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Australian perspectives from the 2011 International Harm Reduction Conference, Beirut. International Overview of PWID, HIV and Opioid Substitution Dr Craig Rodgers Staff Specialist Kirketon Road Centre. International Harm Reduction Association. Now known as Harm Reduction International

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Australian perspectives from the 2011 international harm reduction conference beirut l.jpg

Australian perspectives from the 2011 International Harm Reduction Conference, Beirut

International

Overview of PWID,

HIV and Opioid

Substitution

Dr Craig Rodgers

Staff Specialist

Kirketon Road Centre


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International Harm Reduction Association

  • Now known as Harm Reduction International

  • International non-governmental organisation promoting policies and practices that reduce the harms from all psychoactive substances

  • A key principle of Harm Reduction International’s approach is to support the engagement of people and communities affected by drugs and alcohol around the world in policy-making processes


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MENAHRA

  • Middle East and North Africa Harm Reduction Association

  • Formed in June 2007

  • Supported by WHO, IHRA and Drosos Foundation

  • Aim

    • to strengthen the role of civil society organizations in harm reduction in the Middle East and North Africa

    • to stabilize and decrease prevalence of HIV/AIDS in the region

  • Priority countries - Afghanistan, Egypt, Iran and Pakistan


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Overview

  • IDU occurs in at least 158 countries and territories around the world

  • Estimated 15.9 million PWID globally (range 11-21 million)

  • Largest populations in China, USA and Russia

  • 120 countries report HIV in PWID

  • Approx 3 million PWID living with HIV (range 0.8 – 6.6 million)

  • 8 countries have HIV prevalence in PWID > 40%: Argentina, Brazil, Estonia, Indonesia, Kenya, Myanmar, Nepal and Thailand

The Global State of Harm Reduction 2010. Key Issues for broadening the response. 2010. International Harm Reduction Association.


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Oceania

Australia

  • PWID: 150,000 (0.4% population)

  • HIV prevalence amongst PWID: 1.5%

  • NSP:

    • > 1300 (plus > 2,500 pharmacies)

    • Highest rate of NSP distribution with 213 syringes per person per year

    • Approx 29 million needles/syringes distributed in 2008

  • OST:

    • methadone available since 1969

    • ?132 sites treating approx 43,500 individuals

    • 64% clients receive Rx from private prescribers

    • 85% dosing points in pharmacies

  • Data on IDU and HIV in Pacific Islands and territories largely unavailable


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Problems

  • Cost is an significant barrier to OST

  • Ageing cohort of PWID

  • No new HR initiatives in the past 10 years


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MENA region

  • 1 million PWID (0.2 % population)

  • 460,000 people living with HIV

  • 6 countries with HIV epidemics in PWID: Afghanistan, Pakistan, Iran, Libya, Bahrain and Egypt

  • Hepatitis C prevalence ranges 45-93%

  • 50 % report sharing needles & syringes

  • Average age first IDU 20-28

Elie Aaraj. Plenary session Mon 4th April


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  • Iran has introduced comprehensive harm reduction programs

  • By end 2010 OST had been introduced in Morocco, Lebanon and Afghanistan

  • Pakistan has mobilised resources for introducing OST

  • Oman has requested assistance to develop OST site


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Iran

  • Estimated PWID: 180,000

  • HIV prevalence in PWID: 15%

  • NSP:

    • 420 – 630

    • Distributes approx 41 syringes per person per year

  • OST since 2008: 680 – 1100 (Buprenorphine, Methadone)

    ShabnamSalimi (INCAS):

  • Study on female drug use in Iran (40 female drug users – median age 37yrs)

  • 87% used heroin, 27% stimulants

  • 88% smoked heroin rather than injecting

  • 12% IDU with HIV prevalence 5.5%

  • Stigma far worse for female drug users


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Morocco

  • < 1% prevalence HIV in Morocco (approx 26,000 people)

  • PWID constituted 13% of Moroccans with HIV (approx 3300)

  • Only 4,256 have access to treatment

  • Methadone program began in June 2010

  • Only 77 people on program so far


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Afghanistan

  • Produces more than 90% of the world’s heroin ($2 per gram)

  • Approx 1 million drug users (8% adult population) – 120,000 heroin users

  • HIV prevalence in PWID 7% in 2009

  • Feb 2010: pilot program established to provide OST for up to 200 patients run by Medecines du Monde


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  • Higher induction rates because of increased purity (and residential) – 60-70mg

  • Coordinated by Ministry of Health (MoH) and Ministry of Counter Narcotics (MoCN) which do not work well together

    Problems:

  • Need to import methadone and buprenorphine – results in shortages

  • Funding issues


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Asia

  • Approx 4 million PWID (¼ of the total population of PWID)

  • HIV prevalence frequently above 20-25%

  • Several countries have much nigher national HIV prevalence rates amongst PWID – Indonesia, Myanmar, Nepal, Thailand and Viet Nam (30-50% PWID likely to have HIV)

  • 15 countries now have some form of NSP

  • 12 countries prescribe OST

  • Coverage of harm reduction initiatives still too low to have an impact on HIV epidemic (less than 1/3 PWID are reached by NSP and < 5% receive OST)


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Problems

  • Estimates suggest that current funding for harm reduction in the region is only 10% of actual need

  • Lack of supportive legal and policy frameworks impedes harm reduction responses

  • Several states prohibit possession and/or provision of needles and syringes, methadone or buprenorphine

  • Imprisonment or detention in compulsory centres remains the dominant response to drug use

  • Half the countries in the region retain the death penalty for drug offences (8 countries have executed for drug offences in the past 3 years)


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Indonesia

  • PWID: 220,000

  • HIV prevalence among PWID: 42.5% (52%)

  • NSP: 159

  • OST:

    • Methadone established in 2003 with expansion in 2006 and by 2008 there were 29 programs (15 public health sector, 10 hospitals, 4 prisons) serving 2700 clients

    • Private Buprenorphine treatment

    • Possibility of injectable buprenorphine treatment

      (Dr James Blogg)


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Myanmar (Burma)

  • Second largest producer of opium poppy

  • PWID: 75,000

  • HIV prevalence among PWID: 42.6%

  • NSP:

    • 19 NSPs (pharmacies > NGOs > HCWs)

    • distributing 3.5 million needles (annual requirement of 27 million)

  • OST:

    • MMT began in 2006

    • By 2010 there were 10 MMT sites with approx 820 clients (< 1% that require MMT)


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Thailand

  • PWID: 40,000 - 160,500 (wide variation)

  • HIV prevalence among PWID: 42.5%

  • NSP:

    • 10 (mainly peer driven, no govt funding, available at pharmacies)

  • OST:

    • available in up to 147 hospitals and clinics

    • Methadone clinics first opened in 1989

    • Treatment is free but clients must undergo detox 3 times prior to MMT and treatment has a time limit of 1-2 yrs


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India

  • PWID: 164,000 (1/3 PWID in Nth East - Manipur, Nagaland & Mizoram)

  • HIV prevalence among PWID: 11.15%

  • NSP:

    • 220 (Targeted Interventions/TIs – administered by NGOs)

  • OST:

    • 50 (plan to expand to over 300)

    • Buprenorphine available since 1993 via TIs (supposed to lead to detoxification and rehabilitation)

    • Methadone pilot program ? July 2010


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Other

Viet Nam:

  • HIV prevalence in PWID 33%

  • 380 – 2000 NSPs and 6 OST clinics

    China

  • HIV prevalence in PWID 12%

  • Approx 900 NSPs

  • Approx 600 OST clinics


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Eurasia

  • Comprises Central and Eastern Europe

  • Approx 3.7 million PWID

  • Russia (1.8 million), Azerbaijan (300,000) and Ukraine (291,000)

  • Highest population prevalences of PWID – Azerbaijain 5.21%, Georgia 4.19%, Russia 1.78% and Ukraine 1.16%

  • Estimated that 1 million PWID infected with HIV

  • Leading cause of death is overdose


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  • NSP provided in all 29 countries/territories

    • Coverage: 9 syringes per person per year

  • 24 countries have OST

    • mainly pilot programmes

    • reach only 1% of PWID


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Estonia

  • PWID: 13,801

  • HIV prevalence amongst PWID: 72.1%

  • NSP:36

  • OST: 8 clinics (Buprenorphine and methadone)


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Russia

  • PWID: 1.8 million

  • HIV prevalence amongst PWID: 37.15% (2003)

  • NSP: 70

  • Estimated to only reach 7% PWID

  • Distributes 7 millions needles per year

  • OST: Nil


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Ukraine

  • PWID: 291,000

  • HIV prevalence amongst PWID: 32.4%

  • NSP: 985-1323

  • OST:

    • Buprenorphine and methadone

    • Up to 5000 people on OST


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Western Europe

  • Estimated to be approx 1 million PWID

  • HIV prevalence is generally < 10%

  • Exception of France (12.2%), Italy (12.1%) Portugal (15.6%) and Spain (39.7%)

  • Countries with good HR programs have seen reductions in drug-related HIV transmission

  • HR initiatives include: drug consumption rooms, vending machines, prescription of OST and heroin


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Spain

  • PWID: 83,972

  • HIV prevalence amongst PWID: 39.7%

  • NSP: 1271 - 1458

  • OST: 497 – 2,229

  • Offer Methadone, Buprenorphine and Heroin


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Latin America

  • Most commonly injected drug is cocaine (heroin in parts of Colombia and Northern Mexico)

  • >2 million PWID

  • 580, 500 living with HIV

  • Vast majority of NSPs operate in Brazil & Argentina

  • Only Mexico & Colombia provide OST (approx 25 and 4 clinics respectively)


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Argentina

  • PWID: 65,829

  • HIV prevalence amongst PWID: 49.7%

  • NSP: 25

  • OST: Nil


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Brazil

  • PWID: 540,500

  • HIV prevalence amongst PWID: 48%

  • NSP: 150-450

    • Coverage is very low

    • Estimate that PWID receive < 1 needle/syringe per year

  • OST: Nil


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North America

United States

  • PWID: 1,294,000

  • HIV prevalence amongst PWID: 15.5%

  • NSP: 186

  • OST: 1433 (Bupe/Methadone)

    Canada

  • PWID: 286,000

  • HIV prevalence amongst PWID: 13.4%

  • NSP: >775

  • OST: Bupe/Methadone and Drug Consumption Room


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Sub-Saharan Africa

  • Accounts for 67% new HIV infections world wide

  • Injecting now reported in the majority of the 47 Sub-Saharan states

  • Estimated that 221,000 PWID are living with HIV

  • HIV prevalence in PWID ranges from 5.5% (Nigeria) – 42.9% (Kenya)

  • Mauritius is the only country with OST and NSP

  • OST also available in South Africa, Senegal and Kenya


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However…


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Triangulating data from global collection systems – improving our understanding of the global repsonse to HIV among IDUs. (Bradley Mathers NDARC)

  • Does data from different sources tell the same story?

  • IDU data collated and compared from four 2010 global datasets:

  • UNGASS HIV

  • Global Fund progress reports

  • WHO Universal Access progress data

  • Systemic reviews by the Reference Group to the UN on HIV and IDU (independent of government agencies)


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  • Data rarely in agreement

  • Significant variation between estimates of the response to HIV and IDU depending on methods and definitions employed

    Need

  • Consistency in data collection methods

  • Independent scrutiny of data (including official government data)

  • Estimation methods and bias must be documented


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Lastly…


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Film festival

  • Yajilarra

  • Director: Melanie Hogan

  • Producer: Jane Latimer

  • Shows the determination of 2 women in Fitzroy Crossing dealing with the alcohol problems in the community

  • “Shows what is possible when Indigenous leaders bring the community together to build consensus and act upon it”


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