Diapositive 1

1
Challenges and opportunities for providing ARVs
to IDUs and promoting adherence

Bruno Spire, INSERM U912 AIDES, France
2
Background

• HAART scale up is progressing worldwide, but IDUs
  are the most excluded from HIV care
• In Eastern European and Central Asia, IDUs
  account for more than 80 of HIV cases, but only
  14 of them are receiving HAART.
• In South and South-East Asia, IDUs account for
  more than 20 of HIV cases in 5 countries, but
  only 1.8 of them are receiving HAART.
• Structural and individual barriers to access can
  be identified

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Structural barriers of access to HAART for IDUs

• Providers perceptions about patients adherence
• Guidelines for treatment provision
• Lack of entry points for comprehensive care
• Criminalisation of drug use
• Lack of acknowledgeable civil society in the
  field of HIV or drug use

4
Individual barriers of access to HAART and
continuity of care for IDUs

• Social vulnerability
• Psychiatric co-morbidity
• Ongoing drug use
• Depression
• Fear of experience with side-effects

Role of sustained adherence to assure HAART
efficacy
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Impact of non-adherence on HIV clinical
progression (MANIF 2000 cohort, n 243 IDUs
receiving HAART)
1.00
Adherent patients
0.75
Non-adherent patients

0.50
0.25

• BOUHNIK 2005

Time (months)
0.00
0
20
40
60
80
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Specific risk factors for reduced adherence in
IDUs

• Ongoing drug injection is consistently associated
  with non adherence
• Elevated alcohol consumption and cocaine use
  predict non adherence behaviours
• In individuals who have given up injection,
  social vulnerability is the major predictor of
  non-adherence
• Prevalence of depression is high among drug users
  and represents an additional barrier to adherence

• BOUHNIK 2004, PALEPU 2004, STEIN 2000

• LUCAS 2002, PALEPU 2004, ARNSTEN 2002

• BOUHNIK 2004, PALEPU 2004, STEIN 2000

• TURNER 2003, KLEEBERGER 2004

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Methadone and adherence

• Methadone is effective in reducing injection
• Regular participation in Methadone programs is
  associated with uptake of and adherence to HAART
• Non adherence to HAART in methadone patients is
  comparable to adherence to other chronic
  therapies
• When methadone can reduce drug use, it can assure
  high adherence to HAART and good HAART outcomes
• Directly administered Methadone can assure
  sustained adherence

• MATTICK 2002, 2003, 2004

• SAMBARNOOTHI 2000

• STEIN 2000

• PALEPU 2006

• LUCAS 2004, TYNDALL 2007

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Buprenorphine and adherence

• Buprenorphine is as effective as methadone in
  reducing injection
• Buprenorphine has no negative impact on
  virological response
• Adherence to HAART in buprenorphine patients is
  comparable to adherence in abstinent patients
• Methadone and buprenorphine can both assure
  adherence to HAART in stabilized patients

• MATTICK 2002, 2003, 2004

• CARRIERI 2000

• MOATTI 2000

• ROUX 2008

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Interventions for structural barriers to access

• Training of physicians involved in care for HIV
  and IDUs using international guidelines
• Staff and services need to be user-friendly,
  non-judgmental, and knowledgeable about IDU,
  HIV/AIDS, and related clinical issues
• Need for integrating treatment for HIV, drug
  dependence, psychiatric comorbidity, social
  services and medical treatment (one-site model
  when possible)

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Interventions for individuals barriers to access
and adherence in IDUs

• The importance of co-treating depression to
  enhance adherence
• Management of self-reported side effects and pain
• Adherence counselling possible involvement of
  peers and family for support
• DOT can enhance adherence but can limit social
  rehabilitation and foster stigmatisation
  (prisons)

• YUN 2005

• CARRIERI 2007

• BROADHEAD 2002

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Role of OST

• OST can reinforce patients social support
  networks and increase social stabilisation and
  access to care
• The need to control withdrawal symptoms by OST
  can facilitate a routine approach that can be
  applied to HAART intake
• OST makes HAART more acceptable as OST is already
  a long term treatment
• OST may reduce stigma against IDUs

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Conclusions

• Access to HAART cannot be advocated without
  access to OST
• Respect of human rights and equity of access
  principles should be integrated in public health
  policies
• It is important to identify the most appropriate
  model of care for delivering OST and HAART
• Doing with IDUs and not for IDUs