Download Drug User Health Framework

Addressing HCV through a Drug
User Health Framework
NASTAD Viral Hepatitis Technical
Assistance Meeting, October 21, 2014
Washington, D.C.
Rachel McLean, MPH
California Department of Public Health
STD Control Branch
Overview
1. What is a drug user health framework?
2. What is the role of VHPCs in addressing HCV
through a drug user health framework?
o Perspective from California
3. Resources and questions for discussion
STD Control Branch
What is a drug user health
framework?
STD Control Branch
CA Framework for Injection
Drug User Health and Wellness
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Drug users have a right to protect their health and the health of those around them.
All drug users should:
– have the means by which to protect their health, including access to sterile
injection equipment sufficient to meet their needs.
– receive accurate, non-biased and non-judgmental information on illicit drugs and
other substances.
– receive the same level of care as any other individual accessing health care or
social services.
– have access to drug and alcohol treatment on demand.
Providers should:
– recognize the valid and valuable expertise that people who use drugs can give to
designing, delivering and evaluating effective services.
– ensure that the provision of services to drug users is not contingent upon the
individual’s agreement to enter drug treatment, or abstain from drug use. Service
providers must not withhold appropriate treatments or services from drug users.
Services should be provided to encourage engagement and retention in care.
Source: http://harmreduction.org/wp-content/uploads/2012/06/Framework-for-Injection-Drug-User-Health-and-Wellness.pdf
STD Control Branch
In other words…
Source: HIPS, Washington, D.C.
STD Control Branch
Is it ethical to have a health
framework specific to drug users?
• Pros
– Pushes the agenda
forward to advocate for
the rights of drug users
– Has the potential to
benefit drug users by
changing hearts/minds/
behavior of providers
– Has the potential to
benefit invisible users
and non-IDUs :
“Grandma needs harm
reduction, too”
• Cons
– Potential to be further
stigmatizing
– Reinforces “separate
and unequal” health
care delivery for PWID
– Continues
compartmentalization
that providers don’t
have time to learn:
“Please, not yet another
toolkit!”
STD Control Branch
What does a IDU health
framework look like in practice?
Services
Policies
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• Make services easy to access
• Involve consumers in
program design
• Train/hire users as peers
• Train providers on IDU health
and being nice to drug users
• Practice and advocate for
“radical inclusion” of drug
users in services (e.g., drug
treatment, HCV care)
• Identify/address barriers
Overdose prevention
Safe injection equipment
Tobacco cessation
Methadone/buprenorphine
HIV/HCV testing
HAV/HBV vaccination
Supportive housing
Social/peer support
Mobile/drop-in services
Trauma/violence prevention
Legal support
STD Control Branch
What is the role of VHPCs in
addressing HCV through a drug
user health framework?
Perspective from California
STD Control Branch
Syringe Access
• Collaborating with pharmacists to promote
new law allowing statewide sales of
unlimited # of syringes w/o a prescription
• Assisted State Office of AIDS in developing
regulations for state approval of syringe
exchange programs not approved by county
• Received preliminary approval to use state
STD general funds to purchase syringes
STD Control Branch
HCV Testing
• HCV rapid testing guidelines
– Prioritized people who have ever injected drugs
for testing in non-healthcare settings (e.g., SEPs)
– Analyzed positivity, referrals by IDU status,
encourage testing sites to further prioritize IDUs
• Substance Abuse Prevention and Treatment
Block Grant, HIV Set-Aside funds
– Encouraged state to allow use for HCV testing
– Provided training to alcohol and drug programs
on how to use funds for this purpose
STD Control Branch
HCV Treatment
• CA Department of Health Care Services HCV
treatment policy for sofosbuvir (Sovaldi)
– Estimated prevalence of HCV in Medicaid
population
– Provided extensive comments on draft
treatment guidelines
– Proposed using adherence rather than drug use
as basis for HCV treatment eligibility 
STD Control Branch
Overdose Prevention
• State-level overdose working group
– Got ourselves invited by Connecting the Dots of
Drug User Health: HIV/HCV/Overdose
– Promoted prescription of naloxone w/ opiates
in draft state pain management guidelines
– Shared sample overdose prevention materials
for use by physicians when prescribing opiates
• Pharmacist distribution of naloxone
– Participating in working group planning for
promoting awareness of new law that allows
distribution w/o a prescription (AB 1535)
STD Control Branch
Health Care Reform
• Medicaid 1115 waiver
– Submitted public comments encouraging
expansion of office-based buprenorphine, use
Medicaid funds for shelter (supportive housing)
– Promoted role of CHWs (e.g., SEPs) in health
homes for people with chronic conditions /
substance use disorders
– Convened group of SEPs to leverage their role in
promoting drug user health; linkages to care;
ensure long-term program sustainability
STD Control Branch
Questions for Discussion
1. How have you addressed drug user health
in your state?
2. What has worked well? What resources
and ideas do you have to share?
3. What are you struggling with? Where could
you use some advice/support?
4. How can other VHPCs and NASTAD support
you in your work?
STD Control Branch
Resources
•
Harm Reduction Coalition
www.harmreduction.org/
• Adapting Your Practice: Recommendations for the Care of
Homeless Patients with Opioid Use Disorders, Healthcare for the
Homeless Clinicians Network
http://www.nhchc.org/wp-content/uploads/2014/03/hchopioid-use-disorders_adapting-your-practice-final-to-post.pdf
• SAMHSA Tip 53: Addressing Viral Hepatitis in People With
Substance Use Disorders
http://store.samhsa.gov/product/TIP-53-Addressing-ViralHepatitis-in-People-With-Substance-Use-Disorders/SMA11-4656
STD Control Branch
Contact Information
Rachel McLean, MPH
Viral Hepatitis Prevention Coordinator/
STD Healthcare Policy Analyst
STD Control Branch
California Department of Public Health
Phone: 510-620-3403
Email: [email protected]
Website:
www.cdph.ca.gov/programs/pages/ovhp.aspx
STD Control Branch
Connecting the Dots of Drug
User Health: HIV/HCV/Overdose
Drug overdose is a common cause of non-AIDS death among people with HIV and the leading cause of death for
people who inject drugs.1 Emerging evidence shows that an increasing number of young persons in suburban and
rural areas are transitioning from oral prescription pill use to injection of prescription pills or heroin after <2 years of
prescription pill use,2,3,4 putting them at elevated risk for HIV, HCV, and overdose.
In 2011, the National Alliance of State and Territorial AIDS Directors (NASTAD) Executive Committee issued a
Statement of Commitment: Promoting Injection Drug User Health, which called for coordinated efforts to prevent
HIV, HCV, and overdose among persons who use injection drugs:5
“In addition to becoming infected with HIV and viral hepatitis, people who inject drugs are fatally overdosing at
elevated rates, despite available prevention tools. Access to substance use treatment is limited and overdose
prevention efforts rarely have a “home” in state drug and alcohol, injury prevention or public health agencies.
[…] Recognizing the progress we have made in reducing new HIV infections among the IDU population, we
acknowledge that our nation’s efforts are not sufficient to meet the comprehensive health needs of this
population. To change the course it will require an honest and critical examination of our efforts among all
stakeholders. NASTAD and its members commit to explicitly identify and implement effective public health
programs for IDUs.”
While overdose is not an infectious disease, CDPH, Center for Infectious Diseases has extensive expertise in
serving injection drug users, who are risk for HIV, HCV, and overdose, including through the integration of
preventive services into drug and alcohol treatment programs and primary care.
References:
1.
Green TC et al. HIV infection and risk of overdose: a systematic review and meta-analysis. AIDS. 2012 Feb 20;26(4):403-17.
2.
CDC. Viral Hepatitis Surveillance, 2011.
3.
NIDA Research Report: “Prescription Drugs: Abuse and Addiction”
4.
HHS Technical Consultation: Hepatitis C Virus Infection in Young Persons who Inject Drugs, 2013
5.
NASTAD. Statement of Commitment: Promoting Injection Drug User Health