A TIME FOR URGENT ACTION:
Responding to the HIV Epidemic Among People Who Inject Drugs in Cebu City Advocacy Briefing Paper
NCDPC NEC
Explosive HIV among People Who Inject Drugs The Philippines is currently one of nine countries where more than 25% increase in new HIV infections are reported in 2011 than in 2001 (Global AIDS Report 2012). The rapid spread of HIV infections is primarily due to the sharing of contaminated needles and syringes among people who inject drugs (PWID) and unprotected sex among men who have sex with men (MSM). An explosive HIV epidemic among PWID exists in Cebu City. In 2008 HIV transmission was primarily due to sexual contact (90%), but by 2012 it was injecting drug use (77%). The 2011 biological and behavioural surveillance in Cebu City reported HIV prevalence among PWID to be 54%, with Hepatitis C prevalence reaching 94%. The same study found 15% of freelance female sex workers had injected drugs and among male injectors 24% reported same sex behaviours. There are an estimated 6000 PWID in metro Cebu, with 2000 - 2500 PWID in Cebu City, of which the majority share their injecting equipment; many are sexually active, resulting in spread of HIV to their non-injecting wives/ partners and then possibly to their babies. The current public health crisis requires an urgent and well coordinated response.
Current response Currently the City Health Office (CHO) operates a facility-based health service targeted towards PWID. However, fewer than 30 clients per week are receiving regular services. While some health needs of PWID are addressed, the most critical need of clean needles and syringes is not. Additionally the fear of police among PWID hampers the supportive environment required to encourage larger numbers of PWID to seek services. Among PWID that are found to be HIV-infected, the vast majority are either lost to follow up or do not remain adherent to HIV treatment with the consequence of further medical complications and drug resistance. The current disconnect between services and the majority of PWID contributes to the ongoing spread of HIV transmission.
HIV Prevalence among PWID in the Philippines
60% 50% 40% HIV Prevalence 53.82%
Cebu Mandaue General Santos
30% 20% 10% 0% 3.59% 0.83% 0.40% 0.59% 0.30%
2005
2007 Year
2009
2011
Source: IHBSS 2005, 2007, 2009, 2011 of 10 Sentinel Sites
Seeking Solutions – lessons from other Asian countries Many countries have experienced similar explosive HIV epidemics among PWID as currently found in Cebu City. In Asia, the initial response was to maintain a criminalized approach towards drug use. However, research found people continued to use drugs irrespective of criminal laws, and the HIV epidemic became worse. The health needs of PWID were poorly understood and the HIV risks were not effectively addressed before implementation of harm reduction interventions. Over time pilot studies on needle and syringe programmes and other interventions, accompanied by robust monitoring and evaluation to measure impact of intervention effectiveness within an Asian setting, became popular. As compelling evidence of effectiveness emerged from the piloted interventions, governments throughout Asia shifted their response and policies towards adopting evidence based interventions that reduce the harmful consequences of drug use among PWID. The concept of harm reduction and associated interventions, are endorsed by the World Health Organization, the Joint United Nations Programme on HIV/AIDS, the United Nations Office on Drugs and Crime, the United Nations General Assembly and various other eminent institutions. Most of the nine interventions within the Comprehensive Package for the prevention, treatment and care of HIV among PWID are implemented, to various degrees, in majority of Asian countries and territories: Afghanistan, Bangladesh, Cambodia, China, India, Indonesia, the Lao People’s Democratic Republic, Malaysia, Myanmar, Taiwan (China), Thailand and Viet Nam. Each Asian country introducing interventions to assist and strengthen the health sector response to HIV among PWID have only experienced a scale up and never scaling down of interventions.
Solutions Specific for Cebu City Improve quality of life and reduce death among HIV-infected PWID Currently many PWID are HIV-infected and few receive or remain adherent to antiretroviral therapy (ART) medicines. International research shows that in a supportive environment PWID can successfully undergo treatment and benefit from ART. Evidence is building that ART can also play a role in HIV prevention, lowering viral load and reducing HIV transmission. PWID need to be encouraged, but not coerced, to undertake HIV counselling and testing (HCT) as PWID are often not aware that they may be HIV-infected. HCT is an important gateway to HIV treatment and care and also offers people living with HIV an opportunity to receive information and adopt safer behaviours to prevent them from transmitting HIV to others. It is important that wherever HIV testing is performed there are clear and robust links to HIV treatment, care and support as these linkages are an important determinant of successful treatment of PWID. Poor linkages impede effective and timely uptake of care and ART.
Reduce spread of new HIV infections, and hepatitis among PWID Distributing clean injecting equipment to PWID facilitates the use of new needles and syringes (N/S) and reduces the number of injections with HIV and hepatitis B- and C-contaminated N/S. There is compelling evidence that increasing the availability and utilization of clean injecting equipment contributes substantially to reductions in the rate of HIV transmission . Transmission of hepatitis C is also closely associated with other injecting equipment (spoons or drug ampoule). Thus, additional education is required. Some people believe needle and syringe programmes (NSP) encourage the uptake of drug use and injecting of drugs. However, there is no convincing evidence of major unintended negative consequences of NSP such as initiation of injecting among people who have not injected previously, or an increase in injecting. NSP serves as a contact with a health service, can facilitate access to drug treatment and is strongly shown to be cost effective. NSP are found in most Asian countries and scaled up at multiple sites. Moreover, considering the existence of sex partners of male PWID who are also infected and becoming pregnant, the prevention of sexual transmission of HIV by promoting condom use and encouraging partner notification, as well as prevention of mother-to-child transmission should be included as part of the comprehensive prevention package for PWID.
Create supportive environment for service delivery Many believe drug dependency is due to lack of will power or moral weakness. But this is not the case as drug dependency is recognised by the World Health Organization as a complex medical condition with chronic and relapsing behavioural disorder tendency with a mix of biological, sociological and psychological components. Most PWID are commonly misunderstood and remain fearful of seeking a health service or managing safer behaviours when they are discriminated against, judged and stigmatized in what is commonly a hostile environment. A more supportive environment where a more public health approach is adopted and encouraged, including support by law enforcement, would improve accessibility, availability and delivery of services to PWID resulting in better individual health outcomes as well as public health benefits.
Improve linkages between services and PWID As drug use is a highly stigmatized illegal activity many drug users find it difficult to approach traditional medical and social services for basic care and assistance. Evidence shows that outreach workers and peer educators are highly effective means of delivering various HIV prevention interventions and can play a critical role in linking and accompanying PWID with referrals to other social and health services such as HIV testing and counselling, STI assessment, antiretroviral therapy, drug rehabilitation or tuberculosis assessment, etc. Outreach is a modality for delivering a variety of services rather than a service per se. Outreach is an essential component of all HIV prevention and care programmes for PWID.
Advocacy and building local capacity to act effectively The scale of the HIV epidemic requires a coordinated response with ongoing advocacy, education, training opportunities and capacity building. Efforts will not be primarily just focused on health sector workers - though this is a sector that mainly addresses various adverse health consequences related to drug use. Other sectors such as law enforcement will be closely engaged. All sectors need to understand the situation of drug use, HIV and associated issues so they can contribute positively towards reduction of HIV among PWID. Only through a collective and pro-active effort by all the key stakeholders can the current HIV epidemic among PWID be effectively addressed.
Time to take action The need to prevent and control further spread of HIV and reduce AIDS-related deaths among PWID is more important than ever. Of critical importance is to implement a pilot intervention among PWID in a selected area of Cebu City. This intervention would facilitate the implementation of a comprehensive package of health services for PWID found in this briefing paper. The time has come to be guided by scientific evidence that would surely improve the public health response and best address the multiple harms associated with injecting drug use.
1 Harm reduction refers to policies, programmes and practices that aim to reduce the harms associated with the use of psychoactive drugs in people unable or unwilling to stop. Harm reduction compliments approaches that seek to prevent or reduce the overall level of drug consumption, and reduce HIV infections 2 A Comprehensive Package of interventions for prevention, treatment and care of HIV among PWID includes: Needle and syringe programmes; Opoid substitution therapy and other evidence based drug dependence treatment; HIV testing and counseling; Antiretroviral therapy; Prevention and treatment of STIs; Condom programmes for PWID and their sexual partners; targeted Information Education and Communication for PWID and their sexual partners; Prevention, vaccination, diagnosis and treatment of, viral hepatitis; prevention, diagnosis and treatment of TB. 3 4
Hurley SF, Jolley DJ, Kaldor JM. Effectiveness of needle-exchange programmes for prevention of HIV infection. Lancet 1997; 349(9068):1797-800. WHO, UNAIDS, UNODC. 2004. Policy Brief: Provision of Sterile Injecting Equipment to reduce HIV transmission. WHO, Geneva, Switzerland
This advocacy brief paper was jointly prepared by The Philippines Department of Health, Philippines Cebu City Health Department and the World health Organization Western Pacific Regional Office. For further information, please contact the following: • Dr Ilya Abellanosa-Tac-an Head of Social Hygiene Clinic The Philippines Cebu City Health Department Email: ilya91663@yahoo.com • Dr Gerard Belimac Programme Manager National AIDS STI Prevention and Control Programme The Philippines Department of Health Email: naspcp@yahoo.com • Dr Zhao Pengfei Technical Officer WHO Western Pacific Regional Office Email: zhaop@wpro.who.int