Effectiveness of drug dependence treatment in prevention of HIV among IDUs And other Infectious diseases in Substance Abuse Treatment

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Effectiveness of drug dependence treatment in
prevention of HIV among IDUsAnd other
Infectious diseases in Substance Abuse Treatment

• Michael Farrell1 John Marsden1, Walter Ling3,
  Robert Ali2, Linda Gowing2
• 1 National Addiction Centre, London, United
  Kingdom
• 2 Drug and Alcohol Services Council, South
  Australia, Australia
• 3UCLA, Los Angeles, California,

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Outline

• Background
• Cochrane Systematic Review
• treatment reduces HIV risk
• Evidence for the impact of treatment

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Estimated size of IDU population (1998/2003)
E. Europe C. Asia 3.2m
N. America 1.43m
W. Europe 1.24m
E. Asia Pacific 2.35m
S. S-E Asia 3.33m
MENA0.44m
Caribbean 0.028m
S. Saharan-Africa 0.009m
Australia N. Zealand 0.19m
L. America 0.97m
10.3m (78) in developing/transitional countries
91 of the world adult population (4 billion) is
covered by the data. Information unavailable for
119 countries.
UN Reference Group on HIV/AIDS prevention and
care among IDU

www.idurefgroup.org
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Challenge to the Global Community Develop
Treatment Systems that can meet the needs of
large scale and evolving problems of opioid
dependence and injecting drugs use
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Political and moral values of the social system
SERVICE Provider AND USER VIEW
Research Evidence
A model for evidence-based clinical
decisions (from Haynes et al, 1996)
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The global response UN support for good treatment

• WHO/UNODC/UNAIDS position paper Substitution
  maintenance therapy in the management of opioid
  dependence and HIV/AIDS prevention
• Substitution maintenance treatment is an
  effective, safe and cost-effective modality for
  the management of opioid dependence. Repeated
  rigorous evaluation has demonstrated that such
  treatment is a valuable and critical component of
  the effective management of opioid dependence and
  the prevention of HIV among IDUs.

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Availability of substitution treatment
US 53 8.7 tons
Spain 11 1.8 tons
Germany 6 916.kg
Italy 5 812kg
UK, Canada, Australia, Switzerland, France, Denmark and Belgium, 18
Most of the rest consumed by 9 other countries mostly Europe, Australia Most of the rest consumed by 9 other countries mostly Europe, Australia Most of the rest consumed by 9 other countries mostly Europe, Australia
95 methadone is consumed in developed
countries (2002)

• Substitution treatment is available in few
  countries, outside Europe, North America and
  Australia but include
• Argentina
• China
• Croatia
• India
• Indonesia
• Iran
• Kyrgystan
• Malaysia
• Moldova
• Nepal
• Singapore
• Thailand
• Ukraine ??
• Thanks to Gerry Stimson

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Estimated Opiate dependent Drug Users in
Substitution Treatment per 100,000 population
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Numbers (per mil pop) receiving methadone in 15
EU member states 1993-2000
Source EMCDDA, 2001
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Background HIV spread among IDUs

• Australia
• early methadone, rapid expansion
  
• low incidence of HIV in IDUs
• European Union
• Increase in drug substitution services
• reduction in AIDS cases related to IDU
• Eastern Europe, Russia and new Independent
  Republics New epidemics of HIV in IDUs

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Background HIV spread among IDUs

• Asia Pacific
• relatively new problem for some countries
• need to develop culturally appropriate services
• Methamphetamine Epidemic Presents new challenges
  to treatment and research community to define its
  contribution to risk of HIV spread
• United States of America Canada
• initial evaluator and pioneer of methadone
• lack of public funding have limited the
  comprehensiveness of approaches
• substantial containment of HIV in IDUs but still
  major ongoing problem in US

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Background HIV spread among IDUs

• South America Long standing cocaine crack
  problem substantial contribution to HIV through
  risk behaviour and also less so through
  transition to injecting
• Africa evolving drug and injecting problem but
  drowned out by scale of general HIV and social
  infrastructure problems in many countries
• Central Eastern Europe
• Rapidly evolving HIV problem in IDUs

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HIV in European IDUs

• Generally well contained except for recent
  increases in Portugal
• Spain, France and Italy experienced major HIV
  epidemic in IDUs successfully contained through
  broad prevention strategy including expansion of
  substitution treatment,

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Other Major Infections

• Tuberculosis, major problem where established HIV
  among IDU
• Hepatitis C over 90 plus in those with a long
  history of injecting drug use

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Consequences of drug use within correctional
settings

• Pressures on prison environment
• health services
• prison staff
• security
• HIV, hepatitis B and C
• Tuberculosis
• Recidivism
• use of drugs is a predictor of recidivism

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Substitution in prisons

• Estimated that over 30 million imprisoned
  annually
• We can confidently estimate that at least 10
  million of thos are drug dependent.
• Major risk for blood borne virus spread
• In most countries where measured between one
  third and half have drug dependence
• RCT of methadone in prison (Dolan et al)
  demonstrates role in reduction of blood borne
  virus, and general improvement, and post release
  reduction in mortality for those who continue
• Rapid expansion in Europe in substitution in
  prisons
• Huge challenge for Asia pacific region where
  instutional incarceration standard response to
  opioid dependence
• Consistently 90 relapse to heroin use,
• Mortality risk 70 fold greater in early release
  period

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Changes in ATS Abuse (1995-1997)
Areas with some increase in ATS use
Areas with large increase in ATS use
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Cochrane Systematic Review of Current Controlled
Studies

• Effectiveness
• seroprevalence in IDUs
• rates of seroconversion
• most emphasis on treatment effect on
• injecting drug use
• sharing injecting equipment
• number of sexual partners
• unprotected sexual activity

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Summary of findings from Individual studies - HIV

• Seroprevalence (2 studies)
• methadone and buprenorphine may help prevent HIV
  diffusion
• HIV Seroconversion (3 studies)
• ? if in treatment (e.g. 3.5 vs 22 in 18 mth
  -Metzger 1993)

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HIV infection rates in and out of substitution
treatment (Metzger et al. 1993)
Out
In
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Other treatment outcomes- injecting drug use

• Continued injecting (11 studies)
• 8 MMT, 1 Bup, 1 NTX, 1 DF
• ? if in treatment
• all MMT show significant lower rates
• Sharing of injecting equipment
• ALL showed reduced risk
• increase use of decontamination
• reduce likelihood sharing

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Other treatment outcomes- Sexual risk

• Sex-related risk (8 studies)
• mainly examined continued sex industry
  work/number of partners
• all showed reduced risk (1 exception)
• However reports of personal and informal sex
  behaviour do not indicate any significant impact
  (?)
• Overall HIV risk (3 studies)
• all MMT
• ALL showed reduced global risk

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Large-scale Descriptive Outcome Studies

• DATOS (USA) and NTORS (UK)
• reduction in freq. rate of sharing (some stop
  injecting)
• DATOS - Reduced injecting risk in all tx
  modalities
• NTORS sig. differences b/w intake 4-5 year
  follow-up
• injecting fell from 60 to 37
• self reported sharing fell from 14 to 5

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Systematic Review appraisal rating

• STRONG EVIDENCE
• (e.g. systematic review that includes
  RCTs)
• MODERATE EVIDENCE
• (e.g. reviews limited by research
  factors OR one RCT)
• SOME EVIDENCE
• (e.g.ONE RCT limited by research
  factors)
• LITTLE EVIDENCE
• (e.g. clinical anecdote or editorial)

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Summary of drug treatment findings

• Increasing methadone and buprenorphine doses
• Retention increases,
• heroin use decreases
• most effective methadone programs
• - doses of gt60mg/day
• - maintenance oriented
• most effective burprenophine programs
• -doses of gt 12-16mg
• -maintenance orientated

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Summary of drug treatment findings - MMT

• Maintenance agonist treatment substantially
  reduces heroin use
• Maintenance agonist treatment is more
  effective than no treatment
• or placebo in
• - reducing rates of imprisonment,
• - reducing heroin use,
• - retaining clients in treatment,
• - employment/return to education

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Summary of drug treatment findings Naltrexone

• Patient acceptance of naltrexone is
• poor treatment dropout high
• Craving reduced by naltrexone
• Best outcomes if - highly motivated,
• - employed
• - good social support,
• - older
• - prior treatment

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Summary of drug treatment findings residential
treatment

• High early drop-out from residential rehab.
  (gt40 drop-out in the first month)
• gt3 months treatment required
• Completion of residential rehabilitation
• - reduced drug use and criminal behaviour
• - legal employment increased
• Good outcomes predicted by tx progress in
  addition to time in treatment

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Psychostimulants

• No current pharmacotherapies effective in
  reducing psychostimulant drug use,
• Psychosocial interventions for psychostimulant
  drug dependence indicate significant but modest
  positive effects for drug counselling,
  contingency management

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BRADFORD HILL CRITERIA LOOKING AT THE CRITERIA

• STRENGTH OF ASSOCIATION
• CONSISTENCY
• PLAUSABILITY
• COHERENCE
• EXPERIMENTAL EVIDENCE
• SPECIFICITY OF EFFECT

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But does this evidence apply in developing
countries?

• The majority of countries that have developed
  substitution therapies outside the United States
  have introduced the programmes as part of a pilot
  feasibility study where the main assessment has
  been to determine the capacity of the treatment
  system to operationalise the treatment within
  particular cultural settings, and to assess the
  impact of treatment on those individuals who
  undergo treatment

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• HONG KONG
• BANGKOK
• IRAN
• MALAYSIA
• CHINA
• INDONESIA
• VIETNAM

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Plan for MMT in Near Future in China

• At present, 9 clinics in operation
• Waiting for operation, 25 clinics
• End of 2005, 100 clinics (3466)
• In next 3 years, 1,000 1,500 clinics, covering
  some 200,000300,000 heroin users

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What sort of delivery system is required

• Needs integrated health care system
• Public Health Strategy to achieve maximum
  coverage
• Primary care training in delivery of treatment
• Family Practice Approach
• Prisons based care linked to community ongoing
  treatment

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Direct Observed Therapy

• Enables implementation of Anti TB Therapy
• Enables delivery of HAART
• Enables future delivery of Combination therapies
  for Hepatitis C
• Complex multidisciplinary teams required to
  generate appropriate treatment programmes, much
  work to be done
• Agonist therapies are a critical component of the
  implementation of HAART as part of the
  International 3 by 5 initiative in many countries
  particularly in the Asia Pacific Region

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Substitute prescribing worldwide

• Enormous variation in treatment worldwide in
• Treatment setting
• Quality of treatment
• Availability of harm reduction, injecting
  equipment
• Treatment for hepatitis and HIV
• Most harm reduction and treatment resources go to
  less than 20 of the worlds IDUs in so called
  developed countries
• Most drug users worldwide have no access to
  treatment, suffer ill-health, violence and prison

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Agonist Therapies and ARVThe Three by five
initiative

• Not enough work has been done to ensure that
  agonist therapies are an essential component of
  treatment of IDU who are having ARV treatment
• Need for major guidelines to support policy
  makers and practitioners understanding of the
  critical need to ensure that agonist therapies
  are the foundation on which ARV treatment is
  established for IDU

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Need for upscaling of treatment

• Urgent need in many regions for concerted effort
  to expand treatment
• Discussions and research required on the
  challenge of upscaling
• Monitoring and evaluation of programme
  implementation
• Experimental designs desirable as part of an
  overall implementation programme and not in order
  to make the decision to implement treatment
  programmes
• Evaluation is critical to the ongoing survival
  and further development of such programmes

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Summary

• Evidence for major benefits of treatment in
  reducing spread of HIV
• Strongest evidence for maintenance agonist
  treatment with methadone or burprenorphine or
  other mu opoid agonists
• Strongest evidence for treatment in broader
  context of comprehensive social response to
  social problem of drug use, dependence and
  injecting.
• Belief systems are a greater obstacles to
  implementation in many countries than are
  resource limitations.

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Further details..

• Dr. Michael Farrell
• National Addiction Centre
• 4 Windsor Walk
• London SE5 8AF
• m.farrell_at_iop.kcl.ac.uk