Collaborative TB and HIV Services for Drug Users. Christian Gunneberg M.O. WHO

Transcription

1 Collaborative TB and HIV Services for Drug Users Christian Gunneberg M.O. WHO

2 What I will address The problems of HIV/TB and Drug use. The policy guide. What next.

3 Drug use and HIV Drug users are a large vulnerable group 15.9 million (11-21) injecting drug users worldwide, 3 million ( ) past and current injecting drug users are living with HIV/AIDS (20% of total) 10% of HIV infections are attributable to drug users Injecting drug use is a driver of the HIV epidemic > 60% of all HIV cases in Eastern Europe Central Asia Around 30% South East & East Asia /US Canada/Latin America

4 Explosive HIV spread among IDUs 80 Myanmar* Edinburgh Manipur* & Yunnan Vancouver HIV prevalence (%) 20 Bangkok* Ho Chi Minh City Odessa* *HIV prevalence among general population >1%

5 IV drug use in countries of the SEAR 2007 Country Estimated no of fiv drug users Estimated %HIV positive India 168, % Bangladesh 31, % Nepal 24, % Thailand 169, % Myanmar 75, % Indonesia 222, % REFERENCE: Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, Wodak A, Panda S, Tyndall M, Toufik A, Mattick RP; 2007 Reference Group to the UN on HIV and Injecting Drug Use. Lancet Nov 15;372(9651): Epub 2008 Sep 23

6 What is TB? TB infection (one in 3) transmitted by coughing (overcrowding/country with high TB prevalence) progresses to disease for 1 in 10 infected (unless immunosuppression: HIV, malnutrition, Alcohol/ homelessness/poverty ) INH tablet can clear infection TB is curable.

7 Drug use and TB Drug users have times rates of TB Drug users are in and out of prisons. In prison TB rates are 10 to 50 times higher HIV adds additional risks of TB from 5-10% lifetime risk to 5-10% annual risk of TB 23% of all HIV deaths from TB

8 % of HIV cases that are Drug use related >70% Eastern Europe & Central Asia 50% in China 20% in South/South East Asia This slide shows that a number of the regions/countries where the HIV epidemic is driven by drug users are also those with high estimated rates of MDR TB. This is bad news for drug users and TB control

9 South Africa 24% Uganda 3% UR Tanzania 4% Zambia 3% Zimbabwe 5% Brazil 1% AMR* 1% Russian Federation 2% EUR* 1% Nigeria 9% Other 21% India 8% SEAR* 3% China Mozambique 2% 3% Malawi WPR 2% AFR* 2% Kenya Ethiopia Côte d'ivoire 13% EMR 5% 4% 2% 1% Figure 1.2 Geographical distribution of estimated HIV-positive TB cases, For each country or region, the number of incident TB cases arising in people with HIV is shown as a percentage of the global total of such cases. AFR* is all countries in the WHO African Region except those shown separately; AMR* excludes Brazil; EUR* excludes the Russian Federation; SEAR* excludes India and WPR* excludes China

10 TB/HIV Figures Million TB incident cases 9.3 HIV prevalent cases 30 HIV deaths 2.0 TB/HIV incident cases 1.37 TB/HIV deaths 0.46 TB/HIV causes 23 % of all HIV deaths (0.46/2 million)

11 Drug users have poor access to services HIV prevention coverage is low access to ART treatment is low. Services in "silos" Drug users have to make choice TB inpatient or drug treatment missed opportunities "low threshold" services Prejudice & denial of treatment: adherence Hep C Pi Prison may bar access to services

12 The need for a policy response The need for proper treatment: Human right Service collaboration works better than Silo thinking Adherence measures work Treatment t completion for TB Tx IPT and ART comparable to those not using drugs Failure to act: public health impact. Poor treatment high death rates & morbidity The deadly mix in a vulnerable group: High rates of HIV; High rates of TB. poor treatment adherence -> increase in tuberculosis drug resistance

13 Collaboration UNODC,UNAIDS, WHO Evidence gathering. Expert group meeting Nov 07 Copenhagen Development of recommendations Guideline launch August 08 (IAS Mexico)

14 Recommendations 1. Joint Planning Service providers 2. Package of Care 3. Overcoming Barriers

15 Recommendation: 1. Joint Planning Service providers Prison Services Drug treatment Services Drug users & NGOS Primary care Services HIV Services TB Services Advocacy Harm reduction Support/ Low Threshold Services

16 Recommendations 2. Package of care Intensified case finding for TB & HIV testingti using all "points of contact" t" Treat HIV (ART) and TB Prevent TB: Through IPT in drug users with HIV Prevention of TB through Infection Control Prevent HIV & Harm Reduction: Needle Exchanges Opioid Substitution therapy Condom programming for IDUs and partners STI prevention Hepatitis vaccination and treatment

17 Recommendations 3. Overcoming Barriers to find and treat Service delivery: integrated /patient centred include low threshhold services Adherence: accept possibility and promote methods Co-morbidity: monitoring, not Tx refusal Prisons: give equivalent Tx and follow up patient

18 From paper to practice It is critical that community organisations, NGOs, and local WHO offices make sure that communities and governments receive this message.

19 WHAT NEXT? Distributed to all WHO offices globally Translation into Chinese (WHO) and Russian (UNODC). Dissemination at TB and HIV managers wkshops Highlight national examples of integrated services and challenges faced. Plans for regional training for drug treatment and harm reduction services and country implementation as part of harm reduction programmes-(who/unodc)

20 From the press launch in August 2008 Constraints: Coordination Culture of talking to one another, sharing resources Suppressive national policies Local suppressive environment Local suppressive environment wonderful national policy, local level, suppressive, stigmatising environment.

21 Main Challenge Drug users need to be seen as people who have a medical need and a right to services

22 Acknowledgements External Experts Rick ALTICE, USA Oscar BARRENECHE, Myanmar Alexey BOBRIK, Open Health Institute, The Russian Federation Vioral SOLTAN, Moldova Agnes GEBHARD, Netherlands Peter SELWYN, USA Mark TYNDALL, Canada Jonathan BEYNON, ICRC Konstantin LEVSENTEV, Ukraine Orival SILVERA, Brazil Fabio MESQUITA, Hernan REYES, ICRC Secretariat WHO Nicolas Clark, Mental Health and Subs tanc e Abus e Depart ment HQ Lucica Ditiu Stop TB, Medical Officerf TB/HIV EURO Martin Donoghue (Adviser, HIV/AIDS Injecting Drug Use & Har m Reduction EURO) Reuben Granich HIV Department. HQ Christian Gunneberg Stop TB Department HQ. Kirsten McHarry HIV Department. HQ Paul Nunn Stop TB Depart ment HQ. Kathrin Thomas Stop T B Depart ment HQ. Annette Verster HIV Department. HQ UNODC Monica Beg Fabienne Hariga UNAIDS Alasdair Reid Igor Toskin Jyothi Raja