Addressing injecting drug use in Asia and Eastern Europe

The global movement towards a public health approach to substance use disorders

Drug misuse is a global problem. Markets that supply illegal drugs often span international borders. However, each country has different primary drugs of use, populations that are using and consequences of use. The policy approach of each country to addressing substance use disorders can be characterized along a continuum between purely public health approaches and purely law enforcement approaches. Historically, a law enforcement approach has been the primary strategy in much of the world. However, there is a growing movement towards use of a public health approach. This article provides four case examples, Ukraine, Philippines, Nigeria and Peru, where there is movement to develop addiction public health infrastructure. The work varies by country, but includes regulatory changes, workforce development and resource allocation all of which are supported by the United Nations Office on Drugs and Crime (UNODC) and multi-national organizations that provide training and technical assistance, funded primarily by the European Union and United States governments. All four countries highlighted have barriers to moving towards a more public health approach which may include popularity of the law enforcement approach, turbulent government environments, and economics of being a drug producing nation. However, whether starting from the top down with changed policies, such as Ukraine or from the bottom up with training community members as in the Philippines, each country provides an example of how donor resources can be applied to make the transition towards a more humane and evidence-based approach to addressing substance use disorders.Key MessagesWhile the primary approach to addressing drug use has focussed resources on law enforcement for over 100 years, many countries are adopting elements of a public health approach including prevention and treatment of the harms of drug use including substance use disorders.There is a growing global movement to make policy towards drugs and drug users more humane and evidence-based.Donor nation resources can be applied in a variety of combinations to improve care and outcomes for people who use drugs in low- and middle-income countries.

The impact of Taiwan's implementation of a nationwide harm reduction program in 2006 on the use of various illicit drugs: trend analysis of first-time offenders from 2001 to 2017

Background

After implementing a nationwide harm reduction program in 2006, a dramatic decline in the incidence of human immunodeficiency virus (HIV) infection among people with injection drug use (IDU) was observed in Taiwan. The harm reduction program might have sent out the message discouraging the choice of IDU among illicit drug users in early stage. Based on the yearly first-time offense rates from 2001 to 2017, this study aimed to examine (1) whether the nationwide implementation of the harm reduction program in 2006 led to changes in first-time offenders’ use of heroin; (2) whether the intervention had a similar effect on the use of other illicit drugs; and (3) whether the effect of the intervention was limited to the first-time offenders of young age groups.

Methods

Yearly first-time illicit-drug offense rates from 2001 to 2017 in Taiwan were derived from two national databases for drug arrests that were verified using urine tests: the Criminal Record Processing System on Schedule I/II Drugs and the Administrative Penalty System for Schedule III/IV Substances. A hierarchy of mutually exclusive categories of drug uses was defined by the drug with the highest schedule level among those tested positive in an arrest. Segmented regression analyses of interrupted time series were used to test for the impact of the 2006 intervention.

Results

There was a decrease of 22.37 per 100,000 in the rate for heroin but no detectable level changes in that for methamphetamine or ecstasy after the 2006 intervention in Taiwan. There were baseline decreasing trends in the first-time offense rate from 2001 to 2017 for heroin and ecstasy and an increasing trend for methamphetamine, with the slopes not altered by the 2006 intervention. The postintervention decrease in the first-time offense rate for heroin was detectable among offenders less than 40 years old.

Conclusions

Our results indicate a diffusion effect of the 2006 intervention on decreasing heroin use among young offenders and have policy implications for better prevention and treatment for different age groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-021-00566-5.

Changes in quality of life and its associated factors among illicit drug users in Vietnamese mountainous provinces: a 12-month follow-up study

Background

Sustainability of methadone maintenance treatment (MMT) program involves regularly assessing its impact on health and social outcomes of drug users in different settings, particularly in disadvantaged areas. In this study, we evaluated the change in quality of life (QoL), and identified associated factors amongst drug users over the course of 12-month MMT in Vietnamese mountainous provinces.

Methods

We conducted a longitudinal study among patients from 6 MMT clinics in three mountainous provinces of Vietnam. At baseline, we screened 300 participants and after a 12-month treatment, 244 participants remained to involve in the study. World Health Organization Quality of Life short form instrument (WHOQOL-BREF) was used to measure the QoL of patients. The magnitude of the changes was extrapolated.

Results

There were significant changes in all four dimensions of quality of life measured by WHOQoL-BREF between baseline and 12 months with the effect size ranged from 0.21 to 0.24. Increased age, being workers compared to unemployment and having health problems or comorbidities were positively related to reduced scores of QoL.

Conclusions

To conclude, we observed a significant increase in the QoL level regarding physical, psychological, social relationships and environmental aspects among people who used drug after 12 months of MMT. Findings from this study emphasize the role of continuously receiving MMT treatment among people using drugs to enhance their QoL.

HIV, Drug Injection, and Harm Reduction Trends in Eastern Europe and Central Asia: Implications for International and Domestic Policy

PURPOSE OF REVIEW

Scaling up evidence-based HIV prevention strategies like opioid agonist therapies (OAT), syringe services programs (SSPs), and antiretroviral therapy (ART) to mitigate the harms of drug injection is crucial within Eastern Europe and Central Asia (EECA), the only region globally where HIV incidence and mortality are increasing.

RECENT FINDINGS

Though the proportion of new HIV cases directly attributable to drug injection has recently declined, it remains a critical driver of HIV, especially to sexual partners. Concurrently, scale-up of OAT, SSPs, and ART has remained low, contributing to a volatile HIV epidemic among people who inject drugs (PWID). Despite evidence that drug injection contributes to an evolving HIV epidemic in EECA, coverage of evidence-based harm reduction programs remains substantially below needed targets. Due to a combination of punitive drug laws, ideological resistance to OAT among clinicians and policymakers, and inadequate domestic and international funding, limited progress has been observed in increasing the availability of these programs.

Engagement in HIV care and its correlates among people who inject drugs in St Petersburg, Russian Federation and Kohtla-Järve, Estonia

BACKGROUND AND AIMS

HIV infection and mortality in Eastern Europe are driven by unsafe injection drug use. We sought to compare engagement in care from HIV testing through receipt of antiretroviral treatment among HIV-positive people who inject drugs (PWID) in St Petersburg, Russian Federation (RF) and Kohtla-Järve, Estonia and identify factors associated significantly with failure to progress at each stage of the HIV treatment cascade.

DESIGN

Cross-sectional biobehavioral surveys of PWID with an analysis stratified by location-two Russian-speaking regions with similar HIV epidemic histories and current prevalence.

SETTING

Field-based surveys conducted in St Petersburg, RF and Kohtla-Järve, Estonia.

PARTICIPANTS

We recruited 452 HIV-positive PWID in St Petersburg (November 2012 to June 2013) and 370 HIV-positive PWID in Kohtla-Järve (June-August 2012) using respondent-driven sampling.

MEASUREMENTS

Participants were tested for antibodies to HIV, and administered a questionnaire focusing on participants' medical care histories. Engagement in care was categorized as a cascade of five transitional steps through six stages, ranging from HIV testing to current receipt of antiretroviral medications.

FINDINGS

Progress along the cascade was greater in Kohtla Järve (32.7% were receiving antiretroviral medications) than in St Petersburg (9.7%). In both locations, we found the steps with high failure rates were the transitions from being aware of one's HIV diagnosis to being in regular care and initiation of highly active antiretroviral therapy (HAART). Factors associated significantly with transition failure in both locations and across steps included high alcohol consumption, variables associated with drug choice and injection frequency and lack of basic medical insurance.

CONCLUSION

The two steps in treatment cascade for HIV-positive PWID in St Petersburg, RF and Kohtla-Järve, Estonia requiring greatest improvement are retention in regular care and initiation of HAART. Both individual behavioral and structural factors are associated with failure to transition along the cascade.

Expanding co-payment for methadone maintenance services in Vietnam: the importance of addressing health and socioeconomic inequalities

BACKGROUND

Ensuring high enrollment while mobilizing resources through co-payment services is critical to the success of the methadone maintenance treatment (MMT) program in Vietnam. This study assessed the willingness of patients to pay (WTP) for different MMT services delivery models and determined its associated factors.

METHODS

A facility based survey was conducted among 1016 MMT patients (98.7% male, 42% aged 35 or less, and 67% living with spouse) in five MMT clinics in Hanoi and Nam Dinh province in 2013. Socioeconomic, HIV and health status, history of drug use and rehabilitation, and MMT experience were interviewed. WTP was assessed using contingent valuation method, including a set of double-bounded binary questions and a follow-up open-ended question. Point and interval data models were used to estimate maximum willingness to pay.

RESULTS

95.5% patients were willing to pay for MMT at the monthly mean price of US$ 32 (95%CI = 28-35). Higher WTP was associated with higher level of educational attainment, higher income, male sex, and had high expenses on opiates prior to MMT. Patients who reported having any problem in Pain/ Discomfort, and who did not have outpatient care last year were willing to pay less for MMT than others.

CONCLUSION

High level of WTP supports the co-payment policies as a strategy to mobilize resources for the MMT program in Vietnam. However, it is necessary to ensure equalities across patient groups by acknowledging socioeconomic status of different settings and providing financial supports for disadvantaged patients with severe health status.

Behavioral and quality-of-life outcomes in different service models for methadone maintenance treatment in Vietnam

BACKGROUND

Integrating HIV/AIDS and methadone maintenance treatment (MMT) services with existing health care delivery system is critical in sustaining efforts to fight HIV/AIDS in large injection-driven epidemics. However, efficiency of different integrative service models is unknown. This study assessed behavioral and health-related quality-of-life (HRQOL) outcomes of MMT in four service delivery models and explored factors associated with these outcomes of interest.

METHODS

A cross-sectional survey was conducted in two HIV epicenters in Vietnam: Hanoi and Nam Dinh Province. All patients in five selected MMT clinics were invited to participate, and 1016 were interviewed (80-90% response rate).

RESULTS

Respondents had a mean age of 35.8, taken MMT for average 16.5 months and 3.3% on MMT for 36-60 months. The MMT integrated with rural district health center (DHC) has the highest prevalence of concurrent drug use (11.3%). The percentage of condom use (last sexual intercourse) with primary and casual partners was lowest in the MMT at urban DHCs. Patients at the rural DHC reported very high proportions of pain/discomfort (37.8%), anxiety/depression (43.1%), and mobility (13.3%). In regression models, poorer HRQOL outcomes were found in MMT models in the rural areas or without general health care, and among those patients who were HIV positive, reported concurrent drug use, and had higher numbers of previous drug rehabilitation episodes. Mobility and anxiety/depression are factors that increased the likelihood of concurrent drug use among MMT patients.

CONCLUSIONS

Outcomes of MMT were diverse across different integrative service models. Policies on rapid expansion of the MMT program in Vietnam should also emphasize on the integration with comprehensive health care services including psychological supports for patients.

Reviewing harm reduction for people who inject drugs in Asia: the necessity for growth

BACKGROUND

There is an estimate of three to five million people who inject drugs living in Asia. Unsafe injecting drug use is a major driver of both the HIV and hepatitis C (HCV) epidemic in this region, and an increase in incidence among people who inject drugs continues. Although harm reduction is becoming increasingly accepted, a largely punitive policy remains firmly in place, undermining access to life-saving programmes. The aim of this study is to present an overview of key findings on harm reduction in Asia based on data collected for the Global State of Harm Reduction 2014.

METHODS

A review of international scientific and grey literature was undertaken between May and September 2014, including reports from multilateral agencies and international non-governmental organisations. A qualitative survey comprising open-ended questions was also administered to civil society, harm reduction networks, and organisations of people who use drugs to obtain national and regional information on key developments in harm reduction. Expert consultation from academics and key thinkers on HIV, drug use, and harm reduction was used to verify findings.

RESULTS

In 2014, 17 countries in Asia provide needle and syringe programmes (NSP) provision and 15 opioid substitution therapy (OST). It is estimated that between 60 and 90 % of people who use drugs in Asia have HCV; however, treatment still remains out of reach due to cost barriers. TB testing and treatment services are yet to be established for key populations, yet nearly 15 % of the global burden of new cases of HIV-TB co-infection are attributed to southeast Asia. Eighteen percent of the total number of people living with HIV eligible for antiretroviral treatment (ART) accessed treatment. Only Malaysia and Indonesia provide OST in prison, with no NSP provision in prisons in the region.

CONCLUSION

To reduce HIV and viral hepatitis risk among people who inject drugs, there is a necessity to significantly increase harm reduction service provision in Asia. Although there has been progress, work still needs to be done to ensure an appropriate and enabling environment. At present, people who inject drugs are extremely difficult to reach; structural and legal barriers to services must be reduced, integrated holistic services introduced, and further research undertaken.

Global epidemiology of HIV

The number of persons living with HIV worldwide reached approximately 35.3 million in 2012. Meanwhile, AIDS-related deaths and new HIV infections have declined. Much of the increase in HIV prevalence is from rapidly increasing numbers of people on antiretroviral treatment who are now living longer. There is regional variation in epidemiologic patterns, major modes of HIV transmission, and HIV program response. It is important to focus on HIV incidence, rather than prevalence, to provide information about HIV transmission patterns and populations at risk. Expanding HIV treatment will function as a preventive measure through decreasing horizontal and vertical transmission of HIV.

The cost-effectiveness of harm reduction

HIV prevalence worldwide among people who inject drugs (PWID) is around 19%. Harm reduction for PWID includes needle-syringe programs (NSPs) and opioid substitution therapy (OST) but often coupled with antiretroviral therapy (ART) for people living with HIV. Numerous studies have examined the effectiveness of each harm reduction strategy. This commentary discusses the evidence of effectiveness of the packages of harm reduction services and their cost-effectiveness with respect to HIV-related outcomes as well as estimate resources required to meet global and regional coverage targets. NSPs have been shown to be safe and very effective in reducing HIV transmission in diverse settings; there are many historical and very recent examples in diverse settings where the absence of, or reduction in, NSPs have resulted in exploding HIV epidemics compared to controlled epidemics with NSP implementation. NSPs are relatively inexpensive to implement and highly cost-effective according to commonly used willingness-to-pay thresholds. There is strong evidence that substitution therapy is effective, reducing the risk of HIV acquisition by 54% on average among PWID. OST is relatively expensive to implement when only HIV outcomes are considered; other societal benefits substantially improve the cost-effectiveness ratios to be highly favourable. Many studies have shown that ART is cost-effective for keeping people alive but there is only weak supportive, but growing evidence, of the additional effectiveness and cost-effectiveness of ART as prevention among PWID. Packages of combined harm reduction approaches are highly likely to be more effective and cost-effective than partial approaches. The coverage of harm reduction programs remains extremely low across the world. The total annual costs of scaling up each of the harm reduction strategies from current coverage levels, by region, to meet WHO guideline coverage targets are high with ART greatest, followed by OST and then NSPs. But scale-up of all three approaches is essential. These interventions can be cost-effective by most thresholds in the short-term and cost-saving in the long-term.

The global HIV epidemic: current status and challenges

Three decades after the first reported cases of AIDS we have within our reach sufficient evidence to substantially alter the HIV epidemic at a country level regardless of mode of transmission of HIV. There are a growing number of countries demonstrating control of the epidemic. Human rights violations and/or legislation relating to sexual orientation, status of minors, injecting drug use and sex work together with stigma and discrimination remain key barriers to knowledge of HIV status and access to appropriate services. The use of anti-retrovirals prophylactically to reduce sexual and vertical transmission and systemically to treat infected infants and adults is central to the optimism in responses to the epidemic. In the current fiscal climate careful thought needs to be given to how to efficiently optimise combinations of what is available to have the biggest impact in the context of limited human and infrastructure resources.

Antiretroviral therapy for prevention of HIV transmission: potential role for people who inject drugs in Central Asia

Interest in the use of antiretroviral therapy (ART) for prevention stems from mounting evidence from research studies demonstrating that ART is associated with a decrease in sexual HIV transmission among serodiscordant couples and, perhaps, in other populations at risk. There is paucity of data on the efficacy of ART for prevention in key populations, including persons who inject drugs (PWID). In this paper, we examine the current status of HIV services for PWID in Central Asia, the use of ART by this population and explore ART for prevention for PWID in this context. We also discuss research and implementation questions with relevance to such a strategy in the region.