Download Epidemiology and Prevention of HIV/AIDS among IDU`s

Epidemiology and Prevention
of HIV/AIDS among IDUs
Various Forms of Heroin
Most heroin found in Mexico and the U.S.-Mexico border region
is ‘black tar’ heroin which must be heated to liquefication before injection
Negative Health Consequences
Associated with Injection Drug Use
• Blood-borne Infections (e.g. HIV,
Hepatitis B and C, HTLV-I/II, malaria)
• Abscesses
• Cellulitis
• Endocarditis
• Overdose
Number of Countries, Regions and
Territories Reporting Injection Drug Use
(IDU) and HIV among IDUs
1992
1995
1996
1998
1999
IDU
80
118
121
128
134
HIV/IDU
52
78
81
103
114
Courtesy of A. Ball, WHO, June 2000
HIV/AIDS Cases Attributable to
Injection Drug Use
SOURCE: WHO, UNAIDS
No Data Reported
0% HIV/AIDS cases among IDUs
< 10% HIV/AIDS cases among IDUs
10-40% HIV/AIDS cases among IDUs
40%+ HIV/AIDS cases among IDUs
Explosive HIV spread among IDUs
HIV prevalence (%)
80
Myanmar*
60
Manipur* &
Yunnan
Edinburgh
Vancouver
40
Ho Chi Minh
City
Bangkok*
20
*HIV prevalence among general population >1%
1997
1995
1993
1991
1989
1987
1985
1983
Odessa*
AIDS cases by transmission group
1987-2003, eastern Europe
1600
Cases
Injecting drug users
1400
1200
1000
800
Update at 31 December 2003
600
Persons infected
heterosexually
400
200
0
1987
Homo/bisexual men
1989
1991
1993
1995
1997
Year of diagnosis
1999
2001
2003
EuroHIV
Data adjusted for reporting delays
Source: EuroHIV, available online at www.eurohiv.org
Proportion of Injecting Drug Users Among
Reported HIV Cases*
<20%
11%
20-40%
40-60%
60-80%
19.5%
11.2%
39.8%
8%
7.3%
14.4%
22.7%
11.8%
49.7%
Spain
92.7%
Kazakhstan
72.3%
16%
63.5%
Russia
85%
Estonia
76.3%
10.8%
6.5%
>80%
3.7%
32%
78%
Belarus
62.5%
Poland
4%
Ukraine
69.4%
1.3%
24.5%
1%
Moldova
83%
2.6%
12.5%
24%
59.6%
87.1%
82%
60%
Uzbekistan
<0.1%
50.7%*
70.9%
2.5%
47.7%
1.3% 13.6%
3.8%
49.2%
7.5%
10%
*Proportion among AIDS cases in countries not reporting HIV data (Sources:
European Commission;
*
EuroHIV; Council of Europe)
12.3%
76%
Average age of first injection in
selected international settings
28
20
19
19
19
19
Rio
25
don
Age in Years
30
19
26
24
22
18
27
18
15
10
5
Sources: Des Jarlais et al, 2004, Williams et al, 2005, Booth et al, 2005;
Strathdee et al, 2005, Stachowiak et al, 2006
Lago
s
E Sa
lam
Dar
hanb
e
Dus
ssa
St. P
eter
sber
g
International cities
Ode
Bei j
ing
gkok
Ban
Tijua
na
Lon
ney
Syd
New
York
0
HIV Seroprevalence among IDUs
Nairobi
51%
5%
6%
Beijing
42%
42%
Hanoi
All IDUs
16%
16%
Minsk
23%
36%
34%
St. Petersburg
Rio de Janeiro
New IDUs
10%
Kharkiv
Bogota
58%
0%
1%
2%
9%
Des Jarlais et al, 2004
Characteristics of HCV
Infection
• Nearly 4 million U.S. residents are HCVinfected
• Only 10-15% clear HCV infection
• Treatment success (i.e., cure): 40%
• Clinical outcomes:
– Cirrhosis
– Hepatic cancer
– End stage liver disease
Incidence of Blood Borne Infections
Among Young Injection Drug Users in
Baltimore
HCV incidence: 19.7 per 100 PY
HIV incidence: 6.5 per 100 PY
Front-loading: A Risk Factor for HCV Transmission
HCV is transmitted 10X more
easily than HIV through blood
Risk Factors for Acquiring HIV through
Injection Drug Use
• Individual Level Factors
–
–
–
–
Using “dirty” syringes
Duration of injection drug use
Frequency of injection
Frequency of injection with shared needles
• Environmental Factors
– Injecting in shooting galleries
– Having a high number of IDUs in social network
Sexual HIV Transmission among
IDUs is also Important!
• Male IDUs:
– May also have sex with men (e.g., sex trade)
• Female IDUs:
– Often involved in sex trade
– Regular sex partner is often an IDU
– May rely on sex partner for syringes/drugs,
and are “second on the needle”
Injection Drug Use and HIV in
Mexico
Injection drug use on the “Bordo”
Drug Use in Mexico
• Mexico produces 30% of all heroin and
70-90% of the methamphetamine entering
the U.S.
• Highest consumption of illicit drugs in
Mexico is in Baja California
• Tijuana has ~21,000 drug users, and ~6000
IDUs
• In Mexico overall, men were 13 X more
likely than women to have ever used an illicit
drug; in Tijuana the ratio is 6:1
Bucardo et al, 2005
IDU Interventions in Tijuana
•
•
•
•
No needle exchange programs (NEPs)
Legal access to syringes at pharmacies
Several hundred ‘picaderos’ (shooting galleries)
No public methadone maintenance (2 private
clinics)
• Few NGOs servicing drug users; very limited in
scope
• Only half of IDUs in Tijuana ever had an HIV test
(Magis-Rodriguez et al, 2005)
‘Proyecto El Cuete’ Logo
The “Prevemovihl”: A Mobile Clinic for HIV/TB
Surveillance and Collaborative Research
Dr. Remedios Lozada (El Cuete Co-investigator)
and Antonio Granillo (Field Coordinator)
Prevalence of Blood Borne Infections among IDUs
in Tijuana (n=222) and Cd. Juarez (n=205)*
Tijuana
Cd. Juarez
HIV
2.7%
3.0%
Syphilis
14.1%
3.6%
HCV
96.4%
95.5%
N/A
84.7%
HBV (core)
Frost et al, submitted
*unadjusted for RDS
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% Ever Injected
Drugs ever Injected among IDUs in
Tijuana (n=224) and Cd Juarez (N=205)
120
100
80
60
40
20
0
Tijuana
Cd. Juarez
IDU Risk Behaviors in Tijuana and Cd.
Juarez (last 6 months)
Tijuana
(N=222)
Ciudad
Juarez
(N=204)
Mostly injects in ‘picaderos’
55%
18%
Mostly injects outside
26%
12%
Injects with strangers
21%
15%
Often or Always lends, sells
or rents syringes to others
34%
29%
Often or Always uses
borrowed, bought or rented
syringes
32%
22%
Behavior
Ramos et al, IHRA 2006.
IDUs’ Access to Syringes and Drug
Treatment in Tijuana and Cd. Juarez
Tijuana
Ciudad
Juarez
Ever used a local NEP
8%
14%
Ever received drug treatment
51%
44%
Ever arrested for carrying a
sterile/brand new syringe
42%
42%
Ever arrested for carrying a
used syringe
71%
42%
Ever bought syringes in U.S.
2%
10%
Variable
Ramos et al, IHRA, 2006.
Factors Independently Associated with
Receptive Needle Sharing among IDUs in
Tijuana (n=220) and Cd. Juarez (N=203)
Variable
Ever arrested for carrying
used syringes
Injecting in shooting galleries
3.12
Cd.
Juarez
3.91
2.22
5.01
Injecting methamphetamine
Injecting outside
2.71
2.97
-
-
3.05
Injecting ≥ daily
Tijuana
(Pollini et al, submitted)
Proyecto Mujer Segura: A Behavioral
Intervention Study of Female Sex Workers
(FSWs) in 4 Mexican-US Border Cities
• Prostitution is quasi legal
in Mexico
• Up to 9000 FSWs in
Tijuana alone
• Many women/girls from
southern Mexico/Central
America
• Multiple venues: street,
bars, massage parlors,
hotels
• Sex ‘tourism’ is common
Overall characteristics of FSWs in
Tijuana and Cd. Juarez, Mexico (N=820)
Variable
Age
Median or % (IQR)
32 (26-40)
Duration of sex work (yrs)
4 (2-10)
# of clients, past 2 mo
28 (9-66)
Live with children
94%
Ever had HIV test
49%
(Patterson et al, in press)
Characteristics of FSWs in Tijuana
(N=412) and Cd. Juarez (N=408), Mexico
Variable
Tijuana
p-value
19%
Cd.
Juarez
30%
Married/cohabitating
12
21
<0.001
Ever injected drugs
21%
12%
<0.001
HIV-positive
8%
4%
0.03
Years lived in city
<0.001
(Patterson et al, submitted)
Prevalence of HIV and STIs among FSW-IDUs
versus other FSWs in Tijuana (N=412) and Cd.
Juarez (n=408)
FSW-IDUs
Other FSWs
HIV
16%
4%
Syphilis
49%
22%
Gonorrhea
15%
4%
Chlamydia
Cervical
Cancer*
24%
7%
10%
10%
Overall, 36% of FSWs had one or more STIs
* Self report
Patterson et al, submitted
Characteristics Independently
Associated with HIV Infection among
FSWs in Tijuana and Cd. Juarez (N=820)
Variable
Adjusted Odds Ratio
95% CI
Ever injected
drugs
2.5
(1.3-4.6)
Testing positive
for Syphilis
4.1
(2.2-7.6)
(Patterson et al, submitted)
Interventions to Prevent HIV
and Other Blood Borne
Infections among IDUs
A Continuum of Strategies to Prevent
HIV Infection among IDUs
•
•
•
•
•
Encourage abstinence
Drug treatment programs
Use of sterile injection equipment
Disinfection of syringes (e.g. bleach)
Encourage reduction of high risk behaviors
(sharing syringes, cottons, cookers)
• Medically supervised safer injection sites
Medication-Assisted Treatment
Options for Heroin Addiction
• Methadone
• LAAM
• Buprenorphine
• Naltrexone
• Prescribed Heroin
Drug Abuse Treatment as HIV
Prevention
• Detoxification alone is insufficient
• Methadone maintenance can reduce needle
sharing by 50%, provided that adequate dosages
are provided (average: 80 mg/day)
• More recently, buprenorphine has shown similar
results
• IDUs who are retained in methadone
maintenance have significantly lower HIV
incidence rates
• Barriers to drug treatment (unavailability, high
cost, waiting lists) have severely limited their
impact on HIV/AIDS
Drug Treatment
Every 1$ spent on drug
treatment saves 7$ in
future costs
Barriers to Provision of Drug
Treatment in the USA
• Lack of third party reimbursement
• Lack of sufficient numbers of treatment
slots
• Lack of supportive “wraparound services”
• Only 15% of IDUs in drug treatment at any
given time
Barriers to services among IDUs in
Selected International settings
36%
Nairobi
69%
4%
Difficulty accessing medical care
11%
Beijing
44%
26%
Avoid services for fear of
authorities
29%
30%
Kharkiv
2%
Rio
0
Difficulty accessing drug treatment
48%
28%
9%
20
40
Source: Des Jarlais et al, 2004
60
80
How Else Can We Intervene?
Source: http://www.anypositivechange.org
Interventions designed to
distribute new syringes
1. Needle Exchange Programs (NEPs)
2. Repeal Drug Paraphernalia laws
3. Pharmacy Sales
3. Physician Prescription
4. Safer Injection Rooms
5. Vending Machines
6. Public Disposal Boxes
Why not just distribute Bleach to
Disinfect Syringes?
Studies of IDUs in the USA showed that bleach
disinfection of syringes reduced the risk of HIV
infection by only 13%
>> Use of disinfectants has only a modest
protective effect on the risk of HIV infection;
need to broaden access to sterile syringes
Aspects of Sterile Syringe Coverage
to IDUs
Qualitative
Legal: Syringe paraphernalia/possession laws
Environmental:
• Opposition by police, community, clergy
• Availability of secondary exchange
• 24-hr availability of sterile syringes
Contextual:
• Numbers and types of needle sources
(e.g., needle exchange programs, pharmacy, vending
machines)
• Social norms surrounding needle sharing
Needle Exchange
Programs
(NEPs)
Goals of Needle Exchange Programs
• Provide sterile syringes in exchange for
potentially contaminated syringes
• Decrease the “circulation time” of
contaminated syringes in the community
• Link drug users to ancillary services
Studies of Needle Exchange Program
(NEP) Effectiveness
Type of
City
Year % Reduction
in HIV
Incidence
Study
1994
33%
Surveillance
1984Amsterdam 1992
50%
Cohort
70%
Meta-analysis
(cohort data)
New
Haven
New York 1992City
1995
Case-Control Study of NEP
Effectiveness: Tacoma, WA
Outcome Adjusted Odds
Ratio (OR)*
% Risk
Reduction
Hepatitis B
incidence
5.5
83%
Hepatitis C
incidence
7.3
86%
*odds of HBV or HCV infection associated with non-use of NEP
Potential ancillary services
provided by syringe distribution
and exchange programs
• Condoms (male and
female)
• HIV
testing/counseling
• Referrals to drug
treatment and
medical care
• Overdose prevention
•Screening, diagnosis
and treatment
(e.g. STDs, TB)
•Provision of vaccine
(eg. HBV, HAV)
• Wound/abscess care
• Multi-vitamins
Availability of NSPs worldwide 2000/03
Yes (n = 65) (28%)
No (n = 10) (4%)
Not Known (n =155) (67%)
UN Reference Group on HIV/AIDS prevention and care among IDU
(Slide courtesy of Carmen Aceijas)
Global Coverage
• Only 33% of countries reporting HIV among
IDUs have at least one needle exchange
program
• Only 40% of countries where injection drug use
is known to occur have at least one needle
exchange program
(Strathdee and Vlahov, 2001)
No evidence that NEPs are Associated with:
• Increased drug use (Vlahov, et al., 1997)
• Permissive attitudes towards drugs among
youth (Marx, et al., 2001)
• Formation of high risk needle sharing
networks (Schechter, et al., 1999; Valente, et al., 1998)
• Increases in discarded needles (Doherty, et al.,
2000)
• Increases in crime (Marx, et al., 2000)
Safer Injection Sites
Function
• provide sterile injection equipment
• information about drugs and health care
• access to medical staff
• Doesn’t provide place to sell drugs
Effects
• successful in reducing injection-related risks and
harms (including vein damage, overdose and
transmission of disease)
Safe Injection Site-Rotterdam
1993
Safe Injection Sites (SIS)
Available in Australia, W. Europe, Vancouver,
Canada
Surpassed expectations and community support
is growing
 Associated with entry in drug tx and reductions
in:
 needle sharing
overdose deaths
public injecting
Evidence to support SIS as an integral part of
harm reduction services
Syringe Vending Machines
Other Interventions
• Peer-based interventions to reduce needle
sharing among HIV-/HCV- and HIV+/HCV+
IDUs
• “Macro”-level interventions (e.g., deregulate
syringe paraphernalia laws, reduce
homelessness, improve health care
coverage)
So What About the United
States?
Adult/Adolescent AIDS Cases by Exposure
Category by Year of Diagnosis, 1985-2000
80
Percent of Cases
70
Men who have sex with men (MSM)
60
50
40
30
Injection drug use (IDU)
Heterosexual contact
20
10
MSM & IDU
Other
0
1985
1987
1989
1991
1993
1995
Year of Diagnosis
.
Source: CDC, 2000
1997
1999 2000
HIV Among IDUs in the United
States
• IDUs account for nearly one
third of all AIDS cases.
• Approximately half of all new
HIV infections are among IDUs.
Federal Reports on NEPs
Report and year
Found that NEPs
reduce HIV
transmission
Found that
NEPs don’t
increase drug
use
Recommended
federal
funding ban be
revoked
National Commission on
AIDS, 1991
Yes
Yes
Yes
General Accounting Office,
1993
Yes
Yes
Yes
University of California,
1993
Yes
Yes
Yes
CDC, 1993
Yes
Yes
Yes
National Ac. of Sciences,
1995
Yes
Yes
Yes
Office of Technology
Assessment, 1995
Yes
Yes
Yes
NIH, 1997
Yes
Yes
Yes
Number of US Syringe Exchange
Programs and Syringes Exchanged, by
Size of Program, 1996 (n = 84)
Size of Program
Programs
Syringes Exchanged
No.
(%)
No.
(%)
< 10,000
23
(27)
64,737
(<1)
10,000 – 55,000
27
(32)
810,247
(6)
55,001 – 499,999
24
(29)
3,658,060
(26)
>500,000
10
(12)
9.407,628
(67%)
Total
84
13,940,672
(Paone, et al., 1999)
Drug Paraphernalia Laws
• Restrict the manufacture, sale, distribution, and
possession of items like rolling papers, bongs, pipes,
freebasing kits, and in some states, needles.
• Primarily enacted in the 1960s and 1970s to regulate
the growth of the drug paraphernalia industry.
• Such laws in 47 U.S. states make it illegal for IDUs
to possess syringes
• Exemptions
Access to sterile syringes without a
prescription --United States, 2002
Retail access
(16)
NEP only
(9)
No clearly legal form of syringe access (22)
No legal forms of access
(4)
Burris, Vernick and Strathdee, 2002
Resource Allocation- UNODC
Pharmacy Sales
• Legal in 26 of 50 U.S. states
Example: Connecticut
• changed its paraphernalia and prescription laws in 1992
to allow for possession and sale of up to 10 syringes
– needle sharing among IDUs dropped 40%
– and needle stick injuries to police decreased by 66%
(Heimer, et al, 1995).
– 1995, over 80% of pharmacies voluntarily sold
syringes over the counter.
What about Mexico?
Interventions to Reduce HIV among
IDUs in Mexico
• Legal for IDUs to purchase syringes at
pharmacies, but many barriers persist
• Legal to carry syringes, but arrests happen
anyway
• Only one formal NEP in Mexico in Cd.
Juarez; informal
• Small scale NEP in Tijuana
• Methadone maintenance very limited,
mostly private clinics
• Buprenorphine not available
What we need…
• $11 billion U.S is needed to stop the global
HIV pandemic but only $200 million
needed to stop the IDU-associated HIV
epidemic
• What we are lacking most is political will
Summary
• Potential for rapid HIV spread among IDUs
and general population
• Both drug use and sexual behaviors are
important risk factors for HIV infection
• Macro-level factors (e.g., lack of sterile
syringe access, policing) can indirectly affect
HIV risk behaviors
• Multiple approaches to prevention are
needed across the harm reduction continuum