1. HIV in People Who Use Drugs Adeeba Kamarulzaman University of Malaya Kuala Lumpur, Malaysia

2. Outline Global Burden of HIV due to illicit drug use The Global State of Harm Reduction Unmet needs and new challenges – Women – Adolescents – MSM Prison and people who use drugs Antiretroviral treatment for people who use drugs Can We Do Better?

3. Injecting drug use as a risk factor for HIV, HCV, HBV DALYs per 100,000 people, age-standardised, 2010 Overall, illicit drugs caused 1% of global disease burden – 8 th largest contributor to disability (YLDs) among males Degenhardt, et al (2013). The Lancet, 380, 1564-1574 UNAIDS Global AIDS Report 2012. Overall, illicit drugs caused 1% of global disease burden 8 th largest contributor to disability (YLDs) among males In countries where HIV incidence is increasing, 70% - 80% of HIV cases are among PWIDs

4. Interventions to prevent HIV and Hepatitis C in people who inject drugs: A review of reviews to assess evidence of effectiveness InterventionOutcomeSummary of studies Evidence Statement Needle and syringe programmes (NSP) Injecting risk behaviour (IRB) 43 studiesSufficient evidence to support the effectiveness HIV16 studiesTentative evidence to support the effectiveness Opiate Substitution Treatment (OST) IRB35 studiesSufficient evidence to support the effectiveness HIV8 studiesSufficient evidence to support the effectiveness McArthur G et al. Int J Drug Policy Jan 2014

5. Trends in HIV incidence, injecting and sexual risk behaviour: 1986 to 2011 in the Amsterdam Cohort Study (ACS) 1298 participants Total follow-up - 12,921 person-years (PY) HIV incidence declined from 6.0/100 PY in 1986 to less than 1/100 PY from 1997 onwards (95% [CI] 3.2–11.1) Both injection and sexual risk behaviour declined significantly over time Van der Knaap et al, March 2013

6. Harm Reduction: Coverage Opioid Substitution Therapy Globally, for every 100 PWID, only 8 are receiving OST (range less than 1 to 61) Needle and Syringe Exchange Globally, 2 needles per PWID per month (range less than 1 to more than 200) 72 countries have OST 86 countries with IDU have no OST 82 countries have NSP 76 countries with IDU have no NSP

7. What has been achieved in HIV prevention, treatment and care for people who inject drugs, 2010–2012? China 30% increase in OST recipients between 2009 and 2011 Vietnam significant scale up of NSP, >1000 NSP sites five-fold increase in the number of clients receiving OST Russia number of PWID accessing NSPs decreased by nearly 60%, from around 123,000 (2010) to 49,090 (2011) Ukraine increase in number receiving NSP, OST, ARV USA –reversal of the lifting of the Federal ban on funding NSP Malaysia –shift from a punitive law-enforcement approach Degenhardt et al IJDP 2013

8. Transformation of Compulsory Drug Detention Centers into Voluntary Evidence Based Treatment & Care Centers July 2011 36 000 PWID 6500 receivin g MMT Mistreatment of Drug Users and "Undesirables" in Cambodia’s Drug Detention Centers DECEMBER 9, 2013

9. Unmet Needs & Challenges

10. Women & Drug Use Percentage of women among PWID –4% (Iran) to 45% (North America, Eastern Europe) Higher HIV prevalence rates in female IDUs –Systematic review of 117 studies in 14 countries with HIV rates > 20% (Des Jarlais, DAD 2012) –Studies in 9 European countries (EMCDDA, 2006) Sex work and women who use drugs –10% (US) - 55% (Eastern Europe, China) (EuroHIV 2007, UNAIDS report on the global AIDS epidemic. 2010)

11. Gender-Specific Drivers that Increase Vulnerabilities to HIV Structural “risk environments” that drive the HIV epidemic among women who inject drugs: Intimate Partner Violence - 60-80% Gender norms and gender imbalances in the drug culture Lack of woman-specific drug treatment and services Strathdee, et al., Lancet 2010 El-Bassel, et al., Curr HIV/AIDS Rep 2014 Meyer, et al, J Women Health 2012

12. Female and Transgender Sex Workers in Malaysia: Sex, Drugs and … RDS of F/TG SWs in Kuala Lumpur (underway) Preliminary findings (N=114 of planned 450) – HIV: 21% 12 HIV cases in TGs (35%), 12 in FSW (15%) 54% unaware of being HIV+ – Drug/alcohol use (past 30 days) Amphetamines (62%) Opioids (35%) Alcohol (25%) Injection drug use (16%) – High prevalence of physical and sexual abuse – Interactions with police (89%) – High self-reported condom use (82%)

13. Adolescents and Injection Drug Use Low ages of initiation across regions. In some countries significant proportions of people who inject drugs are adolescents – Nepal, 20% High rates of needle- sharing Jakarta 15-19 age group – 50% needle sharing Poor access to services A global population size estimate for people who inject drugs under the age of 18 is unavailable

14. Ukraine: No. of adolescents who inject drugs versus access to harm reduction services See: O. Balakireva et al Population Size Estimate of Most-At-Risk Children and Youth in the 10–19 Age Group, Kyiv: Unicef, 2011 and D. Barrett, N. Hunt and C. Stoicescu Injecting drug use among under 18s: A snapshot of available data, London: Harm Reduction International 2013.

15. MSM & Drug Use Lancet September 2013

16. Countries with published MSM drug use data use data Bourne IHRA 2013

17. MSM and drug use Use of drugs vary widely – Episodic Prevalence of use higher – further marginalised or minority groups, eg ethnic minority gay men in the USA – younger men – living in large urban centres Polydrug use is common – alcohol, biggest contributor – especially stimulants eg ecstasy, cocaine, amphetamines or ketamine Prevalence of IDU (heroin) generally very low, but…. Bourne, IHRA 2013

18. 1.211.23 1.26 1.71 1.43 1.25 1.49 1.82 2.28 1.86 2.57 3.29 2.11 1.76 2.27 3.00 1.53 1.44 1.46 1.78 Ludford K, PLoS One, 2013 Alcohol and Drug Use Independently Correlate with HIV Risks Among Peruvian MSM Drug Use

19. Drug use, and drugs injected, are changing Looking at those only using ‘Club drugs’, Mephedrone Methamphetamine Ketamine GHB ecstasy The proportion currently injecting has doubled from: 5% (N=531) in 2011-12 to 10% (N=795) in 2012-13. Data Sources: NTDMS / NTA; Shooting Up report 2013.

20. Harm Reduction for People Who Use Drugs Context is Key

21. Prison and People Who Use Drugs

22. Geography and Imprisonment Total Prison Population In 1971 President Nixon declared a War on Drugs

23. Lifetime prevalence (%) of illicit drug use among prisoners in European countries EMCDDA 2012

24. Incarceration: High Risk Environment for HIV Transmission Among HIV+s in Ukraine Izenberg et al, IJDP, In Press Mean number of people sharing among injectors = 4.4 (0-30)

25. Results: N=125 Men (90%), age <40 years (62%), 72% had injected drugs Median CD4 - 337 cells/μL, 19 (15.2%) receiving ARV. Prevalence of undiagnosed active PTB (15/125; 12%) Associated with longer duration of drug use (AOR 1.14, 95% CI 1.03-1.26, for each year of drug use)

26. AIDS-Related Mortality Achieves Parity in Prisons and the General Population AIDS-Related Deaths Relative to All Deaths (%) 1995 State inmates General population 34.2% 10.2% 2008 3.5% 3.4% Maruschak LM. Bur Justice Stat Bull. December 2009. HAART (1996)

27. Independent Correlates of Sustained Retention in HIV Care CovariateAOR95% CIP Male gender2.101.42, 3.11<0.01 Having an HIV provider (pre-incarceration)1.671.09, 2.560.02 Discharge planning (within jail)1.501.06, 2.120.02 Disease management session (within jail)2.251.51, 3.36<0.01 Needs assessment (post-release)1.591.06, 2.370.02 HIV-related education (post-release)2.031.37, 2.99<0.01 Transportation assistance (post-release)1.541.0, 2.220.02 Althoff, AIDS Behav, 2013

28. Evidence-Based Strategies to Reduce HIV Transmission Among PWUDs NSP MAT HIV C&T PrEP Primary & SecondarySecondary Only ART

29. Treatment as Prevention Can Work Among PWIDs, but ….. Ecological studies in Vancouver and Baltimore – documented reduced transmission among PWIDs where community VL has decreased The HIV Continuum of Care for PWUDs is not equal to their non-drug using counterparts – HIV diagnosis – Linkage to care – Retention in care – Receipt of ART – ART adherence – Viral Suppression Differs based on local context and funding priorities

30. Engagement in Care Among PWIDs in Baltimore, ALIVE Cohort, 1998-2011 Fully Retained (30.5%)Continuously on ART (17.3%)Sustained VL<400 (8.0%) Westergaard, AIDS 2013

31. Engagement in Care Among PWIDs in Baltimore, ALIVE Cohort, 1998-2011 Poor Retention in Care Active drug injection Incarceration No health insurance No usual site of care Lack of consistency in HIV care provider Poor Viral Suppression Active drug injection Alcohol use Crack cocaine use Incarceration Lack of consistency in HIV care provider Decreasing CD4 count Westergaard, AIDS 2013

32. HIV Care Cascade: Select Countries in Central Asia McNairy et al. Journal on Drug and Alcohol Dependence, 2013

33. Provider and clinic-level correlates of deferring ART for people who inject drugs Westergaard RP, J Int AIDS Soc, 2012

34. Altice FL et al, JAIDS, 2011 Integrating Buprenorphine Into HIV Clinical Care Settings Prescribed ARTViral Suppression

35. Organization of Healthcare Delivery for HIV+ PWIDs Matters (Ukraine) Bachireddy C, Drug Alcohol Depend, 2013

36. Strategies to overcome healthcare disparities for HIV–infected people who use drugs at each step of continuum of HIV care: Roadmap of Findings Diagnosis of HIV Entry into HIV Care Retention in HIV Care ART Initiation ART Adherence Targeted out-reach programs Opt-out testing On site rapid testing – drug treatment programs, CJS Peer driven interventions Intensive case management Nurse support interventions Community outreach program Evidence based drug treatment Integration of clinical/social services SBIRT Evidence based drug treatment Public health campaigns Targeted outreach CME for providers Evidence based drug treatment DAART Access to treatment for comorbid conditions and social services VIRAL SUPPRESSION Meyer et al CID 2013

37. Economic evidence for interventions with PWID Dutta et al. The Global HIV Epidemics among People Who Inject Drugs, World Bank 2013

38. Cost Effectiveness of the Harm Reduction Program in Malaysia Incremental Cost Effectiveness Ratio (ICER) ScenarioYear2006 – 20132013 - 20232006-2050 NSP vs no intervention QALY gained 28,591316,8521,819,945 USD per QALY gained Cost-effective Combined MMT and NSP vs NSP only QALY gained 22,97476,674344,864 USD per QALY gained 7,396 Cost-effective 4,832 Cost-effective 4,446 Cost-effective CE threshold : 3 x GDP per capita (not cost effective). (WHO Commission on Macroeconomics and Health, 2001) GDP per capita in 2012 was approximately USD10,000 H Naning et al, IAS 2013

39. Global heroin supply increased by 380% from 1980-2010 Price of heroin in Europe decreased by 79%

40. Eliminating laws prohibiting OST and scaling up NSP and OST to 80% coverage could prevent 29% of new HIV infections among IDUs in Nairobi by 2015

41. The Prototype: The Case of Portugal Decriminalisation of personal possession of all illicit drugs since 2001. Continued prosecution of dealers and traffickers. Expansion of treatment and harm reduction. Introduction of guaranteed minimum income. 41 Kent. B Journal Crim 2012

43. Confronting Stigma & Addiction Opioid use disorder as a medical illness is still overshadowed by its misconception as a moral weakness or a wilful choice Separation of opioid use disorder treatment from the rest of health care insufficient attention to other substance use, mental health, and physical health conditions Language mirrors and perpetuates the stigma. Often assign judgmental, pejorative terms. Criminal justice system Olse & Sharstein, JAMA Feb 2014

44. P=0.001 P=NS The Future HIV Healthcare Providers: Stigma & Healthcare Students in Malaysia P<0.0001 Jin et al, AIDS Care 2014

45. What Do We Do Next? No one size of prevention fits all – tailor approaches to local and group context Combination (biomedical, behavioral) and multilevel intervention (e.g., individual, relationship, community, societal) Integrate treatment Address stigma and discrimination – begin with the medical and scientific community Drug Policy Reform

46. Rick Altice, Yale University Nabila El-Bassel, Columbia University Howie Lim, Ezra Akbar, Bertlin Ng, Britton Gibson, H NaningCERiA Chris BeyrerJHU Damon Barrett, Catherine CookHarm Reduction International David Wilson, Louisa DegenhardtUniversity of NSW Ken MayerFenway Institute, Harvard Medical School Tim Hunt, Wafaa el Sadr Columbia University Ministry of Education/University Malaya High Impact Research Grant The World Bank National Institute of Drug Abuse, USA

47. Science can be a catalyst for the realization of human rights And human rights can accelerate the translation of scientific knowledge into practice and policy Richard Horton KL 2011