July 22, 2010
New Global Report Launched By The International AIDS Society Recommends A New Paradigm For Treating Injecting Drug Users: ‘Seek, Test, Treat And Retain’
Access to opioid substitution therapy such as methadone can facilitate access to and retention in ART
Against the backdrop of some of the globe's fastest growing HIV epidemics in Eastern Europe and Central Asia, a report launched today at the XVIII International AIDS conference (AIDS 2010) in Vienna makes the case for a new model for scaling up treatment and prevention of HIV amongst Injecting Drug Users (IDUs).The report, "Prevention and Treatment of HIV/AIDS amongst Drug Using Populations: A Global Perspective", advocates a science based approach and stresses the urgent need to increase access and expand take up of highly active anti retroviral therapy (HAART) among drug using populations to improve health and reduce new infections. (1)
Increasing evidence supports the idea of expanding the implementation of outreach to high-risk, hard-to-reach drug using populations (seek), to encourage HIV testing (test), to link HIV+ individuals to care (treat), and to sustain these individuals in care (retain). The seek, test, treat, and retain model is also deliverable within the criminal justice system.
"The evidence is in, individuals with and without a history of injection drug use derive similar survival benefit from HAART. There is an urgent need to treat drug users, not abuse them as much of the current drug policies do," said Dr Julio Montaner, President of the International AIDS Society. "Sound public health policy demands that we increase access to HIV treatment and prevention for this population."
Two decades of experience have demonstrated that needle exchange programs are a proven way of preventing HIV infection amongst injecting drug users (IDUs). The report outlines how programs can increase this effectiveness by scaling up a comprehensive package of harm reduction interventions.
"Offering Opioid Substitution Therapy (OST), such as methadone or buprenorphine, significantly decreases HIV acquisition and transmission and increases the chances of HIV positive people who inject drugs taking up and staying on highly active anti retroviral therapy (HAART)," said Professor Dr Charles O'Brien, a researcher from the University of Pennsylvania and one of the contributors to the report. "This in turn can lead to reductions in the community viral load and decrease new infections."
Wider uptake of HAART is associated with reduced community viral load and reduced transmission as well as individual survival. "Not only does treatment offer health benefits for the individual," said Dr Montaner, "but in diverse populations, we can now see that HAART is HIV prevention."
The selection of Vienna as the host city of the XVIII International AIDS Conference reflects the role the city has played in bridging Eastern and Western Europe. During the past week there has been a strong focus on Eastern Europe and Central Asia region, now home to what is the fastest growing HIV/AIDS epidemic in the world. Injecting drug use is the main driver of HIV infection in the region.
Some 65 per cent of HIV infections in Russia for instance, are through injecting drug use. The number of HIV infected people in Russia has increased tenfold in the past decade from an estimated 100,000 to one million. Eighty per cent of HIV positive people are under 30 years of age. Methadone is illegal in Russia.
"The Russian government does not implement an evidence based approach to decision-making on public health," said Dasha Ocheret, spokesperson for the Eurasian Harm Reduction Network (EHRN). "The prohibition of substitution treatment such as methadone is based on Soviet ideology and denies drug users the right to life saving treatment and prevention that exist in the vast majority of countries in the region. Methadone treatment began in Lithuania as far back as 1984.
Russian Government funds are used for policing rather than sound public health policy. All attempts by the Russian government over the past decade to control drug trafficking have been counterproductive and resulted in increased incarceration rates of people who use drugs and social exclusion and led to numerous deaths from overdoses and HIV and TB infections."
The report argues that it is now recognized that a punitive approach leads to the creation of incubators for HIV, HCV and TB in prisons.
"We've been witness this week in Vienna to what is an all too familiar story: the unacceptable criminalisation and stigmatisation of a group of people, in this case, people who inject drugs," said Montaner. "As a result of repressive drug policies and frankly, appalling public health policy in many parts of Eastern Europe, people who inject drugs are now shouldering the burden of an HIV epidemic that shows all the signs of moving into the wider community.
"On the other hand we've also heard success stories in the region that give hope to scientists, researchers and policy makers who are committed to addressing HIV and injecting drug use based on sound scientific empiric evidence along the lines suggested in the report we have released today," concluded Montaner.
The report's recommendations include:
* Interventions for scaling up in regions/countries with high or increasing prevalence;
* Match scale-up strategies to epidemiologic need;
* Assess the impact of current interventions;
* Promote effective treatment that combines counselling, pharmacotherapy, and wraparound services e.g. mobile units;
* Integrate HIV prevention measures into all substance abuse treatment, including information on access to condoms, needle exchange, etc.;
* Treat comorbid infections and conditions such as Hepatitis C and Tuberculosis;
* That every client in substance abuse treatment has access to primary care;
* Train general health care providers in substance abuse recognition and SBIRT;
* Test models for scale-up;
* Undertake the cost-effectiveness analysis of scale-up in various locales; and
* Identify barriers and facilitators of effective adoption and intervention
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