A Review of Barriers and Ways Forward Daniel Wolfe 1 M. Patrizia Carrieri 2 Donald Shepard 3 Paper 3 Treatment and Care for IDUS with HIV 1. Open Society Institute 2. INSERM/ORS PACA 3. Brandeis University

ART for IDUs effective and cost effective ART for IDUs successfully initiated in 50 countries Excellent virologic response, and no greater ART resistance, with appropriate supports Methadone and buprenorphine most critical – DAART, pre-loaded pill boxes, peer support, incentives, case management also help ART targeted for IDUs cost-effective; and benefit- cost ratio of drug treatment about 7:1 Treatment as prevention appears viable (though largely untested) in IDUs No reason to exclude active IDUs (WHO protocol; universal access commitments)

Global Progress? No global assessment of IDUs on ART compared to their share of HIV since review of IDU access to ART finds data unavailable for 2/3 (66%) of countries Global Fund does not ask countries to disaggregate data on IDUs PEPFAR does not collect data on IDUs served, despite legal requirement Overall IDU estimates based often on police or treatment data

“Mega-Epidemics” offer global snapshot

Share of IDUs as total HIV cases and those on ART, 2008 *2009 Inequity in ART access IDUs 67% OF HIV CASES, BUT ONLY 25% OF THOSE ON TX

Share of IDUS reached by methadone or buprenorphine OST available to < 2% of IDUs

HEALTH SYSTEM BARRIERS High threshold treatment—fees, tests, commissions – Russia: 18 of 19 cities have “treatment commissions”; 10 exclude on grounds of drug use – China: ART free, but charge for lab tests, OI treatments – Malaysia required patients to pay for 3 rd drug in combo (now changed) Siloed treatment—TB, HIV, OST – TB clinics won’t treat HIV, HIV clinics won’t treat TB (Ukraine) – OST unavailable in many maternity clinics or inpatient wards (China, Ukraine) Discrimination in health settings – Explicit bans on treatment for active IDUs – Assumptions (inaccurate) about adherence – Hostile or untrained health workers

STRUCTURAL BARRIERS I IDU registries, with names of those seeking treatment given to police Police harassment of patients (all countries) Provider harassment – Arrests and fear chill tx (Ukraine), pain prescription (all countries), and open discussion (Russia) Incarceration and tx interruptions – No OST (or ARV) in pre-trial detention – No OST and little ARV in prison Ukraine: 1 in 10 HIV+ prisoners treated Malaysia: 1 in 15 HIV+ prisoners treated Russia: food shortages, medication shortages, unsanitary conditions

STRUCTURAL BARRIERS II Drug detention in name of treatment – No medical evaluation – No right of appeal – Forced labor – No treatment – No effectiveness

3 x greater 33 x greater 1.1 x greater *2008 IDUs in Govt.-funded Methadone v. Detention

Stronger data—including equity ratio OST considered part of ART, included in treatment assessments, and scaled up (take home doses!) Integration of TB, HIV, drug treatment, and reproductive health services Use of peers for reach and stigma reduction -- DAART possible beyond the clinic setting From the Individual to the Systemic

From Criminality to Care End to sharing of registries with police End to compulsory drug detention End to imprisonment for drug use/possession for personal use End to portrayal of drug users as less than human, and so deserving of less-than-human rights

Acknowledgements Johna Hoey Damien Walker Azizbek Boltaev Oleksandr Pokanevych Anna Shubashvili Alexei Bobrik Anya Sarang Volodymr Kurpita Konstantin Lezhentsev China CDC Pavlo Skala Evan Wood Adeeba Kamarulzaman Kasia Malinowska- Sempruch Chris Beyrer Adeeba Kamarulzaman Roxanne Saucier Pamela Das And especially, my co-authors M. Patrizia Carrieri Donald Shepard