of HAART III:Enables future delivery of Combination therapies for Hepatitis C II: Complex multidisciplinary teams required to gen erate appropriate treatment programmes, much work to be done iii Agonist therapies are a critical component of the implementation of HAART as part of the International 3 by 5 initiative in many countries particularly in the Asia Pacific Region Summary Ii Evidence for major benefits of treatment in reducing spread of HIV 1mStrongest evidence for maintenance agonist treatment with methadone or burprenorphine or other mu opoid agonists 1mStrongest evidence for treatment in broader context of comprehensive social response to social problem of drug use, dependence and injecting. 1mBelief systems are a greater obstacles to implementation in many countries that are resource limitations. Further details... Dr. Michael Farrell National Addiction Centre 4 Windsor Walk London SE5 8AF m.farrell(q2iod.kcl.ac.uk 7