The Inequalities that Drive the HIV/AIDS Epidemic Among People Who Use Drugs and People in Prisons

Moderator: Monica Ciupagea Expert, Drug use and HIV, UNODC:

Welcome to all, thank you for joining us for this side event. Fariba Soltani, Chief of HIV/AIDS Section, Global HIV Coordinator, UNODC will be opening, thank you Fariba.

Speaker: Fariba Soltani Chief of HIV/AIDS Section, Global HIV Coordinator, UNODC:

Thank you very much to all who have come to this side event, I also would like to thank the WHO, UNAIDS and International Network of People Who Use Drugs (INPUD) for joining and organizing this.

We have seen major progress in addressing the AIDS epidemic, and have made minor progress for people who use drugs (PWUD), as social, economic and gender inequalities hinder the response. In 2020 people who inject drugs (PWID) and their parnters had the highest rates of HIV outside of sub-Saharan Africa, and PWID are 35 times more at risk of contracting HIV than the general population.

The Global AIDS strategy calls for ending inequalities to end AIDS, we are committed to the synergy of the strategies to magnify the impact for PWUD and people living in prison settings. In the pre-session last week we brought together the academic community and the community of PWUD to talk about the inequalities of PWUD. In this side event we present some ideas that came up in this dialogue; harm reduction, people who use stimulants, and emergency situations. Thank you Ganna Dovbach for participating in this side event. We are following with great concern the events in Afghanistan and Ukraine and working with partners to support the people who use drugs and people who are in prison in the country to receive lifesaving services like opioid substitution therapy and antiretrovirals (ARVs). We hope this side event will highlight the inequalities of PWUD and people in prisons.

We have built strong partnerships, having recently signed the first ever Memorandum of Understanding between UNODC and the Global Fund.  It is important for implementation of all our strategies to end AIDS. Thank you again, and I wish us all a very productive event.

Moderator: Monica Ciupagea

Welcome Ganna Dovbach the Executive Director of the Eurasian Harm Reduction Association to address the issue of access to HIV prevention, treatment, and care for people who use stimulants and barriers they face. She will be focusing on new psychoactive substances (NPS) and the type of stimulants that are more frequently seen in EHRA’s regions.

Speaker: Ganna Dovbach, Executive Director, Eurasian Harm Reduction Association 

In the context of HIV, stimulant use and New Psychoactive Substances (NSP), we have very little responses to them in harm reduction services in the region, this has become a strategic issue. The key problematic areas in our region include NSP, which are different from the NSPs in Western Europe. There is no adequate mechanism to respond to the health and social stress caused by NSP and stimulant use in our region. We at EHRA interviewed doctors and specialists in the region and they said they are lacking resources and knowledge on NSP and stimulants.

Our key recommendations start with what is already recognized in the Global AIDS strategy, the need to decriminalize drug use and particularly with NSPs, it important to think about good strategy as problematic users and youth are being affected by criminalization and it makes impossible to educate and adapt socially for a fruitful life for youth. As for monitoring we see a big need in data collection to introducing an early warning system in all countries, with drug checking and then uploading the results, this is the key service needed for harm reduction services and we need also national systems for drug checking. An early warning system will allow us to conduct better harm reduction for people using NSPs. It is also important to distribute proper information and through online structures, we have been piloting a system of distribution developed with UNODC, UNAIDS, and local NGOs from the region to develop harm reduction further. We summarized what needed to be done to ensure access to health information and health services for people using different drugs and we need to think about drug checking as a service and the emergence of chemsex and unsafe sexual and injecting practices. We also need to promote peer based interventions for PWUD.

There was a lot done with UNODC to help but we need more help on a national level for doctors and mental health doctors to deal with challenges coming from stimulant and NSP use. Mental health doctors need to be added to HIV and HEP C responses and harm reduction. We have already developed some publications and reports and discussed on a national level with regional UNODC office about changes in harm reduction services. We are glad to see in Kyrgyzstan and Georgia that Global Fund programmes are flexible to address NSP and stimulant use. With harm reduction packages its about drug checking, mental health components, and information distribution programmes.

At EHRA, we are really very interested in cooperating with any agencies and all partners to have a comprehensive harm reduction package for NSP and Stimulant use, as these are the key challenges for the region.

Moderator: Monica Ciupagea:

Thank you very much and would like to share with the participants that Ganna’s voice is shaky a bit during this session because she is incredibly busy and tired helping with the Ukraine crisis and providing harm reduction to the people in Ukraine.

Speaker: Ganna Dovbach, Executive Director, Eurasian Harm Reduction Association:

We are struggling and need support but we will overcome and are happy that all colleagues in health and social support field are helping with this crises in Ukraine.

Moderator: Monica Ciupagea:

The inequalities are exaggerated in places of crises and it seems we are moving from one crisis to another. We now have a video from Frederick L. Altice, M.D., M.A. Professor of Medicine and Public Health, Yale University who is involved in supporting people in Ukraine during this conflict.

Speaker: Frederick L. Altice, M.D., M.A. Professor of Medicine and Public Health, Yale University:

Thank you very much for inviting me to speak at this panel. In regards to COVID-19 disruptions in health services delivery in the United States, there was a 12-fold risk of getting COVID-19 if a person has an opioid use disorder (OUD), and therefore an acute increase in opioid-related overdoses during COVID-19. There was a marked decease in “in-person” ambulator visits, and decreased testing for HIV and HCV, as well as decreased medication for OUD treatment. Some emergency recommendations included; an increase in telemedicine with reimbursement, tele-health allowable for those without broadband access, licenced clinicians being able to prescribe buprenorphine induction or refills, and stable methadone patients could receive up to 28 days of medicine.

The immediate response to COVID-19 at our site in New Haven, Connecticut was to transition to pre-ordering of supplies for pickup and home deliveries (social media apps), large mobile medical clinics stopped operating with transition to tele-health mediated through our outreach team, crowd sourcing was used to get information to the PWID community to help solve service delivery challenges, increased outreach worker effort to promote “bundled” testing for HIV, HCV, and OUD – the only required in person visit was going to a licensed laboratory with COVID-19 safety procedures, immediate implementation of tele-health/medicine for SSP clients; buprenorphine, home-induction procedures (app) and home deliver of medications by pharmacy vendor.

Differentiated Care Model – Focus on HCV Screen – Evaluate – Treat: Through assessment, counselling and support is provided using tele-health and urine can be collected for urine positive or negative pregnancy testing, all clients were screened for HBV infection.

Differentiated care outcomes: 66 underwent laboratory testing (the only in-person visit), outreach workers managed most of the communication with patients using texting or calls. HCV outcomes: 35 had chronic HCV and 31 started pan-genotypic DAA treatment (2 lost and 2 were incarcerated), 12 were unstably housed and 8 used stimulants, implementation: timing from first tele-health visit for phlebotomy was 6.9 days and for DAA initiation was 9.9 days, efficacy outcomes; 29 out of 31 (93.5%) achieved SVR. MOUD outcomes included 26 out of 31 (84%) ended up on MOUD, 6 at baseline, new initiations (N=20): BPN (N=14) and methadone (N=6). HIV outcomes were that there were no new diagnoses, all 6 were prescribed ART.

In Ukraine they had a similar response to the COVID-19 crisis, they asked clinicians in March 2020 to move their stable patients to take home dosing and could provide a 10 days supply. Around 1 million clinician and client interactions were reduced meaning that there would be more time available to recruit more clients and in the short run, mortality was unchanged.  During the COVID-19 period in the initial 3 months, the attendance went down but so did the drop outs and so the rate increased over time. We tried to take a look at the regions that have a higher coverage and that were more innovative, and those with lower coverage were not working efficiently so we tried to get them to work on other things. The drop out/retention rate was higher during COVID-19 than the year before in all 3 regions of the country, when controlling for increased dosage, the hazard for drop-out slightly improves (more for the middle category). When take-home dosing is controlled for, however, the innovators in the high coverage areas don’t change their drop-out rate but the less productive ones do – suggestive of better clinical innovations in the high coverage areas. In the less innovative regions there was no difference in mortality, but in higher innovative regions they reduced mortality because they had good systems in place. COVID-19 taught us that we can reduce the clinical demands on both patients and clinicians, as there were more patients brought in and reduced deaths in the innovative regions. What it really does is challenging the paradigm that you need more control over patients and these findings have helped us modify the programmes in place. 

Now with this Russian invasion of Ukraine, there are 278,000 people who inject drugs (PWID) with OUDs, 17600 on OAT at 270 sites in all regions except Crimea. OAT has to be in armoured car with 2 army personal and men can’t leave. Women who use drugs also are not moving though due to being afraid of not being able to access harm reduction services. The region of the country that is safest is in Lviv but the central repository for medicines such as used for OAT is on the other side of the country. Operating collaborative learning sessions with the Chief Narcologists in each region to update, all sites are still operating despite clear danger and have limited times. The Ministry of Health issues emergency guidelines allowing patients to have up to 30 days prescription (free) to pick up at pharmacies. There is variable dispensation of larger quantities (most only 10 days), and some are starting dosing tapers. There are a number of strategies put in place to communicate with patients as patients are afraid to travel, such as an online message board for pharmacies with medication, an online message board to let clients know where open OAT clinics are located, closed social media chat groups, and crowd sourcing to announce when supplies are available in a given location. Strategies to communicate between clinicians include NIATx calls, closed social media chat groups, using the national SyReX database to guide accepting clients travelling from more dangerous regions. An idea for innovations in transportation is to use drones to move the medicine around. Planning for the worst scenario, which in this case would be what happened with Crimea, when 800 patients were stopped within 10 days of annexation, 200 were expatriated to non-conflict regions, over 10% died within 6 months from overdose and suicide, and there was an explosive HIV transmission epidemic. 

Speaker: Ganna Dovbach:

Communication with patients of OAT is happening and using Telegram to address the harm reduction crisis in coordination with national partners, and we need to give thanks to all who are doing what they can under the bombing and threat to their lives.

Moderator: Monica Ciupagea:

Next up is the Nepal experience on continuing harm reduction services during COVID-19, from Recovering Nepal’s CEO, Bishnu Fueal Sharma.

Bishnu Fueal Sharma, CEO, Recovering Nepal:

Thank you for this session. Recovering Nepal is a group of locals working across the country as a network, we conduct resource mobilisation, programme designing and implementation. Most pharmaceutical drugs come from India, with Nepal producing higher amounts of cannabis, and along the border areas of Nepal is where most drug use is found. According to The World AIDS Day Report 2020 by NCASC, Nepal’s HIV epidemic remains concentrated among key populations. An estimated 29,503 people are living with HIV with an estimated 19,410 PLHIV on ART. The Ministry of Health has mapped injecting drug use and HIV-related risks in border districts, yet people who use drugs living in these areas lack access to harm reduction services. The National HIV Strategic Plan for the period 2021-2026 is a set of evidence-informed strategies focused on building one consolidated, unified, rights-based and decentralised HIV programme. According to IBBA, surveys indicate HIV prevalence was seen to be 8.5% among PWID (and 8.8% among women who inject). Nepal implemented harm reduction and community led testing approach to maximise HIV testing among key populations in selected 27 districts also encompassing 13 OST sites. 

The first case in Nepal was identified and confirmed on the 23rd January 2020, the Government of Nepal declared and regulated social distancing norm across the country. However, a country-wide lockdown came to into effect on 24 March 2020, and ended on 21 July 2020. As of 1st December 2020, the Ministry of Health and Population (MoHP) had confirmed a total of 234,756 cases, 216,594 recoveries, and 1,529 deaths in the country. Nepal took steps to prevent a widespread outbreak of the disease while preparing for it by procuring essential supplies, equipment and medicine, upgrading health infrastructure, training medical personnel, and spreading public awareness. 

It was very difficult to continue day to day services during lockdown in the country. Although services were not fully closed, those which were available were limited. From the beginning of lockdown, joint efforts of community, government and partners even came up with the solution to provide take away doses during the lockdown period for OST. The Government of Nepal provided food, support and health services for people with low socio-economic backgrounds, however most key affected populations were unable to access support services adding that they were not specifically prioritized. PWUD are stigmatized, discriminated and generally most of the time in fear of being marginalized since they have already had to suffer a lot during the COVID-10 state of lockdown within the country. 

The following were the community initiatives implemented: enabling of advocacy efforts, community engagement, mitigating negative impacts of COVID-19, building trust to avoid unintended harms, ensuring frequent sharing of information, referral mechanisms, monitoring of the response, and sharing best practices. On 19th March 2020, Recovering Nepal started its advocacy approaches by writing an email to the Ministry of Home Affairs, Ministry of Health, NCASC, National Program Agency, and key concerned authorities to remove legal barriers by a position paper on COVID-19 of Nepal in response to PLHIV and PWUD resulting in the approval of take home doses of OST, emergency harm reduction guideline, emergency reporting system and ideas of using drugs and dealing with vendors in the street. An emergency TWG meeting was conducted b NCASC with the Ministry of Home Affairs to influence approval of take home dose policy and continuation of the harm reduction program including ART. Recovering Nepal, NCASC and TWG members had a meeting with the joint Secretary/Chief of Narcotic and Ministry of Home Affairs to see approval of OST take home doses, continuation of harm reduction services, and issuance of emergency passes in response to COVID 19. We managed to convince Director General Health Department, Chief of District Offices for Vehicle movement Passes which was provided to key field workers for the delivery of life saving medicines including food and other daily necessities. NCASC organized regular harm reduction TWG meetings to discuss progress and updates as part of a monitoring report of the OST and NSP programmes. Meeting and frequent communications with higher police authority, traffic to provide safety of staffs were mobilised in COVID-19 during the lockdown. From day 1 of the COVID-19 lockdown in the country takeaway home doses started for OST ad ART, door to door service for OST and ART delivery was established, cooked food was delivered to women who use drugs at street and door to door level, emergency relief packages were delivered door to door and on the street, updated PPE in service settings and distributed to individuals, and relief packages were delivered to 114 care centres (for 2 months) and approximately 5,500 active users under the OST and NSP programmes. 

We want to thank our government for listening to us and understanding us. Another major break through happened recently with the government approving naloxone to be distributed. The government are also looking at creating a new drug control act that decriminalizes PWUD, they have requested Recovering Nepal to be in the drafting team, so we will have community members helping to draft the law. They also decided to revise the OST guideline too as they saw that OST take home dose can help reduce the dropout and improve quality of life.

Moderator: Monica Ciupagea:

We have one more presentation from Prof. Louisa Degenhardt on updated global systematic reviews of the epidemiology of injecting drug use, HIV, and interventions to prevent and reduce harm among people who inject drugs.

Speaker: Prof. Louisa Degenhardt, Scientia Professor, NHMRC Senior Principal Research Fellow, Deputy Director NDARC, Faculty of Medicine, UNSW

I wanted to acknowledge the very large team that were centrally involved in these reviews as well as all of the other people that we reached out to on a semi regular basis, including many people from the organizations who are organizing this session today.

We’re currently really reaching out to our colleagues to really check the information that we’ve collected so far is accurate, and the best that we can collect. So just to give you a bit of a background, some of you will be very familiar with these reviews. We first undertook this as part of the work of the The Reference Group to the United Nations on HIV and Injecting Drug Use, and they were published in 2008. So we wanted to update these reviews again, but also expand the scope of what’s been covered. So re-reviewing evidence on the prevalence of injecting prevalence of HIV, hepatitis B and hepatitis C among people who are looking at the characteristics of people who inject and expanding the range of dimensions that we’re looking for, what is being done and what is available and how much is being delivered to people. I’ll go in more detail in just a minute. Just a bit of detail about the methods so this incorporates what is typically done in systematic review. MISSING METHODS 1

Some decision rules around PWID, and BBW estimates included: all eligible estimates collected published since 2016, study quality graded, higher grade evidence included in preference to lower grade, extracted 95% CI confidence intervals or ranges, and if multiple estimates were available, we pooled via random effects meta-analysis. Data from previous reviews also used (adding to existing datasets). Regional, weighted estimates will be made of the prevalence of HIV, HCV, HBV, and IDU using all the observed estimates and 95% CIs in each country within that region, and deriving a weighted estimate and UIs, taking into account country population. Uncertainty of regional estimates of the number of PWID with HIV, HBV, HCV estimated with Monte Carolo simulation taking 100,000 draws; incorporated uncertainty around IDU and BBV prevalence estimates. 

Data from all eligible studies since 2016 on the percentage of young women younger than 25 years, the percentage of recently homeless and recent sex workers, the percentage of incarceration history and arrest, and drugs injected and risk behaviours. We used all eligible estimates, and if multiple estimates are available, we pooled via meta-analysis (generating 95%CI). Regional estimates generated in the same manner as for BBV regional estimates. 

Additional features of current reviews: there was a wider range og information about people who inject drugs extracted, including: injecting drug use among sexual partners; more detail on incarceration history; gender and sexual identity; sexual partners; incarceration history; patterns of non-injecting drug use; sexually transmitted infections; physical health conditions; child maltreatment; mental disorders; and IRID. Collating time series data on harm reduction interventions can inform modelling (e.g. global burden of disease), and will allow a more straightforward review of changes over time. Data on a wider range of interventions, formerly OAT, NSP, condoms, HIV testing, ART, and now also including HCV testing, DAA treatment, PrEP, Naloxone, drug checking, and supervised consumption sites.

When it comes to screening of the studies, in the 2017 review we screened 55,671 papers or reports, with ultimately 1,147 papers or reports were extracted for at least one aspect of our review. These papers/reports all re-reviewed to extract the additional variables we were collecting for this review. In the current review we screened 11,392 papers or reports, and ultimately 552 epidemiology of PWID papers/reports were extracted, 157 coverage of harm reduction interventions papers/reports were extracted. 

Here is a brief summary of the data collected in 2008 vs. 2017 vs. 2022: with countries with injecting drug use being 148, 179 and 188 respectively; countries with IDU percentage estimate being 61, 83, and 92 respectively; countries with HIV percentage estimate at 82, 108, and 115 respectively; countries with anti-HCV percentage at 77, 98, 106 respectively; percentage of the population with injecting drug use reported being 94%, 99%, and 99% respectively; percentage of the population with IDU percentage estimate being 76%, 82%, and 86% respectively; percentage of PWID population with HIV percentage estimates at 83%, 90%, and 91%; and the percentage of PWID population with anti-HCV percentage estimate at 84%, 88%, and 90% respectively.

In terms of data on HIV and HCV testing and treatment from studies with people who inject drugs, the following was analysed: countries with recent HIV testing data was 77% in 2022; countries with ever treated for HIV data was 32%; countries with current HIV treatment data was 25%; countries with recent HCV antibody testing data was 35%; countries with recent HCV RNA testing data was 5%; countries with data on ever treated for HCV with any treatment was 49%; counties with data on ever treated for HCV with DAA was 23%; and countries with current DAA HCV treatment data was 3%. 

Comment: Judy Chang, Executive Director, International Network of People Who Use Drugs (INPUD):

You know, i think the community of PWUD lack is really very simple, you know, the ability to enter, stay engaged. and retained, continue and exit program in the same way that the general population does and can and we want to be able to do this choice, agency, and volition. But I think as we’ve seen from other presentations as well, like, you know how seriously far away we are from that goal, you know, across so many contexts globally, but especially I think when we look at and consider the emergency situations the whole world has had to go through in the last couple of years, it shows the inequality has become so much more starkly unquestionable. When talking about Ukraine, communities are fighting on the front line. But they’re also in the midst of all this they’re having to worry about being disrupted and having their OAT access disrupted, its such a serious situation that really highlights the need to really change and overturn the whole system happening, you know, withdrawal. Forced withdrawal from OAT is honestly, one of the most physically and psychologically painful things that we go through, so I think it’s really heart-breaking, being a representative in the community to think about people having to go through this in the middle of all the chaos and violence that surrounding them at the same time.

What we really need is for the global community to really step up and take action and truly make services for people who use drugs including OAT and naloxone and drug checking widely available. Right now we have these moral kind of barriers to doing this and goes to creating real harm and
suffering. Thank you. 

Moderator: Monica Ciupagea:

Thank you very much, i think Judy summarized very well what the presentations said, and the conversation we had last week. The Global AIDS Strategy mentions the inequalities. Encourage you to follow the Plenary tomorrow as the President of the International AIDS Society will give a presentation. All of these presentations will be available on our website. Thank you for being with us today and staying with us throughout. Thank you very much.

 

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