How can we tailor the delivery
of the TB/HIV package to IDU?
David H.-U. Haerry
European AIDS Treatment Group
(European Community Advisory Board,
Policy Working Group)
Eastern Europe & Central Asia
 1,4 million HIV infected by end of 2004.
 490’000 women, 210’000 new infections &
60’000 deaths in 2004.
Ukraine
 Exponential increase of epidemic since
2000 (+7%) – 2002 (+25%).
 In 2003, 30% of new infections heterosexual
transmission (within IDU subpopulation).
 10 – 15% of TB cases in Ukraine MDR.
 TB leading cause of death among PWAs,
50% of AIDS-related deaths are due to TB.
 45’000 patients in need of ARV, 1500
treated (GFATM component).
Russia
 70% of all HIV infections registered in Eastern
Europe/Central Asia.
 Estimated 860’000 PWHAs in Russia, 80% aged
15 – 29, >1/3 women (Dec. 2003).
 1.5 – 3 million Russian IDUs (1 – 2% of
population), 30 – 40% use non sterile syringes.
 In 2004, 80% of reported HIV cases among IDU.
 70% sexually active.
 Sharp increase of pregnant women with HIV.
Latvia, Estonia, Lithuania
 Latvia: 5-fold increase 1999 – 2002 (2300).
 Estonia: 1999 12 new cases, 2003: 840.
 Lithuania: 2001 72 new cases, 2002
increase more than 5-fold.
Infections mostly due to injecting drug use,
sexual transmission is gaining ground.
Eastern Europe / Central Asia
 90% of HIV cases caused by injecting drug use.
 <1% of HIV-positive IDUs have access to ARV treatment
(or medical care in general).
 TB patients are 10 times more likely to have MDR-TB than
in the rest of the world.
 Estonia, Kazakhstan, Latvia, Lithuania, Russia and
Uzbekistan: MDR up to 14%.
 79% of MDR-TB cases are "super strains", resistant to at
least three of the four main drugs used to cure TB.
 Kaliningrad: highest documented HIV prevalence within
Russia. 70 – 80% of HIV-infected IDUs have had hepatitis
C exposure.
Treatment access in the region
 11% of patients in need of ARV are getting
treatment.
 Due to legal restrictions &
discrimination, HIV-positive IDUs have
limited or no access to treatment.
Problems we are facing
 Conflict healthcare priorities - current drug
policy.
 Double-stigma in society.
 Discrimination in medical institutions.
 Fear of police harassment.
 Unwillingness of medical infrastructure to
meet the demands of this patient group.
Main barriers for equal access to
HAART
 No political commitment to meet the requirements of the
epidemic.
 Repressive drug policies supersede the principles of public
health.
 High prices for ARV and diagnostic equipment.
 No national protocols on HIV treatment and care that meet
international standards focusing IDU patients.
 Vertical and centralised AIDS-service infrastructure.
 Illegal substitution treatment programmes (Russia).
 Limited number of ST programmes.
 Limited NGO involvement into HIV care and treatment.
 Stigma and discrimination within medical institutions.
Ukraine – assessment on TB
treatment in IDUs
Artur Ovsepyan, All-Ukrainian Network of PWHAs, 2005
 AIDS-centres, TB hospitals and drug-addiction clinics in 13 regions of
Ukraine.
 40 medical institutions assessed.
 14 have access to opiate analgetics.
 13 have license for storage and prescription of opiate medications,
2 are planning to obtain license.
 2 medical institutions prescribe buprenorphine for ST – Kherson and
Odessa drug addiction clinics.
 16 patients received ST with buprenorphine in 2004.
 2540 patients have interrupted TB treatment because of drugaddiction (expelled from hospital because of drug-use).
 420 TB patients with HIV co-infection that have interrupted TB
treatment because of drug-use.
Conclusions
(based on assessment)
 TB and AIDS-service infrastructure are
desintegrated and parallel in Ukraine.
 TB and HIV services do not have legal or
administrative authority to ensure access to
opiates as part of palliative care and ST.
 Clear evidence: most IDU patients cannot receive
appropriate TB care without access to ST.
 Urgent need to overcome these barriers
a) to provide required medical care for IDUs
b) to overcome of TB/HIV epidemic.
Brazil
 São Paolo: epicenter of injection-driven epidemic, 50% of
all HIV cases in Brazil.
 Assessment has shown that 69% of all people on
treatment successfully followed treatment procedures.
 Decentralized and widely available “user-friendly” network
of clinics (up to 300 day clinics across the country).
 Development of a harm reduction strategy on national
scale.
 Effective integration of harm reduction projects in care
programs (incl. hepatitis vaccination etc).
 Creation of a national drug-user organisation with strong
support of health professionals and local authorities.
Key factor of Brazilian success
 Government commitment to provide
universal and equal access to treatment
as part of the overall strategy to fight HIV
in the country.
Recommendation:
Need of a comprehensive care programme,
including
 TB treatment & prevention – isoniacid?
 Hepatitis treatment & prevention.
 HIV/AIDS treatment & prevention.
 Effective harm reduction & substitution
programmes, including prison settings.
 Access to safe conception methods.
Requirements
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
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Support community-based advocacy, education and mobilisation.
Promote international care standards for HIV-TB-Hepatitis co-infection.
Promote reference centres for integrated HIV-TB-Hepatitis care.
Promote substitution programmes as integrated part of the TB/HIV
service kit for IDUs (one stop shopping model).
 Perform ARV/TB/hepatitis drugs – street drug interaction studies.
 Coordinate ARV-TB-hepatitis drug provision at affordable prices; plan
first-, second-line and salvage regimens.
 Invest in training: health care professionals & patient organisations.
Conclusions
 IDUs must be identified as a special
category of patients with specific needs.
 Interaction studies in ARV/TB/Hepatitis
treatment – street drug must be performed.
 ST access in TB / HIV medical services is a
cornerstone of effective HAART and TB
treatment for IDUs and a vital factor for
overcoming the TB/HIV epidemic in the CIS
region.