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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”


Opioid Substitution Therapy: The missing link to curbing HIV in Eastern Europe and Central Asia

By Julio Montaner, President, and Craig McClure, Executive Director, International AIDS Society (IAS)

Achieving universal access to HIV prevention, treatment and care by 2010 in Eastern Europe and Central Asia (EECA) will not be possible without dramatically expanding access to opioid substitution therapy (OST).

An estimated 3.7 million people in EECA inject drugs, the vast majority of whom are dependent on heroin or related opioid drugs. This is close to four times higher than the overall prevalence of injecting drug use (IDU) worldwide. [1] Sixty-two percent of the HIV epidemic in this region is attributable to injecting drug use; over 35% of HIV positive women were infected through sharing of contaminated injecting equipment; and another 50% of women living with HIV were infected via unprotected sex with an infected IDU.[2]

OST, using methadone or buprenorphine, has been endorsed by WHO, UNAIDS, UNODC, The Global Fund, and countless researchers and health care professionals as one of the most effective interventions for the treatment of opioid dependence.[3,4,5,6] OST leads to substantial cost savings in health care and criminal justice. Research also demonstrates that OST enhances HIV-related prevention, care and treatment, as well as IDUs’ contact with the primary health care system. To date, methadone is one of the few treatment interventions for IDU which has shown efficacy for prevention of HIV infection in controlled trials. [7,8,9,10] .

Misuse of methadone and/or buprenorphine poses some challenges, including the potential for illegal diversion of these medicines to the black market which can lead to illicit, use and compromise public acceptance of OST programmes [11].  However, these challenges are overblown by critics of OST and can be addressed by strengthening support and supervision of OST patients and securing the supply of these medicines. [12]

OST is a vital tool in the response to the public health problems posed by both HIV and IDU. Without it, IDUs are more likely to be tested late and delay care, with resultant increases in morbidity and mortality.[5,13,14] Despite such overwhelming evidence, as of 2007, less than 2 percent of IDUs in EECA countries with injection-driven HIV epidemics had access to OST.[14,15]

While important progress has recently been made in introducing OST together with other harm reduction interventions through Global Fund and government-funded pilot projects in a number of countries in the region, coverage remains woefully inadequate. [16,17] OST programmes exist largely as perpetual pilot initiatives, with the numbers of IDUs participating remaining stable or increasing very slowly. [14,15,18] In Russia, a country with over 1.8 million IDUs and an epidemic that is overwhelmingly due to injecting drug use, methadone remains illegal. [1,14,15] The continued polarization of the issue across societies in the region has hampered efforts to introduce OST.

From 17-18 October 2008, the IAS convened a meeting of 25 senior narcologists, psychiatrists and infectious disease specialists from across EECA in Yalta, Ukraine. These experts, whose work focuses on injecting drug use and HIV, reviewed the current state of HIV among IDUs in the region, the body of evidence supporting the use of OST and country experiences with this intervention. In addition, the significant challenges and opportunities for expanding access to OST were discussed.

Based on this review, the IAS has identified the following obstacles to the adequate scale up of OST in EECA:

·         Stigma against drug dependence trumps science. A serious chasm exists between the scientific evidence on OST and the views and actions towards OST among policy makers, law enforcement authorities, the medical community and the general public. [14,15,17]

·         Knowledge and awareness of the evidence is severely lacking in the region.  There is a virtual absence of reliable information in Russian and other languages spoken in EECA regarding research, policy and programme development of OST. [19]

·         Burdensome law enforcement regulations and criminal justice strategies undermine IDU participation in programmes where they exist. Inconsistent criteria for entry into treatment, varying standards of care, and policies such as those requiring the involvement of multiple specialists to authorize initiation of treatment, or those forbidding take home doses of medication further undermine efforts to reach more IDUs. [14,15,16,18] Where OST has worked, high level political support has been critical. [14,17]

·         Unanswered research questions further hamper scale up. Some research gaps, including estimating IDU populations and defining adequate levels of coverage required to curb injection-driven HIV epidemics in EECA, are hampering efforts to set targets and measure progress. [17,19]

A massive effort in EECA to rapidly scale-up OST is urgently needed to improve HIV-related and other public health outcomes associated with opioid drug injection. Action on the part of all stakeholders in the region is needed, including researchers and other health professionals, parliamentarians, policy makers and civil society, for the swift removal of legal and policy barriers to OST.  The alternative will be the tragic loss of hundreds of thousands, if not millions, of young lives. In a region with rapidly falling population levels, supporting all young people to reach adulthood and lead productive lives is essential, including those who have fallen victim to a devastating health condition – dependence on illicit drugs.



References:

1. Mathers B.M. et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. The Lancet (online edition) September 24, 2008.

2. UNAIDS. 2008 Report on the Global AIDS Epidemic. July 2008.

3. Michels II, Stover H, Gerlach R. Review: Substitution treatment for opioid addicts in Germany. Harm Reduction Journal 2007; 4.

4. Donaher PA and Welsh C. Managing Opioid Addiction with Buprenorphine. American Family Physician 2006; 73: 1573.

5. Wodak A and McLeod L. The role of harm reduction in controlling HIV among injecting drug users. AIDS 2008; 22 (suppl 2):S81–S92.

6. WHO/UNODC/UNAIDS. Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention. Position Paper. 2004. (accessed September 2008).

7. Institute of Medicine. Preventing HIV Infection among Injecting Drug Users in High Risk Countries: an Assessment of the Evidence. Institute of Medicine of the National Academies (2006) Washington DC: The National Academic Press.

8. Farrel M, Gowing L, Marsden J, Ling W, Ali R. Effectiveness of drug dependence treatment in HIV prevention. Int J Drug Policy 2005; 16: 67-75.

9. Spire B, Lucas G.M, Carrieri M.P. Adherence to HIV treatment among IDUs and the role of opioid substitution treatment (OST). Int J Drug Policy 2007; 18: 262-270.

10. Lert F and Kazatchkine M.D. Antiretroviral HIV treatment and care for injecting drug users: An evidence-based overview. Int J Drug Policy 2007; 18: 255-261.

11. Varenbut M. et al. Tampering by office-based methadone maintenance patients with methadone take home privileges: a pilot study. Harm Reduction Journal 2007; 4: 15.

12. Bell J. The Role of Supervision of Dosing in Opioid Maintenance Treatment; Background document prepared for third meeting of technical development group (TDG) for the WHO “Guidelines for Psychosocially Assisted Pharmacotherapy of Opioid Dependence”. London: National Addiction Centre, 2007. (accessed November 2008)

13. WHO. Effectiveness of Drug Dependence Treatment in Prevention of HIV Among Injecting Drug Users. Evidence for action technical papers. 2005. (accessed September 2008).

14. WHO Europe. Progress on Implementing the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia. 2008.

15. Harm Reduction Developments: 2008 Countries with Injection-driven HIV Epidemics. International Harm Reduction Development Program (IHRD) Open Society Institute, 2008.

16. Bruce R.D, Dvoryak, S, Sylla L, Frederick L.A. HIV treatment access and scale-up for delivery of opiate substitution therapy with buprenorphine for IDUs in Ukraine—programme description and policy implications. Int J Drug Policy 2007; 18: 326-328.

17. Sarang A, Stuikyte R, Bykov R. Implementation of harm reduction in Central and Eastern Europe and Central Asia. Int J Drug Policy 2007; 18: 129-135.

18. Barriers to Access: Medication-Assisted Treatment and Injection-Driven HIV Epidemics. International Harm Reduction Development Program (IHRD) Open Society Institute, 2008.

19. Donoghoe M.C. et al. Setting targets for universal access to HIV prevention, treatment and care for injecting drug users (IDUs): Towards consensus and improved guidance. International Journal of Drug Policy, April 2008.

Authors, Julio Montaner and Craig McClure, confirm the following: We agree that we have seen and approved the final version of this text, and that we have no conflicts of interest to declare in this regard.

This paper was written by Jacqueline Bataringaya (IAS Policy and Advocacy Coordinator) and edited by Regina Aragon (IAS Communications Consultant). It has been approved for submission to the Lancet, in this form, by the declared authors, Julio Montaner and Craig McClure.