Key Components of Good HIV/AIDS Policy
Targeting The Drugs-HIV Nexus with
Pragmatic Health interventions

Dr. Jean-Paul C....
The Drugs
and HIV
Nexus
The Micro Risk Environment
of Drug Injecting: Drug Culture
Tradition of Self Preparation of Drugs
Use of Cooking Utensils, Nizhniy Novgorod
Frontloading Cheornaya, Nizhniy Novgorod
Group Injecting, Nizhniy Novgorod
Group Injecting, Nizhniy Novgorod
Group Injecting, Rostov Na Donu
Group Injecting of Heroin, Volgograd
Group Injecting, Volgograd
Drug Use Soviet Style: Do It Yourself!
IDUs’ Relationships with Law Enforcement
IDUs’ Relationships with Law Enforcement
Needle Exchange Programs
Slide:Courtesy of S. Strathdee
Global Expansion of Needle Exchange Programs
(December 2000)

Countries with at Least One Existing Needle Exchange Program...
NEPs in the Russian Federation
• Recent, explosive epidemic of injection
and blood borne infections
• ~ 1 million IDUs
• A...
Injection-Related HIV Risk Behaviors of Russian
Syringe Exchange Participants1 N = 1,076
N. N.
Pskov
R-N-D St. Petersb.
Ru...
Drug Use Characteristics of Russian
Syringe Exchange Participants N = 1,076
N. N.
Pskov R-N-D St. Petersb. Volgograd
N = 2...
Methadone Maintenance Programs

Why Do We Need Them?
Great Need for New Scientific Treatment Concepts
When Substitution Treatment is Unavailable
Do Methadone Maintenance
Programs Work?
YES! There is evidence from around
the world showing the efficacy of
Methadone Mai...
Effect of Methadone Treatment
on Level of Heroin Use
Heroin Use in Past 30 Days
407 MM Patients by Current Methadone Dose
Percentage Heroin Use
100
90
80
70
60
50
40
30
20
10
...
Effect of Methadone Treatment
on Injecting Drug Use
and Syringe Sharing
IDU And Needle Sharing Practices Among 507
Methadone Maintenance Patients In Six Programs
IN TREATMENT SAMPLE
(n=402)

IV ...
Effect of Methadone Treatment
on HIV Prevalence and Incidence
Absence of HIV Antibodies in Long-term, Socially
Rehabilitated Methadone Maintenance Patients

• Patients Entering MMT Bef...
Eighteen-month HIV Seroconversion By Methadone
Maintenance Treatment Retention
30
22%
20
Percent of
Seroconversion
Rate

1...
Effect of Methadone Treatment
on Prevalence of Hepatitis
Increased Methadone Maintenance Census
And Decreased Hepatitis Cases: NYC, 1971-1973
Patients in
Methadone
Maintenance
Tre...
Effect of Methadone Treatment
on Crime and Incarceration
CRIME BEFORE AND DURING Methadone
Methadone TREATMENT AT 6 PROGRAMS
(Ball and Ross, 1991)
Last Addiction Period, "On Stree...
Time of Incarceration Before and
During Methadone Treatment
Days in prison
per year 45

40
35

44,3 Days
(100%)

30

Reduc...
HIV is not the only harm
Harm Reduction and Overdose
Overdose Deaths: Frankfurt/M, 1969-1998
160
140
120
100
80
60
40
20
0
69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 8...
State Repression vs. Community Integration
Conclusion: Good AIDS Policy
• Multi-Sectoral Approach: HIV/AIDS policy is a
matter of all areas and levels of government ...
“In Essence, a Policy of Harm Reduction

Requires an Approach of Pragmatism
Rather Than Purism – an Acceptance That
It May...
Photo Credits
Black & White Photographs:
© John Ranard

Color Photographs:
© Jean-Paul Grund
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Dushanbe, 10 02 - hiv prevention & harm reduction

  1. 1. Key Components of Good HIV/AIDS Policy Targeting The Drugs-HIV Nexus with Pragmatic Health interventions Dr. Jean-Paul C. Grund UNAIDS Vienna
  2. 2. The Drugs and HIV Nexus
  3. 3. The Micro Risk Environment of Drug Injecting: Drug Culture
  4. 4. Tradition of Self Preparation of Drugs
  5. 5. Use of Cooking Utensils, Nizhniy Novgorod
  6. 6. Frontloading Cheornaya, Nizhniy Novgorod
  7. 7. Group Injecting, Nizhniy Novgorod
  8. 8. Group Injecting, Nizhniy Novgorod
  9. 9. Group Injecting, Rostov Na Donu
  10. 10. Group Injecting of Heroin, Volgograd
  11. 11. Group Injecting, Volgograd
  12. 12. Drug Use Soviet Style: Do It Yourself!
  13. 13. IDUs’ Relationships with Law Enforcement
  14. 14. IDUs’ Relationships with Law Enforcement
  15. 15. Needle Exchange Programs
  16. 16. Slide:Courtesy of S. Strathdee
  17. 17. Global Expansion of Needle Exchange Programs (December 2000) Countries with at Least One Existing Needle Exchange Program N= (46)
  18. 18. NEPs in the Russian Federation • Recent, explosive epidemic of injection and blood borne infections • ~ 1 million IDUs • At least 42 NEPs • 58% of NEPs surveyed in Dec 2000 had opened in the last year Source: D. Burrows, 2001
  19. 19. Injection-Related HIV Risk Behaviors of Russian Syringe Exchange Participants1 N = 1,076 N. N. Pskov R-N-D St. Petersb. Russian syringe exchange program=participants Volgograd N = 236 N = 201 N 199 N = 221 N = 219 reported a strong pattern of risk reduction, associated Daily Injection of at withleast one drug (%) in the program. In particular participation 30 Ds. Prior to SEP 64 25 52 66 74 substantial andDays statistically significant decreases in Last 30 64 11 36 77 71 P .7237 .2009 “receptive syringe sharing” <.0001 reported. .0031 were <.0001 Receptive Sequential Syringe Use (%) 30 Ds. Prior to SEP Last 30 Days P Injected @ Anonym. Injecting Venue (%) 30 Ds. Prior to SEP Last 30 Days P Total N = 1,076 53 53 .0001 41 9 <.0001 26 4 <.0001 39 9 <.0001 48 29 <.0001 37 3 <.0001 38 11 <.0001 62 47 <.0001 25 9 <.0001 54 28 <.0001 37 19 <.0001 45 33 <.0001 45 28 <.0001 Single-digit percentages of respondents reportedly engage in receptive syringe sharing fororthe recent 30 days in four 1 Totals may not equal 100% due to rounding missing data. out of five cities.
  20. 20. Drug Use Characteristics of Russian Syringe Exchange Participants N = 1,076 N. N. Pskov R-N-D St. Petersb. Volgograd N = 236 N = 201 N = 199 N = 221 N = 219 Age First IDU1 (Mean/SD) Total N = 1,076 19 (4) 21 (5) 21 (5) 18 (3) 19 (4) 20 (4) < 3 years 3+ – 6 years 6+ – 10 years >10 years 22 33 33 12 47 31 10 12 18 22 25 35 43 27 16 14 26 41 26 6 30 32 23 15 Powder Heroin Amphetamine 47 9 53 61 5 24 96 9 90 4 59 20 Reported Secondary Exchange (%) 40 46 40 43 48 44 Years Injecting1 (%) Almost half of Russian Syringe Exchange Participants reported Secondary Exchange (40-48%), whether the Drug Injected program (%) encouraged it or not. 84 Homemade opiates 83 15 6 21 42 1,2 1 2 N differs because results are derived from intake questionnaires that linked with risk assessment questionnaires, only, so that N for Nizhny Novgorod = 165; N for Pskov = 153; N for Rostov-na-Donu = 109; N for St. Petersburg = 56; N for Volgograd = 160; and the total N for the five programs = 643. Percents may sum to > 100; more than one response may apply.
  21. 21. Methadone Maintenance Programs Why Do We Need Them?
  22. 22. Great Need for New Scientific Treatment Concepts
  23. 23. When Substitution Treatment is Unavailable
  24. 24. Do Methadone Maintenance Programs Work? YES! There is evidence from around the world showing the efficacy of Methadone Maintenance Programs
  25. 25. Effect of Methadone Treatment on Level of Heroin Use
  26. 26. Heroin Use in Past 30 Days 407 MM Patients by Current Methadone Dose Percentage Heroin Use 100 90 80 70 60 50 40 30 20 10 0 0 1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 90+ Methadone Dose SOURCE: Ball and Ross 1991, p. 248.
  27. 27. Effect of Methadone Treatment on Injecting Drug Use and Syringe Sharing
  28. 28. IDU And Needle Sharing Practices Among 507 Methadone Maintenance Patients In Six Programs IN TREATMENT SAMPLE (n=402) IV USERS (no needle sharing) 29% DROPOUT SAMPLE (n=105) Needle Sharing IV USERS 8% NO IV USE in the past year 63% SOURCE : J.C. Ball, University of Maryland, Baltimore, 1987. IV USERS (no needle sharing) 51% NO IV USE since treatment 29% Needle Sharing IV USERS 20%
  29. 29. Effect of Methadone Treatment on HIV Prevalence and Incidence
  30. 30. Absence of HIV Antibodies in Long-term, Socially Rehabilitated Methadone Maintenance Patients • Patients Entering MMT Before 1983 (N = 58): 0% HIV+ in 1990 • Out of Treatment IDUs in New York: 55-60% HIV+ in 1990 Source: D. Novick, H. Joseph, et al., Archives of Internal Medicine, Vol 150, Jan. 1990
  31. 31. Eighteen-month HIV Seroconversion By Methadone Maintenance Treatment Retention 30 22% 20 Percent of Seroconversion Rate 10 3.5% 4.4% 0 In Treatment (N = 85) Adapted from Metzger et al., 1993 Partial Treatment (N = 45) Treatment Status No Treatment (N = 55)
  32. 32. Effect of Methadone Treatment on Prevalence of Hepatitis
  33. 33. Increased Methadone Maintenance Census And Decreased Hepatitis Cases: NYC, 1971-1973 Patients in Methadone Maintenance Treatment 40000 2400 2000 30000 1600 20000 1200 800 10000 400 0 0 1971 1972 1973 3-Year Increase (19,900 Additional Patients) Source: Dole, Joseph, and Des Jarlais, 1981 1971 1972 1973 3-Year Increase (1,500 Fewer Cases) Reported Cases of Serum Hepatitis
  34. 34. Effect of Methadone Treatment on Crime and Incarceration
  35. 35. CRIME BEFORE AND DURING Methadone Methadone TREATMENT AT 6 PROGRAMS (Ball and Ross, 1991) Last Addiction Period, "On Street" CrimeDays Per Year at Risk 300 300 282 264 273 250 224 189 200 In Methadone Maintenance Treatment 210 250 200 150 150 100 100 50 50 Program: 0 37 27 15 14 A B C 19 21 E F Program: 0 A B C D E F Before Treatment Crime D In-Treatment Crime Red bars = crime days per year when addicted. Blue bars = crime days per year after 6 months or more in treatment. (N = 491)
  36. 36. Time of Incarceration Before and During Methadone Treatment Days in prison per year 45 40 35 44,3 Days (100%) 30 Reduction of 92% of time spent in prison 25 20 15 3,4 Days (8%) 10 5 0 Days in prison per year of heroin addiction Days in prison in the last 12 months
  37. 37. HIV is not the only harm
  38. 38. Harm Reduction and Overdose
  39. 39. Overdose Deaths: Frankfurt/M, 1969-1998 160 140 120 100 80 60 40 20 0 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 No. Of ODs under "No Tolerance" Policy No. Of ODs under "Harm Reduction" Policy
  40. 40. State Repression vs. Community Integration
  41. 41. Conclusion: Good AIDS Policy • Multi-Sectoral Approach: HIV/AIDS policy is a matter of all areas and levels of government and civil society; • Evidence-Based Interventions; • Biggest Bang for the Buck: Direct funding to where the Epidemic is and goes; • Keep Your Priorities Clear; • Pragmatism is Essential:
  42. 42. “In Essence, a Policy of Harm Reduction Requires an Approach of Pragmatism Rather Than Purism – an Acceptance That It May Sometimes Be Better to Go for a Probable Silver Than a Possible Gold.” John Strang
  43. 43. Photo Credits Black & White Photographs: © John Ranard Color Photographs: © Jean-Paul Grund

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