HIV in People Who Use Drugs

Adeeba KamarulzamanUniversity of Malaya

Kuala Lumpur, Malaysia

Outline• Global Burden of HIV due to illicit drug use • The Global State of Harm Reduction• Unmet needs and new challenges

– Women– Adolescents– MSM

• Prison and people who use drugs• Antiretroviral treatment for people who use drugs• Can We Do Better?

Injecting drug use as a risk factor for HIV, HCV, HBVDALYs per 100,000 people, age-standardised, 2010

• Overall, illicit drugs caused 1% of global disease burden– 8th largest contributor to disability (YLDs) among

males

Degenhardt, et al (2013). The Lancet, 380, 1564-1574UNAIDS Global AIDS Report 2012.

• Overall, illicit drugs caused 1% of global disease burden• 8th largest contributor to disability (YLDs) among males• In countries where HIV incidence is increasing, 70% - 80% of HIV

cases are among PWIDs

Interventions to prevent HIV and Hepatitis C in people who inject drugs: A review of reviews to assess evidence of effectiveness

Intervention Outcome Summary of studies

Evidence Statement

Needle andsyringeprogrammes (NSP)

Injecting risk behaviour (IRB)

43 studies Sufficient evidence to support theeffectiveness

HIV 16 studies Tentative evidence to support theeffectiveness

Opiate Substitution Treatment (OST)

IRB 35 studies Sufficient evidence to support theeffectiveness

HIV 8 studies Sufficient evidence to support theeffectiveness

McArthur G et al. Int J Drug Policy Jan 2014

• Trends in HIV incidence, injecting and sexual risk behaviour: 1986 to 2011 in the Amsterdam Cohort Study (ACS)

• 1298 participants • Total follow-up - 12,921 person-years (PY)• HIV incidence declined from 6.0/100 PY in 1986 to less

than 1/100 PY from 1997 onwards (95% [CI] 3.2–11.1)

• Both injection and sexual risk behaviour declined significantly over time

Van der Knaap et al, March 2013

Harm Reduction: Coverage

Opioid Substitution TherapyGlobally, for every 100 PWID,only 8 are receiving OST (range less than 1 to 61)

Needle and Syringe ExchangeGlobally, 2 needles per PWIDper month (range less than 1

to more than 200)

• 72 countries have OST• 86 countries with IDU have no OST

• 82 countries have NSP• 76 countries with IDU have no NSP

What has been achieved in HIV prevention, treatment and care for people who inject drugs, 2010–2012?

• China• 30% increase in OST recipients between 2009 and 2011

• Vietnam• significant scale up of NSP, >1000 NSP sites • five-fold increase in the number of clients receiving OST

• Russia• number of PWID accessing NSPs decreased by nearly 60%, from

around 123,000 (2010) to 49,090 (2011)

• Ukraine• increase in number receiving NSP, OST, ARV

• USA – reversal of the lifting of the Federal ban on funding NSP

• Malaysia – shift from a punitive law-enforcement approach

Degenhardt et al IJDP 2013

Transformation of Compulsory Drug Detention Centers into Voluntary Evidence Based Treatment & Care Centers• July 2011• 36 000 PWID • 6500 receiving MMT

Mistreatment of Drug Users and "Undesirables" in Cambodia’s Drug Detention CentersDECEMBER 9, 2013

Unmet Needs & Challenges

Women & Drug Use

• Percentage of women among PWID– 4% (Iran) to 45% (North America, Eastern Europe)

• Higher HIV prevalence rates in female IDUs

– Systematic review of 117 studies in 14 countries with HIV

rates > 20%

(Des Jarlais, DAD 2012)

– Studies in 9 European countries

(EMCDDA, 2006)

• Sex work and women who use drugs

– 10% (US) - 55% (Eastern Europe, China)

(EuroHIV 2007, UNAIDS report on the global AIDS epidemic. 2010)

Gender-Specific Drivers that Increase Vulnerabilities to HIV

Structural “risk environments” that drive the HIV epidemic among women who inject drugs:

• Intimate Partner Violence - 60-80%

• Gender norms and gender imbalances in the drug culture

• Lack of woman-specific drug treatment and services

Strathdee, et al., Lancet 2010El-Bassel, et al., Curr HIV/AIDS Rep 2014Meyer, et al, J Women Health 2012

Female and Transgender Sex Workers in Malaysia: Sex, Drugs and …

• RDS of F/TG SWs in Kuala Lumpur (underway)• Preliminary findings (N=114 of planned 450)

– HIV: 21%• 12 HIV cases in TGs (35%), 12 in FSW (15%)• 54% unaware of being HIV+

– Drug/alcohol use (past 30 days)• Amphetamines (62%)• Opioids (35%)• Alcohol (25%)• Injection drug use (16%)

– High prevalence of physical and sexual abuse– Interactions with police (89%)– High self-reported condom use (82%)

Adolescents and Injection Drug Use

Low ages of initiation across regions. • In some countries significant

proportions of people who inject drugs are adolescents – Nepal, 20%

• High rates of needle-sharing• Jakarta 15-19 age group – 50%

needle sharing

• Poor access to services

A global population size estimate for people who inject drugs under the age of 18 is unavailable

Ukraine: No. of adolescents who inject drugs versus access to harm reduction services

See: O. Balakireva et al Population Size Estimate of Most-At-Risk Children and Youth in the 10–19 Age Group, Kyiv: Unicef, 2011 and D. Barrett, N. Hunt and C. Stoicescu Injecting drug use among

under 18s: A snapshot of available data, London: Harm Reduction International 2013.

MSM & Drug Use

Lancet September 2013

Countries with published MSM drug use data use data

Bourne IHRA 2013

MSM and drug use• Use of drugs vary widely

– Episodic• Prevalence of use higher

– further marginalised or minority groups, eg ethnic minority gay men in the USA

– younger men– living in large urban centres

• Polydrug use is common – alcohol, biggest contributor– especially stimulants eg ecstasy, cocaine, amphetamines or

ketamine• Prevalence of IDU (heroin) generally very low, but….

Bourne, IHRA 2013

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Any Alcohol Use Disorder

Hazardous Drinking

Harmful Drinking

Dependent Drinking

Rela

tive

Haz

ard

1.21

1.23 1.26

1.71

1.43

1.25

1.49

1.82

2.28

1.86

2.57 3.

29

2.11

1.76

2.27 3.

00

1.53

1.44

1.46

1.78

Ludford K, PLoS One, 2013

Alcohol and Drug Use Independently Correlate with HIV Risks Among Peruvian MSM

Drug Use Drug Use Drug Use

Drug use, and drugs injected, are changingLooking at those only using ‘Club drugs’,• Mephedrone• Methamphetamine• Ketamine• GHB• ecstasy

The proportion currently injecting has doubled from: 5% (N=531) in 2011-12 to 10% (N=795) in 2012-13.

Data Sources: NTDMS / NTA; Shooting Up report 2013.

Harm Reduction for People Who Use DrugsContext is Key

Prison and People Who Use Drugs

Geography and ImprisonmentTo

tal P

rison

Pop

ulat

ion

In 1971 President Nixon declared a War on Drugs

Lifetime prevalence (%) of illicit drug use among prisoners in European countries

EMCDDA 2012

Incarceration: High Risk Environment for HIV Transmission Among HIV+s in Ukraine

Any IDU Syringe Sharing Among PWIDs

0102030405060708090

10088.4

53.656.4

74.1

58.1

23.6

30d PreincarcerationDuring IncarcerationPost-Release

Perc

ent

Only 19.4% received

ART

Izenberg et al, IJDP, In Press

Mean number of people sharing among injectors = 4.4 (0-30)

Results:

• N=125• Men (90%), age <40 years (62%), 72% had injected drugs • Median CD4 - 337 cells/μL, • 19 (15.2%) receiving ARV. • Prevalence of undiagnosed active PTB (15/125;

12%)• Associated with longer duration of drug use• (AOR 1.14, 95% CI 1.03-1.26, for each year of drug use)

AIDS-Related Mortality Achieves Parity in Prisons and the General Population

0

10

20

30

40

AID

S-R

elat

ed D

eath

sR

elat

ive

to A

ll D

eath

s (%

)

1995

State inmates

General population34.2%

10.2%

2008

3.5% 3.4%

Maruschak LM. Bur Justice Stat Bull. December 2009.

HAART(1996)

Independent Correlates of Sustained Retention in HIV Care

Covariate AOR 95% CI P

Male gender 2.10 1.42, 3.11 <0.01

Having an HIV provider (pre-incarceration) 1.67 1.09, 2.56 0.02

Discharge planning (within jail) 1.50 1.06, 2.12 0.02

Disease management session (within jail) 2.25 1.51, 3.36 <0.01

Needs assessment (post-release) 1.59 1.06, 2.37 0.02

HIV-related education (post-release) 2.03 1.37, 2.99 <0.01

Transportation assistance (post-release) 1.54 1.0, 2.22 0.02

Althoff, AIDS Behav, 2013

Evidence-Based Strategies to Reduce HIV Transmission Among PWUDs

NSP

MAT

HIVC&T

PrEP

Primary & Secondary Secondary Only

ART

Treatment as Prevention Can Work Among PWIDs, but …..

• Ecological studies in Vancouver and Baltimore– documented reduced transmission among PWIDs where community

VL has decreased

• The HIV Continuum of Care for PWUDs is not equal to their non-drug using counterparts

– HIV diagnosis– Linkage to care– Retention in care– Receipt of ART– ART adherence– Viral Suppression

Differs based on local context and funding priorities

Engagement in Care Among PWIDs in Baltimore, ALIVE Cohort, 1998-2011

Fully

Ret

aine

d (3

0.5%

)

Conti

nuou

sly

on A

RT (1

7.3%

)

Sust

aine

d VL

<400

(8.0

%)

Westergaard, AIDS 2013

Engagement in Care Among PWIDs in Baltimore, ALIVE Cohort, 1998-2011

Poor Retention in Care

• Active drug injection

• Incarceration• No health insurance• No usual site of care• Lack of consistency in HIV

care provider

Poor Viral Suppression

• Active drug injection• Alcohol use• Crack cocaine use• Incarceration

• Lack of consistency in HIV care provider

• Decreasing CD4 countWestergaard, AIDS 2013

HIV Care Cascade: Select Countries in Central Asia

McNairy et al. Journal on Drug and Alcohol Dependence, 2013

Provider and clinic-level correlates of deferring ART for people who inject drugs

Westergaard RP, J Int AIDS Soc, 2012

Altice FL et al, JAIDS, 2011

Integrating Buprenorphine Into HIV Clinical Care Settings

Prescribed ART Viral Suppression

Organization of Healthcare Delivery for HIV+ PWIDs Matters (Ukraine)

Bachireddy C, Drug Alcohol Depend, 2013

Strategies to overcome healthcare disparities for HIV–infected people who use drugs at each step of continuum of HIV care:

Roadmap of Findings

Diagnosis of HIV

Entry into HIV Care

Retention in HIV Care

ART Initiation

ART Adherence

• Targeted out-reach programs• Opt-out testing• On site rapid testing – drug

treatment programs, CJS• Peer driven interventions• Intensive case management• Nurse support interventions• Community outreach program

• Evidence based drug treatment• Integration of clinical/social services• SBIRT

• Evidence based drug treatment• Public health campaigns• Targeted outreach• CME for providers

• Evidence based drug treatment• DAART• Access to treatment for comorbid conditions

and social services

VIRAL SUPPRESSIONMeyer et al CID 2013

Economic evidence for interventions with PWID

Dutta et al. The Global HIV Epidemics among People Who Inject Drugs, World Bank 2013

Cost Effectiveness of the Harm Reduction Program in Malaysia

Incremental Cost Effectiveness Ratio (ICER)Scenario Year 2006 – 2013 2013 - 2023 2006-2050

NSP vs no intervention

QALY gained 28,591 316,852 1,819,945

USD per QALY gained Cost-effective Cost-effective Cost-effective

Combined MMT and NSP vs NSP

only

QALY gained 22,974 76,674 344,864

USD per QALY gained 7,396

Cost-effective4,832

Cost-effective4,446

Cost-effective

CE threshold : <GDP per capita (highly cost effective); 1-3 x GDP per capita (cost effective); > 3 x GDP per capita (not cost effective). (WHO Commission on Macroeconomics and Health, 2001)

GDP per capita in 2012 was approximately USD10,000

H Naning et al, IAS 2013

Global heroin supply increased by 380% from 1980-2010Price of heroin in Europe decreased by 79%

Eliminating laws prohibiting OST and scaling up NSP and OST to 80% coverage could prevent 29% of new HIV infections

among IDUs in Nairobi by 2015

41

The Prototype: The Case of Portugal

• Decriminalisation of personal possession of all illicit drugs since 2001.

• Continued prosecution of dealers and traffickers.

• Expansion of treatment and harm reduction.

• Introduction of guaranteed minimum income. HIV AIDS

0

100

200

300

400

500

600

700

800

900

1000

Incidence of HIV and AIDS among drug users, 2000-2008

20002008

Kent. B Journal Crim 2012

Confronting Stigma & Addiction• Opioid use disorder as a medical illness is still

overshadowed by its misconception as a moral

weakness or a wilful choice

• Separation of opioid use disorder treatment from the rest

of health care insufficient attention to other

substance use, mental health, and physical health

conditions

• Language mirrors and perpetuates the stigma. Often

assign judgmental, pejorative terms.

• Criminal justice system

Olse & Sharstein, JAMA Feb 2014

General Patients HIV+ Patients PWID Patients MSM Patients0

10

20

30

40

50

60

70

80

9080.3

59.4

39.933.3

73.2

51.2

35.732.1

Medical Students (N=486)Dental Students (N=658)

Mea

n Sc

ore

P=0.001 P=0.001 P=0.001 P=NS

The Future HIV Healthcare Providers: Stigma & Healthcare Students in Malaysia

P<0.0001

P<0.0001

P<0.0001

Jin et al, AIDS Care 2014

What Do We Do Next?

• No one size of prevention fits all– tailor approaches to local and group context

• Combination (biomedical, behavioral) and multilevel intervention (e.g., individual, relationship, community, societal)

• Integrate treatment• Address stigma and discrimination

– begin with the medical and scientific community

• Drug Policy Reform

Rick Altice, Yale University

Nabila El-Bassel, Columbia University

Howie Lim, Ezra Akbar, Bertlin Ng, Britton Gibson, H Naning CERiAChris Beyrer JHUDamon Barrett, Catherine Cook Harm Reduction InternationalDavid Wilson, Louisa Degenhardt University of NSWKen Mayer Fenway Institute, Harvard Medical School Tim Hunt, Wafaa el Sadr Columbia University

Ministry of Education/University Malaya High Impact Research GrantThe World Bank

National Institute of Drug Abuse, USA

Science can be a catalyst for the realization of human rights And human rights can accelerate the translation of

scientific knowledge into practice and policy

Richard Horton KL 2011