Mr Aldo Lale-Demoz, UNODC Deputy Executive Director: Distinguished delegates, welcome to this event on Science addressing drugs and HIV: State of the art. I would like to like to explain that this is a follow-up to previous events that have taken place at the CND in Vienna. I think most of you would agree that drug policy has for too long been driven by morals and politics, but science is finally becoming an undisputed partner in pushing forward drug policy. The UNGASS outcome document is specifically including science as an important factor as well as the SDGs. We work hard to reach SDG and UNAIDS targets. For this however, the rights of all people must be effectively promoted and barriers must be brought down. Today, the science community will present their findings and recommendations.
Mr Catalin Negoi-Nita, Romanian National Anti-Drug Agency: Welcome to this event. Let me introduce our first speaker, Dr. David Wilson.
Dr David Wilson: Thank you very much. Evidence based science is important in driving not just drug policy. Drug users are particularly vulnerable for infectious diseases and related risks, for example, drug users have almost 50 times higher mortality rate. It is important to urge governments to invest into the right kind of treatment. Look how high the reliance on external financing especially in Asian countries is in this chart. However, if we consider carefully what we would like to invest into, we can make this funding more efficient. If we optimise our fundings, the total costs are affordable. In the case study of Kazakhstan, we can see that the right targeting of funding can actually significantly reduce HIV rates. We need to focus on those services that are actually effective. These are NSP, OST; ART are those services that have been proven to be the most effective. Compulsory detention programs however have been proven to have a relapse rate of almost 90%. Only about 14% of HIV positive people who inject drugs access ART, and there are many other examples which show how access is insufficient. Integrating HIV into Universal Healthcare would only mean a 2% budget proportion. We have many opportunities to invest for impact by implementing supportive laws and policies. Wherever legal barriers exist, users have far less access. We can do much more to improve treatment costs. The region that has the highest proportion of HIV due to users, Eastern Europe and Asia, pay more for ARV than any other BRIC countries. We have a study from Thailand about Men who have sex with Men which shows that creating demand and reducing barriers increases the efficiency of services without increasing costs. In conclusion, inaction is costly, in terms of addiction, mortality, etc. This is the case whether we speak of TB, HIV, or any other epidemic. Harm reduction investment is effective in terms of negative events averted and cost-effective in terms of healthy years gained.
Mr Aldo Lale-Demoz: Thank you for this intervention. I would now like to introduce Professor Leo Beletsky from Northeastern University and UC San Diego.
Professor Beletsky: Thank you to the organisers including UNODC and country delegations that have made this possible. This is an important panel. Today I will be talking as a lawyer and public health researcher about HIV, drugs and the legal environment. Health is affected by many different factors including genetic, social etc. Today I will mostly talk about the legal factors. One way to look at this and drug policy in general is that it focuses on reducing drug use in general. Laws are structural approaches to try and reduce harmful drug use, however, our undertakings have not been effective at reducing addition or substance use as it is called today. Supressing the supply of substances has been ineffective and the price has actually gone down and the availability has increases. There have been a lot of unintended consequences including increasing violence, environmental damage etc. I will focus on HIV rates, and as Dr Wilson has said there is limited access to evidence-based HIV prevention, such as syringe exchange. There has been reinforced stigma and discrimination and policing has increased risky behaviour and HIV infections such as arrests and syringe confiscation. Police in the US are constantly engaging between the affected population and the services, even though they can actually refer people to services. Laws are not necessarily always harmful and can authorize substitution-based therapy, syringe exchange etc. However, laws do not always function when implemented. This is a global problem. Research in Mexico has shown that decriminalizing small amounts of drugs was not particularly effective. Most people did not know about the decriminalization because the law on the grounds did not match that in the books. We are now engaging in police education programs (PEP) which focuse on needle injuries as officers tend to be very concerned by this but also provides information on harm reduction services and referral schemes. It is critical to follow the evidence in implementing laws and it is important to keep up a loop mechanism which keeps updating the laws according to the results achieved by them.
Mr Catalin Negoi-Nita : Our third speaker is professor Don Des Jarlais who is a professor at Mount Sinai and who will speak on stimulants and HIV.
Professor Des Jarlais: Thank you also for inviting me to this event. I’d also like to thank my collaborators who helped me prepare this presentation. The relationship between HIV and drug use is very complex and we cannot expect uniform effects. There are different stimulants including Cocaine and ATS. There are also methods of administering such as injecting, smoking and oral. Drug effects include impaired judgment, continuation of the high. Chronic drug effects include dependence and need for Monday. There are multiple ways drugs can affect risk behaviour and HIV transmission. The social networks where risk behaviour is occurring such as sexual behaviour or injection behaviour play a role as well. Factors that affect this are the HIV prevalence in the group, the size of the group, the density of connections and the risk partner currency as well as the social norms for behaviour. For example, some groups have the norm that everybody should bring enough needles and condoms for yourself and for others. All these networks vary also on the drugs that are used. There are particular issues that make preventing HIV in these groups more difficult. Injecting cocaine is one issues as people will inject cocaine every 30 minutes or so, therefore a large supply of needles is requires. Crack-cocaine and amphetamine type stimulants tend to have increase sexual behaviour. A disorganized lifestyle among heavy users is another contributing factor. People can organize their life around this, as this is often the case for heroin, but people who use stimulants often do not dosage their drug adequately and crash instead. Another special issue is the lack of scalable effective treatments for large numbers of people. Needle-exchange programs, opiate substitution programs and ART are difficult to implement in our focus group. HIV prevalence is usually found to be more likely in stimulant groups although there are different studies showing different results. Overall there is a lot of mixed evidence but stimulant consumption is generally considered to be linked to increased HIV rates. Interviews with consumers have shown that condoms are not considered useful for the high when people are taking stimulants. All of this sounds very negative but maintained efforts can contribute to an improvement in HIV rates in consumers, as this is the current trend. Such effects have been seen in case studies from places such as Brazil and the US. We need to continue to increase access to harm-reduction services. We need to consider stimulant use a mixed subjects and not generalize, but we know that there are ways of targeting this issue successfully.
Mr Aldo Lale-Demoz: Our next speaker is Professor M. J. Milloy from the University of British Colombia who will speak of infectious diseases and drug use.
Professor Milloy: The heart of the UN 90:90:90 strategy is to target HIV rates and antiroviral therapy is one of the top four strategies in doing this. However, in many places, people who use drugs lack access to all four of the main strategies. A lot of the gains in HIV combating have not been reflected in populations of people who use drugs, including in my home country of Canada. However, people who use drugs can benefit from access and treatment just as much. The question is how close are we to our 90:90:90 goal and what are our most specific barriers. We systematically review the relevant literature to identify progress and barriers. We identified 21 studies mostly from high-income countries such as the US and Canada. The bad news is that in the studies we surveyed level of viral suppression is very low. The good news is that there is evidence that access to HIV treatment can be increased if efforts are increased and campaigned for. The proportion of people who are virally suppressed has gone up in case studies of regions where efforts have been significantly increased. Rates of resistance of treatment have gone down. There are a number of barriers to achieving VL status, increasing stimulant use, suboptimal OST, and socio-economic challenges. We think that to scale up treatment we need to address the issue through multi-level approaches.
Mr Catalin Negoi-Nita: The next two speakers will present outcomes of the scientific consultation held at the 57th CND in March of this year.
Ms Monica Beg: Thank you very much. We focused the consultation on several topics. The statement that came out of this consultation was an opportunity to engage countries in addressing the issue of drugs and HIV. There were several key conclusions. 1.) The sharing of injecting equipment but also restrictive drug policies and policing are key factors in increasing HIV rates. 2.) Needle and syringe exchange programes and OST are effective in reducing the sharing of injecting equipment and averting HIV. 3.) Harm reduction interventions are very cost effective. However, there remains a gap between what science has shown to be effective and what is implemented in reality especially in countries most affected by HIV and Hepatitis C. 4.) There is an urgent need to integrate hepatitis C treatment services into harm reduction services to enhance treatment uptake and cure rates.
Speaker: The 2016 scientific statement written at the CND included these main points.
- All public spending is based on explicit or implicit prioritization. In a matter as central to human life as health, it is important to use all available evidence to make prioritization explicit and ensure that the best possible health outcomes can be achieved. Mathematical models and other scientific tools are available to inform decision making. They should be increasingly applied in the development of policies and programmes in the field of drug use and HIV. This means that resources need to be used for the most effective interventions, for the people who most need services, 3 where they need them and applying the most efficient service delivery modalities.
- Allocative efficiency (the allocation of resources to maximize health impact) of HIV programmes has been extensively studied in all regions of the world. In countries with substantial epidemics among people who inject drugs, analyses have consistently shown that investment in harm reduction programmes for people who inject drugs are part of the optimal mix of interventions to minimize new HIV infections and deaths. By prioritizing needle-syringe programmes, opioid substitution therapy and anti-retroviral therapy, countries could improve coverage and achieve fewer new infections and deaths among people who inject drugs. This will also reduce new HIV infections among sexual partners of people who inject drugs and the wider population.
- Country case studies show that high coverage of programmes for people who inject drugs including needle and syringe programmes and opioid substitution therapy were followed by substantial reductions in new HIV infections. Mathematical modelling suggests that scaling up proven interventions including needle syringe programmes, opioid substitution therapy and anti-retroviral therapy as part of a package of related health services would represent a major step towards ending AIDS as a threat to public health by 2030. Prioritizing these programmes now is also an investment, which will substantially reduce future health care cost, recognizing that every new HIV infection implies future cost for life-long treatment of HIV and opportunistic infections. To maximize return on investment, it is therefore important for countries to review spending on HIV, health and wider drug control programmes to ensure that resources can be reallocated to evidence-based interventions.
- In addition to evidence-based prioritization, countries can enhance the effect of HIV prevention and treatment for people who inject drugs by improving implementation efficiency. Reviews have shown that cost for procurement of drugs such as methadone, buprenorphine and anti-retrovirals can be substantially reduced through enhanced price comparison, price negotiation, international procurement and use of generic suppliers. Optimized models of care including standard operating procedures ensure that service provider interactions with clients focus on core services. Increasing access to services, through removing barriers and strengthening effective linkages between services, can contribute to optimal utilization of staff and site capacity, which will improve economies of scale and reduce cost. Increased domestic financing of programmes for people who inject drugs requires simultaneous efforts to build mechanisms and capacities for contracting civil society organizations providing outreach and performance management of programmes. Good governance principles, quality assurance, and best clinical practices should be consistently applied.
- In countries where we have conducive policies, adequate resource allocations, access to needle and syringe programmes, opioid substitution therapy and antiretroviral therapy, great progress has been made in reducing HIV transmission among people who inject opiates. The field now needs to more fully address the challenges of HIV prevention and treatment for injecting and non-injecting users of stimulant drugs: cocaine and amphetamine type stimulants (ATS). Additionally there are emerging drugs such as mephedrone and other new synthetic drugs that may create risks for HIV transmission.
- This issue is particularly important for some subgroups of key populations, such as men who have sex with men and people who exchange sex for drugs or money. There are complex relationships between stimulant drug use and HIV transmissions. Mediator factors and other structural, social and personal factors, such as poly-drug use, mental health, homophobia, discrimination, punitive laws and practices, other sexually transmitted infections, should also be taken into account when trying to understand the link between HIV and stimulant drug use.
- It is difficult to quantify the exact risk of stimulant use in increasing HIV infection. But the preponderance of the evidence points towards a positive association between stimulant use, sexual and injecting risk behaviours and HIV infections. A particular problem is the lack of scalable drug dependence treatment for stimulant use disorders. We have successful examples of reducing HIV transmission associated with stimulant use including crack-cocaine epidemics and cocaine injecting epidemics. New prevention strategy such as Treatment as Prevention (TasP) for people who use drugs living with HIV should be implemented to reduce HIV transmission in this key population. Gaps in the literature need to be acknowledged such as the lack of cohort studies, lack of focus on women and minorities, few studies from lower and middle income countries, few studies on new prevention approaches, such as Pre-exposure Prophylaxis (PrEP) for men who have sex with men using stimulant drugs, scalable drug dependence treatment approaches and use of social media.
- Among opioid dependent people living with HIV, methadone maintenance therapy (MMT) reliably increases adherence to antiretroviral therapy, even among homeless individuals. If adherence to antiretroviral therapy is maintained, the use of cocaine or methamphetamine among men who have sex with men living with HIV does not reduce the effectiveness of antiretroviral therapy (ART). All people who use drugs and are living with HIV require access to antiretroviral therapy.
- However, access and adherence to ART for many people living with HIV who use drugs is constrained by important social, structural and environmental factors, such as stigmatization, incarceration and homelessness. While provision of HIV care in correctional settings may serve to improve rates of HIV testing and linkage to care, significant challenges exist with ensuring continuum of care within and between 6 correctional and non-correctional settings, which can lead to interrupted ART. 10.Multi-faceted and multi-level approaches are required to support access and adherence to ART among people who use drugs living with HIV, including integrated ART, opioid substitution therapy and other evidence-based drug dependence treatment, supportive housing and opportunities for employment and alternatives to conviction and punishment. Increasing access and adherence to ART will require health-focused drug policies based on evidence and human rights of people who use drugs.
- Increasing access will require health-focused policies based on evidence and human rights.
Mr Aldo Lale-Demoz: Thank you very much, we now have time for some very fast interventions from the floor.
Speaker: Thank you, I am speaking on behalf of the Kazakhstani delegation that has helped organise this side event. HIV is currently being tackled by our government and HIV is increasingly being transmitted less by drug use. Our government is committed to covering 100% of all problems by 2017. I would like to agree with the professor that we need to increase the efficiency of the treatment management. I would also like to bring to attention that we closely collaborate with the civil society and we have more than 60 NGOs in our country working with us on HIV related issues.
Speaker: Thank you. I am from Switzerland, and as some of us have been advocating for the inclusion of more wording on harm reduction in the outcome document it is bittersweet to hear these presentation here today. I would like to encourage you all to speak up earlier in the processes in the future. It is important that you all speak here today but I wish it had been earlier in the processes. Thank you.
Mr Catalin Negoi-Nit : The 2014 and 2016 scientific statements complete each other. HIV needs to be addressed effectively, inside and outside of prison settings, and advocacy is needed to shift the focus from control to treatment and prevention. We have the scientific evidence guiding us on how to best do this. I would like to also express my gratitude to the speakers here today for their work today and in advance of this event.