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Experts Warn that HIV Treatment Excludes Drug Users
Even When They Are Vast Majority of Those in Need

WHO HIV/AIDS Director, New Report from Open Society Institute
Remind Governments that Treatment for Drug Users is Effective and Possible.

Bangkok, July 15 -- Governments across the world are excluding drug users from HIV treatment, leaving millions without treatment and potentially fueling the world's fastest-growing HIV/AIDS epidemics, experts at the XV International AIDS Conference warned today.

The call for greater inclusion of drug users in HIV treatment efforts came at a meeting organized by a coalition of leading international AIDS organizations including the Central and Eastern European Harm Reduction Network, the European AIDS Treatment Group, Gay Men’s Health Crisis, the International Harm Reduction Program of the Open Society Institute, the Thai Drug Users’ Network, and the Thai AIDS Treatment Action Group. Jim Kim, MD, Director of the World Health Organization’s HIV/AIDS program, served as co-chair of the meeting. This meeting follows another consultation held in April that brought together WHO representatives with those from harm reduction networks from Central and Eastern Europe, Asia and Latin America to discuss strategies for increasing access to HIV treatment for drug users.

“Available data show clearly that drug users, offered proper support from the health sector, receive the same benefits from treatment as other people with HIV,” Dr. Kim said at a press conference before the meeting. “Yet drug users are routinely written off as unreachable and noncompliant. In an increasing number of countries, failure to offer HIV treatment to drug users means that an effective response to the epidemic is being fatally compromised.”

UNAIDS estimates that injecting drug use accounts for ten percent of annual HIV infections worldwide, as many as one of three new HIV infections outside Africa, and the driving force behind the world’s fastest growing epidemics. In Russia, as many as one million people have been infected with HIV in less than ten years, with over 80% of infections being among injecting drug users (IDUs). In China, more than 60% of the country’s one million estimated infections are among IDUs. All of the countries of Central Asia, and many in Southeast Asia and the Southern Cone of Latin America report that IDUs account for a majority of HIV infections or a rapidly growing share of total cases.

The International Harm Reduction Program (IHRD) of the Open Society Institute, a co-sponsor of the meeting, released a report here, Breaking Down Barriers: Lessons on Providing HIV Treatment to Injection Drug Users, detailing successful efforts to offer drug users antiretroviral treatment (ARV) and the dangers of failure to do so.

“The common assertion that drug users cannot comply with treatment represents a failure of vision by AIDS program administrators, not a description of reality,” said IHRD program officer Konstantin Lezhentsev, MD, noting that the report described successful efforts to offer ARV to IDUs in Brazil, Argentina, and a number of urban settings in the U.S. and Europe. “Like exhausted single mothers, farmers in remote villages, or gay men in intolerant cultures, drug users find it easier to access treatment if offered specific approaches that recognize their needs. The question is whether governments and healthcare systems will step up to their responsibility to meet the specific needs of this group, or continue to simply deny treatment to drug-users based on the myths that are based more on prejudice and discrimination than on healthcare and human rights principles.”

The OSI report noted both treatment shortfalls and promising developments, including

Failure to offer HIV treatment to drug users has been justified in many developing countries by the extremely limited supply of medication available. But experts here said that new developments like the formation of the Global Fund to Fight AIDS, TB and Malaria and the manufacture of generic drugs will sharply increase availability of antiretroviral therapy, without necessarily removing the discrimination the keeps drug users from treatment.

“Mechanisms like the Global Fund or WHO’s 3 by 5 target are a source of excitement and great plans,” said Mauro Guarinieri of the European AIDS Treatment Group. “But in many parts of the world, increased funds have not yet been matched by commitment to prioritise health care over punitive law enforcement. Unless governments act immediately to scale up not only HIV treatment for drug users, but also such interventions as methadone maintenance and needle exchange, the promise of AIDS treatment will be an empty one. What does it mean if we create an AIDS service structure in Asia or the former Soviet Union that systematically ignores the majority of those with AIDS?”

Coalition members also cautioned that overly punitive policies on illicit drugs influenced the course of HIV treatment, whether by forcing thousands of drug users into high-risk environments such as prisons and forced treatment centers or by penalizing such measures as possession of a clean syringe.

“While the world hails Thailand’s successes this week, we must also acknowledge the failures,” said Paisan Suwannawong of the Thai AIDS Treatment Action Group. “Long after the government began receiving global praise for the manufacture of generics, drug users were on the list of those who were not eligible. The government has now committed to treating 70,000 people on treatment by 2005, but there is a danger that injecting drug users will not gain from this program because they will be afraid that police will take them from the clinics.”

Speakers at the meeting and the report released by the Open Society Institute, offered a number of steps to increase drug user access to ARV, including


“There is evidence that treatment for drug users works,” said Dr. Kim.
“The question now is how to cure the discrimination that keeps them locked out of treatment.”


Copies of the Open Society Institute Report can be accessed at www.soros.org   (in English and Russian)

Contact:
Daniel Wolfe or Raminta Stuikyte (English) local mobile: 091154722
Sasha Levin (Russian) mobile: 067080059
Karyn Kaplan (Thai) mobile: 018661238


Availability of ARV For Injecting Drug Users: Key Facts

While exact figures are difficult to obtain, recent estimates suggest that there are over 13 million injecting drug users (IDUs) worldwide. More than ten million of these live in the developing world. While data in many regions is incomplete, the number of countries reporting HIV among injecting drug users has more than doubled in the past decade, from 52 in 1992 to 114 in 2003. Contaminated needles account for the largest share of new infections in China, Russia, Ukraine and the other European Newly Independent States, all the Baltic States, all of Central Asia, most of Southeast Asia, North Africa, Iran, Afghanistan, Pakistan, Nepal, Indonesia, Portugal, and the Southern Cone of Latin America. UNAIDS estimates that IDUs represent as many as 10 percent of annual global HIV infections, and one of every three new infections outside Africa. Individuals at greatest risk for HIV through injection include those already among society’s poorest and most marginalized: ethnic minorities, migrants, unemployed youth, and those exchanging sex for survival.

Extremely limited supplies of antiretroviral therapy (ARV), and the suggestion that drug users cannot comply with or benefit from ARV, have been used in many countries to justify longstanding restrictions on provision of HIV treatment to IDUs. Recent developments, including the formation of the Global Fund to Fight AIDS, TB, and Malaria, World Health Organization’s (WHO) “3 by 5” initiative, and the manufacture of generic ARV for as little as $300 a month, are expected to sharply increase availability of ARV worldwide. Greater commitment to ensuring that IDUs receive treatment has not yet been demonstrated. In spite of data showing that they receive the same benefits from treatment as other patients and achieve high levels of adherence when offered appropriate social and medical support, IDUs remain locked out of treatment even in countries where they are the vast majority of those infected.

IDUs are routinely excluded from ARV in industrialized countries

Excluded in North America

Excluded in Western Europe

IDUs are routinely excluded from ARV in countries where they are the vast majority of those infected with HIV

Excluded in Central and Eastern Europe and Central Asia (CEE/CA)

Excluded in Asia

Excluded—though less so—in Latin America and the Caribbean

Expert guidelines offer rhetorical support on ARV to IDUs, but little monitoring


For reference: Availability of ARV for Injecting Drug Users: Key Facts (2004). Coalition ARV4IDUs and www.soros.org   (in English and Russian)

This fact sheet was released at the XV International AIDS Conference by a coalition of the below listed organizations: Central and Eastern European Harm Reduction Network (CEE-HRN), International Harm Reduction Development Program of the Open Society Institute (IHRD/OSI), European AIDS Treatment Group (EATG), Gay Men’s Health Crisis, Thai Drug Users’ Network (TDN) and Thai AIDS Treatment Action Group (TTAG).


ARV For Injecting Drug Users: Key Facts on HIV Treatment Efficacy

Medical professionals and AIDS program administrators in many countries routinely exclude those who use illicit drugs from antiretroviral therapy (ARV), suggesting that drug users are less likely to adhere to treatment and less likely to experience virologic and immunologic response. Reluctance to offer ARV to drug users includes not only injecting drug users (IDUs), but also extends to those on medically prescribed opioid substitution treatment such as methadone, users of non-injecting drugs, and former drug users.

In the absence of randomized controlled trials, beliefs that drug users are non-compliant or untreatable are based as much on prejudice as on data. A number of studies—many of which offered drug users no services tailored to their needs —have shown mixed results on IDUs adherence and virologic response to ARV. A growing body of evidence, however, demonstrates that with proper supports IDUs can receive the same benefits from treatment as other patients, and achieve high levels of adherence.

ARV treatment is clearly effective for IDUs

While large, randomized controlled trials are needed, cohort studies show clear clinical benefits for IDUs on ARV.

A 1999 study of 6,645 patients from 51 centres across Europe receiving ARV found no significant difference between IDUs and non-drug users in CD4+ or virologic response.

A 2004 study of 1,522 patients in Vancouver, BC (Canada) found that drug users who adhered to ARV experienced the same increases in CD4+ count as adherent non-drug users.

In a 2004 study of clients of a mobile syringe exchange program in New Haven, CT (USA), 77% of drug users offered peer support along with ARV achieved reduction of viral load to less than 400 copies/ml and a 25% increase in CD4+ after six months.


IDUs demonstrate high levels of adherence to antiretroviral therapy

Even poor and homeless IDUs can adhere to ARV.

In a 2001 study of 673 mostly poor patients with HIV in Sao Paolo (Brazil), active drug use had no impact on ARV adherence in multivariate analysis. Overall adherence to ARV among participants was 69%.

In a 2001 study of 796 inner city patients in Baltimore, MD (USA), active users achieved levels of adherence of 66% without any special supports. Former drug users in the study demonstrated higher levels of adherence (83%) than those who had never used drugs (76%).

In a 2004 study among 72 HIV-infected clients of New Haven needle exchange site (USA), those receiving ARV together with peer support achieved adherence rates of 85% after six months. These rates were achieved even though 35% of the users in the study were homeless, and 74% were deeply depressed.

A 2000 study of 164 French ARV recipients found that those on buprenorphine achieved higher levels of adherence (78.1%) than either former drug users (65.5%) or active IDUs not on buprenorphine (42.1%). Higher adherence was reported even by those patients who continued to inject illicit drugs while receiving buprenorphine treatment.


A “one-stop shopping” approach sharply increases ARV treatment success and adherence among IDUs

Including as many health and social services as possible at a single site has been shown to improve both adherence and treatment outcomes for IDUs.

In a 2002 study of 39 patients offered ARV daily at a methadone clinic in Dublin (Ireland), 58% achieved optimal viral suppression (<50 copies/ml) in 48 weeks.

In a 2003 study, a Buenos Aires (Argentina) hospital program providing food, public transport, and access to ARV helped drug users to decrease the severity of their drug use and achieve the same levels of adherence as other patients of similar economic status.

Jumpstart, a program in New York (USA) serving large numbers of low-income drug users, offers intensive adherence education and support. In a 2003 study of 78 patients who had previously “failed” on ARV, 66% achieved undetectable viral load within one year and experienced CD4+ gains higher than a control group of patients starting ARV without such supports.

In a 2004 study among 286 patients in Baltimore, MD (USA), patients receiving ARV at their methadone clinic achieved viral suppression within six months at higher rates (58%) than non-drug users who were self administering ARV (39%).


International guidelines support provision of ARV to IDUs

WHO’s 2004 Protocols for HIV/AIDS Care state explicitly:

“Access to HIV treatment should not be artificially restricted due to political or social constraints. Specifically there should be no categorical exclusion of injection drug users from any level of care. All patients who meet eligibility criteria and want treatment should receive it, including IDUs, sex-business workers and other populations.”


Clinical data and review of best practices suggest four key principles for effective ARV treatment for IDUs

Key Principle 1: Care must be accessible

Key Principle 2: Care must be comprehensive

Key Principle 3: Care should be offered to patients at whatever level they are able to utilize

Key Principle 4: Outreach strategies are a vital component of HIV care


For reference: Availability of ARV for Injecting Drug Users: Key Facts (2004). Coalition ARV4IDUs and www.soros.org   (in English and Russian)

This fact sheet was released at the XV International AIDS Conference by a coalition of the below listed organizations: Central and Eastern European Harm Reduction Network (CEE-HRN), International Harm Reduction Development Program of the Open Society Institute (IHRD/OSI), European AIDS Treatment Group (EATG), Gay Men’s Health Crisis, Thai Drug Users’ Network (TDN) and Thai AIDS Treatment Action Group (TTAG).


 


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