Michel Kazatchkine

The evidence is clear, Eastern European and Central Asian countries should adopt opioid maintenance therapy and needle exchanges to curb HIV and Hep C outbreaks, says Michel Kazatchkine

September 13, 2019 from BMJ

For many years, evidence has shown the effectiveness of opioid maintenance therapy in the treatment of opioid dependence and the effectiveness of opioid maintenance therapy and needle syringe programmes in preventing HIV infection among people who inject drugs. [1,2] Recent evidence shows that both opioid maintenance therapy and needle syringe programmes can also prevent people who inject drugs from getting hepatitis C. [3]

The spread of HIV/AIDS among people who inject drugs and their partners has been contained in Western Europe, Australia, Canada, China and other countries of Asia, because interventions such as clean needle exchange and opioid maintenance therapy programmes became mainstream government health policy sanctioned by the World Health Organisation. 

Harm reduction is receiving increasing attention from policy makers across Sub-Saharan Africa. Unsafe drug injection is recognized as an underestimated component in preventing HIV and hepatitis C infection in vulnerable groups in high prevalence settings across sub-Saharan Africa and Asia. 

However, in Eastern Europe and central Asia, harm reduction policies are conspicuous by their absence, even though there are high rates of HIV and hepatitis C infection.  

The absence of harm reduction policies is conspicuous as rates of injecting drug use are persistently high in Eastern Europe and Central Asia, approximately four times that of the global average, although the trend is decreasing. [4] Heroin continues to be the dominant injected drug, but many countries in the regions are seeing increasing rates of injected stimulant use (metamphetamines). [5] 

People who inject drugs or have injected drugs at some point in the past continue to represent 40–50% of newly reported HIV diagnoses across Eastern Europe and central Asian region. [6]

Around 25% of the estimated 3.1 million people who inject drugs in the region are infected with HIV and 65% test positive for hepatitis C. [7]

Co-morbidities such as HIV-TB and HIV-hepatitis C co-infection have now become normalised in countries like the Russian Federation which accounts for around 80% of the region ‘s HIV infections. [8] 

The uptake of antiretroviral therapy (ART) has been increasing in the region in the past few years as the price of medicines has been decreasing and antiretroviral regimens have been simplified and standardised. Yet, only 35% of the estimated number of people living with HIV in the region currently access antiretroviral treatment, and that figure is only close to 10% for people who inject drugs. [9] Figures are much lower when it comes to treatment of hepatitis C with direct antiviral agents (DAAs). Other than the extensive hepatitis programme that is in place in Georgia, still less than 5% of patients access curative hepatitis C treatment across the region. [10]

Further evidence now shows that opioid maintenance therapy and needle syringe programmes are effective in preventing the acquisition of hepatitis C in people who inject drugs. A meta-analysis of data published in the last eighteen months shows that opioid maintenance therapy reduces the risk of hepatitis acquisition by 50% among people who inject drugs, while opioid maintenance therapy and needle syringe programmes reduce the risk of acquiring hepatitis C. [11]

The effectiveness of opioid maintenance therapy and needle syringe programmes in reducing the risk of HIV infection among people who inject drugs has allowed Western European countries to reduce the proportion of people who inject drugs among new HIV infections to less than 1-2%. Opioid maintenance therapy has further allowed a large number of people to regain normal family and working lives in the society. 

The Russian Federation accounts for nearly 80% of all new HIV infections in the region and modelling shows the potential benefit of introducing and scaling up these interventions in that country. [12] 

It is estimated that extending access to opioid maintenance therapy and needle syringe programmes to 50% of people who inject drugs, together with access to antiretroviral therapy for those in need, would result in a 53% and 76% reduction in the number of new infections within ten years in Omsk and Ekaterinburg, two cities with severe HIV epidemics associated with unsafe drug injection. [13,14] 

The epidemics of HIV and hepatitis among people who inject drugs and their partners continue to severely affect the Eastern European and central Asian region. Yet, we have evidence that opioid maintenance therapy and needle syringe programmes are effective at prevention. It is the right time for governments in the region to review the evidence, review their policies, and reign in their HIV and hepatitis epidemics. 

Michel Kazatchkine is the Special Advisor to the Joint United Nations Program on AIDS (UNAIDS) in Eastern Europe and Central Asia
Competing interests: None declared.

References

1. WHO. https://www.who.int/substance_abuse/activities/treatment_opioid_dependence/en/
2. Wodak A, McLeod L. The role of harm reduction in controlling HIV among injecting drug users. AIDS 2008; S2:s81-s92.
3. Platt L, Minozzi S, Reed J, et al. Needle Syringe programs and Opioid Substitution Therapy for preventing hepatitis C transmission in people who inject drugs.  Cochrane database of systematic reviews 2017; 9: CD012021.
4. UNAIDS. 2016. Prevention gap report. http://www.unaids.org/sites/default/files/media_asset/2016-prebetion-gap-report_en.pdf 
5. Degenhardt L, Peacock A, Colledge S, et al. Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review. Lancet Glob Health 2017; 5:e1192-207.
6. UNODC. World drug report. 2018. https://www.unodc.org/wdr2018.
7. WHO. World hepatitis report. 2017. https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en 
8. UNAIDS. Global AIDS update: miles to go: closing gaps, breaking barriers, righting injustices 2018. hhtp://www.unaids.org/sites/default/files/media_asset/miles-to-goen.pdf
9. UNAIDS. 2016. Prevention gap report. http://www.unaids.org/sites/default/files/media_asset/2016-prebetion-gap-report_en.pdf 
10. UNAIDS. Global AIDS update: miles to go: closing gaps, breaking barriers, righting injustices 2018. hhtp://www.unaids.org/sites/default/files/media_asset/miles-to-goen.pdf
11. WHO. World hepatitis report. 2017. https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en
12. Cepeda JA, Eritsyan K, Lyubimova A, et al. Potential impact of implementing and scaling up harm reduction and antiretroviral therapy on HIV prevalence and mortality and overdose deaths among people who inject drugs in two Russian cities: a modelling study. Lancet HIV 2018; 5: e78-87.
13. Cepeda JA, Eritsyan K, Lyubimova A, et al. Potential impact of implementing and scaling up harm reduction and antiretroviral therapy on HIV prevalence and mortality and overdose deaths among people who inject drugs in two Russian cities: a modelling study. Lancet HIV 2018; 5: e78-87.
14. Bekker LG, Alleyne G, Baral S, et al. Advancing global health and strengthening the HIV response in the era of sustainable development goals: the international AIDS Society-Lancet commission. 2018;18:7-53.

February 20, 2018  BMJ

The announcement by UNAIDS that some 21 million people living with HIV are now on treatment uncovers an extraordinary achievement and one of the great global health milestones of this century.

It gives us hope that the other 15 million or so people living with HIV can also soon access antiretroviral treatment, and hope that we can begin to turn around the spiralling rates of HIV infection occurring in Eastern Europe and Central Asia (EECA). Much of the media coverage focused on the intransigence of the government of the Russian Federation to changing its prevention policies around HIV/AIDS, namely via the supply of clean needles and opioid substitution therapy (OST) such as methadone. And with the number of people living with HIV in Russia now officially exceeding 900,000 compared to 250,000 a decade ago, and people using drugs still representing over 40% of newly diagnosed cases, that criticism is fair.

However this focus also obscures the fact that in Eastern Europe and Central Asia, which has been much maligned over the past decade for its slowness in responding to the HIV/AIDS epidemic, we are now beginning to see strong hints that public health initiatives based on scientific evidence are taking on a legitimacy across the region.

On a political level we are seeing increased awareness and leadership, for example the Russian Federation government for the first time adopted a state HIV/AIDS strategy followed by an action plan 2017-2020.

There is growing national dialogue across sectors in Kazakhstan, Kyrgyzstan, and Moldova on the back of national multi-partner AIDS conferences held in both countries in 2016 and 2017. Very significantly, Kazakhstan has now successfully transitioned from external financing from the Global Fund to Fight AIDS, TB and malaria to cover the majority of costs for their AIDS response from domestic sources.

Truly encouraging too has been the decision by the Ukrainian cities of Kiev, Odessa, and Balsi in Moldova and Almaty in Kazakhstan to associate themselves as Fast-Track Cities committed to reaching the 90-90-90 treatment target by 2020, the aim of which is to ensure that, by 2020, at least 90% of people living with HIV know their status, 90% of all people diagnosed with HIV infection will receive sustained antiretroviral therapy, and 90% of all people receiving antiretroviral therapy will have viral suppression.

Finally, and hugely important, we are now seeing significant health system reforms in countries like Ukraine and Kazakhstan that are vital to responding to the AIDS and TB epidemics more effectively and efficiently.

This groundswell of change in the region has been building up for some time now and we are seeing the fruits of it beginning to emerge.

Quite remarkably, nine of the 12 EECA countries now implement national programmes around OST, with Uzbekistan currently considering its uptake. Russia and Turkmenistan are certainly isolated on this front, by not implementing a similar strategy.

Armenia and Belarus have now officially been declared by the WHO as having eliminated the transmission of HIV from mother to child.

Equally encouraging is the increase by 13% in antiretroviral treatment coverage across the region in the last two years. Armenia, Belarus, Kazakhstan, Georgia and Ukraine have already adopted a “Test and Treat” strategy and several more countries in EECA are currently pending approval.

Lastly and perhaps a strong indicator of commitment to respond to the epidemic across the region is the significant headway being made across the region to reduce the high prices of antiretroviral drugs. The positive steps being made in the region on HIV/AIDS provides genuine hope. We will need to build on these growing expectations if we are to successfully overcome the barriers that have come to define the epidemic in the EECA. Despite the progress, new cases and AIDS-related mortality continue to increase as a result of previous neglect and inadequate policies over the past fifteen years. Some 400 000 people do not know their HIV positive status, antiretroviral therapy coverage is still the lowest among any region of the world, and prevention programmes are poorly funded and fail to reach the majority of those vulnerable groups at high risk of contracting HIV, and who also continue to be stigmatizsed, criminalised, and often denied access to services.

The growing signs that we may be seeing perceptible changes in HIV/AIDS responses from governments across the EECA region is cause for hope for those at risk of and living with the disease. Those changes will definitely need to be predicated on respect for the human rights of all people to have access to health care if we are truly to change the trajectory of the HIV epidemic in EECA.

Remarks given at the 40th Programme Coordinating Board meeting of UNAIDS in Geneva, June 27,  2017

Thank you Mr Chair.

Thank you Michel for your report and contextual analysis. Your words and those of the First Lady of Panama, strongly resonate for countries in Eastern Europe and central Asia.

Eight out of 12 countries in Eastern Europe and Central Asia, including the largest one, have been reporting a continuous increase in the number of new HIV infections and on an epidemic that continues to grow by about 10% per year.

Also of significant concern is the steady increase in the number of HIV-TB co-infections. The number of people living with HIV among newly diagnosed TB cases has doubled in the last five years; HIV-TB co-infection in the region, often means co-infection with resistant forms of TB.

Despite the acknowledged concentrated character of the epidemic, testing and access to prevention programs remains low among vulnerable groups of the population. Harm reduction programs for example, reach less than 10% of PWID in the region. Opioid maintenance therapy is now part of the national strategy in nine of the twelve countries of EECA but remains illegal in three.

Access to antiretroviral treatment also remains low, of less than 25% of those estimated to be in need, although these figures have been significantly increasing in several countries in the region in the last three years. The region has conducted strong and effective programs to prevent vertical transmission of HIV.

Stigma is high and many obstacles of societal, cultural, legislative and political nature remain. We still have much to do to ensure that the tremendous programmatic knowledge we have about how to respond to concentrated epidemics is more effectively translated into national strategies.

As a Special Envoy, I have conducted high level advocacy and dialogue to promote country-specific strategic priorities to fast-track the AIDS response. I focused on addressing the needs of key populations and on the issue of sustainable financing for the fight AIDS, TB, DR-TB and hepatitis in a region where funding from international sources has been diminishing or discontinued. More specifically, I also worked with local and international partners to ensure uninterrupted access to HIV and DR-TB treatment for people living in the conflict areas of Eastern Ukraine and for labor migrants in Central Asia.

It has been an honor to serve under Secretary General Ban Ki Moon whose commitment to the fight against HIV/AIDS and to the health of the most vulnerable I had learned and respected also throughout my years at the Global Fund. I welcome SG Guterres’s commitment to human rights and development.

I would like to particularly thank Michel for his support; thank the regional and country teams of UNAIDS, WHO, UNDP, UNODC, UNFPA and UNICEF for a truly excellent cooperation; thank the governments, civil society and community organizations in the region for a trustful relationship throughout these few years.

We need to maintain the international leverage and dialogue in the region.

I remain strongly positive, recognizing the progress that is being made, having faith in the wonderful people of the region and remaining confident that if we do what needs to be done, the fight against AIDS in the region will ultimately be won.

The commitments made by the governments to support access to treatment and care, defense of human rights, fight against inequality, discrimination, vulnerability and violence – and the values that underpin them – are always measured in the light of health and women’s rights.  We are all reminded of this in celebrating women today, on the occasion of International Women’s Day.

By placing women’s health and rights at the heart of the Sustainable Development goals adopted in September 2015, the international community recognizes their power for development. Despite the incredible progress made in recent years in global health, progress for women’s health remain insufficient.

– HIV / AIDS is the leading cause of death for women aged 15-44 worldwide and tuberculosis is among the top five causes of women death in this age bracket in low- and middle-income countries.

– Every week 7,500 women and girls aged 15-24 years, are infected with HIV. 60% of new HIV infections among 15-24 years old are contracted by girls and women. In HIV high burden countries, 80% of newly infected adolescents are girls.

– 35% of women worldwide have experienced intimate partner violence or non-partner sexual violence.

– 225 million women who do not wish to become pregnant, do not have access to modern contraception and family planning means. Every year, 74 million of unwanted pregnancies are counted in developing countries, which will result in 36 million of abortions and among them 21 million are unsafe generating about 13% of maternal deaths.

By reinstating the Global Gag Rule 101 on January 22, President Donald Trump directs the Secretary of State, the Administrator of USAID and the Secretary of Health and Human Services to take all necessary actions, to the extent allowable by law, to ensure that federal US public resources will not fund any organization or program supporting or participating in the management of coercive abortion or involuntary sterilization.

Consequently, any non-governmental US organization financed by federal funds, not only for family planning but also for global health, HIV / AIDS and maternal and child health may not provide nor promote services relevant to abortion or providing abortion as a method of family planning, nor inform nor advocate for such measures on both US and foreign soil. This prohibition applies to the entire activity of these organizations regardless of their source of funding. Should these organizations not comply with these prescriptions, they would lose all the resources from federal US funds, including those dedicated to the provision of condoms or modern contraceptives for women.

Those restrictions deny the major effects of sexual and reproductive health on women’s health, global health and development.

By increasing unwanted pregnancies, unsafe abortions, and maternal and child deaths, this decision endanger years of hard-won gains, not only from reproductive and maternal health, but also from the fight against HIV / AIDS and other sexually transmitted infections, as well as child health.

When a woman is able to choose the number of pregnancies, spacing between two births, she can better manage her resources and give her children better nutrition, better health and a better education. Giving children a better chance to live better is the right way to fight poverty.

Such restrictions alter the living forces of development. They destroy entire sections of global and community health services, expertise, know-how, and partnerships that are so difficult to build on.

Finally and even more severely, by limiting women’s rights, autonomy, ability to economically empower themselves and to support the development of their communities, they help to keep countries and populations in poverty.

The international community cannot ignore the consequences of these provisions and their impact on global health and development. It must mobilize any additional resources to continuously and sustainably provide all women and girls with the indispensable services that guarantee health, autonomy and rights.

 

Laurent VIGIER, former advisor of the French President, Jacques Chirac for International Summits and multilateral instruments – Chair of Friends of the Global Fund Europe Board

Heidemarie WIECZOREK-ZEUL, Former German Minister for Economic Cooperation and Development – Vice-Chair of Friends of the Global Fund Europe Board in charge of GERMANY

Charles GOERENS, former Minister of International Cooperation and Humanitarians Affairs, Member of the European Parliament – Vice-Chair of Friends of the Global Fund Europe Board in charge of The European Institutions – Luxembourg and Belgium

Stefano VELLA, Director of the Center for Global Health, Italian National Health Institute – Vice-Chair of Friends of the Global Fund Europe Board in charge of ITALY

Michèle BARZACH, former French Minister of Health – Member of Friends of the Global Fund Europe Board

Michel KAZATCHKINE, UN Secretary General Special Envoy on HIV/AIDS in Eastern Europe and Central Asia  – Member of Friends of the Global Fund Europe Board

Andris PIEBALGS, Former European Commissioner for Development – Member of Friends of the Global Fund Europe Board