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Pyramid unaids 10 19-01 (v2)

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  • 1. Building Pyramids: Designing HIV Prevention and Treatment Systems for Drug Users in Eastern Europe Dr. Jean-Paul C. Grund
  • 2. 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.” 10/18/01, Building Pyramids J-P Grund
  • 3. Drug Use after Socialism: Prevalence Russia & Ukraine Table 1. Registered & Estimated Number of Drug Users in Russia & Ukraine Russia Registered Number of Drug Users Ministry of Internal Affairs: Ministry of Health: 1 99 0 19 94 19 96 20 01 158.000 249.000 25.000 85.000 450.000 (Users) 270.000 (Addicts) Estimates: 1996: 600,000 1998: 1-2.5 million 2001: LTP: 3 million Ukraine Registered Number of Drug Users: “Early 1990s”: 20.000; 1997: 80.000 Estimate (MIA): 1997: 600.000 – 700.000 (75 - 80% IDUs) Sources: Brunet 1996; USAID/CDC 1998; Khodakevich & Dehne 1998; Dehne et al. 1999; MOH, 2001
  • 4. 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 City Total IDUs % of Population 35000 2.6 Nizhniy Novgorod 9000 3.6 Novorossiisk 380-440 0.2 Pskov 10000 1 Rostov Na Donu 70-80000 1.7-1.9 St. Petersburg 18000 1.7 Volgograd 25000 2 Odessa up to 10000 3 Poltava 7000-8000 0.4-0.5 Estonia 2000-3000 0.3-0.5 Vilnius 1416 0.2 Kishineu 15-20000 1-1.5 Sofia 2500 1 Szeged
  • 5. Drug Use after Socialism: Qualitative Prevalence Assessments “People drink or inject in this place.” (Outreach suggest that Both national and city-level dataWorker, Volgograd) in several NIS countries more than 1% of the population is involved in (injecting) drug use. “It is difficult to find a building in this town that is not affected by drug use.” (Epidemiologist, Rostov Na Donu) 10/18/01, Building Pyramids J-P Grund
  • 6. Drug Use under Socialism: Do It Yourself!
  • 7. Collective Drug Preparation & Injecting, Friendship Networks, & HIV Transmission
  • 8. A Culture of Collective Drug Use 10/18/01, Building Pyramids J-P Grund
  • 9. 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.”
  • 10. 0 Ap 0 r01 Ju l-0 1 99 98 97 96 95 94 93 92 71 5 17 70 16 10 59 2 26 10 87 7 9 3 1 8 71 60 52 44 33 70 23 26 05 40000 20 19 19 19 19 19 19 19 19 91 90 89 88 87 20000 19 19 19 19 19 4 80 160000 140000 120000 1 1 15 03 0, ,0 00 24 0 100000 35 Cumulative number of reported HIV cases Russian Federation, 1987 - July 1, 2001 80000 60000 0
  • 11. 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. 10/18/01, Building Pyramids J-P Grund
  • 12. Pyramid Model: Establishing a Typology of Care Services for IDUs Threshold to Care High Threshold Services Medium Threshold Services Low Threshold Services ‘No’ Threshold Services 10/18/01, Building Pyramids J-P Grund
  • 13. Pyramid Model Professional Care Services for IDUs High Threshold Services • 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 10/18/01, Building Pyramids J-P Grund
  • 14. Pyramid Model Professional Care Services for IDUs Medium Threshold Services • 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 10/18/01, Building Pyramids J-P Grund
  • 15. Pyramid Model Professional Care Services for IDUs Low Threshold Services • 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 10/18/01, Building Pyramids J-P Grund
  • 16. Pyramid Model Professional Care Services for IDUs Low Threshold Services • 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 10/18/01, Building Pyramids J-P Grund
  • 17. Pyramid Model A Dynamic Model Key Characteristics • 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. 10/18/01, Building Pyramids J-P Grund
  • 18. Pyramid Model Considerations for Setting Priorities Public Health Considerations • 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 Economic considerations • Available $$ Resources (Funding) • Costs of Services 10/18/01, Building Pyramids J-P Grund
  • 19. Coverage: What proportion of the IDU Population Needs to be Reached? Slide: Courtesy of S. Strathdee 10/18/01, Building Pyramids J-P Grund
  • 20. Pyramid Model Care Services for IDUs: Level & Coverage Level of Care Potential Coverage of Population (%) High Threshold Services 1-20 (?) Medium Threshold Services 15-40 (?) Low Threshold Services 70-80 ‘No’ Threshold Services Nx 10/18/01, Building Pyramids J-P Grund
  • 21. Pyramid Model Treatment Costs by Type of Modality Type of Treatment Relative Costs per Treated Drug User $$$ High Threshold Services $$-$$$ Medium Threshold Services $ Low Threshold Services Q: Where to Invest Scarce Resources? A: Where we get the Biggest 10/18/01, Building Pyramids Bang for the Buck! J-P Grund
  • 22. Mean Costs Per Year For 1 Heroin Addict (USA) $ 50000 40000 Security 30000 Theft, etc. 20000 10000 Heroin Jail or Prison and Court Costs 0 On Street Incarcerated Residential Drug-Free Treatment MMT Residential Treatment Methadone Maintenance Treatment SOURCE: Slide: M. Reisinger, Adapted from NYS DSAS, 1991, by Dole & Des Jarlais. 10/18/01, Building Pyramids J-P Grund
  • 23. 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. 10/18/01, Building Pyramids J-P Grund