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].
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].
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