Injecting Drug Use, HIV/AIDS Epidemic and Harm Reduction Strategies

Injecting Drug Use, HIV/AIDS Epidemic and Harm Reduction Strategies Fabio Mesquita, MD, PhD Harm Reduction Adviser IHPCP - Indonesia Pertemuan Nasional HIV & AIDS Ke – 3 Surabaya – 2007

TWO MAJOR EPIDEMICS AIDS DRUGS

Drug Epidemic AIDS Epidemic

WORLD DRUG REPORT, UNODC 2005

10,6 million users of heroin

13,7 millions users of cocaine

26, 2 millions users of amphetamines

Over 130 countries report injecting drug users – 80% of population in developing, transitional countries

WORLD DRUG REPORT,

UNODC 2005

Total trade of illegal drugs is around

U$ 322/BILHÕES/ANO from that :

COCAÍNE 70 billions

HEROINE 65 billions

New forms and new formulas usage of Drugs –

ATS (amphetamines-type stimulants) 44 billions

Guiyang Kunming Mandalay Yangon Chiang Mai Bangkok Hanoi Vientian e Phnom Penh Ho Chi Minh City Songkhla MYANMAR LAOS CAMBODIA THAILAND VIETNAM CHINA Hong Kong MAJOR HEROIN TRAFFICKING ROUTES IN SE Asia Source: UNODC Regional Centre for East Asia and the Pacific Courtesy BBC World

HIV/AIDS Hepatitis B, C and D Overdoses Hepatic chronic diseases Co-Morbidity with Mental Health Addiction Abscesses Endocarditic Syphilis, Malaria, HTLV, etc Tuberculosis/Other Respiratory diseases Car accident Occupational Accidents Violent deaths HEALTH CONSEQUENCES

Adults and children estimated to be living with HIV as of end 2005 Total: 40.3 (36.7 – 45.3) million Western & Central Europe 720 000 [570 000 – 890 000] North Africa & Middle East 510 000 [230 000 – 1.4 million] Sub-Saharan Africa 25.8 million [23.8 – 28.9 million] Eastern Europe & Central Asia 1.6 million [990 000 – 2.3 million] South & South-East Asia 7.4 million [4.5 – 11.0 million] Oceania 74 000 [45 000 – 120 000] North America 1.2 million [650 000 – 1.8 million] Caribbean 300 000 [200 000 – 510 000] Latin America 1.8 million [1.4 – 2.4 million] East Asia 870 000 [440 000 – 1.4 million]

Most countries have IDU ignited HIV Non IDU initiated IDU initiated

Case Study

Big country;

Developing World

enormous population;

immeasurable social problems;

recent democracy;

one main and powerful religion;

an impressive HIV/AIDS epidemic;

Rich country, poor people

Brazil: the epidemiological picture

Estimated HIV Prevalence (2005): 0.6% ( 15-49 age group)

Estimated number of PLWHA (2004): 597,443

AIDS incidence rate (2005): 7.1 per 100,000

Cumulative AIDS cases reported (06/2006): 433,067

Cumulative AIDS-related deaths (1980-2006): 183,074

AIDS mortality rate (2005): 6.0 per 100,000

Stakeholders

Ministry of Health

Multisectoral Response

Governments at all level (States and Cities)

Non Governmental Organizations

Strong Support from Parliament (including national budget

and legislation)

All sectors of the Brazilian Society (including media,

Catholic Church, among others)

International Organizations (bilateral and multilateral)

Three Main Aspects:

Comprehensive Prevention

Care, Support and Treatment for all

Human Rights Framework

Main Vehicles of Deliver:

Decentralized:

Public Health System

NGOs as complementary

Universities

CONDONS AVAILABLE FOR FREE DISTRIBUTION 800 MILLION FOR 2006 1 BILLION FOR 2007 PLUS REGULAR MARKET AND SOCIAL MARKET (DKT)

TEST AND COUNSELING FIRST VCT OPEN IN 1989 TOTAL POPULATION EVER TESTED 28,1% - AUGUST 2004

BRAZILIAN ARV ACCESS PROGRAM: MAJOR ASPECTS

UNIVERSAL AND FREE OF CHARGE ACCESS TO ARV:

POLICY ESTABLISHED IN MID 90’S (Congress

Law, November/1996)

NATIONAL ARV TRETAMENT GUIDELINES

(Adults, Children and Pregnant Women)

ALL CLIENTS HAVE THE SAME RIGHTS TO

GET IN TREATMENT WITH HAART

0 20000 40000 60000 80000 100000 120000 140000 160000 180000 jan/97 abr/97 jul/97 out/97 jan/98 abr/98 jul/98 out/98 jan/99 abr/99 jul/99 out/99 jan/00 abr/00 jul/00 out/00 jan/01 abr/01 jul/01 out/01 jan/02 abr/02 jul/02 out/02 jan/03 abr/03 jul/03 out/03 jan/04 abr/04 jul/04 out/04 jan/05 abr/05 jul/05 out/05 170.000 * Dados preliminares Projected Number of patients receiving ARV therapy. Brazil, 1997 – 2005

* Brazilian local production

RITONAVIR (1996) *

SAQUINAVIR (1996) *

INDINAVIR (1997) *

NELFINAVIR (1998)

AMPRENAVIR (2001)

LOPINAVIR/r (2002)

ATAZANAVIR (2004)

ZIDOVUDINE (1993) *

ESTAVUDINE (1997) *

DIDANOSINE (1998) *

LAMIVUDINE (1999) *

ABACAVIR (2001) DIDANOSINE EC (2005)

TENOFOVIR (2003)

NEVIRAPINE (2001) *

EFAVIRENZ (1999)

ITRN and ITRNt

ENFUVIRTIDE (2005)

IP FUSION INHIBITOR ITRNN Antiretroviral drugs distributed through Brazilian public health system, according to therapeutic category. Brazil, 2005

ARV availability in low and middle income countries, according to geographical region. June, 2005* Source: “Progress on Global Access to HIV Antiretroviral Therapy, June 2005 update, World Health Organization Region Number of people receiving ARVs Estimated need Coverage Sub-Saharan Africa 500,000 4,700,000 11% East, South and South-East Asia 155,000 1,100,000 14% North Africa and Middle East 4,000 75,000 5% Eastern Europe and Central Asia Central 20,000 160,000 13% Latin America and the Caribbean 290,000 465,000 62% Total 970,000 6,500,000 15% (Average) *Adults only, average figures

AIDS Hospital Admissions in Public Health System in Post HAART Era. Brazil (1996-2001) Source: MOH, 2002

2002 - STUDY FROM THE UNIVERSITY OF SAO PAULO

SCHOOL OF MEDICINE SHOWED THAT:

ADHERENCE RATES WERE QUITE SIMILAR TO

ANY OTHER INTERNATIONAL STUDY SO FAR.

THEY INTERVIEWED 1038 AIDS CLIENTS UNDER

HAART THERAPY AND FOUND AN ADHERENCE

RATE IN 69% OF THE CLIENTS (COMPLIANCE ≥ 80)

THE USE OF ILLIGAL DRUGS WAS NOT A PREDICTOR

FACTOR FOR NO ADHERENCE.

AIDS incidence and mortality rates (by 100,000 inhabitants) Brazil, 1985-2003 Sources: Incidence - PN STD-AIDS/SVS/MH. Mortality – SIM/DASIS/SVS/MH 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 0 5 10 15 20 25 Mortality Incidence

Distribution of PCP, Toxoplasmosis and Tuberculosis in Reported AIDS Cases to MOH (Brazil, 1981-2001) Source: MOH, 2002 HAART

Estimate of HIV Infected Individuals (among 15 a 49 years old) by year 2000 Word Bank Projection (1992) Brazilian MOH Estimate (2000) 0 200 400 600 800 1000 1200 1400 Thousands 1,200,000 600,000 MOH, 2002  50%

Dados de Casos de AIDS no Brasil Gráfico 1 – Casos de aids segundo ano de diagnóstico. Brasil, 1980-2003. Fonte: MS/SVS/PN DST e Aids/SINAN.

INDONESIAN RESPONSE FOR HIV/AIDS CRISIS AMONG AND FROM IDUS First AIDS case in Indonesia: 1987 First case in IDU: 1995 First Harm Reduction Project: 1999 Ongoing: NEP. Methadone, CST for IDUs

Grafik 1: Jumlah Kasus AIDS di Indonesia 10 Tahun Terakhir Berdasarkan Tahun Pelaporan sd 31 Maret 2006 ----------------------------------------------------------------------------------------------------------- Figure 1 : Number of AIDS Cases in Indonesia in Last 10 Years up to March 31, 2006

Risk Factors Indonesian Epidemic

Harm Reduction Definition

A term that defines policies, programs, services and actions that work to reduce the health, social and economic harms to the individuals, community and society, that are associated with the use of drugs. (Newcombe, 1992)

HIV PREVENTION AND CARE FOR IDUs After 25 years of the HIV/AIDS we’ve learned how to confront the epidemic among and from injecting drug users

The three priority interventions are:

Needle and Syringe Exchange

Treatment for their drug related problems

Care, Support and Treatment for IDUs

HIV PREVENTION AND CARE FOR IDUs IN INDONESIA

Using the existing Public Health System. Improve its quality. Public Health Centers (Puskesmas), hospitals and laboratories. Improve pharmaceutical capacity to produce genereics. Strong connections to DINKES. Inside of Prisons connecting with Dep Human Rights

Cooperating with the civil society by their NGOs and their network (Jangkar)

Giving special role to drug users, specially their national network (IDUSA) and locals.

How to deliver services

Evolution of Indonesian Response - NSP

Pilot Project WHO and DEPKES since 2003 two Hospitals RSKO (JKT) and Sanglah (Bali). They were both supported mainly by IHPCP since 2004.

FROM 2 TO 10

2005/2006 expansion for Puskesmas Tanjung Priok (JKT) + 4 in DKI; Puskesmas Kuta (Bali); Puskesmas Denpasar Bali; Hospital Hassan Sadikin in Bandung; Hospital in Dr Soetomo Surabaya

Evolution of Methadone services

Recent data published in 2006 pointed out for 31% of people under ARV in Indonesia are IDUs (not defined if current or former). This represents 25% of the need.