Consultative Meeting on Optimal Models of Care for People who Inject Drugs

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1 Consultative Meeting on Optimal Models of Care for Dar es Salaam, Tanzania April 2014 Meeting Report

2 TABLE OF CONTENTS ACKNOWLEDGEMENTS... 3 ABBREVIATIONS... 4 EXECUTIVE SUMMARY... 5 BACKGROUND... 7 DAY 1: MONDAY, APRIL 14, Updates and Recent Developments of Critical Interest... 9 Session 01: Comprehensive Package of Services for PWID... 9 Session 02: WHO Consolidated Guidelines for Key Populations Session 03: Tanzania s Implementation Science Initiative Session 04: Needle and Syringe Program Delivery Session 05: Opioid Substitution Therapy DAY 2: TUESDAY, APRIL 15, Session 06: Integration of Services: Health Facility and Community Models Session 07: Integration of Services: HIV Diagnosis, Care and Treatment Session 08: Integration of Services: Tuberculosis Diagnosis, Care and Treatment Meeting Conclusions and Next Steps REFERENCES APPENDIX I: KEY RECOMMENDATIONS APPENDIX II: KEY LESSONS LEARNED APPENDIX III: AGENDA APPENDIX IV: LIST OF PARTICIPANTS Consultative Meeting on Optimal Models of Care for 2

3 ACKNOWLEDGEMENTS Pangaea Global AIDS would like to thank all conveners, experts and participants who attended the meeting. Consultative Meeting on Optimal Models of Care for 3

4 ABBREVIATIONS AIDS ART CAHR CBO CDC CSO HBV HCV HR HIV HTC IDU IEC KANCO KenPUD KP MARP MAT M&E MDH MdM MMT MNH MOH MRH MSF NACADA NAS NGO NSE NSP OST Pangaea PE PEPFAR PMTCT PWID PWUD IBBSS SOP STI SW TB TanPUD UNAIDS UNODC USAID USG WHO Acquired Immunodeficiency Syndrome Antiretroviral therapy Community Action on Harm Reduction Community-based organization United States Centers for Disease Control and Prevention Civil society organization Hepatitis B virus Hepatitis C Virus Harm Reduction Human immunodeficiency virus HIV testing and counseling Injection drug user Information, education and communication Kenya AIDS NGOs Consortium Kenyan Network of People who Use Drugs Key population Most-at-risk population Medication-assisted treatment Monitoring and evaluation Management and Development for Health Médecins du Monde Methadone maintenance treatment Muhimbili National Hospital Ministry of Health Mwananyamala Regional Hospital Médecins Sans Frontières National Authority for the Campaign against Alcohol and Drug Abuse National AIDS Secretariat Non-governmental organization Needle and syringe exchange Needle and syringe program Opioid substitution therapy Pangaea Global AIDS Peer educator President s Emergency Plan for AIDS Relief Prevention of mother-to-child transmission People who inject drugs People who use drugs Integrated Biological and Behavioral Surveillance Survey Standard operating procedure Sexually transmitted infection Sex worker Tuberculosis Tanzanian Network of People who Use Drugs Joint United Nations Program on HIV/AIDS United Nations Office on Drugs and Crime United States Agency for International Development United States Government World Health Organization Consultative Meeting on Optimal Models of Care for 4

5 EXECUTIVE SUMMARY HIV and drug abuse are serious inter-related health problems around the world. Recent estimates indicate that there are 16 million people who inject drugs (PWID) throughout 148 counties, among which three million (range million) are living with HIV. In most countries, the prevalence of HIV among PWID is higher compared to the general population due injection-related and sexual risk behaviors associated with drug use. Despite increased HIV risk among PWID, harm reduction and HIV prevention programs among this group are limited, especially in resource-constrained countries. Supported by the Bill and Melinda Gates Foundation, the consultative meeting on Optimal Models of Care for was organized to identify best practices and models of care that provide comprehensive, evidence-based interventions, promote successful linkage to HIV testing, care and treatment, and integrate collaborative TB and HIV services for people who inject drugs. Recommendations from this meeting are intended to inform the World Health Organization s (WHO) 2014 consolidated treatment guidelines for key populations (KP). The meeting took place in Dar es Salaam, Tanzania on 14 and 15 April With a focus on facility- and community-based service delivery models, participants presented and discussed approaches and case examples of the comprehensive package of HIV services for people who inject drugs. In particular, this meeting focused on needle and syringe exchange (NSE), opioid substitution therapy (OST), facility and community-based models, and integration of services for the diagnosis, care and treatment of HIV and TB. People who use and inject drugs are commonly marginalized and mobile. To effectively deliver a harm reduction program, varied models of service delivery (e.g. fixed sites, mobile, outreach workers) and involvement of peer educators (PEs) as outreach workers should be considered. Harm reduction programs should be free-of-charge, always available and include comprehensive, integrated services. Treatment of concurrent illnesses such as mental illness (e.g., depression) and other medical conditions associated with injection drug use (e.g., HIV, Hepatitis B, Hepatitis C and TB) should be integrated within OST or NSE sites. To increase their effectiveness and impact, OST programs should streamline the admissions process with rapid access to treatment dosing on the day of presentation is ideal. OST programs provide stability and improve well-being, thereby providing an opportunity for improving the uptake of and retention in other health services, including HIV and TB treatments. Prior to implementation, community programs should conduct a mapping exercise to identify and integrate key stakeholders into the program planning. Community interventions work well with the involvement of non-governmental organizations (NGOs) and local social workers because they are well equipped and knowledgeable of the socio-cultural issues that might affect entry and sustainability of the program. Community advocacy should also be an ongoing activity. Programs should continue to engage and sensitize the drug user community, general community members and law enforcement at all times. Peer educators are instrumental in registering and supporting the follow-up of clients. Community programs should aim to provide other HIV prevention services such as mobile HIV testing and counseling (HTC) services, awareness and sensitization, information, education and communication (IEC), distribution of kits comprised of the full range of injection equipment and safe waste collection. Once established, harm reduction programs can be scaled up rapidly since wider coverage is important to realize the intended HIV prevention impact. Programs should also design and implement mechanisms to Consultative Meeting on Optimal Models of Care for 5

6 ensure adherence and retention, create linkages and referrals to other services, and support PWID networks and community support groups. In addition to providing evidence of best practices, this meeting report will support the WHO s consolidated guidelines on HIV prevention, care and treatment for key populations. Ongoing and new programs will also benefit from lessons, best practices and strategies described in this report. Consultative Meeting on Optimal Models of Care for 6

7 BACKGROUND Recent estimates indicate that there are 16 million people who inject drugs (PWID) throughout 148 countries, among which three million (range million) are living with HIV. 1 In most countries, the prevalence of HIV among PWID is higher compared to the general population due to increased risk behaviors associated with unsafe injection practices and sexual behaviors. Extensive evidence supports a comprehensive package of services and interventions for PWID. 2 In particular, PEPFAR supports a package with three central components: 1) community-based outreach programs; 2) sterile needle and syringe programs (NSP); and 3) drug dependence treatment, including medication-assisted treatment (MAT) with methadone or buprenorphine and/or other effective medications as appropriate, based on country context. WHO, with support from Pangaea Global AIDS and the Bill and Melinda Gates Foundation, convened the consultative meeting on Optimal Models of Care for to identify best practices and models of care that provide comprehensive, evidence-based interventions, promote successful linkage to HIV testing, care and treatment, and integrate collaborative TB and HIV services for people who inject drugs. Objectives With a focus on facility- and community-based service delivery models, five overarching objectives were set for this meeting. 1. Define a minimal package of integrated services for people who inject drugs; 2. Highlight challenges and barriers to provision of HIV services for people who inject drugs; 3. Identify innovative approaches for HIV prevention, testing, care and treatment for people who inject drugs; 4. Identify successful models of HIV service delivery for people who inject drugs; and 5. Identify research gaps among people who inject drugs. The recommendations of this meeting are intended to inform WHO s 2014 consolidated guidelines on HIV prevention, care and treatment for key populations. In addition, outcomes of this meeting will be published and shared widely to accelerate adoption of best practices amongst countries that are starting to scale up HIV-related services for PWID, guide operational research initiatives and strengthen the development of best practice guidelines in the future. Process Each session focused on a component of the comprehensive package of services for PWID. In each session, the panel convener and moderator provided a brief technical overview, global status update, and evidencebased best practices summary. Each panelist was invited to provide case examples of service delivery, with an emphasis on: 1. Challenges and barriers to provision of HIV services; 2. Innovative approaches to overcome barriers for HIV prevention, testing, and care; 3. Uptake and effectiveness of delivery models; and 4. Existing research gaps associated. Following panelist presentations, a facilitated discussion took place to allow for questions and comments from other invited participants. This report summarizes the content of the meeting s sessions and attendee input. The report is organized by day and documents the opening remarks, daily session summaries, and consensus of expert opinions. Consultative Meeting on Optimal Models of Care for 7

8 This meeting report does not present officially endorsed guidelines or guidance by the World Health Organization. Its purpose is to inform the 2014 consolidated guidelines on HIV prevention, care and treatment for key populations. Consultative Meeting on Optimal Models of Care for 8

9 DAY 1: MONDAY, APRIL 14, 2014 Updates and Recent Developments of Critical Interest Session 01: Comprehensive Package of Services for PWID Speakers/Facilitators: R. Douglas Bruce (Pangaea) Overview Epidemics of HIV among people who inject drugs are emerging throughout the former states of the Soviet Union, Southeast Asia and China, South America, and East Africa. Approximately three million (range million) PWID worldwide are living with HIV. In addition to increased risk for HIV, PWID also face serious co-morbidities such as Hepatitis B and C and Tuberculosis (TB) infection. In Tanzania, TB rates among PWID receiving methadone are estimated to be 4,000 per 100,000, nearly 23 times higher than the general population. The World Health Organization strongly supports harm reduction as an evidence-based approach to HIV prevention, treatment and care for people who inject drugs and has defined a comprehensive package (Table 1). Table 1. Comprehensive Package for the Prevention, Treatment and Care of HIV for 2 Community-based outreach; Needle and Syringe Programs (NSPs); Opioid substitution therapy (OST) and other drug dependence treatment; HIV counseling and testing (HCT); Antiretroviral therapy for drug users living with HIV; Prevention and treatment of sexually transmitted infections (STIs); Condom programs for IDUs and their sexual partners; Targeted information, education and communication (IEC) for IDUs and their sexual partners; Vaccination, diagnosis and treatment of viral hepatitis; and Prevention, diagnosis and treatment of tuberculosis Despite the overwhelming health benefits of OST, the uptake and scale-up of OST in many areas of the world remains one of secondary, rather than primary, HIV prevention. However, with flexible eligibility requirements and delivery of services, low threshold programs can expand treatment accessibility to hardto-reach populations. Low threshold programs have also been shown to effectively engage clients who were previously referred but failed to enter traditional treatment programs. In addition to reaching at-risk individuals, rapid assessment and dissemination of evidence-based services, through high volume sites, is needed to have the maximum impact on drug use and HIV risk behaviors. High threshold programs often require a more healthy and motivated client from the beginning and therefore limits access to many. There is limited evidence that delaying treatment for more comprehensive psychosocial services improves outcomes. Therefore, clinics must lower thresholds by reducing unnecessary barriers to care and focus on provision of a minimal package of services in order to reach high volumes of clients. In general, low threshold models associated with higher volume. Consultative Meeting on Optimal Models of Care for 9

10 While primary prevention will prevent an uninfected individual from acquiring HIV, secondary prevention will prevent someone living with HIV from transmitting the virus to others. Low threshold programs attract a high volume of clients and targets primary prevention of HIV. Evidence-based prevention interventions for PWID should be provided to those who need them, regardless of the injection status, coinfections, or length of drug use. It is therefore pragmatic to provide pharmacological support such as OST to all who need it. Methadone shouldn t be treated as gold. Among the chronic illness drugs in use today, it is one of the cheapest drugs available when you calculate individual dose per year. - Dr. R. Douglas Bruce, Pangaea Small-scale NSP and OST programs are feasible and effective in resource constrained settings, however coverage is often uneven. Scale-up of OST has been successful in many areas, including New York City and Hong Kong where 30,000 and 15,000 clients were started on methadone within 24 months, respectively. In these programs, it has clearly been shown that increasing the number of people on treatment resulted in reductions in HIV infection. These programs provide practical examples of success and effectiveness. Scaleup of PWID-focused interventions, including methadone programs in particular, should be prioritized. The only real criteria for admission to methadone should be the injection of an opioid for any length of time and all non-injectors who clearly need pharmacological support. - Dr. R. Douglas Bruce, Pangaea Key Recommendations Low threshold programs are needed to increase access to OST and other HIV prevention services. Interventions should include strategies for both primary and secondary prevention of HIV. To scale up this program, it will be important for program to normalize care and refine triaging criteria to allow for mass enrollment. Session 02: WHO Consolidated Guidelines for Key Populations Speakers/Facilitators: Graham Shaw (WHO) Overview Key populations (KP) are disproportionately affected by HIV and are key to both the dynamics of and the response to the epidemic. The WHO definition of key populations includes men who have sex with men (MSM), people in prison and other closed settings, PWID, male and female sex workers (SW) and transgender people with a focus on transgender women. Adolescent members of key populations may also exist and should be considered in any program planning. Currently, each key population has a separate set of WHO guidelines for implementing agencies working with these groups of individuals. In July 2014, WHO will issue consolidated guidelines for national program managers and other decision makers to consider in their HIV response for KPs. The consolidated approach calls for horizontal thinking in the provision of services for KPs. Guidelines for each population will continue to inform field teams on how to respond in specific situations and groups. Health sector interventions for HIV include services for HIV prevention, sexual and reproductive health, HIV treatment and care, ARV-related prevention, substance use related harm reduction interventions, and prevention and management of co-infection and co-morbidities. Specific examples of activities under each service area are presented in Table 2. These evidence-based activities are generally well understood. However, interventions must be coupled with critical enablers for the success and sustainability of programs. Critical enablers are activities that are necessary to support the effectiveness and efficiency of basic program activities. 3 Critical enablers overcome major barriers to service provision and uptake. Examples include fostering a supportive, non-discriminatory policy and legal environment, reducing stigma Consultative Meeting on Optimal Models of Care for 10

11 and discrimination, community empowerment for key populations, and reducing violence against key populations. Table 2. Health Sector Interventions for HIV 4 HIV prevention Sexual and reproductive health Comprehensive condom and Contraception lubricant programming Safe abortion Behavioural interventions Cervical screening Voluntary medical male Conception and pregnancy circumcision for HIV prevention Sexually transmitted infections HIV testing and counselling HIV treatment and care ART Prevention of mother to child transmission (PMTCT) Drug interactions Nutrition ARV related prevention Pre-exposure prophylaxis (PrEP) Post-exposure prophylaxis (PEP) Early initiation of ART Substance use related harm interventions Needle and Syringe Programmes (NSP) Medically Assisted Treatment (MAT) Other drug dependence treatment Overdose prevention and management Prevention and management of co-infections and comorbidities Tuberculosis Viral hepatitis Mental health Session 03: Tanzania s Implementation Science Initiative Speakers/Facilitators: Eva Matiko (CDC, Tanzania) and Richard Needle (CDC) Overview To respond to and align resources with the nature of a changing epidemic, the President's Emergency Plan for AIDS Relief (PEPFAR) has introduced the Key Populations Implementation Science Fund (KPIS) and Key Populations Challenge Fund. KPIS will provide funding for the implementation and evaluation of innovative public health strategies and the challenge fund will support scale-up of KP services in 17 countries. At least ten KPIS awards are anticipated and so far, four countries- Tanzania, Kyrgyzstan, Ukraine and Kenya- have received KPIS grants. In Dar es Salaam, the capital city of Tanzania, the prevalence of HIV among PWID is estimated between 30-50%, which is very high compared to the prevalence of general population in the city (7%). 5-7 A population estimates review conducted in April 2014 by the Tanzanian Ministry of Health and Social Welfare (MoHSW) and its partners estimated 30,000 PWID in Tanzania. In 2010, the government of Tanzania began developing national guidelines for the provision of comprehensive services for KP. In 2011, Tanzania launched the first publicly-funded medication-assisted treatment clinic (i.e. methadone clinic) on the mainland of sub-saharan Africa. There are now three MAT clinics in Dar es Salaam, with just over 1,000 clients initiated on treatment. However, the burden on methadone patients is high and programs should explore innovative strategies to enable scale-up of services to PWID. Take Home Methadone Proposal Funded by KPIS, Tanzania s proposed initiative will examine alternative and flexible dosing options to provide take-away methadone doses and reduce the number of clinic visits for stable patients. The main Consultative Meeting on Optimal Models of Care for 11

12 outcome of interest is to increase coverage, while secondary outcomes include evaluating retention in MAT, ART and TB treatment, cost per client and to the client, client satisfaction and quality of life, and provider satisfaction. Session 04: Needle and Syringe Program Delivery Convener: Rich Needle Expert Panel: Ancella Voets (MdM, Tanzania), Anouchka Saddul (NAS, Mauritius), George Githuka (MOH/NACADA, Kenya), and Sylvia Ayon (KANCO, Kenya) Overview Needle and syringe exchange programs are one of the most important evidence-based interventions. NSPs provide access to sterile needles, syringes, and other safe injection equipment; and subsequently increase access to other HIV prevention services, referrals and care and treatment. NSPs contribute to reduction of injection-related risk behaviors (e.g. decreased frequency and sharing, increased cleaning), reduction in circulation of contaminated needles, increased uptake of health services, and decrease in HIV and HCV transmission without increasing frequency of drug use or number of PWID. Best practices for NSPs include early implementation, large-scale with no restrictions on exchanges, encouragement of secondary exchange, flexible delivery strategies, and co-location of ancillary services. In addition, program planning and operations should include PWID community members and local law enforcement. Structural interventions, including the use of low dead space syringes, can further prevent transmission of HIV. High dead space syringes retain up to 1,000 more volume of blood after rinsing and subsequently transmit up to 1,000 more HIV when shared. Despite strong scientific evidence and affordability, coverage is quite low. In many areas, NSPs have not reached sufficient coverage levels needed to realize the intended public health outcome and impact (Figure 1). Figure 1. Coverage of Harm Reduction Programs Worldwide 8 Consultative Meeting on Optimal Models of Care for 12

13 Case Presentation: Varied Models of Delivery in Mauritius In Mauritius, the prevalence of HIV and HCV among PWID are 44% and 97%, respectively. A variety of delivery models are used to provide services, which include fixed sites, mobile caravans, motorcycles, and on-foot outreach workers or peer educators. Secondary distribution of injection equipment is also being practiced to provide access to hard-to-reach individuals. In addition to distribution of injection equipment, ancillary services are provided at specific sites and at times convenient to the client. Ambitious targets helped drive decentralization and scale-up of NSPs in Mauritius. With diverse models of care, the program has been able to reach different pockets of the PWID population. Drop-in centers allow for personal privacy and confidentiality while outreach workers are able to serve individuals with limited mobility and schedule flexibility. We started a backpack program, after realizing that we were not hitting our targets. If it wasn t for the ambitious targets, we could probably relax as the fixed services were working quite well. We noted that we were not reaching the number of people we intended. - Anouchka Saddul, NAS, Mauritius To ensure quality and uptake of syringes, programs should consult with local PWID to evaluate different types of syringes and determine which are preferred or acceptable. Community engagement, family and peer support and local law enforcement support are critical to the success of these programs. These can be achieved by conducting power mapping before initiation of the program and leveraging partnerships between government and religious leaders and civil society organizations (CSO). Case Presentation: Services beyond WHO Intervention Package in Tanzania In Tanzania, Medecins du Monde (MdM) provides needle and syringe exchange in a drop-in center (DIC) and conducts outreach using outreach workers and peer educators. They also refer and escort clients for MAT and HIV-related services. The DIC provides comprehensive services such as HTC, testing and management of STIs and condom distribution. The program realized the need to expand services beyond the WHO-recommended intervention package, subsequently providing services such as wound dressing, basic medical care, accompanied referral for other medical care, counselling by a psychologist (individual, group, couple, and family), training on human rights for PWUD, legal aid for PWUD, coaching and support for cooperative businesses and alphabetization classes. They also raise awareness through a training and resource center (e.g. training and sensitization sessions for police, medical staff, religious leaders, ward & street leaders, municipal councilors, etc.) and train peers on overdose signs and management of overdose, while advocating for use of Naloxone. During International Overdose Awareness Day, we ask PWID to write the names of those they want to remember and who, presumably, passed away due to overdose. The list is alarming. Perhaps not all died due to overdose, but there is no question that, overdose has claimed a magnitude of PWID. - Ancella Voets, MdM It is important to develop supporting mechanisms for re-entry into communities. Regardless of current drug use, all clients who are interested and assessed capable, are able to participate in trainings for incomegenerating activities. Even for active users, it is important to support them in finding their way back into society. The International Labour Organization (ILO) in Dar es Salaam, has supported a program to train and support corporative business. Seven groups of PWID have since started businesses. Case Presentation: Scale-up of NSP in Kenya Forty-eight percent of PWID reported using another person s syringe during last injection. Among the most common reasons for sharing, 67.1% indicated having no clean syringe/needle available and 14.2% indicated using a needle/syringe after a person whom he/she trusted. NSPs are operated in fixed sites and through mobile outreach. In addition to providing clean equipment, sites also conduct advocacy to communities and law enforcement and offer a wide-range of services to PWID (e.g. education, health care, Consultative Meeting on Optimal Models of Care for 13

14 immunization). Recent scale-up of NSP has resulted in nearly 15 times more syringes distributed and 10 times more PWID reached. Despite these efforts, current coverage of NSP remains low, at 11%, among KANCO-supported sites in Nairobi and Coastal Regions. Challenges to scale-up of programs include resource constraints, continued criminalization of drug users, high levels of stigma and limited drug treatment options. Qualitative and operational research initiatives are underway to assess access to care and inform the appropriate package for NSP kits. The TLC-IDU Kenya study will leverage NSPs and other related services for PWID to evaluate effects on HIV incidence. As part of this research, peer case managers will conduct rapid HIV testing, point-of-care (POC) CD4 screenings, provide linkage to ART, and evaluate community viral load impact. Discussion A well-defined monitoring and evaluation system is essential for implementers to trace clients as they move between areas and health care delivery points. It is equally important to monitor the trends through regular integrated biological and behavioral surveillance (IBBS) while also measuring client and provider satisfaction levels. Programs should estimate population size and set ambitious targets that enable them to think beyond regular service provision. Early initiation and large scale are important in achieving full impact of NSP. To achieve this, removing unnecessary barriers such as one-to-one syringe exchange are important. Where appropriate, NSPs should also provide other services such as HTC, HCV testing, TB screening and management of diseases. Strategies that have contributed to the success of the program include PWID ownership and involvement in the program. In particular, programs should give autonomy to outreach workers and peer educators to conduct services and follow-up with clients. Services should be free-of-charge, voluntary and nondiscriminatory. Other successes to programs are attributed to creating and motivating a team and staying updated on the trends or changes of the epidemic and behaviors. To ensure sustainability, programs should engage in capacity building of PWID organizations and communities through education, including job training and internship programs. Key Recommendations Whenever feasible, NSPs should be initiated as early as possible. Following initiation, there are opportunities to learn and scale-up. Programs should evaluate preferences and acceptability of syringe types from the PWID community. To effectively operationalize NSPs, varied and flexible models of service delivery should be considered (e.g. fixed sites, mobile, outreach workers, peer educators). Harm reduction programs should be free of charge and accessible to the intended clients. Services should be established at convenient locations and with flexible hours of services. NSPs should design and encourage secondary distribution of needles and syringes (e.g. pharmacies, DIC, health points). Whenever possible the goal should be to provide full range of injection equipment. NSPs should eliminate unnecessary restrictions such as numbers of syringes per exchange or oneto one exchange. NSPs should involve members of the PWID community and peer educators throughout planning and implementation. NSPs should provide related services in the comprehensive package such as HIV and HCV testing, condom distribution, outreach, and education. Initial and continued cooperation is needed from local law enforcement. Strong monitoring and evaluation systems are needed to evaluate the uptake of services and identify programmatic gaps. Consultative Meeting on Optimal Models of Care for 14

15 Session 05: Opioid Substitution Therapy Convener: Eva Matiko Expert Panel: Cassian Nyandindi (MRH, Tanzania), Deus Buma (MNH, Tanzania), and Sewraz Corceal (MOH, Mauritius) Overview It is well established that upon early initiation of an adequate dose of opioid substitution therapy, with sufficient adherence, PWID will have better clinical outcomes and better able to return to their community. OST prevents withdrawal and relieves cravings for opioids. It is however, important to note that OST should not be designed as an isolated service, since most PWID suffer from concurrent medical conditions such as HIV, HCV, HBV, TB and fungal infection, abscesses, dental caries and mental illnesses. OST programs provide stability and improve well-being, thereby providing an opportunity for improving the uptake of and retention in other health services, including HIV and TB treatments. Therefore, integration of complementary services should be considered within existing programs. OST clinics should have strong community programs that support the recruitment, registration, counseling, induction, dispensing and follow up of clients on treatment. The induction process seems to be rather long, requiring a series of psychosocial counseling and induction preparation. The existing methadone treatment models include residential to day care clinics, outpatient clinics and mobile van dispensing units. To prevent overdose, Naloxone can be provided by community outreach workers who are trained to identify symptoms of overdose and administer at any time. Optimal dosing of methadone is associated with early stabilization, increased retention and adherence and better clinical outcomes. Upon methadone initiation, patients should be assessed frequently to determine the optimal dose of methadone. Providers also need to consider drug interactions during treatment initiation. In particular, many clients may be on medications to treat TB, malaria or HIV. Flexible dosing strategies, including take-away doses and peer groups for methadone distribution, can decrease burden on health care workers and clients and lead to improved retention. These strategies should be evaluated within the local context. Case Presentations: Clinical Experiences in Dar es Salaam When launched, the methadone program in Dar es Salaam initiated clients on 15 mg/day of methadone with daily increments of 5-10 mg/day until stabilization. During this pilot period, providers observed continued illicit drug use, high attrition rates, and poor clinical outcomes. The baseline dose was increased to 30 mg/day with daily increments of 5-10 mg/day until stabilization, which resulted in earlier stabilization, increased retention and adherence, and better clinical outcomes. Programs must consider treatment for common co-morbidities among PWID and contextual characteristics that may affect appropriate methadone dosing. Drug interactions with ART and anti-tb medications or hormonal contraceptives should be carefully considered. In addition, high levels of drug purity in Tanzania necessitated higher doses of methadone. Flexible dosing strategies, integration of services, and genderappropriate care are needed for a successful program. Of special interest in Tanzania, is the methadone dispensing model employed at the clinic. Through a single dispensing window, the pharmacy team distributes doses to approximately 500 daily clients in approximately four hours. Two attendants work concurrently, whereby one measures and dispenses doses while the other records and observes clients. The team attributes its efficiency to preparing the next day s records and exchanging roles to avoid burn out. Despite the efficiency of the program, flexible strategies of dosing are needed to concurrently facilitate scale-up of methadone and decrease then burden on health care workers and clients. Programs in Dar es Salaam are working collaboratively to plan for and implement take-away doses through its KPIS initiative. Consultative Meeting on Optimal Models of Care for 15

16 Case Presentations: Addressing Gender Inequities in Dar es Salaam Tailoring a program to meet the specific needs of female drug users is critical. A low threshold model for female drug users can lead to increased uptake among this hard-to-reach sub-population. At Mwananyamala, eligibility criteria were amended so female heroin injectors and non-injectors are able to enroll in methadone. Walk-ins and peer-referrals are encouraged for female drug users and referral from a community-based organization (CBO) is no longer required. This low threshold model was adopted at Mwananyamala (the second clinic in Tanzania) and has improved uptake by female drug users. The current proportion of female clients at Mwananyamala Regional Hospital (MRH) is 23%, more than three times higher than the first clinic at Muhimbili National Hospital (MNH) (6.9%). Case Presentation: Scale-up of OST in Mauritius Strong political commitment and partnerships between the government and NGOs have supported the rapid scale-up of OST in Mauritius. Currently, methadone is distributed through one residential induction center, four drop-in centers and 18 fixed and mobile dispensing points. Fixed and mobile sites include regional hospitals, mobile caravans and a prison service. A total of 6,425 PWID have initiated methadone treatment. However, the proportion of female PWID initiated on methadone remains low, at 5%. Challenges cited include stringent eligibility criteria, overcrowding at dispensing sites, community resistance, and burdensome preparation of doses. Despite these challenges, significant impacts on HIV among PWID have been observed. Among new HIV cases, the proportion of PWID has gradually decreased from 93% in 2005 to 38% in Strategies for the future include further decentralization of dispensing, female-focused services, integration within primary care settings, flexible dosing, take-away doses, and involvement of the private sector. Key Recommendations A streamlined admissions process with rapid access to treatment dosing on the day of presentation is ideal. Once established, OST programs should be scaled up rapidly since wider coverage is important to realize the intended impact on HIV prevention. OST programs should implement varied models of dispensing (e.g. take-away, satellite dispensing sites, mobile, etc.) to lower the threshold and increase accessibility. Once established, OST programs should explore models of integration for HIV and TB services, including co-location and peer-supported approaches. OST should be introduced in targeted settings such as prisons and drop-in centers. Gender-specific barriers to care should be examined and addressed to ensure equity. Programs should consider and address social issues (e.g., homelessness, unemployment, nutrition support etc.) that might affect adherence and treatment outcomes. Programs should ensure culturally-appropriate counseling for addiction and conduct targeted psychosocial intervention. Programs should design and implement mechanisms to ensure adherence and retention. It is crucial to explore opportunities for support rather than punishment for non-adherence. Programs should minimize waiting times and burden on the patient. Implement queue cards for various service needs: clinician, social worker, dosing only, so that the first client in is the first client out. Consultative Meeting on Optimal Models of Care for 16

17 DAY 2: TUESDAY, APRIL 15, 2014 Session 06: Integration of Services: Health Facility and Community Models Convener: R. Douglas Bruce Expert Panel: Omary Ubuguyu (MNH, Tanzania), Happy Assan (TanPUD, Tanzania), John Kimani (KenPUD, Kenya), and Omar Mattar (ZAYADESA, Zanzibar) Overview A number of facility- and community-based strategies, such as a decentralization of services, are needed to increase access to care. Community outreach programs are ideal for initiation of PWID-focused interventions. Community-based harm reduction programs can be introduced through provision of known services such as HIV testing and counseling that targets PWID population. In Tanzania, the harm reduction program started as an HIV and HCV testing program using a mobile van. Slowly, the program expanded its services based on identified hotspots and additional needs of PWUD and PWID. It continues to distribute kits comprised of condoms, bleach, and cotton swabs while advocating and raising awareness on safe injection practices and harm reduction interventions. Community power mapping exercises should precede any harm reduction intervention. Stakeholders should be engaged throughout the process to advocate and sensitize the community on the importance of the harm reduction intervention. Specifically, community leaders and law enforcers must be engaged. Outreach workers, including peer educators, are the backbone of any community program. Community workers should receive a standard training package and be supervised. Outreach workers can support recruitment, provide basic counseling, educate on safe injection practices, distribute commodities, follow up with clients, escort clients for additional health services and identify new hotspots. Feedback from outreach workers is critical to identifying programmatic gaps and implementing improvements. Outreach workers are also an important link to initiate dialogues with community gate keepers including community leaders and law enforcers and support family reintegration. In addition to provision of services, community programs should continue to advocate and raise awareness on importance of supporting drug users, rights for services and the need to reduce stigma and discrimination. Case Presentation: Nothing for Us, Without Us Female PWID are at higher risk for HIV and struggle under a higher burden of polysubstance use, sexual risk taking, anxiety, depression, sexual violence and discrimination. Due to lack of shelter, if a man provides you with a place to stay, [he] might end up forcing you out of your will. You have an investment, and you don t want to use it. - Happy Assan, TanPUD Services must be adapted to increase access and minimize stress for female PWID seeking care. A dedicated dosing window and waiting area for female clients would help prevent any unwanted interaction with male clients. In addition, services such as vocational training, general education, and family counseling are needed to support female PWID. Community groups and anonymous support meetings are crucial in supporting users through treatment and provide a platform to discuss challenges and share experiences. Community-facility linkages enable PWID to access services available through the healthcare system, and acts as a buffer to the healthcare system by providing ongoing psychosocial support. Current and prior drug users, who become peer educators, play an important role in the implementation of programs, including the recruitment and tracking of their peers. Consultative Meeting on Optimal Models of Care for 17

18 In addition to assisting with program planning and implementation, community groups are vital to fostering critical enablers. Current and prior drug users are critical advocates for improved services, increased governmental support, expanding research agendas for KPs, and addressing stigma, discrimination and criminalization. Nothing for us, without us. John Kimani, KenPUD Case Presentation: Targeting Key Populations in Zanzibar In a concentrated epidemic, KP-focused community programs become the mainstay of HIV prevention. In Zanzibar, where the HIV prevalence is 1% in the general population and 11.3% among PWID, the ZAYADESA program has set up a comprehensive community HIV prevention program for key populations. ZAYEDESA has adapted numerous best practices, evidenced by different organizations and countries, for its local population. PWID are currently offered a holistic package, comprising of psychosocial support, community-based outreach, mobile and static site HTC, ART for PWID living with HIV, STI prevention (including condom distribution) and treatment, and screening for TB and referral to treatment, safe injection education and materials and training for PWID to reintegrate into their communities. Taking advantage of technological advancements, a toll-free helpline was established to provide members of key populations with HIV-related information and referrals for victims of gender-based violence. Creative outreach methods employing films, music and drama expand the program s reach. In addition to provision of services, community programs need to continue to sensitize and advocate on services for PWUD without failing. In Zanzibar, ZAYADESA provides month-long campaigns on specific services (e.g. May becomes hepatitis month whereby the NGO raise awareness and test for HBV). Key Recommendations Programs should conduct a power mapping exercise before initiation to identify and integrate key stakeholders into the program planning and implementation. Community interventions work well with the involvement of NGOs and local social workers who are familiar with socio-cultural issues that might affect entry and sustainability of the program. Community advocacy should be ongoing. Programs should continue to engage and sensitize the drug using community, general community members and law enforcement during all stages. Peer educators, including current and prior drug users, are instrumental in registering, supporting and following up on clients. Community interventions should provide other HIV prevention services such as mobile HTC services, awareness and sensitization, IEC, and condom distribution. Community outreach workers should work in teams and wear identifiable uniforms to allow them to be recognized by law enforcers. Community programs should distribute health packages comprised of the full range of injection equipment and institute mechanisms to support waste collection. Effective community programs should create linkage and referral to other services. To ensure sustainability, programs should support PWID networks and community support groups. Unique identifiers should be used when collecting data so that participants can be tracked over time. Monitoring and evaluation systems linking community- and health facility-based programs should be strengthened to evaluate the progress and impact of programs. Consultative Meeting on Optimal Models of Care for 18

19 Session 07: Integration of Services: HIV Diagnosis, Care and Treatment Convener: Graham Shaw Expert Panel: Jessie Mbwambo (MNH, Tanzania) and Eric Aris (MDH, Tanzania) Overview Organizing health services based on the needs of PWID is critical in facilitating access to HIV and TB care and treatment. Because no single approach fits all, integration strategies must be tailored to the local needs and context. The process to integrate service delivery will depend upon the specific healthcare setting and the structural, human resource, financial, educational, legal and advocacy available in specific settings to achieve integration. Individual-level barriers should also be evaluated when planning. Integration may require partnering with other organizations or changes in legislation. Therefore, it is important to define assets for and obstacles against integration as one of the initial steps. In addition to addressing the unique needs of PWID, a truly effective program must be sustainable. This can only be achieved when critical enablers are in place to appropriately incorporate the program into the regular health system. NSP and OST programs have served as platforms for integration of HIV related services. The specifics of an appropriately integrated model of care are context-specific and will vary between settings. For example, a referral-based system may work well only when clients are assisted or escorted to the referral point. Colocation of services may result in improved quality of life and increased access to services, but may also be expensive. Peer-supported models of service delivery should also be considered to engage clients, promote adherence and improve clinical outcomes. Innovative approaches for delivery of medications, such as community ART groups (CAGs), can also decrease the burden on healthcare workers and patients. In any model, it is important to consider stigma associated with delivery of care. Case Presentation: Integrated HIV care for PWID in Tanzania Often times, an integrated approach means provision of services such as ART and TB treatment in the same location. At Muhimbili National Hospital, the methadone clinic employs provider-initiated counseling and testing for HIV and provides escorted referrals to the HIV care and treatment center. Once a client is initiated on ART, he/she may receive HIV medications through the methadone pharmacy window. We noted that, when we asked PWID from methadone clinic to come for ART at CTC, they were not that comfortable. They feel somewhat alienated. We thought, it will be better directly administer ART at the MAT clinic. - Dr. Jessie Mbwambo, MUHAS Additional capacity building and technical support is provided by MDH to promote an integrated approach. Clinicians at the HIV care and treatment centers (CTC) are being trained to identify and refer PWID who are not receiving methadone. In addition, CTC clinicians are based at the methadone clinic and continue to offer services to stable clients while linking them to other services. Key recommendations Whenever possible, harm reduction programs should provide comprehensive and integrated HIV prevention, treatment and care. Programs should consider implementing peer-supported approaches for the delivery of ART and to encourage adherence to ART, including community ART groups. When planning for integration of services, it is important to define assets for and obstacles against integration. An integrated model of care must work collaboratively with the existing health system and must be tailored to the local needs and situations. Consultative Meeting on Optimal Models of Care for 19

20 Integration of additional medical treatments may result in increased need for counseling on multiple aspects of treatment. Staff should be trained on effects of HIV or TB treatment while on methadone. Session 08: Integration of Services: Tuberculosis Diagnosis, Care and Treatment Convener: R. Douglas Bruce Expert Panel: George Githuka (MoH, Kenya) and Alex Tindwa (MUKIKUTE, Tanzania) Overview PWID, particularly those living with HIV, are at higher risk of tuberculosis infection. Outreach workers can play an important role in screening, collection of sputum, referral of clients, administering of TB drugs and tracing defaulters. Harm reduction programs provide a platform for TB screening and treatment. NSP and OST programs can also serve as platforms for integration of TB related services. An OST clinic can provide an appropriate avenue for directly observed therapy (DOT) of TB drugs, but this should not be the gold standard. Other community-based treatment delivery strategies involving peers, family members, or outreach workers should be explored. Community programs that identify, screen, refer and link clients to health facilities are crucial for integration of TB services into harm reduction programs. When outreach workers and peer educators are well trained and scaled-up, they have been effective in supporting peers to take medication and escort them for other services. Importantly, programs working with TB clients are encouraged to consider nutritional support in their intervention. Often clients with TB infection also are living with HIV. Proper nutritional support is critical to improving health and also becomes an incentive to stay on treatment. As we continue to think about scaling up treatment for PWID, we should not forget the lessons we learnt from community and family support when we were scaling up DOT treatment in late 1990s. Indeed peers and community members can be very helpful in supporting clients to adhere to their treatment. Eric Aris, MDH Case Presentation: The MEWA Project Experience in Kenya Outreach workers facilitate counseling and testing for HIV and TB and accompany PWID who test positive for HIV for care. Outreach workers were trained to conduct TB screenings, collect sputum on location and provide active case management and DOT in some cases. Among 948 contacts in 2013, 115 (12%) tested positive for TB. Follow-up of TB clients was challenging due to mobility of the population. Despite this, 80 (70%) of TB clients were initiated on treatment. Key Recommendations Well trained community outreach workers and peer educators can support peers to take medication and escort them for services. NSP sites and methadone clinics provide an effective platform for TB screening and provision of daily observed therapy. Programs should consider implementing peer-supported approaches for the delivery of anti-tb medications and to encourage adherence. Consultative Meeting on Optimal Models of Care for 20

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