Participant Manual
Module 2
Comprehensive Services for Injecting Drug Users Treatment and Care for HIV-Positive Injecting Drug Users
Regional Office for South-East Asia
Family Health International
Module 2
Comprehensive services for injecting drug users
Participant Manual
2007
The Association of Southeast Asian Nations (ASEAN) was established on 8 August 1967. The Member States of theAssociation are Brunei Darussalam, Cambodia, Indonesia, Lao PDR, Malaysia, Myanmar, Philippines, Singapore, Thailand and Viet Nam. The ASEAN Secretariat is based in Jakarta, Indonesia. For inquiries, contact The Public Affairs Office, The ASEAN Secretariat, 70A Jalan Sisingamangaraja, Jakarta 12110, Indonesia, Phone: (62 21) 724-3372, 726-2991, Fax: (62 21) 739-8234, 724-3504. E-mail: public@aseansec.org. General information on ASEAN appears on-line at the ASEAN Website: www.aseansec.org. Catalogue-in-Publication Data Treatment and Care for HIV-Positive Injecting Drug Users Jakarta: ASEAN Secretariat, December 2007 616.9792 1. ASEAN – USAID 2. HIV – Drugs – Modules ISBN 978-979-3496-63-4 (NLM classification: 503.6)
This publication is available on the internet at www.aseansec.org, www.fhi.org and www.searo.who.int/hiv-aids publications. Copies may be requested from: The ASEAN Secretariat, 70A, Jl. Sisingamangaraja, Jakarta 12110, Indonesia. e-mail: public@aseansec.org and Family Health International, Asia/Pacific Regional Office, 19th Floor, Tower 3, Sindhorn Building, 130–132 Wireless Road, Lumpini, Phatumwan, Bangkok 10330, Thailand, e-mail: sunee@fhibkk.org and HIV Unit, Department of Communicable Diseases, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi-110 002, India, e-mail: hiv@searo.who.int Module 1: Drug use and HIV in Asia: participant manual Module 3: Initial patient assessment – participant manual Module 4: Managing opioid dependence – participant manual Module 5: Managing non-opioid drug dependence – participant manual Module 6: Managing ART in injecting drug users – participant manual Module 7: Adherence counselling for injecting drug users – participant manual Module 8: Drug interactions – participant manual Module 9: Management of coinfections in HIV-positive injecting drug users – participant manual Module 10: Managing pain in HIV-infected injecting drug users – participant manual Module 11: Psychiatric illness, psychosocial care and sexual health – participant manual Module 12: Continuing medical education – participant manual Trainer manual: Treatment and care for HIV-positive injecting drug users © ASEAN Secretariat 2007
All rights reserved. The text of this publication may be freely quoted or reprinted with proper acknowledgment.
Typesetting and Design: Macro Graphics Pvt. Ltd. Printed in India
Contents Abbreviations and acronyms.......................................................................................................................................iv Sub-module 2.1: Comprehensive services and continuity of care for IDUs.................................................1 Overview................................................................................................................................................................................ 1 Exercise 2.1: Small group discussion ........................................................................................................................... 2
Sub-module 2.2: Services for IDUs in closed settings...........................................................................................3 Overview................................................................................................................................................................................ 3 HIV transmission in closed settings.............................................................................................................................. 4 Drug dependence treatment in closed settings .................................................................................................... 6 HIV testing in closed settings (ethics, confidentiality, risks) ............................................................................... 7 ART for IDUs in closed settings...................................................................................................................................... 7 Adherence............................................................................................................................................................................. 9 HIV and TB in closed settings........................................................................................................................................13 Discharge/release programmes .................................................................................................................................13 Prison staff . ........................................................................................................................................................................14 References and recommended reading...................................................................................................................16 Exercise 2.2: Case studies...............................................................................................................................................17
Annex 1: PowerPoint presentation 2.1: Comprehensive services and continuity of care for IDUs........20 Annex 2: PowerPoint presentation 2.2: Services for IDUs in closed settings............................................. 26
Abbreviations and acronyms AIDS ART ARV ASEAN CBO CDC DOT FBO FDC FHI HBV HCV HCW HIV IDU KOP MOU NGO NNRTI NSP OI OST PEP PI SAT TB USAID VCT WHO acquired immunodeficiency syndrome antiretroviral therapy antiretroviral Association of Southeast Asian Nations community-based organization Centers for Disease Control and Prevention (US Government) directly observed treatment faith-based organization fixed-dose combination Family Health International hepatitis B virus hepatitis C virus health-care worker human immunodeficiency virus injecting drug user keep on person memorandum of understanding nongovernmental organization non-nucleoside reverse transcriptase inhibitor needle and syringe programme opportunistic infection opioid substitution therapy post-exposure prophylaxis protease inhibitor self-administered treatment tuberculosis United States Agency for International Development voluntary counselling and testing World Health Organization
PLWHA people living with HIV and AIDS
Sub-module
2.1 Overview
Comprehensive services and continuity of care for IDUs
F
Objectives: By the end of the session participants will be able to describe the elements of a comprehensive package of services for IDUs including: HIV prevention services for IDUs including outreach and needle and syringe programmes Drug dependence treatment programmes including opioid substitution therapy (OST) Clinical services for IDUs, including primary health care, testing and counselling Care and treatment for HIV-positive IDUs, including management of co-morbidities, ART Removing barriers that IDUs face in accessing care, treatment and support services Continuity of care Time to complete session: 1 hour 30 minutes
º
Session content: Why is a continuum of services needed for IDUs? Defining the essential package – what are the services needed in the continuum? Models of service delivery in Asia – examples from the region “One-stop shopping” – what is it and why is it recommended? Advantages and challenges to delivering “one-stop shopping” Staff training and management issues in the delivery of comprehensive services for IDUs Other strategies for comprehensive service provision Training materials:
4
PowerPoint presentation 2.1: Comprehensive services and continuity of care for IDUs
Comprehensive services for injecting drug users
Exercise 2.1 Small group discussion Group 1 Your group has 20 minutes to write down in bullet points: What difficulties do HIV-positive IDUs in your community face in gaining access to HIV prevention, care and treatment services? Was anything done to resolve this problem and, if so, what was done? A representative from the group speaks to the class about their findings (5 minutes). Group 2 Your group has 20 minutes to: Examine the “model” list of service delivery for HIV-positive IDUs. Write down which areas are being poorly addressed. Select a couple of these areas and suggest practical ways of improving services. A representative from the group speaks to the class about their findings (5 minutes).
Participant Manual
2.2 Services for IDUs in closed settings Overview
F º
Objectives: By the end of the session participants will be able: To describe the importance of providing treatment in closed settings To identify and discuss the range of treatment and care services that are recommended in closed settings Time to complete session: 1 hour 15 minutes Session content: HIV transmission in closed settings Drug dependence treatment in closed settings HIV testing in closed settings (ethics, confidentiality, risks) ART for IDUs in closed settings HIV and tuberculosis (TB) in closed settings Discharge/release programmes Prison staff Training materials:
4
Sub-module PowerPoint presentation 2.2: Services for IDUs in closed settings Sub-module 2.2: Services for IDUs in closed settings Exercise 2.2: Case studies – closed settings
Comprehensive services for injecting drug users
Closed settings include any kind of camps and correctional facilities, including jails and prisons. Closed settings can be facilities housing accused persons awaiting trial or convicted criminals serving short or long sentences, or places where injecting drug users (IDUs) are required to stay to receive compulsory “treatment” (such as compulsory detoxification and rehabilitation centres and labour camps). For the sake of simplicity, when referring to the same generic detention facilities (or closed settings), the terms prison or correctional facility will be used in the text. Minority populations, which are overrepresented in the inmate population, are the ones that are hardest hit by HIV in most countries. Prisoners most often come from disadvantaged and marginalized social groups, such as the urban poor, ethnic minorities, recent immigrants (from the countryside or from abroad) and IDUs. HIV-infected populations shift frequently in and out of correctional facilities. Prisons are key points of contact with millions of individuals living with or at high risk for HIV infection, who are largely out of reach of the medical system in the community. However, prisoners should be considered a part of the society. Prisons, in fact, are not cut off from the world outside. Most prisoners leave prison at some point to return to their communities, some after only a short time inside, and some enter and leave prison many times. In countries where injection of drugs is a significant route of HIV transmission, its prevalence rates in prison are closely related to the rate of HIV infection among IDUs in the community and the proportion of people who injected drugs prior to imprisonment. In general, several reasons for higher rates of HIV infection among prisoners include higher prevalence rates of risk factors associated with acquiring HIV infection, including injecting drug use, co-morbid mental illness, lower socioeconomic status, commercial sex work, and lower level of education as compared with persons in the general community. As it will be evident throughout the sub-module, most interventions need to be coordinated and linked with existing services in the community to achieve good results.
HIV transmission in closed settings Patterns of HIV transmission in closed settings in Asia Injecting drug use Many prisoners come to prison with established drug habits and often find a way to continue drug use during incarceration. Some prisoners start using drugs inside. No country has been able to stop drug use, including injection drug use, in prisons. This has been evidenced in Asian countries too. In Indonesia up to 40% of IDUs in prison injected during detention (MOH Indonesia, 2005). In addition, a study carried out in Bangkok central prison (Thailand) showed that almost 50% of IDUs injected while in custody, and more than 90% of them shared injection paraphernalia with others (Thaisri et al. 2003). Sex between men and sexual transmission in general Sex occurs also within correctional facilities, and laws or policies prohibiting sex among inmates have been difficult to implement or enforce. Although the frequency is difficult to quantify, in a few studies 4–30% of inmates reported sex (oral or anal) while incarcerated. The occurrence of sex in prison is evidenced by occasional outbreaks of sexually transmitted infections (STIs) in prisons. Sex occurs in prison on a daily basis, whether it is consensual, “quasi-consensual” (i.e. submission based on intimidation, or submission in return for protection or other favours), coerced, “exchange
Participant Manual
Comprehensive services for injecting drug users
sex” (e.g. for money, food or cigarettes), bartered, or involuntary. There is prostitution and there are “same-sex relationships” in prison. Sexual activity is not limited to prisoners; in fact, correctional staff may also engage in unsafe sex with inmates. Most sexual activity that takes place in closed settings involves sex between men. Some such activity occurs as a consequence of sexual orientation. However, most men who have sex in penal institutions do not identify themselves as homosexuals. Sexual activity between prisoners varies in frequency and kind within and across prisons and prison systems. Sex in the prison environment, particularly in the form of rape, is considered to be more often about power and asserting control over another human being than about sexual fulfilment. Among inmates who report any consensual sex, some report using condoms or other improvised barrier methods (e.g. rubber gloves or plastic wrap), but usually barrier methods are not used during rape. Other high-risk behaviours Many inmates receive tattoos in prison. Some can access clean tattooing equipment or bleach to clean tattooing equipment, but in many cases used tattooing equipment is not cleaned. Sometimes the same needles used for injecting drugs are then used for tattooing. In particular, this risk factor has been identified frequently in prisons in Thailand. Because of the severe underfunding of health-care services in some countries in the Region, HIV and hepatitis virus (HCV) transmission may also occur through the use of non-sterile equipment during medical procedures. Prison health services must have adequate material and resources available to ensure that transmission does not occur in this way.
Reducing HIV transmission in closed settings Some HIV prevention options (e.g. HIV education, testing and prevention counselling) that are effective for non-incarcerated populations are also recommended for inmates. HIV prevention education in prisons should address all risk behaviours occurring during detention and after release. Such interventions have been recently introduced in some Asian countries (e.g. Indonesia, Bangladesh). Separate housing of HIV-infected inmates has never been proved to be an effective strategy to reduce the spread of HIV and other sexually transmitted, opportunistic, and bloodborne infections. In addition, it increases the risk for outbreaks of TB and raises concerns about the disclosure of inmates’ HIV status. Prevention of sexual transmission of HIV in closed settings includes condom promotion. Making condoms and water-based lubricants available is not enough. They must be easily and discreetly accessible, ideally in several locations. Reasons for not providing condoms include the conflict with policies forbidding sexual intercourse (or sodomy) and the potential for condoms to be used as weapons or to smuggle contraband. Condoms are available to inmates of prisons in many countries and few problems related to condom distribution have been reported. In addition, providing condoms to prisoners has additional public health advantages beyond the prison walls if exposure to and experience with condoms in this setting translates into increased use after release. However, condoms are of no use in situations of non-consensual sexual activity; therefore, it is also important to prevent violent attacks on prisoners, including rape. Combating aggressive sexual
Sub-module 2.2
Comprehensive services for injecting drug users
behaviour, such as rape, exploitation of vulnerable prisoners, and all forms of prisoner victimization results in a safer environment. Adequate staffing, effective surveillance, disciplinary sanctions, and education, work and leisure programmes are necessary components to reach this goal. Needle and syringe programmes (NSPs) can be useful for those inmates still injecting while in prison. Needles can be made available in prisons in a manner that is non-threatening to staff. There are several models of distribution of sterile injection equipment, including automatic dispensing machines, distribution by medical staff or counsellors, and distribution by prisoners trained as peer outreach workers. Since the first prison needle and syringe programme started in 1992, not even a single case of a needle being used as a weapon either against prison staff or other prisoners has been reported. Existing programmes show that the availability of needles does not result in an increased number of drug injectors, an increase in overall drug use, or an increase in the amount of drugs in the institutions. In addition, needle and syringe programmes in prisons facilitate referral and access of drug users to drug dependence treatment programmes. Nevertheless, drugs remain prohibited in institutions where needle and syringe programmes are in place. Security staff remain responsible for locating and confiscating illegal drugs. However, it is recognized that if and when drugs find their way into the prison and are used by prisoners, the priority must be to prevent HIV transmission via unsafe injecting practices. Therefore, while drugs themselves remain illegal, needles that are part of the official needle and syringe programme are not. If needle and syringe exchange schemes are not feasible, disinfection programmes can be used. Disinfection is usually achieved with chemical substances, such as bleach, and users should disinfect injecting equipment before and after injecting. Serious problems are related to the use of bleach in prisons. In fact, prisoners are highly unlikely to spend the long required time shaking the syringes to clean them while waiting to inject in some hidden corner of the prison. Bleach can therefore create a false sense of security among prisoners sharing paraphernalia. Another effective preventive intervention for IDUs is opioid substitution therapy (OST). As in the community, OST has the potential of reducing injecting and needle sharing in prisons. In addition, there is evidence that people who are on OST in the community and who are forced to withdraw from such treatment because of incarceration often return to opioid use within the prison system, and often via injection. It is therefore widely recommended that prisoners who were on OST outside prison be allowed to continue it in prison. Detoxification does not seem to be a long-term efficient preventive intervention. In fact, the majority of heroin-dependent patients relapse to heroin use after detoxification; and few are attracted into, and retained in, drug-free treatment long enough to achieve abstinence.
Drug dependence treatment in closed settings The period of drug withdrawal on admission to prison can cause serious problems, including selfharm and violence. This calls for a specific care programme for drug-dependent prisoners. Specific interventions in this situation are detoxification and OST. OST includes medically supervised treatment of individuals dependent on opioids based on the prescription of opioid agonists, such as methadone or buprenorphine. Detoxification on its own rarely constitutes adequate treatment of substance dependence since relapse after detoxification is extremely common. Therefore, the options include managing withdrawal on admission as gradual detoxification, proceeding to abstinence-oriented treatment, or to long-term substitution
Participant Manual
Comprehensive services for injecting drug users
maintenance. Successful interventions are as client-tailored as possible and applied using a caseby-case approach. Maintenance treatment also offers opportunities for improving ART delivery to drug users, notably by increasing access to treatment and improving retention in programmes and adherence to treatment. (See also the section on discharge/release programme.) There are many compelling reasons for prison services to introduce OST. These include: Reducing the risk of suicide and self-harm during the period of withdrawal among imprisoned problematic drug users and drug-dependent people Reducing difficulties for staff in managing withdrawal among inmates, drug smuggling, and related acts of violence toward staff and other prisoners Ensuring equity in provision of treatment between prisons and communities, and continuity of care Providing clinical services at a standard equivalent to internationally agreed best practices Reducing the risk of fatal overdose in the first few days following release from prison, especially for short-term prisoners. In fact, substitution therapy programmes report several valuable benefits, including decreased use of other drugs, decreased crime, decreased mortality, less HIV transmission, less hepatitis C transmission, and marked improvement in the health of drug users. This treatment works and is cost-effective. Substitution therapy in the form of methadone or buprenorphine maintenance is already provided in prisons of many countries, including Asia (e.g. methadone is provided in some Indonesian settings).
HIV testing in closed settings (ethics, confidentiality, risks) Correctional facilities are not only places where HIV-positive individuals are housed, but often where they are first tested or where they test positive for the first time. Proposing HIV testing in correctional facilities aims to increase access to voluntary testing, to increase the proportion of HIV-positive inmates who know their HIV serostatus and are therefore referred to prevention and treatment services, and to prevent new infections. There is no public health or security justification for compulsory or mandatory HIV testing of prisoners, or for denying prisoners access to HIV testing. Rather, prisoners should be encouraged to test voluntarily for HIV, with their informed, specific consent, with pre- and post-test counselling, and with assurance of confidentiality of the test results.
ART for IDUs in closed settings Introduction The positive effects of ART have been observed even in “difficult” HIV-infected populations (e.g. IDUs, homeless people, ethnic minorities, closed settings and others). Providing access to ART following the existing national and/or international guidelines for HIV/AIDS care for those in need in the context of correctional facilities can be seen as a tremendous challenge, but it has proven feasible in many countries, including Asia. A project being carried out in Thailand has shown that the introduction of an ART programme in closed settings could dramatically reduce the death rate among AIDS cases and increase CD4
Sub-module 2.2
8
Comprehensive services for injecting drug users
counts in more than 90% of treated inmates. This project enrolled more than 400 patients between June 2004 and October 2005 (Source: Dr Weerakit Hanpariphan).
relevant issues regarding antiretroviral treatment in correctional facilities There are several issues/challenges to be considered when treating HIV-positive prisoners with combination ART. In many countries, the biggest challenge is the lack of resources devoted to health care in prison. Other challenges, however, relate to the place of prison health care within the correctional system: “corrections is a public safety or law enforcement activity rather than a public health activity” (Brewer, 1991). The main relevant issues that will be discussed in this section, but also throughout the sub-module, are listed in Box 1.
Box 1. relevant issues regarding antiretroviral treatment in closed settings
Basic health care for all prisoners Responsibility for health care in prisons — Prison authorities — Public health authorities HIV care for those infected — Availability — Provision Correctional facilities as entry point for HIV care (especially for marginalized populations) Sociocultural barriers: ethnic minorities, immigrants, language, education Policy and guidelines on ART Formularies including antiretroviral (ARV) drugs Availability and procurement of ARVs Specialized HIV care — HIV nurse — HIV specialist part of the prison health staff — HIV consultant Laboratory tests available — Routine haematology and biochemistry — Immunology — Virology Adherence to ART Administration of ART — Directly observed therapy (DOT) — Keep-on-person (KOP) treatment/self-administered therapy — Modified DOT Confidentiality Education of prison staff Peer support
Participant Manual
Comprehensive services for injecting drug users
9
Box 1. (cont.) relevant issues regarding antiretroviral treatment in closed settings
Continuity of care — In/out: from community to prison to community — Transfers within prison system — Discharge planning — Link with external/community health services Inmates’ behaviour — ART refusal — Hunger strike — Therapy strike Co-morbidities (TB, hepatitis B virus [HBV], HCV, mental illness, others) — Prevention, diagnosis and treatment — Drug–drug interactions Access to experimental treatments available in the community Updated information on ART in prison setting
Provision of ART in closed settings requires that national policies and guidelines for the use of ARVs are followed. No other special guidelines are necessary in this context. The same drugs that are available outside the prison system should be available and regularly procured inside the prison system. Limited formularies may result in some medications not being available. This causes unnecessary discontinuation of ART for inmates already under treatment prior to incarceration. The availability (inside or outside the correctional facility) of laboratory services for monitoring drug-related toxicities (routine haematological and biochemical tests) and treatment efficacy (immunological and virological tests) is another necessary component. Again, the same laboratory services available in the community should be accessible for inmates being treated. Specialist HIV/AIDS care should be available in closed settings at least as easily as in the community, if not more. This depends on the size of the prison, HIV prevalence among inmates, and links with community services.
Adherence Full adherence to the prescribed ARV regimen is key to obtaining the greatest benefits from ART. The special environment in the prison system can offer small and large obstacles to adherence, but also has a few advantages. Specific solutions should be found to optimize adherence to treatment and to adapt strategies to the country guidelines, the kind and size of closed setting, and availability of trained staff. Treatment guidelines help in simplifying ART as much as possible. Nevertheless, it is necessary to remember that patients may still be non-adherent to even the simplest of regimens. There can be many reasons for not taking the correct dose of ARVs at the right time while in prison. Such reasons are often divided into “institutional” or “non-institutional” . Some of the most common institutional barriers to receiving correct doses can be: Medication is not available. Patient is not allowed to attend the medicine call.
Sub-module 2.2
10
Comprehensive services for injecting drug users
Patient does not want to go to the medication room. Patient is in “lockdown” (i.e. the prisoner is locked in his or her cell and is unable to receive the medication). Patient is moved to another cell. Patient is out of the unit. The medication is on hold.
The most commonly reported non-institutional barriers include: Patient feels fatigued or sleepy. Patient feels sick. Patient does not want to get out of bed. Patient feels depressed. Patient has a possible adverse event. Patient refuses treatment. In this setting, attitudes related to trust in medications and the health-care provider, and satisfaction with health care in the correctional system, have particular relevance to the acceptance of, and adherence to, ART. If non-health care workers (e.g. the correctional staff ) dispense ART, they could face inmates’ lack of trust that can result in decreased adherence. The modality of ARV administration can profoundly affect adherence to treatment. Some correctional health services administer ARVs under direct observation. The high level of adherence to therapy required to maintain virus suppression (over 95% of drug doses taken) may justify DOT. Alternatives to DOT include: modified DOT, where patients receive their daily ARVs and swallow the morning dose in front of the staff and self-administer the others; and “keep on person” , (KOP) where patients keep the full box of drugs with them in their cell (when refrigeration is not necessary) and self-administer ART (Spaulding et al. 2002; Pontali, 2005). Any of these strategies can be chosen, and they are sometimes used simultaneously in the same prison, with different patients. The advantages and disadvantages of each modality are given in Box 2.
Box 2. Advantages and disadvantages of different modalities of Art administration Directly observed therapy: in this situation the inmate goes directly to the medical unit or pharmacy for all medication doses and the nurse watches them swallowing medications. Administration of each dose for each patient should also be recorded. Such a system offers the advantage of more frequent interactions with the health-care team, which allows for earlier identification of issues, concerns and side-effects. In general, there is greater adherence with this system. Unfortunately, for some inmates the need for frequent visits to the medical unit or pharmacy may be a barrier to treatment, particularly if they are housed at a distance from the unit or if they are involved in some work or study activity. Another disadvantage of DOT is the potential loss of confidentiality as many inmates feel that the frequency of treatment and large number of pills taken will be clues that they are on treatment for HIV. Inmates who receive ART under DOT may have to stand in line and wait to receive their medications, while a nurse or correctional officer dispenses ARVs and watches as they are taken. Many DOT programmes in prisons are inflexible, involuntary, non-confidential and non-individualized. The lack of confidentiality and long lines have been reported by many
Participant Manual
Comprehensive services for injecting drug users
11
Box 2. (cont.) Advantages and disadvantages of different modalities of Art administration HIV-positive prisoners as barriers to taking medications. This is due to the stigma attached to HIV by both correctional facility staff and inmates. However, in other settings, inmates receive their treatment from nurses when they are still locked in their cells, as hospitalized patients do in their rooms. These differences may depend on the drug distribution policy in the country or in the single institution and on the daily load of drug distribution in the institution. Modified DOT: ART is distributed daily to prisoners by nurses. The nurses may or may not watch the patient swallowing the morning dose of the prescribed medications. The patient takes the other doses on their own. This approach carries most of the advantages of the other two strategies, but it is less time-consuming for nurses compared with full DOT. On the other hand, it leaves at least one dose of medication under the inmate’s full responsibility. Sometimes this strategy can be used for prisoners to shift from DOT to KOP, especially those who will be released soon. Keep on person or self-administered therapy: This approach allows inmates to keep their medications in their cells and take them independently. Monthly or weekly supplies are obtained from the medical unit or pharmacy. This system offers greater privacy and confidentiality regarding HIV status. The inmate also develops self-sufficiency in managing their medications, which might facilitate improved adherence upon release. However, with less interaction with the medical staff, it can be more difficult to identify problems with adherence or side-effects of medications. Other potential problems include the possibility of breaching inmate confidentiality and may result in stolen, lost or confiscated medications.
All considerations related to adherence and modality of ART administration should be viewed in the context of a specific country or correctional facility. In particular, the use of ARVs in fixed-dose combinations (FDCs) and/or regimens administered once daily may render DOT in closed settings easier and less resource-consuming. On the other hand, lack of health staff can also be an obstacle to implementation of the DOT strategy. As in the general population, it is important to include the patient in the decision-making process regarding HIV treatment. A regimen that can more easily fit into the patient’s lifestyle will lead to improved adherence. Linking the dose to a regular part of the daily routine (such as breakfast or dinner) also supports adherence. This is relevant in closed settings too. In fact, prisoners have different daily routines depending on the length of stay, isolation, reason for conviction, and work or study activities. Peer support is an established and very useful strategy for ART adherence. It has also proved to be effective in prison populations, especially when inmates feel “down” . In addition, it is a common experience that many inmates are spontaneously reminded to take their medication by a friend or cellmate. Therefore, it can be helpful to encourage inmates under ART to participate in groups and possibly consider becoming peer counsellors. Patients who do well with ART often find it rewarding to “give back” to others in the same situation. Closed settings represent special environments where, even when ART is clinically required and correctly prescribed, patients sometimes can receive ARVs but do not take them. This can happen because legislation allows prisoners in worsening physical condition to request special benefits for health reasons, such as anticipated release, home or hospital arrest, or others. It is sometimes very
Sub-module 2.2
12
Comprehensive services for injecting drug users
hard for the clinical team to establish if the patient is really taking medicines or not. However, when such a situation is suspected, patients should be warned about the risks to their health and given a choice between ART discontinuation and DOT administration. Another critical situation that can lead to non-adherence to ART is a hunger strike. It can easily happen in correctional facilities and can be accompanied by therapy strike. In this latter case, the clinical team should counsel the inmate about risks to health and suggest that the inmate take at least full ART. In case of a “simple” hunger strike, the prescribed regimen could possibly be modified to include only ARVs not requiring administration with food. In the experience from Thailand, patients are started with ART under DOT and are later shifted to partial or modified DOT or self-administered therapy with team assistance.
Choice of ARVs in prison The choice of ART regimens in closed settings – based on available drugs from the national ART programme – should include simple regimens, possibly once or twice daily administration, limited food restrictions and low pill burden. In addition, particular attention should be directed to co-morbidities and their treatment (chronic hepatitis B or C, tuberculosis, mental illness, etc.), OST, and history of drug and/or alcohol dependence.
Confidentiality A key issue that may drive inmates away from receiving adequate care and ART is the fear of disclosure of their HIV status. In closed settings, a significant number of HIV-infected inmates feel socially isolated as a consequence of being HIV positive, and a large number of patients keep their HIV infection hidden from other prison inmates and prison staff.
Continuity of care Continuity of care within the prison system is extremely important for adequate adherence to ART. Inmate facility transfers (because of overcrowding or for disciplinary, judicial or personal reasons) or court dates may cause problems in coordinating medical care and supplying needed medications in a timely fashion. This increases the risk of treatment discontinuation for short or long periods of time. Furthermore, smaller correctional facilities with a minor load of HIV-positive prisoners may not have adequrate stocks of ARVs. In these instances procurement of drugs may be difficult or slow, and specific ARV drugs could be unavailable for some time causing partial or total ART discontinuation. To reduce these difficulties, ARVs (one weeks’ prescription or more) could “follow” prisoners during transfers; this would allow the new prison sufficient time to procure the needed ARVs.
Co-morbidities Various co-morbidities, such as chronic viral hepatitis, TB and mental illness often accompany HIV infection in closed settings. Such concomitant clinical manifestations can make the choice of ARV combination difficult, because of:
Possible drug interactions: especially protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs ) with rifampicin, benzodiazepines and other drugs Increased hepatotoxicity Haematological toxicity (e.g. ribavirin use in zidovudine [ZDV]-treated patients)
Participant Manual
Comprehensive services for injecting drug users
13
Reduced adherence to ART because of mental illness Increased pill load
Opioid substitution therapy Opioid substitution therapy offers opportunities for improving the delivery of ARVs to IDUs. Maintenance therapy enables opioid-dependent drug users to stabilize their lives, and avoid or manage many of the complications of injection drug use, especially in closed settings. It is therefore seen as an essential component of strategies for retaining active IDUs on ART. In addition, there should be awareness of the possible drug interactions between drugs used for OST particularly methadone and ARVs.
HIV and TB in closed settings Tuberculosis (TB) disproportionately afflicts persons incarcerated in correctional facilities. Not surprisingly, inmates with TB more often have a history of excess alcohol use, drug use and homelessness during the year prior to TB diagnosis. Coinfection with HIV is common among inmates with TB disease. IDUs entering correctional facilities should be screened for symptoms of suspected TB infection. Particular attention should be paid when many IDUs and especially many HIV-infected IDUs are housed in the same facility in conditions of overcrowding to avoid TB outbreaks in prisons (reported in many settings).
Discharge/release programmes When treating HIV-positive patients, the clinician’s target is to help them strictly adhere to their ART regimen even when they are no longer under the clinician’s direct responsibility. Because a large number of prisoners move in and out of the prison system, there should be some form of continuity of care from the community to the prison and back to the community. Among patients who are incarcerated, transition between prison and the community is often associated with interruptions in care and treatment. It is also known that although HIV-positive inmates may achieve viral suppression in prison, these gains may be attenuated once they are released in to the community. Prisoners face many obstacles upon release, including problematic access to care and medications, relapse to substance use, untreated mental illness and unstable living circumstances, including poverty and homelessness. Such obstacles interfere with adherence to their medical care and especially to ART. Before release, prisoners should receive discharge planning and linkages to care in the community. Prison authorities could provide up to a 30-day supply of ARV drugs on release of ART-treated inmates. Other helpful interventions can include individualized case management, job and housing placement, substance use and mental health treatment, transportation, child care, enrolment in benefit programmes, and referrals for assistance with employment and other social services. However, one of the most challenging but effective interventions is provision of uninterrupted OST upon release from prison. In fact, continuity of care is required to maintain the benefits of drug use treatment in prison. In addition, proper preparation for discharge from prison is essential to reduce the chance of fatal overdose. Characteristics of good discharge models include: adequate period of time available for treatment transition; the availability of close links to community health and drug services; and the quality and quantity of retraining provided for the physicians and nurses involved.
Sub-module 2.2
14
Comprehensive services for injecting drug users
It may be helpful for prisoners to have face-to-face meetings with an outside health-care provider before discharge from prison. In jurisdictions where a large distance separates the correctional facility and the eventual home community, HIV programmes could maintain prisoner follow up by different means or link inmates with faith-based communities, OST programmes, and/or job programmes. However, at the minimum, released prisoners should be referred to HIV/AIDS care centres in their community; and they should have written updated information on their health status and HIV treatment, and enough ART (when necessary) for a few days while they get in touch with a new care provider.
Prison staff In the past, it was primarily correctional officers who attended to prisoners’ health-care needs. This sometimes still happens. With the advent of the modern prison health-care system, this responsibility should be reassigned to nurses, physicians and other health-care workers (HCWs). Unfortunately, understaffing is a chronic problem in correctional facilities, and prisons are once again relying on correctional officers to perform some tasks that are the responsibility of HCWs. Treatment of HIV infection requires constant updates, education and a high degree of expertise. The use of those whose main responsibility is custody and control – and with whom prisoners not surprisingly tend to have adversarial relationships – can present substantial barriers to the delivery of quality care.
Educational programmes for staff Educational programmes for staff are a priority. Training in HIV/AIDS, hepatitis and other infectious diseases must be a part of the core training of all prison staff, including correctional officers. In particular, staff need to learn about how to deal with prisoners with HIV/AIDS and to respect their rights and dignity, and about the need to respect medical confidentiality. NGOs and people with HIV should be involved in training delivery. Another advisable intervention is educating security staff about the essential need for inmates to get their medications in a timely fashion and recommending communication with other facilities in advance of a transfer, thus eliminating or limiting missed doses. Prison staff should be trained not only to obtain full collaboration for care programmes, but also to guarantee safety in planned interventions, as has been done in Indonesia.
Protective measures for staff It is crucial to make sure that the staff workplace is safe. In this context, staff are rightly concerned about overcrowding in the institutions and understaffing which, rather than measures taken to prevent the spread of HIV in prisons, constitute real threats to their safety. Prison systems have to address staff concerns in these areas. Additional interventions include education on universal precautions (and availability of gloves) and provision of specific counselling and post-exposure prophylaxis (PEP) in the event of occupational exposure to HIV of correctional staff. This can increase the confidence of prison staff in dealing with HIV-positive inmates. This would also show prison staff that HCWs’ attention is not exclusively towards prisoners, and that they are also included. It must be underscored that education on prevention of HIV transmission for prison staff extends its benefits beyond the prison walls; in fact, the same safe knowledge can be useful for their lives out of the prison.
Participant Manual
Comprehensive services for injecting drug users
15
National governments have a responsibility to ensure that the problem of HIV in prison is accorded the same level of urgency as HIV in the general community. For governments wanting to tackle the issue of HIV transmission in prison, there are several strategies to consider. In order of priority, these include the following: 1. 2. 3. 4. 5. 6. Reduce overall levels of incarceration. Provide prison staff and inmates with HIV education. Provide OST to inmates using opiates. Provide condoms, and sterile needles and syringes. Provide bleach, if authorities are resistant to needle and syringe exchange programmes. Conduct anonymous HIV surveillance of prisoners (Dolan et al. 2007).
Sub-module 2.2
16
Comprehensive services for injecting drug users
References and recommended reading Altice FL, Mostashari F, Friedland GH. Trust and the acceptance of and adherence to antiretroviral therapy. Journal of Acquired Immune Deficiency Syndromes, 2001, 28:47–58. Babudieri S et al. Directly observed therapy to treat HIV infection in prisoners. Journal of the American Medical Association, 2000, 284:179–180. Bazant W. Drug abuse, HIV/AIDS, and prisons. International experience, regional needs and planned responses. Presented as part of Asian Harm Reduction Network Advocacy Seminar, Yangon, June 2004. Brewer TF. HIV in prisons: the pragmatic approach. AIDS, 1991, 5:897. Dolan K et al; for the Reference Group on HIV/AIDS Prevention and Care among Injecting Drug Users in Developing and Transitional Countries. HIV in prison in low-income and middle-income countries. Lancet Infectious Diseases, 2007, 7:32–41. Jürgens R. Evidence for action technical papers. Effectiveness of interventions to manage HIV/AIDS in prison settings. Geneva, World Health Organization, 2007. Mesquita F. Biregional informal technical consultation on the development of clinical protocols on HIV treatment and care for injecting drug users. Presentation at Kuala Lumpur, Malaysia, 15–17 May 2006. Ministry of Justice and Human Rights Working Group on Prisons and HIV. Lokakarya Penanggulangan HIV/AIDS, Kelompok Kerja LAPAS/RUTAN Jawa Tengah. Presented at Hotel Dibya Puri, Semarang, Indonesia, 22–23 Maret 2006. Pontali E. Antiretroviral treatment in correctional facilities. HIV Clinical Trials, 2005, 6:25–37. Priohutomo S. Harm reduction intervention and policy in Indonesia. Presented at the ASEAN Regional Dialogue on HIV and Drug Use, Kuala Lumpur, December 2005. Spaulding A et al. Human immunodeficiency virus in correctional facilities: a review. Clinical Infectious Diseases, 2002, 35:305–312. Springer SA, Altice FL. Managing HIV/AIDS in correctional settings. Current HIV/AIDS Reports, 2005, 2:165–170. Thaisri H et al. HIV infection and risk factors among Bangkok prisoners, Thailand: a prospective cohort study. BMC Infectious Diseases, 2003, 3:25. Wohl DA et al. Adherence to directly observed antiretroviral therapy among human immunodeficiency virus-infected prison inmates. Clinical Infectious Diseases, 2003, 36:1572–1576.
Additional recommended reading Dobkin J. Comprehensive care and treatment of HIV-positive injecting drug users. Geneva, World Health Organization, (in press). Lines R et al. Prison needle exchange: a review of international evidence and experience. Montreal, Canadian HIV/AIDS Legal Network, 2004 (http://www.aidslaw.ca/Maincontent/issues/prisons.htm). WHO, UNODC, UNAIDS. Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention. Geneva, WHO, UNODC, UNAIDS, 2004 (WHO/UNODC/UNAIDS position paper) (http://www.who.int/substance_abuse/publications/treatment/en/). World Health Organization, UNAIDS, UNODC. Policy brief: reduction of HIV transmission in prisons. Geneva, World Health Organization, 2004 (http://www.who.int/hiv/pub/advocacy/idupolicybriefs/en/). World Health Organization. Dublin declaration on HIV/AIDS in prisons in Europe and Central Asia: prison health is public health. Dublin, Ireland, 23 February 2004 (http://www.euro.who.int/eprise/ main/who/progs/HIPP/Home). World Health Orgainzation. Status paper on prisons, drugs and harm reduction. Copenhagen, Denmark, World Health Organization, Regional Office for Europe 2005.
Participant Manual
Comprehensive services for injecting drug users
17
Exercise 2.2 Case Studies Case study 1: Introducing ART in closed settings You will find below a list of possible components of your national ART programme. You can add more components if you think it appropriate. Your task is to: 1. Identify those components of the national ART programme that are available in all or some closed settings in your country. 2. Identify what ideally should be available in closed settings. 3. Elaborate a strategic plan on how to introduce the components not yet available in closed settings. Components of the National ART Programme Is available Staff Specialists ARV drugs Guidelines (ART, OI management, etc.) Formularies Training for health staff Linkage with community Training for non-health staff Linkage with OST services Laboratory Forms Coordination team Peer support group Involvement of CBOs/ FBOs/ NGOs VCT Should be available
Strategic Plan for Introducing ART Goal
Objectives
Strategies
Sub-module 2.2
18
Comprehensive services for injecting drug users
Case study 2: Continuity of care (part 1) First, try to identify what types of closed settings exist in your country. Then identify what services are available in the community for IDUs and what services are available for them in the different closed settings in your country. Next, identify ways of linking the different services. For each service to be linked you should identify the best (most appropriate or most efficient) modality: phone, paper, fax, referral of patient, electronic forms, patients accompanied by social workers, etc. Explain your reasons for selecting a specific modality. Your next task is to identify who should be in charge (responsible person or service) in closed settings for this linking: security staff, health staff, social workers, CBOs, FBOs, NGOs, etc. In the next box you will find some services that may be available in closed settings and others in the community. Try to connect those on the left to those on the right based on the need to establish a linkage between them. You can link each of them to one or more on the other side. CLOSED SETTINGS OST services COMMUNITY Art clinic
Health unit
Social services
Security staff
OST services
Education services
IDU clinics
Social workers
FBOs
NGOs
Prevention services for IDUs
FBOs
Peer support groups
Peer support groups
CBOs
NGOs
Participant Manual
Comprehensive services for injecting drug users
19
How to establish linkage with prison services (part 2) Now, following the example below, identify the flow of information required for an efficient care programme in closed settings with good linkage with a national programme. Use a black or blue marker to identify the flow of information when the patient enters a closed setting. Use a red marker to identify the flow of information when the patient leaves the closed setting. The following is only an example; you should use the previous exercise to identify the components to be included in this second part.
Peer support group
ART centre
Prison staff
OST services
IDU prisoner
Prison HCWs
CBOs
Case study 3: Relevant issues regarding antiretroviral treatment in closed settings Turn to Module 2.2, page 8, Box 1 titled, “Relevant issues regarding antiretroviral treatment in closed settings” . From the list identify the issues that are relevant to the different types of closed settings in your country. Then try to identify possible solutions to the most relevant issues you have just identified.
Sub-module 2.2
Annex 1
Presentation 2.1: Comprehensive services and continuity of care for IDUs Session objectives
Understand and be able to describe the elements of a comprehensive package of services for IDUs:
Comprehensive services for IDUs
HIV prevention services for IDUs including outreach and needle and syringe programmes Drug dependence programmes including opioid substitution therapy (OST) Clinical services for IDUs including primary health care, testing and counselling Care and treatment for HIV-positive IDUs, including management of co-morbidities, ART
The importance of continuity of care
Describe the key challenges to comprehensive service delivery for IDUs Be familiar with models of comprehensive services for IDUs implemented in Asia Understand the need for continuity of care
Why drug users need a continuum of services – 1 Continuity over time Substance use, specifically opioid use, is a chronic relapsing condition It can last years (sometimes lifelong), with periods of chaotic use, controlled use and abstinence Continuity of services is required to meet the various needs along the continuum of drug use in a drug user’s life Continuity between different settings and locations IDUs often move between community, prison and rehabilitation settings IDUs who travel or move to another suburb, town or country
Why drug users need a continuum of services – 2 Depending on finances, law enforcement activity, or how an individual drug user is feeling, they may move between smoking, chasing and injecting. This means that they need different services at different points in time. As with non-drug users, health and other needs evolve as individuals become older. Continuity of services is crucial for retaining people in treatment and/or keeping them in contact with risk reduction services.
Why drug users need a continuum of services – 3
Major health and psychosocial problems of IDUs
Evidence shows that the longer you can retain people in treatment/interventions, the lower their chances of contracting bloodborne infections (and the higher their chances of recovering from harmful drug use). Drug users are individuals and one size does not fit all – evidence from other public health fields shows that the greater the choice and accessibility of methods offered at a site, the more clients are likely to accept and continue treatment/services.
Source: UNODC Regional Centre for East Asia and the Pacific
Skin and soft tissue infections Musculoskeletal infections Sepsis Endovascular complications Tetanus/wound botulism Respiratory tract infections Tuberculosis Sexually transmitted infections (STIs)
Hepatitis B and C HIV infection and advanced HIV disease/ AIDS Psychiatric disorders – particularly substance-induced psychosis, sleep disorders, depression and suicide Overdose Withdrawal Pain
Comprehensive services for injecting drug users
21
The essential package of services in the continuum
12 components of a comprehensive service for IDUs Clean Up/ Syringe incineration Peer education Primary health services
Primary health care Counselling (including VCT) Safe injecting equipment Condom distribution Outreach Referrals to other services Support groups Appropriate behaviour change ART provision Home-based care and treatment
OST Detoxification and rehabilitation Crisis care Risk reduction education Sexual health services Peer education Day care Abscess management Narcotics Anonymous (NA) Employment training
NSP
Treatment and care
STI
Comprehensiveness Continuity Quality Scale
OST
VCT
Drug treatment
Counselling Outreach
Condoms
Source: Mesquita F, 2006
Key challenges to comprehensive service delivery for IDUs – 1
Key challenges to comprehensive service delivery for IDUs – 2
Lack of resources and political will – few governments have displayed a strong commitment to, and ownership of, services for IDUs Services are frequently donor-funded and driven Stigma and discrimination compromise service delivery by suppressing both demand and supply of services Due to the stigma attached to drug users, referrals are often not honoured
Establishing effective coordination and referral linkages between different agencies/providers is a real problem. This can have real costs to the client. The continuum of services approach has so far not been able to address people in closed settings in the region (where it is perhaps needed the most), with the strong focus on abstinenceonly in these countries.
Examples of comprehensive services for IDUs in Asia – 1
Examples of comprehensive services for IDUs in Asia – 2
Several agencies have been delivering comprehensive services to IDUs for over a decade in resource-poor settings. These include Nai Zindagi, SAHAI Trust, FRIENDS, SHARAN, SANKALP, SASO, Persepolis, Dhaka Ahsania Mission and CREA. Examples of innovation and resourcefulness for comprehensive service provision abound in the region.
These services are delivered through fixed as well as mobile sites. However, with a few exceptions, these have tended to remain “boutique” rather than scaledup services. The need to improve coverage of prevention and care services is still unmet in the Region.
Annex 1
22
Comprehensive services for injecting drug users
The NAI ZINDAGI programme
Abscess care
Source: AHRN picture gallery. Photo by A. Backer
Source: FHI, Bangladesh
STI treatment
Outreach
Source: FHI, Bangladesh Source: FHI, Bangladesh
Outreach
Counselling
Source: FHI, Bangladesh
Source: FHI, Bangladesh
Participant Manual
Comprehensive services for injecting drug users
23
Methadone clinic
Condom demonstration
Source: Department of Health, Hong Kong Source: FHI, Bangladesh
Self–help groups
Drop-in centre
Source: FHI, Bangladesh
Source: FHI, Bangladesh
“One–stop shopping” – 1
“One–stop shopping” – 2 Key to improved adherence and treatment outcomes for HIV-infected users is quality service provision, particularly:
Providing many health and social services at one site has been shown to improve both adherence to ART and treatment outcomes among HIVinfected IDUs. This approach has now come to be known as a “one–stop shopping” approach.
Opioid substitution therapy Counselling Treatment of depression Concomitant treatment of coinfections and co-morbidities Management of side-effects
Annex 1
24
Comprehensive services for injecting drug users
Advantages of “one–stop shopping” – 1
Advantages of “one–stop shopping” – 2
Multiple needs of the client are met at one site – convenient for clients Clients are not “lost” to referral to different services but are retained in treatment Easier to monitor and ensure the quality of care of different interventions as they are located at one site
Reduced costs of follow up and referrals for the service provider, while reducing costs for transport and waiting time for the client Reduced stigma – IDUs are often denied services or feel uncomfortable in facilities that provide services to the general population
Key challenges in providing “one–stop services”
Provision of ART requires highly trained staff and drugs Will probably need more outreach for ensuring compliance Require extra training of medical personnel to deal with ARV complications specific to IDUs Is it possible to scale up one–stop shopping services for IDUs across the region? Implications for human and financial resources?
Comprehensive service provision in places without “one–stop shopping” – 1 “One–stop shopping” is clearly preferable, but may not always be possible or feasible. Efforts should be made to provide as many services (if not all) under one roof. Strategies for effective referral need to be developed. Good coordination and ongoing advocacy is key.
Comprehensive service provision in places without “one–stop shopping” – 2
Comprehensive service provision in places without “one–stop shopping” – 3
Explore who provides clinical and social services for marginalized groups in your area and set up a resource directory. Individual visits to these agencies are recommended to explore what they can offer in practice. MOUs between agencies is a good way to start this process. Do not rely on personal relationships alone.
It is useful to provide accompanied referrals initially, particularly in sites with high stigma and discrimination. Use NGO groups or self-help groups for enhancing access to health facilities that are not targeted to IDUs. Encourage them to place a person who liaises between the IDU and the health provider. This approach has been used successfully in Manipur (India) and Bangladesh, and has sharply increased access to ART.
Participant Manual
Comprehensive services for injecting drug users
25
Comprehensive service provision in places without “one–stop shopping” – 4
Conclusions
To prevent the loss of people to follow up and referral, a very strong outreach team is required. Outreach teams should be trained to provide health messages and basic health care in the community and homes. To aid access and reduce the fear of stigma, outreach team members should come from the community itself.
IDUs are a special population with needs that differ at various points in time. They need a continuum of services, which are best provided using a “one–stop shopping” approach. Providing comprehensive services requires more skills and specialization than is usually available. Coordination and effective referral are vital to comprehensive service delivery.
Annex 1
Annex 2
Presentation 2.2: Services for IDUs in closed settings Session objectives
Services for IDUs in closed settings
Describe the importance of provision of treatment in closed settings Identify and discuss the range of care and treatment services which are recommended in closed settings Source: S. Wignall
Large group discussion
What are closed settings? Closed settings in Asia include:
Who has ever been in a prison? What was it like? What HIV prevention, care and treatment services are required in closed settings? What are the barriers to providing opioid substitution therapy (OST) in prison?
Prisons – long and short prison terms Drug detoxification centres and rehabilitation centres
Voluntary Involuntary
Immigration detention centres Police lock-ups
Prisons and IDUs Prisons are very important in the development of the HIV epidemic among IDUs: Many prisoners are IDUs. Many IDUs have been to prison. Many continue to inject in prison. Some prisoners start using drugs in prison. Drugs are available in all prison systems. No country has been able to stop drug use, including injection drug use, in prison. Few needles/syringes, so high rates of sharing occur. Source: Bazant W, 2004.
Prisons High-risk environment for HIV transmission
Injecting drug use Sex (male-to-male and heterosexual) Consensual Rape Favour, trade and protection Tattoos Non-sterile injecting equipment
Limited resources Overcrowding Short prison terms
Comprehensive services for injecting drug users
27
… Prisons are a part of society!
Viet Nam
Prisons are not cut off from the world outside. Most prisoners leave prison to return to their community. Some prisoners enter and leave prison many times. Prisons are key points of contact with millions of individuals living with or at high risk for HIV infection who are largely out of reach of the medical system in the community.
Estimated 112 000–215 000 IDUs Prevalence nationally 28%
HCMC 53%, Haiphong 64%
83 06 camps = 83 government rehabilitation centres – 60 000 IDUs
Urban: 1000–1500 drug users in each Provincial/district: 300–500 15 000 due for release in 2006, most over next 2 years
Ho Chi Minh city – 30 000 IDUs in 22 centres
Recidivism rate after discharge >90%
Source: Priohutomo S, 2005
HIV prevalence among IDUs and prisoners 100 Drug Treatment, Jkt Drug Treatment Bogor Sex Worker, Jakarta Per cent
Risk behaviours continue in institutions 100 SSP IDU Jakarta, Bandung dan Surabaya 2005
Jakarta (n = 402) Bandung (n = 343) Surabaya (n = 496)
80 Prevalensi HIV
Male Prison, Jakarta
60 48 40 20 0 41 30 16 0 1996 0 1997 0 1998 0 1999 16 12 1.5 2000 2001 2002 18 7 2003 45 25 48
50
43 37
42
Of those ever in jail 35 31
27 18 16
27
0 Ever jailed Injected in jail Received HIV/AIDS info in jail
Source: Priohutomo S, 2005
Source: Ministry of Justice and Human Rights Working Group on Prisons and HIV, 2006
HIV infection and risk factors among Bangkok prisons, Thailand
Needle and syringe programmes inside prisons
Incarceration associated with HIV infection among IDUs A prospective cohort of 689 male inmates in a Bangkok central prison studied during 2001–2002 Half (50.9%) were IDUs Of the IDUs, 49% injected while in prison Most (95%) had shared injection paraphernalia
Needle and syringe programmes in prisons in four countries
Spain Germany The Netherlands Kyrgyzstan
Source: Thaisri H et al. BMC Infectious Diseases, 2003
Annex 2
28
Comprehensive services for injecting drug users
Thailand’s prison ART programme Thai Medical Correctional Institute ART programme – three large urban prisons
Best practice: comprehensive services within the correctional system
216 PLWHAs on ART (December 2005) ~60% IDUs DOT Once-a-day regimen Monitoring with CD4 counts
Source: Weerakit Hanpariphan. ART in injecting drug users and HIV/AIDS. KL December 2005.
Voluntary drug dependence treatment Risk reduction education Staff training Health hardware: condoms, clean needles Substitution therapy Voluntary and confidential counselling and testing Primary health care – abscess and overdose management TB screening and treatment (with post-release follow up) OI prophylaxis, ART (DOT) Pre-release Post-release
Issues in prisons Mandatory testing Involuntary segregation Prison records/confidentiality Violence and rape Consensual sex
Prevention of IDU-related HIV transmission Some HIV prevention options that are effective for non-incarcerated populations are recommended for inmates too (e.g. HIV education, testing and prevention counselling) Specific interventions include:
Clean needles and syringes Bleach disinfection of injection paraphernalia OST Peer education
HIV sexual transmission in prison – 1
HIV sexual transmission in prison – 2
Men in prison have sex Laws and policies prohibiting sex among inmates have been difficult to implement or enforce Sex in prison can be:
Most sexual activity in closed settings is male-tomale sex. Most men who have sex in prison do not identify themselves as gay. Sex in prison (especially rape) is about power and asserting control over another human being rather than about sexual fulfilment.
Consensual (each person agrees) Quasi-consensual (submission based on intimidation, or submission in return for protection or other favours) Coerced Exchange sex (e.g. for money, food or cigarettes) Involuntary (rape) Same-sex “marriages” in prison
Correctional staff may have unsafe sex with inmates
Participant Manual
Comprehensive services for injecting drug users
29
Preventing sexual transmission of HIV – 1
Preventing sexual transmission of HIV – 2
Consensual sex – some condom use or other improvised barrier methods (e.g. rubber gloves or plastic wrap) Rape – usually no barrier methods used Even if condoms are provided in prison, unlikely to be used in non-consensual sex Important to prevent violent attacks on prisoners, including rape
Condoms and water-based lubricants:
Easily and discreetly accessible In several locations Aggressive sexual behaviour/rape Exploitation of vulnerable prisoners All forms of prisoner victimization Adequate staffing Effective surveillance Disciplinary sanctions Education, work and leisure programmes
Combat:
Provide a safe prison environment
Preventing sexual transmission of HIV – 3
HIV testing in prisons
In some countries correctional facilities are the place where:
Providing condoms to prisoners may yield additional public health advantages beyond the prison walls. Experience with condoms in prison may lead to increased use after release.
HIV testing in prisons can have positive or negative consequences depending on how it is provided:
Inmates are first tested, or They test positive for the first time Is it voluntary? Are the results confidential? Who knows who is HIV-positive?
There is no public health or security justification for compulsory or mandatory HIV testing of prisoners, or for denying prisoners with HIV testing access. If it is voluntary testing with good confidentiality:
Increases access to VCT More HIV+ inmates know their HIV serostatus and, if there are services available in prison, have access to treatment Ultimately can prevent new infections
Confidentiality
A key issue that may drive inmates away from receiving adequate care and ART is the confidentiality of their HIV status In closed settings:
Antiretroviral therapy for IDUs in closed settings
A significant number of HIV-infected inmates feel socially isolated as a consequence of being HIV positive A large number of patients keep their HIV infection hidden from other prison inmates and prison staff
The positive effects of ART have been observed even in “difficult” HIV-infected populations (e.g. IDUs, homeless people, ethnic minorities, closed settings and others). ART in correctional facilities in Asia is feasible.
Annex 2
30
Comprehensive services for injecting drug users
Key issues for ART in closed settings – 1
Key issues for ART in closed settings – 2
Basic health care for all prisoners Responsibility for health care in prisons
Specialized HIV care
Prison authorities Public health authorities Availability Provision
HIV care for those infected
Laboratory tests available
HIV nurse HIV specialist part of the prison health staff HIV consultant Routine haematology and biochemistry Immunology Virology DOT Keep-on-person (KOP) treatment/self-administered therapy (SAT) Modified DOT
Correctional facilities as entry point for HIV care Sociocultural barriers: ethnic minorities, immigrants, language, education Policy and guidelines on ART Formularies including ARVs Availability and procurement of ARVs Updated information on ART in prison settings
Adherence to ART Administration of ART
Confidentiality Education of prison staff
Key issues for ART in closed settings – 3
ART in closed settings
Peer support Continuity of care
The same drugs available outside the prison system should be available and regularly procured inside. Limited formularies may result in some medications not being available. This would cause unnecessary discontinuation of ART for inmates already under treatment. The same laboratory services available in the community should be accessible for inmates.
Inmates’ behaviour
In/out: from community to prison to community Transfers within prison system Discharge planning Link with external/community health services ART refusal Hunger strike Therapy strike
Co-morbidities (TB, HBV, HCV, mental illness, other)
Access to experimental treatments available in the community
Prevention, diagnosis and treatment Drug–drug interactions
Adherence to ART
Institutional barriers to ART
Full adherence to the prescribed ARV regimen is essential to obtain the greatest benefits from ART. The special environment in the prison system can offer small and large obstacles to adherence, but also a few advantages. There can be many reasons for not taking the correct dose of ARVs at the right time while in prison. Barriers to good adherence in prison may be institutional or non-institutional.
Medication is not available. The patient is not allowed to attend the medicine call. The patient does not want to go to the medication room. The patient is in “lockdown” (i.e. the prisoner is locked in his or her cell and is unable to receive the medication). The patient is moved to another cell. The patient is out of the unit. The medication is on hold.
Participant Manual
Comprehensive services for injecting drug users
31
Non-institutional barriers to ART
DOT, modified DOT, and KOP The way ARVs are given to prisoners can have a big effect on adherence to treatment
The patient feels fatigued or sleepy. The patient feels sick. The patient does not want to get out of bed. The patient feels depressed. The patient has a possible adverse event. The patient refuses treatment.
DOT Modified DOT KOP
Directly observed treatment (DOT). This is justified by the high level of adherence to ART required to maintain virus suppression (over 95% of drug doses taken) Alternatives to DOT include:
Modified DOT, where patients receive their daily ARVs and swallow the morning dose in front of the staff and self-administer the others KOP, where patients keep the full box of drugs with them in their cell (when refrigeration is not necessary) and self-administer ART
Directly observed therapy (DOT) – 1
Directly observed therapy (DOT) – 2
The inmate goes directly to the medical unit or pharmacy for all medication doses and the nurse watches him/her swallowing medications. Administration of each dose for each patient should also be recorded. Offers the advantage of more frequent interactions with the health-care team, which allows for earlier identification of issues, concerns and side-effects. Unfortunately, for some inmates, the need for frequent visits to the medical unit or pharmacy may be a barrier to treatment, particularly if they are housed at a distance from the unit or if they are involved in some work or study activity. Another disadvantage of DOT is the potential loss of confidentiality as the frequency of treatment and large number of pills taken are clues that they are on treatment for HIV.
Unfortunately, many DOT programmes in prisons are:
Inflexible Involuntary Non-confidential, stigmatizing Non-individualized
The lack of confidentiality and long lines are barriers to taking medications. In other settings, inmates receive their treatment from nurses when they are still locked in their cells (as in hospitals).
KOP or SAT
Modified DOT
Inmates keep medications in their cells and take them independently. Monthly or weekly supplies obtained at the medical unit or pharmacy Offers greater privacy and confidentiality regarding HIV status Inmate develops self-sufficiency in managing his/her medications Might facilitate improved adherence upon release Less interaction with medical staff – can be more difficult to identify problems with adherence or side-effects Possibility of breaching inmate confidentiality Can result in stolen, lost or confiscated medications
ART is distributed daily to prisoners by nurses. The nurses may or may not watch the patient swallowing the morning dose of the prescribed medications. The patient takes the other doses of medication on his/her own. This approach carries most of the advantages of the other two strategies, but it is less timeconsuming for nurses than full DOT. On the other hand, it leaves at least one dose of medication under the inmate’s full responsibility. Sometimes this strategy can be used for prisoners to shift from DOT to KOP, especially those who will be released soon.
Annex 2
32
Comprehensive services for injecting drug users
ART administration
Continuity of care
Any of these strategies can be chosen, and they are sometimes used at the same time in the same prison, with different patients. In Thailand patients are started with DOT and later shifted to partial DOT or SAT with team assistance.
Inmate facility transfers (because of overcrowding, disciplinary, judicial, or personal reasons) or court dates may result in problems in coordinating medical care and supplying needed medications in a timely fashion. This increases the risk of treatment discontinuation for short or long periods of time. Smaller correctional facilities with a minor load of HIV- positive prisoners may not have stocks of ARVs and/or may lack some ARVs. In these instances procurement of drugs may be difficult or slow, and specific ARV drugs could be unavailable for some time causing an unnecessary and unhealthy partial or total ART discontinuation. To avoid many of these problems, ARVs (1-week prescription or more) could “follow” prisoners during transfers.
Co-morbidities Various co-morbidities, such as chronic viral hepatitis, TB and mental illness often accompany HIV infection in closed settings. Can make the choice of ARV combination difficult, because of:
Opioid substitution therapy (OST) – 1
Possible drug interactions: especially PIs and NNRTIs with rifampicin, benzodiazepines and others Increased hepatotoxicity Haematological toxicity (e.g. ribavirin use in zidovudine-treated patients) Reduced adherence to ART because of mental illness Increased pill load
OST includes medically supervised treatment of opioid-dependent individuals with methadone or buprenorphine. Substitution therapy programmes report several valuable benefits, including decreased use of other drugs, decreased crime, decreased mortality, less HIV transmission, less hepatitis C transmission, and marked improvement in the health of drug users.
Opioid substitution therapy (OST) – 2
Post-release programmes – 1
Continuity of care:
There are other strong reasons to introduce OST in prisons:
Outside–inside–outside Community–prison–community Substance use and mental health treatment (including OST) Job and housing placement Up to a 30-day supply of ARVs on release Transportation, child care, enrolment in benefit programmes, and referrals for assistance with employment and other social services
Risk of suicide and self-harm during the period of withdrawal among imprisoned problematic drug users and drug-dependent people Problems in managing staff difficulties arising during withdrawal, drug smuggling, and related acts of violence toward staff and other prisoners Equity in provision between prisons and communities, and continuity of care Provision of clinical services at a standard equivalent to internationally agreed best practice Risk of fatal overdose in the first few days following release from prison, especially for short-term prisoners
Helpful interventions upon release:
Bangladesh: CREA Viet Nam: pilot planned
Participant Manual
Comprehensive services for injecting drug users
33
Post-release programmes – 2
Prison staff – 1
Face-to-face meetings with an outside healthcare provider before discharge If home community far from prison – link inmates with faith-based organizations, OST programmes, and/or job programmes in home community As a minimum, released prisoners:
Educational programmes for prison staff
Referred to HIV/AIDS care centres in their communities Take with them written updated information on their health status and ART Take with them enough ART until they can access more
Transmission of HIV/AIDS, hepatitis and other infectious diseases Risk-reduction education Medical confidentiality Treatment adherence Stigma and discrimination
NGOs and PLWHA involved in training Thailand: training curriculum for prison staff Transfer of medical records if prisoner transferred
Prison staff – 2
Best practice = safe workplace HIV is an occupational health and safety issue for prison staff
Priority strategies to prevent HIV in prisons
Overcrowding Understaffing Inadequate budgets for health services
Reduce imprisonment Provide prison staff and inmates with HIV education Provide methadone maintenance therapy to inmates using opiates Provide condoms and sterile needles and syringes Provide bleach, if authorities are resistant to needle and syringe programmes Anonymous HIV surveillance of prisoners
Education on prevention of HIV transmission for prison staff extends its benefits beyond prison walls PEP for prison staff:
Increases confidence of prison staff in dealing with HIV–positive inmates Demonstrates HIV programme’s commitment to occupational health and safety (OHS) issues
Source: Dolan K et al. Lancet Infectious Diseases, 2007.
Annex 2
Treatment and Care for HIV-Positive Injecting Drug Users The “Treatment and Care for HIV-Positive Injecting Drug Users” training curriculum is designed for clinicians who provide treatment and care, including ART, for HIV-positive injecting drug users. The training curriculum consists of a trainer manual, 12 participant manuals, and a CD-ROM with PowerPoint presentations and reference articles. Topics covered in the curriculum include: Module 1: Drug use and HIV in Asia Module 2: Comprehensive services for injecting drug users Module 3: Initial patient assessment Module 4: Managing opioid dependence Module 5: Managing non-opioid drug dependence Module 6: Managing ART in injecting drug users Module 7: Adherence counselling for injecting drug users Module 8: Drug interactions Module 9: Management of coinfections in HIV-positive injecting drug users Module 10: Managing pain in HIV-infected injecting drug users Module 11: Psychiatric illness, psychosocial care and sexual health Module 12: Continuing medical education Trainer manual
The ASEAN Secretariat 70A, Jl. Sisingamangaraja Jakarta 12110 Indonesia Phone: +62 21 724 3372, 726 2991 E-mail: public@aseansec.org
World Health Organization Regional Office for South-East Asia Mahatma Gandhi Marg Indraprastha Estate, New Delhi - 110002 India Phone: +91 11 233 70804 E-mail: hiv@searo.who.int www.searo.who.int
Family Health International Asia/Pacific Regional Office 19th Floor, Tower 3, Sindhorn Building 130-132 Wireless Road, Lumpini, Phatumwan Bangkok 10330, Thailand Phone: +662 263 2300 E-mail: sunee@fhibkk.org www.fhi.org
ISBN 978 979 3496 63 4
978 979 3496 63 4