1. A Review of Barriers and Ways Forward Daniel Wolfe 1 Patrizia Carrieri 2 Donald Shepard 3 Paper 3 Treatment and Care for IDUS with HIV 1. Open Society Institute 2. INSERM U912 - ORSPACA 3. Brandeis University

2. The HIV risk environment Levels: – Macro – Micro Types: – Physical – Social – Economic – Policy Adapted from Rhodes 1999 and Glass and McAttee 2006 Illustrate how varying levels of environmental influence affect IDUs’ risk behaviours, HIV incidence and attributable risks (Strathdee et al. Lancet 2010)

3. Impact of Scaling up Combination HIV Interventions: Example from Odessa ( Impact of Scaling up Combination HIV Interventions: Example from Odessa ( Strathdee et al. Lancet 2010) Reducing unmet need of OST, NSP and ART by 60% could prevent 41% of incident HIV infections

4. 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 dependence 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)

5. Global Progress? No global assessment of IDUs on ART compared to their share of HIV since 2004 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 often based on police or treatment data

6. “Mega-Epidemics” offer global snapshot

7. 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

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

9. 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 “If you are under the influence of narcotics, please—come back tomorrow” Sign from AIDS center, Ukraine

10. 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

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

12. 3 x greater 33 x greater 1.1 x greater *2008 IDUs in Govt.-funded Methadone v. Detention

13. From the Individual to the Systemic 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 Use of peers for reach and stigma reduction -- DAART beyond the clinic setting

14. From Criminality to Care End to registries 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

15. 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 American-Austrian Foundation