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Harm reduction   atma jaya

Harm reduction atma jaya






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  • Harm minimisation refers to policies and programs aimed at reducing drug-related harm. Harm minimisation aims to improve health, social and economic outcomes for both the community and the individual and encompasses a wide range of integrated approaches, including • supply-reduction strategies designed to disrupt the production and supply of illicit drugs; • demand-reduction strategies designed to prevent the uptake of harmful drug use, including abstinence-oriented strategies to reduce drug use; • a range of targeted harm-reduction strategies designed to reduce drug-related harm for particular individuals and communities.’ National Drug Strategic Framework 1998-99 to 2002-03  15 These strategy areas are not mutually exclusive – some activities will relate to more than one strategic area.
  • So moving onto the findings from the review of the evidence for whether drug treatment is effective in preventing HIV in IDUs. During the course of this review, effectiveness has been considered in terms of seroprevalence in injecting drug users - (both in and out of treatment) and rates of seroconversion. However, studies that have measured these aspects of effectiveness are few in number – so the review places most emphasis on the effect of treatment on behaviours associated with high risk of HIV transmission namely: injecting drug use, sharing of injecting equipment number of sexual partners unprotected sexual activity
  • The authors identified two studies that reported lower prevalence of HIV in Injecting Drug Users in methadone maintenance treatment. However, it is important to note that the extent to which the lower seroprevalence is actually due to participation in treatment is unclear. For example, Tidone and colleagues clients commencing MMT showed a significantly higher incidence of HIV infection than others already in treatment - suggesting that methadone treatment may help in preventing HIV diffusion. There were also very few studies of HIV seroconversion rates. This is probably because large numbers of participants and long periods of time are needed in order for such studies to achieve statistical significance. However, a study by Metzger reported seroconversion rates of 3.5% for drug users in treatment, compared to 22% for those not in treatment over an 18 month period.  
  • This slide illustrates data from this study showing differences in HIV infection rates among IDUs in and out of substitution treatment. As you an see the rates of infection were much higher in those not in treatment.
  • The authors also examined a number of other key treatment outcomes relating to risk– particularly around injecting practices and sexual behaviours. 11 studies that examined treatment outcomes in terms of injecting drug use were identified: 8 focusing on methadone maintenance treatment, 1 on Buprenorphine maintenance, 1 Naltrexone study and 1 Drug Free. Overall there were lower rates of injecting drug use among those in treatment and in particular, all the methadone maintenance studies showed a reduced frequency of injecting together with an increased likelihood of NOT injecting. In terms of sharing injecting equipment, all 11 studies showed evidence linking treatment with reduced risk. Those in treatment were more likely to use effective methods to clean their injecting equipment and were less likely to share equipment with other users.
  • Eight studies addressed sex-related risks for HIV infection. These mainly examined continued work in the sex industry and the total number of sexual partners reported by drug users. Overall, seven of these studies showed a reduction in sex-related risks associated with treatment. Finally three studies examined overall HIV infection risk. All of these were outcome studies of Methadone Maintenance Treatment and all three showed reduced global risks in terms of drug and sex-related behaviours.
  • Now, the studies that have tended to have the BIGGEST impact on social policy are descriptive outcome studies and so the authors included these in their review. These sorts of observational studies are particularly important because they measure the impact of treatment in real life settings in different geographical areas and across different types of treatment. Two such studies are the Drug Abuse Treatment Outcome Study (DATOS) in the United States and the National Treatment Outcome Study (NTORS) in the United Kingdom . Both are major multi-site pre-post studies of treatment impact. Overall these studies consistently report a significant impact of treatment on injecting behaviours. - while for some individuals injecting is eliminated , for many, the impact of the treatment is to reduce the frequency of the behaviour and to reduce the rate of equipment sharing . For example, DATOS found that all modalities of treatment reduced injecting risk significantly. NTORS reported that injecting rates fell from 60% at intake to 37% at 4-5 years follow up and the rate of self reported sharing was reduced by two thirds.
  • Now the review contains a lot of detail on a range of treatment types which I’ve had to condense considerably. KEY findings concerning the effectiveness of methadone maintenance treatment include the following: First of all, there is strong evidence that increasing methadone doses result in better retention in treatment and less heroin use. Secondly, it seems that there is moderate evidence that the most effective methadone maintenance treatment programs use doses of at least 60mg/day and are oriented towards maintenance rather than abstinence.
  • Thirdly, there is strong evidence to support the assertion that methadone maintenance substantially reduces heroin use. And that this type of treatment is more effective than no treatment or placebo at reducing rates of imprisonment, reducing heroin use, retaining clients in treatment, and supporting employment or return to further education. Overall, the key finding for both buprenorphine and LAAM were very similar to those for MMT – so higher doses were associated with better retention in treatment, lower rates of heroin use and use of other illicit drugs.
  • Generally, the evidence found for the effectiveness of abstinence -based treatments was less compelling. There was SOME evidence to suggest that rates of dropout from residential rehabilitation programs are very high in the early stages of treatment but then decline. There was also SOME evidence that at least three months of treatment is required in order to achieve change. Those who complete residential rehabilitation programs, are subsequently less involved in drug use and criminal behaviour, and report increased legal employment And finally there was a LITTLE evidence to suggest that Treatment PROGRESS , NOT just time in treatment, is predictive of good outcomes.

Harm reduction   atma jaya Harm reduction atma jaya Presentation Transcript

  • HIV, harm reduction and the right to the highest attainable standard of health Adeeba Kamarulzaman
  • Estimated numbers of IDUs and regional prevalence of HIV in people who inject drugs, 2010 * No countries have a prevalence of 5% to <10% Copyright, The Lancet 16 million people in 148 countries inject drugs 3.3 – 6 million people inject drugs and are HIV+ve
  • Global HIV situation
    • HIV now accounts for 1: 6 global deaths
    • World beyond Sub Saharan Africa (SSA) now accounts for 30% new HIV
    • IDUs account for 30% new HIV beyond SSA;
    • 10% global new HIV
    • Sometimes HIV in IDUs rapid spread general population
  • Controlling HIV among IDUs
    • Best results if implemented:
      • Early
      • To scale
    • But global implementation
      • Very poor - < 5% - 12 needles/IDU/year
      • Increasing rapidly
  • Current Response Where 3 programmes work together, at all levels : Negative consequences of drug use can be reduced Long term problem of drug use can itself be addressed Supply Reduction Supply Reduction Demand Reduction Harm Reduction
  • Principles of Harm Reduction
    • Emphasis on achieving short-term pragmatic goals based on a hierarchy of risk
    • A focus on reducing the harms to the individual and society associated with drug use
    • Use of multiple strategies to achieve goals
    • Involvement of current drug users in the planning and implementation of programs.
  • Harm Reduction Hierarchy
    • Reduce the sharing of injecting equipment
    • Reduce the incidence of injecting
    • Reduce the use of street drugs
    • Reduce the use of prescribed drugs
    • Increase abstinence
  • Comprehensive Package of HIV Prevention and Treatment Services to IDU
    • • Needle and syringe programmes  • Opioid substitution therapy  • Voluntary HIV counselling and testing  • Anti-retroviral therapy  • Prevention and treatment of STI  • Condom programming  • Targeted information, education and communication  • Hepatitis diagnosis, treatment and vaccination  • Tuberculosis prevention, diagnosis and treatment 
  • Effective HIV prevention for IDUs – the evidence base International Journal of Drug Policy. Vol.16,suppl. 1 (2005)
    • Outreach
        • Evidence from 40 studies
        • Needle et al, Effectiveness of community-based outreach in preventing HIV/AIDS among injecting drug users
    • Sterile needle and syringe programmes (NSP)
        • Evidence from 50+ studies
        • Wodak A and Cooney A, Effectiveness of sterile needle and syringe programmes
    • Substitution treatment (ST)
        • Farrell M, Gowing L, Marsden J, Ling W, Ali R, Effectiveness of drug dependence treatment in HIV prevention
    • Information, education and communication (IEC)
        • Aggleton P et al, HIV/AIDS and injecting drug use: Information, education and communication
    • Sexual risk behaviour of IDUs
        • Des Jarlais DC, Semaan S, Interventions to reduce the sexual risk behaviour of injecting drug users
  • Models of Operation
    • 3 basic types of needle and syringe program:
    • Fixed site – a specific place that injectors can come to collect and dispose of injecting equipment
    • Mobile services – using a van or bus, usually with a regular route and regular hours of stopping in several locations
    • Outreach/backpack – in which workers travel through the streets distributing clean needles and syringes and collecting used injecting equipment for safe disposal
  • Do outreach-based interventions reduce HIV risk behaviours—drug using, injecting equipment use and sexual
    • Effective in reaching out-of-treatment IDUs and providing the means for effective behaviour change (> 40 studies) ( Coyle, Needle, & Normand, 1998 )
    • Significant and strong post-intervention reductions in:
      • cessation of IDU (10 of 11 studies);
      • injecting frequency (17 of 18 studies);
      • multi-person reuse of syringes (18 of 22 studies);
      • use of other injecting equipment (9 of 13 studies);
    • India - self reported reductions in HIV-related risk behaviours Kumar, Mudaliar, and Daniels (1998)  
    R Needle IJDP 2005
  • Evidence of Effectiveness of Needle Syringe Program
  • Effectiveness of NSPs
    • 45 studies from 1989 to 2002
    • 6 out of 10 studies, which evaluated HIV seroconversion or seropositivity as outcomes, found that NSP use was protective
    • 33 studies - HIV risk behaviour : 23 were positive
    • Efficacy of individual NSPs reported in at least 10 different countries, including several resource-poor countries
    Wodak, Cooney IJDP 2005
  • HIV seroprevalence in cities with and without NSPs Hurley Lancet 1997
  • Effectiveness of NSPs Return of Investment 2 - Australia
    • Over the last decade (2000-2009) NSPs have directly averted:
    • 32,050 new HIV infections
    • 96,667 new HCV infections
    • This investment yielded:
    • Healthcare costs saved of $1.28 billion
    • Approximately 140,000 DALYs gained
    • Net financial cost-saving of $1.03 billion   
  • Effectiveness of NSPs Return of Investment 2 - Australia
    • For every $1 invested in NSPs, > $4 were returned in healthcare cost-savings in the short-term (10 years)
    • If patient/client costs and productivity gains and losses are included in the analysis
      • then the net present value of NSPs is $5.85bn
      • for every $1 invested in NSPs (2000-2009), $27 is returned in cost savings. This return increases considerably over a longer time horizon
    • NSPs are very cost-effective compared to other common public health interventions.
  • Evidence of Effectiveness of Drug Dependence Treatment in HIV Prevention
  • Effectiveness of Drug Dependence Treatment Cochrane Systematic Review
    • Effectiveness:
      • seroprevalence in IDUs
      • rates of seroconversion
    • most emphasis on treatment effect on:
      • injecting drug use
      • sharing injecting equipment
      • number of sexual partners
      • unprotected sexual activity
    Gowing et al Cochrane Rev 2008
  • Summary of findings from Individual studies - HIV
    • Seroprevalence (2 studies)
      • methadone and buprenorphine may help prevent HIV diffusion
    • HIV Seroconversion (3 studies)
      •  if in treatment (e.g. 3.5% vs 22% in 18 mth -Metzger 1993)
    Gowing et al Cochrane Rev 2008
  • HIV infection rates in and out of substitution treatment (Metzger et al. 1993) Out % In %
  • Other treatment outcomes- injecting drug use
    • Continued injecting (11 studies)
      • 8 MMT, 1 Bup, 1 NTX, 1 DF
      •  if in treatment
      • all MMT show significant lower rates
    • Sharing of injecting equipment
      • ALL showed reduced risk
        • increase use of decontamination
        • reduce likelihood sharing
    Gowing et al Cochrane Rev 2008
  • Other treatment outcomes Sexual risk
    • Sex-related risk (8 studies)
      • mainly examined continued sex industry work/number of partners
      • all showed reduced risk (1 exception)
      • However reports of personal and informal sex behaviour do not indicate any significant impact (?)
    • Overall HIV risk (3 studies)
      • all MMT
      • ALL showed reduced global risk
    Gowing et al Cochrane Rev 2008
  • Large-scale Descriptive Outcome Studies
    • DATOS (USA) and NTORS (UK)
    • reduction in freq. & rate of sharing (some stop injecting)
      • DATOS - Reduced injecting risk in all tx modalities
      • NTORS – sig. differences b/w intake & 4-5 year follow-up:
        • injecting fell from 60% to 37%
        • self reported sharing fell from 14% to 5%
    Gowing et al Cochrane Rev 2008
  • Summary of drug treatment findings
    • **** Increasing methadone and buprenorphine doses
    • Retention increases,
    • heroin use decreases
    • *** most effective methadone programs
    • - doses of >60mg/day
    • - maintenance oriented
    • *** most effective burprenophine programs
    • -doses of > 12-16mg
    • -maintenance orientated
    Gowing et al Cochrane Rev 2008
  • Summary of drug treatment findings - MMT
    • **** Maintenance agonist treatment substantially reduces heroin use
    • **** Maintenance agonist treatment is more effective than no treatment
    • or placebo in:
    • - reducing rates of imprisonment,
    • - reducing heroin use,
    • - retaining clients in treatment,
    • - employment/return to education
    Gowing et al Cochrane Rev 2008
  • Summary of drug treatment findings – residential treatment
    • ** High early drop-out from residential rehab. (>40% drop-out in the first month)
    • ** >3 months treatment required
    • ** Completion of residential rehabilitation
    • - reduced drug use and criminal behaviour
    • - legal employment increased
    • * Good outcomes predicted by tx progress in addition to time in treatment
    Gowing et al Cochrane Rev 2008
  • Intervention coverage – crucial, but often inadequate Coverage of target population is critical for HIV prevention
  • NSP Coverage in Malaysia * assuming 400 injections per IDU/year COVERAGE IDU population No. of NSP IDUs in contact % IDUs contact Syringes distributed (year) % all injections with a syringe from a NSP* 135 000 9 (110) 5500 4% 750 000 1.3 %
  • Coverage of substitution treatment is poor in much of the world
    • Malaysia
    • ~ 7000 receiving MMT through national program
    • 20 000 receiving methadone/bupenorphrine/bup-naloxone through the private system
    90% + methadone is consumed in developed countries (2003)
  • What sort of delivery system is required
    • Needs integrated health care system
    • Public Health Strategy to achieve maximum coverage
    • Primary care training in delivery of treatment
    • Family Practice Approach
    • Prisons based care linked to community ongoing treatment
  • Harm Reduction IS Effective What Are the Obstacles?
  • What Are The Obstacles? Political will – lack of are there votes in harm reduction? Denial national immunity myths Legal restriction laws against outreach, needle distribution, ST drugs classed as ‘narcotics Prejudice – medical, political, societal HR, ST ‘condones drug use’, Lack of concern and compassion drug users ‘have selves to blame’, ‘God’s punishment’ Disinformation campaigns misuse of science Reliance on law enforcement… … rather than public health Imbalance between prevention and care too much emphasis on, excitement about, clinical issues
  • Harm Reduction is a Western Concept
    • Asian countries adopting Harm Reduction
    • Malaysia
    • Iran
    • Indonesia
    • Bangladesh
    • China
    • Vietnam
    • Nepal
    • Cambodia
    • India
  • Harm Reduction is Against Islamic Principles
    • The injunctions of the Shariah (Islamic law) are stipulated to preserve the faith, life, intellect, progeny and wealth of mankind which are threatened by drug use and HIV/AIDS
    • In Islam life and good health must be protected and promoted in all circumstances and this includes prevention and treatment of any illness and disease
    • In this regard, the numerous harms associated with drug addiction, a chronic medical condition should be prevented through measures that have been scientifically proven
    • Islam also believes that every disease has a treatment known or discoverable by further scientific research.
  • Harm Reduction is Against Islamic Principles
    • The principle of injury in Islam ( Darar ) asserts that no one should be hurt or cause hurt to others, la darara wa la dirar .
    • Drug addiction and HIV/AIDS hurt patients and their family in their life and health
    • The law requires that any injury should be mitigated to the extent possible. A legal dictum in Islam gives the provision that “a lesser harm may be tolerated in order to eliminate a greater harm”; a l-darar al-ashadd yuzalu bi al-darar al-akhaff .
  • Harm Reduction is Against Islamic Principles
    • In Islam public interest takes precedence over personal interest
    • A relevant legal dictum in the context of harm reduction is that “a particular harm may be tolerated in order to prevent harm to the general public”. This means that whenever a conflict between personal and public interests arises, harm to the former may be tolerated so as to protect the latter
  • Harm reduction 20 years of experience Human rights Public health Two strands, shared ethos Evidence based Assessment based Pragmatic Targeted Realistic goals Rights to: Life and security Health protection Medical care Protection against hurts from community and state Ethos: Facilitative Non-coercive Non-punitive Cooperative