How can we tailor the delivery of the

How can we tailor the delivery of the TB/HIV package to IDU? David H. -U. Haerry European AIDS Treatment Group (European Community Advisory Board, Policy Working Group)

Eastern Europe & Central Asia § 1, 4 million HIV infected by end of 2004. § 490’ 000 women, 210’ 000 new infections & 60’ 000 deaths in 2004.

Ukraine § Exponential increase of epidemic since 2000 (+7%) – 2002 (+25%). § In 2003, 30% of new infections heterosexual transmission (within IDU subpopulation). § 10 – 15% of TB cases in Ukraine MDR. § TB leading cause of death among PWAs, 50% of AIDS-related deaths are due to TB. § 45’ 000 patients in need of ARV, 1500 treated (GFATM component).

Russia § 70% of all HIV infections registered in Eastern Europe/Central Asia. § Estimated 860’ 000 PWHAs in Russia, 80% aged 15 – 29, >1/3 women (Dec. 2003). § 1. 5 – 3 million Russian IDUs (1 – 2% of population), 30 – 40% use non sterile syringes. § In 2004, 80% of reported HIV cases among IDU. § 70% sexually active. § Sharp increase of pregnant women with HIV.

Latvia, Estonia, Lithuania § § § Latvia: 5 -fold increase 1999 – 2002 (2300). Estonia: 1999 12 new cases, 2003: 840. Lithuania: 2001 72 new cases, 2002 increase more than 5 -fold. Infections mostly due to injecting drug use, sexual transmission is gaining ground.

Eastern Europe / Central Asia § 90% of HIV cases caused by injecting drug use. § <1% of HIV-positive IDUs have access to ARV treatment (or medical care in general). § TB patients are 10 times more likely to have MDR-TB than in the rest of the world. § Estonia, Kazakhstan, Latvia, Lithuania, Russia and Uzbekistan: MDR up to 14%. § 79% of MDR-TB cases are "super strains", resistant to at least three of the four main drugs used to cure TB. § Kaliningrad: highest documented HIV prevalence within Russia. 70 – 80% of HIV-infected IDUs have had hepatitis C exposure.

Treatment access in the region § 11% of patients in need of ARV are getting treatment. § Due to legal restrictions & discrimination, HIV-positive IDUs have limited or no access to treatment.

Problems we are facing § Conflict healthcare priorities - current drug policy. § Double-stigma in society. § Discrimination in medical institutions. § Fear of police harassment. § Unwillingness of medical infrastructure to meet the demands of this patient group.

Main barriers for equal access to HAART § No political commitment to meet the requirements of the epidemic. § Repressive drug policies supersede the principles of public health. § High prices for ARV and diagnostic equipment. § No national protocols on HIV treatment and care that meet international standards focusing IDU patients. § Vertical and centralised AIDS-service infrastructure. § Illegal substitution treatment programmes (Russia). § Limited number of ST programmes. § Limited NGO involvement into HIV care and treatment. § Stigma and discrimination within medical institutions.

Ukraine – assessment on TB treatment in IDUs Artur Ovsepyan, All-Ukrainian Network of PWHAs, 2005 § AIDS-centres, TB hospitals and drug-addiction clinics in 13 regions of Ukraine. § 40 medical institutions assessed. § 14 have access to opiate analgetics. § 13 have license for storage and prescription of opiate medications, 2 are planning to obtain license. § 2 medical institutions prescribe buprenorphine for ST – Kherson and Odessa drug addiction clinics. § 16 patients received ST with buprenorphine in 2004. § 2540 patients have interrupted TB treatment because of drugaddiction (expelled from hospital because of drug-use). § 420 TB patients with HIV co-infection that have interrupted TB treatment because of drug-use.

Conclusions (based on assessment) § TB and AIDS-service infrastructure are desintegrated and parallel in Ukraine. § TB and HIV services do not have legal or administrative authority to ensure access to opiates as part of palliative care and ST. § Clear evidence: most IDU patients cannot receive appropriate TB care without access to ST. § Urgent need to overcome these barriers a) to provide required medical care for IDUs b) to overcome of TB/HIV epidemic.

Brazil § São Paolo: epicenter of injection-driven epidemic, 50% of all HIV cases in Brazil. § Assessment has shown that 69% of all people on treatment successfully followed treatment procedures. § Decentralized and widely available “user-friendly” network of clinics (up to 300 day clinics across the country). § Development of a harm reduction strategy on national scale. § Effective integration of harm reduction projects in care programs (incl. hepatitis vaccination etc). § Creation of a national drug-user organisation with strong support of health professionals and local authorities.

Key factor of Brazilian success § Government commitment to provide universal and equal access to treatment as part of the overall strategy to fight HIV in the country.

Recommendation: Need of a comprehensive care programme, including § TB treatment & prevention – isoniacid? § Hepatitis treatment & prevention. § HIV/AIDS treatment & prevention. § Effective harm reduction & substitution programmes, including prison settings. § Access to safe conception methods.

Requirements § § Support community-based advocacy, education and mobilisation. Promote international care standards for HIV-TB-Hepatitis co-infection. Promote reference centres for integrated HIV-TB-Hepatitis care. Promote substitution programmes as integrated part of the TB/HIV service kit for IDUs (one stop shopping model). § Perform ARV/TB/hepatitis drugs – street drug interaction studies. § Coordinate ARV-TB-hepatitis drug provision at affordable prices; plan first-, second-line and salvage regimens. § Invest in training: health care professionals & patient organisations.

Conclusions § IDUs must be identified as a special category of patients with specific needs. § Interaction studies in ARV/TB/Hepatitis treatment – street drug must be performed. § ST access in TB / HIV medical services is a cornerstone of effective HAART and TB treatment for IDUs and a vital factor for overcoming the TB/HIV epidemic in the CIS region.