Pyramid unaids 10 19-01 (v2)

Dr. Jean-Paul C. Grund

Building Pyramids: Designing HIV Prevention and Treatment

Systems for Drug Users in Eastern Europe

10/18/01, Building Pyramids J-P Grund

Building Pyramids Introduction

• While not absent during the days of communist rule, the transition

towards democracy has undoubtedly been followed by an increase in

the availability and use of illicit drugs in all former socialist

countries.

• As a result, injecting drug use, addiction and, as a consequence, HIV

are developing into a serious public health problem.

• Addiction is associated with compromised economic, social and

psychological situations.

• It is increasingly viewed as a complex, multi-causal, chronic

relapsing condition or disease, for which ”to date there is no effective

curative treatment.”

Drug Use after Socialism: Prevalence Russia & Ukraine

RRuussssiiaa

RReeggiisstteerreedd NNuummbbeerr ooff DDrruugg UUsseerrss

MMiinniissttrryy ooff IInntteerrnnaall AAffffaaiirrss::

MMiinniissttrryy ooff HHeeaalltthh::

11999900 11999944 11999966 22000011

115588..000000 224499..000000

2255..000000 8855..000000 445500..000000 ((UUsseerrss))

227700..000000 ((AAddddiiccttss))

EEssttiimmaatteess:: 11999966:: 660000,,000000

11999988:: 11--22..55 mmiilllliioonn

22000011:: LLTTPP:: 33 mmiilllliioonn

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RReeggiisstteerreedd NNuummbbeerr ooff DDrruugg UUsseerrss:: ““EEaarrllyy 11999900ss””:: 2200..000000;; 11999977:: 8800..000000

EEssttiimmaattee ((MMIIAA)):: 11999977:: 660000..000000 –– 770000..000000 ((7755 -- 8800%% IIDDUUss))

Table 1. Registered & Estimated Number of Drug Users in Russia & Ukraine

Sources: Brunet 1996; USAID/CDC 1998; Khodakevich & Dehne 1998; Dehne et al. 1999; MOH, 2001

City Total IDUs % of Population

Nizhniy Novgorod 35000 2.6

Novorossiisk 9000 3.6

Pskov 380-440 0.2

Rostov Na Donu 10000 1

St. Petersburg 70-80000 1.7-1.9

Volgograd 18000 1.7

Odessa 25000 2

Poltava up to 10000 3

Estonia 7000-8000 0.4-0.5

Vilnius 2000-3000 0.3-0.5

Kishineu 1416 0.2

Sofia 15-20000 1-1.5

Szeged 2500 1

Drug Use after Socialism: Prevalence in Cities Across the CEE Region

Table 2. Total Number of IDUs and Percentage of Population by City

Sources: • MSF/H RSAs • Grund et al. 2001


Drug Use after Socialism: Qualitative Prevalence Assessments

“People drink or inject in this place.” (Outreach Worker, Volgograd)

“It is difficult to find a building in this

town that is not affected by drug use.” (Epidemiologist, Rostov Na Donu)

Both national and city-level data suggest that in several NIS countries more than 1% of the

population is involved in (injecting) drug use.

Drug Use under Socialism: Do It Yourself!

Collective Drug

Preparation & Injecting,

Friendship Networks,

& HIV Transmission


A Culture of Collective Drug Use

A Culture of Collective Drug Use

“It is very seldom when you use alone. At minimum you use with two or

three people. … “Somebody has money for drugs, a second knows where

to get good drugs, a third has some anhydride or a place to cook and yet

another has syringes. … It is also much cheaper to use in groups.”

23 70 338

441

523

609

717

875

1071

2617 70

1626

054

8035

110

3,02

415

0,00

0

1059

2

0

20000

40000

60000

80000

100000

120000

140000

160000

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

Apr-

01

Jul-0

1

Cumulative number of reported HIV cases

Russian Federation, 1987 - July 1, 2001


Building Pyramids:

A Model for Policy & Service Development

• Metaphorical model of the development of drug treatment

and health & social care services for drug users.

• The model is essentially a thinking model to support realistic

policy development.

• It includes graphical representations

of key variables and processes,

relevant to decision making.

• It can inform a range of

policy choices, considering and

matching these key variables.


‘No’ Threshold Services

Pyramid Model:

Establishing a Typology of Care Services for IDUs

High Threshold Services

Medium Threshold Services

Low Threshold Services

Threshold to Care


• In-Patient Detoxification

(Reduction, Cold Turkey)

• Mid-Term In-Patient

Treatment

• (Long-Term) Residential

Therapeutic Communities

• Psychiatric Interventions

• After Care, Rehab, Relapse

Prevention, Acupuncture

• (Re-Entry) Housing

Pyramid Model Professional Care Services for IDUs



• Out-Patient Detoxification

(Reduction, Acupuncture)

• Specialized Medical

Treatment (HIV, HBV,

HCV, Dental Problems)

• Social Work, Counseling,

Case Management

• Job Training, Work

• (Supported) Housing

• Money Management





• Out-Patient Opiate Agonist

Treatment: Methadone,

Buprenorphine, Codeine

• Emergency Medical and

General Practice Care

• (Emergency) Psychiatry

• Syringe Access: Exchange,

Distribution, Pharmacy e.a.

Sales (kiosks-coupons?)

• Outreach Work

• Overdose Prevention




• Drop-In Centers,

• Safer Consumption Facilities

• Food, Clothing and Shelter

Projects

• Drug Use Management

programs

• Acupuncture, Stress

Reduction

• Safer Drug Use Information

• Chill-Outs @ R@ves



Pyramid Model A Dynamic Model

• Easy access @ multiple

entry points.

• Includes all service levels

• (coordinated) transfer

between services.

• Easy use of ancillary services

• Increases demand for high

threshold treatment: develops

naturally with growing contact rates.

• Can reach 70-80% of IDUs.

• Collaborative Model.

Key Characteristics


Pyramid Model Considerations for Setting Priorities

• Fighting the HIV/AIDS Pandemic

and Other Infectious Diseases

• Reducing Drug-related Morbidity

and Mortality

• Coverage of Populations at Risk

• Treatment Retention

• Treatment of Problem Drug Use

• Available $$ Resources (Funding)

• Costs of Services

Public Health Considerations

Economic considerations


Slide: Courtesy of S. Strathdee

Coverage: What proportion of the

IDU Population Needs to be Reached?


Pyramid Model Care Services for IDUs: Level & Coverage

‘No’ Threshold Services




Level of Care

Nx

15-40 (?)

70-80

1-20 (?)

Potential Coverage of Population (%)


Type of Treatment




Pyramid Model Treatment Costs by Type of Modality

$$$

$$-$$$

$

Relative Costs per Treated Drug User

Q: Where to Invest Scarce Resources?

A: Where we get the Biggest Bang for the Buck!



Mean Costs Per Year For 1 Heroin Addict (USA)

0

10000

20000

30000

40000

50000

On Street Incarcerated Residential

Treatment

Methadone

Maintenance

Treatment

$

Security

Theft, etc.

Heroin

Jail

or

Prison

and

Court

Costs Residential

Drug-Free

Treatment MMT

SOURCE: Slide: M. Reisinger, Adapted from NYS DSAS, 1991, by Dole & Des Jarlais.


Conclusion Building Pyramids: A Useful Metaphor for

Development of Drug Policy and Services?

• Pyramids were not built in one

day. Nor are treatment services

for Injecting Drug Users.

• Pyramids were built stone

for stone, layer for layer,

fitting seamlessly on the

preceding layer.

• Pyramids were built to last:

Sustainable Development

• Ancient Architectural Rule:

Start with the Fundament(al)s.

Health & Medicine

Pyramid unaids 10 19-01 (v2)