HIV+ drug users lagging behind on the road to ARV treatment

Drug users living with HIV/AIDS make up only a tiny proportion of people receiving antiretroviral (ARV) drugs throughout the world. According to reports presented at the recently concluded International Conference on the Reduction of Drug Related Harm, held in Belfast, Northern Ireland [20-24 March], drug users are being left out of ARV treatment programmes as a result of double-standards within health services, even in countries where drug use is a major determinant of HIV spread.

Basic data were provided by Dr Chris Ford, a British-based general practitioner, who summarised conservative estimates that about 200 million people consume illicit drugs globally. Opiates are used by about 15 million, heroin specifically by 9 million, cocaine by 13 million, marijuana by 146 million and amphetamines and ecstasy by 38 million. Worldwide, there are in excess of 13 million injection drug users in over 130 countries. But most harm reduction and treatment resources go to 20% of those users, and mostly to those living in rich countries. That leaves the vast majority of drug users worldwide with little or no access to treatment options.

For example, injection drug users represent less than 8% of all people receiving antiretroviral treatment in developing and transitional countries.

Referring to the latest UN data on the availability of ARVs, Dr. Carmen Aceijas of Imperial College, London, reports that a total of 53 countries currently provide ARV treatment through some sort of public scheme, and that an additional 41 countries rely on the nongovernmental and/or private sectors. In total, as of Dec. 2004, 432,453 people in 44 developing and transitional countries were receiving antiretroviral treatment.

Of those people in developing/transitional countries receiving ARVs, only 35,391 people are identified as drug users and of these approximately 30,000 of them are in Brazil.

ARV treatment through any means is completely unavailable in at least eight countries: Azerbaijan, the Republic of Korea, Kyrgyzstan, Somalia, Syria, Tajikistan, Turkmenistan and Uzbekistan.

Discussing the urgent need of expanding ARV treatment for HIV-positive drug users, Dr Michel Kazatchkine of the Agence Nationale de Recherches sur le Sida, France, confirms that access among drug users who should be eligible for ARV treatment remains poor in many regions of the world. While injection drug users represent over 80% of patients currently in need of treatment in Ukraine, Belarus and Russia, for example, they represent less than 5 % of patients currently receiving ARV treatment in those nations.

For Kazatchkine, limiting access to treatment raises important ethical and societal issues - because it is an inappropriate approach from a public health perspective; and because there is a high risk of disease progression in patients initiating treatment at later stages and with HIV-associated conditions. For him, limiting IDU access to treatment stems from a double standard of thinking.

Olga Kuzenna and Susie McLean of the International HIV/AIDS Alliance, UK, describe how Eastern Europe has one of the largest and fastest growing HIV epidemics among drug users, who account for 71% of new HIV infections; according to World Health Organization (WHO) estimates, approximately 15,000 people living with HIV/AIDS in the region are in need of ARV treatment.

Prior to the initiation of a Global Fund Against AIDS, Tuberculosis and Malaria (GFATM) in the Ukraine, for example, 118 people were receiving ARV as part of a Medicines Sans Frontieres (MSF) programme and an additional 137 as part of a government programme. Now, after 8 months of the GFATM programme, over 1400 people are receiving treatment. Yet, these are still low numbers relative to estimates of active drug users, and deaths of people on ARV waiting lists, a lack of integrated tuberculosis care, poor access to health care generally for drug users and challenges in changing the attitudes of health care workers all remain formidable obstacles.

Dr Andrew Ball of the Department of HIV/AIDS at WHO provides an update on reaching drug users with through the current ‘3 by 5’ Initiative, aimed at expanding ARV access to reach 3 million people with HIV in developing countries by the end of 2005.

According to Ball, WHO is making it a priority to promote good drug-related practices through policy guidelines and position papers, incorporating harm reduction principles in key WHO resolutions and basic documents, conducting country advocacy visits to countries including China, India, Indonesia, the Islamic Republic of Iran, Libya, Russia, Ukraine and Viet Nam, as well as establishing collaborative partnerships with affected communities, including harm reduction networks.

In addition, WHO is developing models of HIV/AIDS treatment scale-up for countries with high levels of injecting drug use through linking and integration of HIV/AIDS treatment services with drug dependence and drug user outreach services; through advocating continuity of care for prisoners, capacity building, support for pilot programmes, adaptation of relevant tools and guidelines, and assisting countries to mobilize and utilize resources, including funds specifically for treatment of drug users.

As Ball summarised “Drug users are entitled to treatment and are worth investing in.”

[This is an HDN Key Correspondent report from the International Conference on the Reduction of Drug Related Harm, held in Belfast, Northern Ireland, March 20-24, 2005.]

HDN Key Correspondent Team
Email: Correspondents@hdnet.org

(April 2005)

Pharmacotherapy for drug users waiting for ARVs

Where antiretroviral (ARV) treatment may not be available, can pharmacotherapy therapy, such as methadone, keep drug users with HIV alive until ARV treatment arrives?

Participants at the recently concluded International Conference on the Reduction of Drug Related Harm, held in Belfast, Northern Ireland [20-24 March] comment on this question.

According to Bernard Gardiner, Manager of the Global AIDS Program of the International Federation of Red Cross and Red Crescent Societies: “Methadone can help stabilise the situation of drug users so that they can be in control of their circumstances, this means that they are less likely to share injecting equipment, they are less likely to get HIV in the first place, or if they are HIV positive, they are less likely to have chaotic circumstances.”

“That kind of stability means they actually have real choices to be able to look after their health with the things that are available to them and keep themselves as well as possible until the ARVs are available.”

“They may be less likely to be involved in risk through being marginalised and the desperations that come with addictions and the risk taking that goes on in an illicit context.”

“That is the role that it [pharmacotherapy] can play in keeping people alive. There is 40 years of evidence that methadone works, and it is about time that this way of reducing human suffering was made available to people who need it.”

“It is a rational approach to the treatment of addiction, the reduction of human suffering, and the well being of drug users, their families and the communities that they live in. Methadone can keep them alive to advocate for ARVs to be there, and that is the kind of push that it will probably take to get it there.”

For Joe Salvaretnam, Program Director at the Malaysian AIDS Council, the role of methadone in the care of injection drug users with HIV or AIDS is key.

“It is part of the continuum of care. In countries, like Malaysia, for example, if you contact the drug user and convince them that he can be stabilised through methadone, then you can link them up with other care and support services. When we talk about ARVs in our kind of resource setting, where drug users face extraordinary stigma and discrimination, this could be a vicarious way of getting them on methadone and linking them up.”

Chris Buckner is the Manager of HIV and AIDS and Harm Reduction Services for Vancouver Coastal Health, in British Columbia, Canada. He explains: “In Vancouver there are 1,300 IDU [injection drug users] who are eligible for ARVs but only about 300 have ever been on them, and so that is one of the big challenges: seeing how we can increase that access.”

“Some of the barriers are bureaucratic in that a lot of the programs are clinic-based and maybe you get your methadone there, or maybe you hate the doctor there, or maybe you hate that there is a security guard standing there.”

“Some of the folks, some of the researchers and other people who have control over the ARVs and the protocols are a little bit anxious about those sorts of things, like ‘oh, we are going to get a superbug,’ or ‘oh, we are going to do more harm than good,’ but I think there is an area in between the doomsday and the hyper-control.”

Buckner says we should explore “what adherence mean to someone. Maybe five years of adherence is unrealistic, but maybe there is some benefit in terms of smaller windows of adherence that can be obtained, rather than saying you are at the gold standard of adherence or you are nothing.”

“Some of the unethical practices, saying ‘I will give you this but only if you do this,’ we’ve got to bust that open and call it what it is: It is unethical to withhold medical treatment from people who want it based on this coercion to enter into appropriate drug treatment…you have got to divorce those things. They don’t hold back people who are in treatment for cardiovascular disease, they don’t say ‘we are only going to give you this angioplasty if you never eat McDonalds again.’ So why are we doing this thing with people with addictions?”

“The answer is clear: Because they are in a disadvantaged place and we feel we need to put our moral concept onto them, so you withhold valuable medical treatment.”

“It’s a struggle on the same level as the shift that happened with mental illness or people with physical disabilities having rights to access to care. An addiction is different, but on a purely ethical, theoretical level it shouldn’t be different.”

Fiona Reid, from the Perth Women’s Centre in Western Australia, can’t see any reason why drug users with HIV shouldn’t be able to access methadone and antiretroviral therapies “for the same reason that the women we work with can access treatments for Hepatitis C.”

“The women we work with have children and they are surprisingly used to schedules, they are often involved with courts and law or family disputes. If it is a priority, and for most of them it is a priority.”

“I think that it is a myth or a misnomer that people who use intravenous drugs don’t see their health as a priority, they do, its just whether they can access it and accessing it is about being able to be treated with respect, not being judged for what they do, regardless of their drug use.”

“They will access it [health services] if it is available on those human levels.”

Ralf Jürgens, from the Canadian HIV/AIDS Legal Network, believes it is a “very important step to increase access to methadone… in those countries where methadone is currently not available as well as those where it is available but not accessible.”

“People who are on methadone have a better chance to be able to take the treatments [eg. ARVs]; it is part of the care and the support that some people may need to be able to benefit from treatment.”

However while Jürgens thinks there is a link, he doesn’t believe we should “require that ‘you have to be on methadone to take ARVs’. That is not what we are doing in Canada or in other countries. Access to methadone needs to be a choice and it needs to be very accessible – and ARVs need to be very accessible too.”

“People shouldn’t be forced to take methadone treatment in order to benefit from ARVs, but they should have that option if they choose.”

“There are human rights to health and methadone is a medical treatment – people have a right to methadone, and it is the same with ARVs.”

But Dr Rusli Ismail, a geneticist and member of the Malaysian AIDS Council Harm Reduction Working Group, is more reserved.

“With or without methadone, if they don’t have access to antiretroviral drugs it is not going to change anything because what methadone does is get rid of the craving for the opiate, but it doesn’t do anything for the HIV.”

“If they are free of the needles that can expose them to various kinds of things that is probably the only protection you get in terms of exposure, but in terms of the body function it is not going to change anything.”

Ismail recounts how: “In Hong Kong there was a robbery at one of the big pharmacies, and almost everything was stolen except for methadone, because there was no black market for methadone because in Hong Kong all you need to do is prove that you are a heroin dependent individual and you can get it.”

HDN Key Correspondent
Email: Correspondents@hdnet.org

[These comments were made at the recent International Conference on the Reduction of Drug-Related Harm, held in Belfast, northern Ireland, in March 2005].

Methadone comes of age – almost...

by HDN Key Correspondent
April 2005

(Cross-posted from the SEA-AIDS eForum)

Moderators’ note: Given a wealth of evidence demonstrating the effectiveness of substitution therapy, including its role in reducing the spread of HIV transmission rates among drug users, it is worrying that the highly anticipated announcement by the World Health Organization (WHO) to include methadone in its Essential Drug List (EDL) has not yet been made. This is despite an apparent agreement by the relevant WHO committee weeks ago.

The EDL is the advisory list that WHO gives to all governments about the basic drugs that their health workers should have available.

Why has the announcement been so delayed? There are suggestions circulating in the international media that the WHO is being pressured by the US government over the new EDL recommendations. With the ‘abortion pills’ mifepristone and misoprostol also on the new EDL list of recommended drugs, however, it is not clear if current US pressure and resulting delay even relates to methadone.

If it does, however, it is vital that the WHO Director-General (DG), Dr LEE Jong-wook, stands by not only WHO’s own process for identifying medicines to be added to the EDL, but also the evidence that methadone is a critical and life-saving treatment option for drugs users throughout the world.

Endorsement of the recommendations of the WHO Expert committee on essential medicines (March 2005) by the WHO DG will be consistent with and support the various positions taken by the WHO, the United Nations Office on Drugs and Crime and the Joint United Nations Programme on HIV/AIDS in their recent joint position paper on substitution therapy.

We had hoped to use an outline of that inter-agency position paper on substitution therapy (see below) to help highlight the methadone/EDL announcement when it was made. In light of the current delay in an EDL announcement, it may be even more important to share that summary now.

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Methadone comes of age – almost...
HDN Key Correspondent
April 2005
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“PROVIDING PHARMACOTHERAPY TO HIV POSITIVE INJECTION DRUG USERS CAN MINIMIZE THE RISK OF FURTHER TRANSMISSION OF THE VIRUS AND STABLIZR THE UNDERLYING CONDITION” [WHO]

Imagine there was a simple, effective and affordable medicine that could reduce the death rate among people who use drugs such as heroin by about two-thirds. Fat chance? Now imagine that medicine does exist, but that because of a reluctance on the part of policy-makers and government officials, it was not widely available in many countries. Hard to believe? Dream no more. The medicine exists and is hopefully about to break out of its shrouded history: methadone is coming of age.

Between 5 and 10% of the world’s HIV infections are reportedly due to injection drug use. The figure may rise to as high as 70% of HIV transmission in some countries – in Asia and Europe in particular. Injection drug use is also now the predominant mode of transmission of hepatitis C virus throughout the world.

Due to the unregulated nature of illicit substances, injection drug users often use drugs of unknown potency and quality, which can frequently lead to overdoses. It is estimated that approximately 2–3% of injection drug users die each year, resulting in a mortality rate for heroin users, for example, of between six and twenty times that seen among those in the general population of the same age and sex.

Substitution therapy is a treatment approach that helps opioid drug users (e.g. Heroin) to reduce the withdrawal symptoms and craving when drug use is stopped or reduced. Methadone is one of the oral medications used for substitution therapy. Because users taking methadone are far less likely to inject drugs, it also has a significant impact on reducing their risk of HIV injection.

In their recent position paper Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention, the World Health Organization (WHO), United Nations Office on Drugs and Crime (UNODC) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) state that opioid “drug dependence treatment is an important strategy to improve well-being and social functioning of people with opioid dependence and to reduce its health and social consequences, including HIV infection.”

Participation in substitution maintenance therapy also provides opportunities for early diagnosis of other health problems, HIV, Tuberculosis, Hepatitis and STD counselling and testing, as well as referral for additional services. It is arguably the most effective, cost effective treatment option for injection drug users, and brings them into contact with various other services within the health system.

The UN paper further enlightens that “methadone maintenance therapy is correlated with reduction in HIV risk behaviours related to drug-taking, or an increase in protective behaviours.” According to WHO, “IDUs who do not enter [methadone] treatment are up to six times more likely to become infected with HIV than injectors who enter and remain in treatment.”

“The death rate for people with opioid dependence in methadone maintenance treatment is one-third to one-quarter the rate for those not in treatment.”

According to several conservative estimates, every dollar invested in opioid dependence treatment programmes may yield a return of between $4 and $7 in reduced drug-related crime, criminal justice costs and theft alone. When savings related to health care are included, total savings can exceed substitution therapy costs by a ratio of twelve to one.

The UN position paper concludes that because substitution therapy (also known as pharmacotherapy) has proven effective in terms of promoting retention of users in treatment, reduction of drug use, improvements of drug users’ psychological and social functioning, as well as reduction of risk-associated injecting and sexual behaviours, it should be given serious consideration both as an HIV prevention measure, and as a treatment measure for individuals with opioid dependence who are already infected with HIV.

“Programmes that combine pharmacotherapy with HIV/AIDS treatment and care should be encouraged as directly observed pharmacotherapy also provides an opportunity for directly observed antiretroviral therapy, as well as therapy for opportunistic infections such as tuberculosis,” the paper states.

“Individuals with opioid dependence benefit from substitution maintenance therapy through increased stability and improved well-being and social functioning. People receiving substitution therapy can make significant progress in their physical and emotional life, as well as in their relationships with others and their ability to contribute meaningfully to their community and society at large.”


HDN Key Correspondent
Email: Correspondents@hdnet.org