1. March 2003 slide number 1 Monitoring of the implementation of UNGASS Commitments: HIV Prevention among IDUs by Karl L. Dehne, UNAIDS, Vienna Senior Advisor on HIV and Drug Use Senior Advisor on HIV and Drug Use

2. March 2003 slide number 2 Presentation overview l UNGASS on HIV/AIDS commitments regarding IDUs l Original behavioural IDU indicator l Proposed (supplementary) service coverage indicator l First round results l Advantages and disadvantages of the two indicators l Conclusions

3. March 2003 slide number 3 UNGASS ON HIV/AIDS DECLARATION OF COMMITMENT TARGETS Reduce by 2003, HIV incidence for groups with high/increasing rates of infection Reduce by 2003, HIV incidence for groups with high/increasing rates of infection Develop/strengthen, by 2003, national strategies to promote health of groups with high rates of HIV infection, e.g. injecting drug users Develop/strengthen, by 2003, national strategies to promote health of groups with high rates of HIV infection, e.g. injecting drug users Ensure, by 2005, a wide range of prevention programmes, including efforts to reduce drug use related harm Ensure, by 2005, a wide range of prevention programmes, including efforts to reduce drug use related harm

4. March 2003 slide number 4 10 Areas of Commitment l Leadership l Prevention l Care, support and treatment l Human rights l Reducing vulnerability l Orphans IDU commitment interpreted as prevention l Social and economic impact l Research and development l Conflicts and disasters l Resources

5. March 2003 slide number 5 Behavioural indicator (1) Definition: Percentage of injecting drug users who have adopted safe behaviours (avoided equipment sharing last 30 days and used condom on last intercourse). Purpose To assess progress in preventing IDU associated HIV transmission Applicability Countries where injecting drug use is a significant mode of HIV transmission Frequency Biennial

6. March 2003 slide number 6 Safe injecting and sexual practices (2) Method of measurement: Cluster sample or targeted snowball sample survey (BSS style) Sequence of 4 questions (injected? shared? had sex? Used condoms?) Score of those replying yes for denominator (1+3) and numerator (2+4) Interpretation: Gaining access to IDUs a challenge (especially where there are no services!), survey data rarely representative nationally Extent of IDU related HIV epidemic also dependent on size of vulnerable population

7. March 2003 slide number 7 Coverage indicator (1) Definition: with either (outreach) prevention services or drug dependence treatment, either longer-term drug-free or substitution therapyPercentage of injecting drug users reached during last month with either (outreach) prevention services or drug dependence treatment, either longer-term drug-free or substitution therapy. Purpose To assess progress in the implementation of programmes and services for the prevention of HIV transmission associated with injecting drug use Applicability Countries where injecting drug use is a significant mode of HIV transmission Frequency Biennial

8. March 2003 slide number 8 Coverage indicator (2) MeasurementMeasurement Denominator (estimated number of regular IDUs):Denominator (estimated number of regular IDUs): Multipliers, as many as possible Multipliers, as many as possible If possible, other methods (e.g. capture-recapture) If possible, other methods (e.g. capture-recapture) Extrapolate from cities, regions/provinces Extrapolate from cities, regions/provinces In reality, often multiplier guesstimate In reality, often multiplier guesstimate NumeratorNumerator Inventory of outreach projects and treatment sites Inventory of outreach projects and treatment sites Service statistics (No. of individual clients last month) Service statistics (No. of individual clients last month) InterpretationInterpretation Denominator data will have a considerable margin of error: best available estimatesDenominator data will have a considerable margin of error: best available estimates Different types of services (outreach with provision of advice, counselling only, needle-syringe programmes, various types of treatment) all be weighted the sameDifferent types of services (outreach with provision of advice, counselling only, needle-syringe programmes, various types of treatment) all be weighted the same

9. March 2003 slide number 9 Coverage indicator, definitions (1) OutreachOutreach Any designated programme activity through which injecting drug users have contact (face-to-face interaction) with service providers, including, for example, outreach workers, trust points, counselling centres or clinics, mobile services, etc., and are provided with one of the followingAny designated programme activity through which injecting drug users have contact (face-to-face interaction) with service providers, including, for example, outreach workers, trust points, counselling centres or clinics, mobile services, etc., and are provided with one of the following Information on HIV/AIDSInformation on HIV/AIDS Counselling on safer injecting methodsCounselling on safer injecting methods Clean needles, syringes and condomsClean needles, syringes and condoms Outreach can be conducted by professional health care workers as well as by volunteer peer workers (current or ex-drug users). Outreach does not include activities, where there is no face-to-face contact between service provider and drug injector, e.g. media campaignsOutreach can be conducted by professional health care workers as well as by volunteer peer workers (current or ex-drug users). Outreach does not include activities, where there is no face-to-face contact between service provider and drug injector, e.g. media campaigns

10. March 2003 slide number 10 Supplemental IDU indicator, definitions (2) Substitution treatmentSubstitution treatment Any activity, in which daily* and for a longer period of time (more than 6 months) a substitute for opiates is provided; most common substitution therapies include methadone maintenance and provision of buprenorphine. Note that drug-assisted detoxification is not considered substitution therapyAny activity, in which daily* and for a longer period of time (more than 6 months) a substitute for opiates is provided; most common substitution therapies include methadone maintenance and provision of buprenorphine. Note that drug-assisted detoxification is not considered substitution therapy Drug-free dependence treatmentDrug-free dependence treatment Any residential treatment lasting more than four weeks with the goal of total abstinence, including for instance, therapeutic communities; any longer-term (designed for 6 months and more) drug -free outpatient treatment, in which the individual has had contacted at least once during the last 30 daysAny residential treatment lasting more than four weeks with the goal of total abstinence, including for instance, therapeutic communities; any longer-term (designed for 6 months and more) drug -free outpatient treatment, in which the individual has had contacted at least once during the last 30 days For the purpose of estimating the numerator, detoxification- only in whatever form is not considered treatmentFor the purpose of estimating the numerator, detoxification- only in whatever form is not considered treatment

11. March 2003 slide number 11 Some preliminary results l 20 countries approached, in extra effort to obtain IDU UNGASS indicator results l Coverage indicator results obtained from 9 countries (plus some in-official results) l Behavioural indicator results obtained from 3 countries

12. March 2003 slide number 12 IDU Service Coverage in Selected Countries COUNTRY Estimated No. of IDUs % IDUs reached with prevention services in last month Belarus 50,000 50,000 1.8 1.8 Brazil 800,000 800,000 10.5 10.5 China* 400,000 400,000 5.0 5.0 Indonesia 160,000 160,000 1.5 1.5 Iran* 135,000 135,000 0.6 0.6 Nepal 20,000 20,000 21.9 21.9 Pakistan 60,000 60,000 0.4 0.4 Romania 30,000 30,000 2.2 2.2 Viet Nam 84,000 84,000 62.7 62.7 * reported by UN staff

13. March 2003 slide number 13 Other important countries Coverage indicator results not reported COUNTRY Estimated No. of IDUs % IDUs reached with prevention services Ukraine540,00010-15 Russian Federation 1.5-2.5 million < 10 India 0.5-1.6 million ?

14. March 2003 slide number 14 Behavioural indicator results COUNTRY No. of IDUs sampled % IDUs reporting safe behaviours Ukraine 600 600 65 65 Kazakstan 1365 1365 14.5 14.5 Surinam 9 0

15. March 2003 slide number 15 Summary of differences and commonalities l Impact (like young peoples behaviour) versus service coverage (like MTCT) l Both composite (IDU & sexual behaviours and different type of services respectively), requiring analysis by individual component l Both would require aggregation or extrapolation from local sites to national level

16. March 2003 slide number 16 Differences & commonalities (2) l Measurement of both indicators requires extra efforts beyond existing data compilation in most countries, but….. l Promotion of coverage indicator measurement process may be more beneficial for program development (e.g. inventories, intersectoral consultations on IDU population size) than series of behavioural surveys l Political commitment versus commitment of IDUs

17. March 2003 slide number 17 Additional interpretation issues l Behavioral indicator: – –Safe behaviours: only those reached? Consistent over time? Definition of sharing – –Unsafe behaviours: risk of blaming the addicted l Coverage indicator – –Official underestimates of No. of IDUs – –Quality of services – –Definition of treatment (e.g. Vietnam)

18. March 2003 slide number 18 Issues related to current patterns of IDU epidemics and responses l IDU population size crucial (and important vulnerability factor) l Drug dependency tends to make a significant spontaneous reduction in risk behaviours, in the absence of face-to-face service contacts, unlikely, and …. l … prevention service currently coverage low (care service coverage virtually non-existent)

19. March 2003 slide number 19 Conclusion l Prevention service coverage indicator currently most appropriate l Behavioural and/or HIV prevalence indicator to be used in addition, where either –epidemic is recent, or –service coverage is significant and likely to have an impact