Integration of Methadone Maintenance

Treatment (MMT) and HIV Care

for Injecting Drug Users (IDU) :

A Cohort Study in Bandung, Indonesia

Yanni Melliandari Achmad 1, D.Norviatin1

AN.Istiqomah1,2, R.Wisaksana1,3, I.Afriandi1,4, R.van Crevel1,5, T.Hidayat1,2

1IMPACT, Health Research Unit, Faculty of Medicine, Padjadjaran University/Hasan Sadikin Hospital, Bandung, West Java, Indonesia2Department of Psychiatric, Faculty of Medicine, Padjadjaran University/Hasan Sadikin Hospital, Bandung, West Java, Indonesia

3Department of Internal Medicine, Faculty of Medicine, Padjadjaran University/Hasan Sadikin Hospital, Bandung, West Java, Indonesia4Department of Public Health, Faculty of Medicine, Padjadjaran University, Bandung, West Java, Indonesia

5Department of Internal Medicine, Radboud University Nijmegen Medical Centre, The Netherlands

melliandari@yahoo.com

Presented in Brother in Arms, Nijmegen, The Netherlands

• High prevalence, low CD4, high mortality

IDUs and HIV

IDUs don’t like regular clinics…..

and regular clinics don’t like IDUs…

Common belief

• Low adherence, high drop-out

• Many problems, low success rate

• Cause of death :

– 2 unknown

– 2 over-dose

– 13 HIV-related

Mortality (n=17)

– 13 HIV-related

• Median age (IQR) : 28 (25 – 32)

HIV-care integrated with methadone

• ‘one-stop care’ (patient friendly)

• Established doctor – patient relation

• Opportunity for more frequent counselling• Opportunity for more frequent counselling

(adherence, side effects etc)

• Comprehensive

(drug interactions, toxicity)

• Cost-effective

Research Questions

1. Does methadone maintenance treatment (MMT) increase access to HIV-care?

2. How effective is HIV-treatment when combined with methadone service?

Results: MMT increases access to HIV Care

Total Tested/started in MMT

HIV-tested 102 41 (40.2%)

HIV-positive 75 25 (33.3%)

HIV treatment 38 19 (50%)

How effective is ART for MMT-clients ?

• Endpoints

- Retention to ART

- Mortality

-Virological failure-Virological failure

• Control group:

patients taking ART outside MMT

with history of IDU, matched for starting ART date

MMT

(n=35)

Control

(n=175)

p-value

Male gender, % 97.1 93.7 0.425

Mean age, years (SD) 29.9 (3.8) 29.1 (3.4) 0.165

Marital status; Single, % 54.3 46.3 0.387

Education; Academy or university, % 51.4 38.3 0.148

Baseline Characteristics

Education; Academy or university, % 51.4 38.3 0.148

Median BMI, kg/m2 (IQR) 19.4

(17.8-20.6)

19.7

(17.9-21.7)

0.299

HBsAg-positive, % 2.9 8.2 0.266

Anti HCV-positive, % 90.3 92.5 0.673

CD4

< 200 cells/mm3, %

median, cells/mm3, %

65.7

177 (47-244)

57.9

133 (34-269)

0.817

0.392

Results : Retention in ART : 2 years

100% versus 93.1%

HR loss to FU = 0.30 (95% CI : 0.04 – 2.10)

Results : Survival in ART : 2 years

93.9% versus 92.3%

HR mortality = 0.8 (95% CI : 0.2 – 3.2)

Results: Virological Response after ART ( > 6 months)

MMT

(n=27)

Control

(n=114)

HIV-RNA

< 400 copies/ml, % 100 89.5

RR virological failure for patients in MMT:

0.35 (95% CI 0.02-2.3)

400 - 10000 copies/ml, %

> 10000 copies/ml, %

0

0

0.9

9.6

ART combined with MMT

• Mortality

• Retention in treatment

• Virological response

• Similar between MMT and control group

– Possibly better in MMT (small numbers…)

median: 55mg

(1.9-195 mg)

Last month average methadone dose

Methadone dose and retention to MMT

59.4% versus 38.8%

HR = 1.91 (95% CI : 0.99 – 3.68)

Drop out

(n=101)

Non drop out

(n=122)

Stable dose (2 months) 70(10-175)

80(15-150)

Last dose 35 65

Methadone Dose*

Last dose 35(4-170)

65(1-195)

Last month average dose 40(6.38-166.2)

67.7(1.9-195)

Last 3 months average dose 39.4(7.1-165.8)

62.5(12.13-195)

* Median, mg

Methadone Dose

Methadone Metabolism

ARTefavirenz, nevirapine

Higher dose

* Induction of liver metabolism ~ 1 week

- withdrawal symptoms with same dose methadone

Methadone Metabolism

TB drugrifampicin

Higher dose

of methadone*

Last month methadone dose

n=31n=21 n=33

Logistic regression : p value 0.024

Conclusions

• High HIV-prevalence among MMT patients (73%)

• MMT : entry point for HIV-testing & treatment

• Outcome similar between MMT and control group

• ‘One-stop care’ – patient friendly & efficient• ‘One-stop care’ – patient friendly & efficient

• Higher methadone dose with ART & TB drugs

Challenges

• Securing access & quality of services

`

Acknowledgements

Hasan Sadikin Hospital

• Psychiatric Department : Ike MP Siregar, Lucky Saputra, Shelly

• MMT Clinic : Agus, Warsa, Tria, Novi, Hera, Danis, Julianto, Atu

• Teratai Clinic : Agnes R. Indrati, Laila, Kiki, Nuni

IMPACT

• Lucas Pinxten

University of AntwerpUniversity of Maastricht University of NijmegenPadjadjaran University

Nijmegen Institute for Scientist-Practitioners in Addiction, The Netherlands

• Prof Cor de Jong

Financial support: European Union, Cordaid, Nuffic/Neso