Opioid dependence treatment & HIV/AIDS management

WHO Collaborative Research Project on Drug Dependence Treatment and HIV/AIDS

 

Beijing, 29 May – 2 June 2006

 

Dr A Wodak, St. Vincent’s Hospital,

Sydney, Australia

 

‘We should spend more time on

practical matters.

That means saying less and doing

more’.

Deng Xiao Ping

Methadone and HIV control

•      Several excellent rigorous reviews

•      Effectiveness methadone HIV control  shown many, high quality studies

•      Reported effect size varies but all from moderate to considerable        

Selected Reviews

•       Gowing L, Farrell M, Bornemann R & Ali R. 2004 Substitution treatment of injecting opioid users for prevention of HIV infection (Cochrane Review). In: The Cochrane Library, Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd.

 

•       Gibson DR; Flynn NM; McCarthy JJ Effectiveness of methadone treatment in reducing HIV risk behavior and HIV seroconversion among injecting drug users [editorial] AIDS, 1999 Oct, 13:14, 1807-18

Reviews: 2

•       Evidence for Action. Technical Papers. Effectiveness of Drug Dependence Treatment in Preventing HIV among Injecting Drug Users.

     http://www.synergyaids.com/documents/DrugDependence_finaldraft.pdf

 

•       WHO/UNODC/UNAIDS position paper: Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention            http://www.who.int/substance_abuse/publications/en/PositionPaper_English.pdf

Questions:

Moving from advocacy to implementation phase:

 

•             Does methadone reduce HIV?

        # Abundant, quality evidence confirms benefit

 

•             Does methadone improve ART?

        # Sufficient data shows clear benefit

 

•             How maximise population benefit of methadone on HIV control?

        # Limited direct data, some indirect

       

How improve HIV control?

•           How much coverage?

•           How establish high coverage quickly?

•           How achieve acceptable retention?

•           Identify, overcome barriers to high retention

•           How achieve quality control?

•           Are there special populations?

•           How to support a healthy system?

Importance of high coverage

•      How to estimate denominator?

•      What should coverage be?

•      How define coverage?

•      What should coverage goals be?

•      Higher coverage needed if HIV prevalence already high

•      How estimate size unmet demand?

Establishing high coverage quickly

•      Importance of primary health care

•      Do not have luxury of time

•      Expanding too quickly risks quality control problems, sustainability

•      Expanding too slowly risks HIV epidemic continuing to spread

•      But many examples of rapid expansion with minimal quality problems

Methadone Rx in NYC 1970-72
Acknowledgement: RG Newman

Hong Kong, 1975-76
Acknowledgement: RG Newman

•     End 1974: one “pilot” programme, 500 patients

 

 

•     End 1976: approximately 10,000 enrolled

 

•     Admissions to voluntary in-patient drug-free programmes stable 1974-76: 2,300-2,500/year

 

Australia 1985-2003
Acknowledgement: RG Newman

Germany, 1987-2001
Acknowledgement: RG Newman

Methadone & Buprenorphine,
France 1996-2001 Acknowledgement: RG Newman

Rapid expansion

•      Plan targets: patient/clinic numbers x target date

•      Estimate needs: staff; computers; accommodation; administration; medication; funding

•      Planning training critical – long lags

•      Quality control systems

 

‘The really nice thing about not

planning is that failure comes as a

complete surprise’

Importance of high retention

•      High retention: good proxy for program effectiveness

•      Low retention and cycling: costly, inefficient, ineffective HIV prevention

•      Shorter retention higher HIV incidence

•      Measurement problems: definitions, collecting data

Identifying barriers to high retention

•      Variance mainly (80%) treatment factors

•      Low dose

•      Poor staff morale, poor quality director

•      Cost of methadone treatment: 12 months retention - free 54%; $2.50/day 34%

      Maddux, Priboda, Desmond   1994

      Treatment Fees and Retention in Methadone Maintenance

•      Rigid program, low satisfaction

•      Inconvenience; police antagonism

Overcoming these barriers

•      Higher dose

•      Maintenance approach, harm reduction orientation

•      High staff morale, good director

•      Free

•      Strong police support

•      Reasonable funding

•      Integrating with ARV

Overcoming these barriers: 2

•      Convenient location, times

•      Many choices

•      One stop shop

•      Seamless continuity: community, hospital, prison

•      Patient input into treatment

•      Take away doses

Quality control

•      Quality assurance program?

•      Mortality review?

•      Complaint system?

•      Regular reviews, audit, accreditation

•      Research evaluation?

•      Good data systems: local, state

•      Quality/quantity trade off?

Special populations

•      Why are ‘special populations’ important?

•      Who? Bridge populations: e.g. injecting drug users + commercial sex workers or men who have sex with men

•      Prison inmates: pre-release or continuous

Supporting a healthy system

•      Critical role: central / province health department

•      Registration systems, monitoring

•      Guidelines, protocols

•      Networking, e-mail, internet

•      Conferences

•      Training, accrediting doctors

Supporting a healthy system: 2

•      Organisations for professionals

•      Involve patients in governance structures

Supporting a healthy system: 3

‘Regulating controversial programs for

unpopular people: methadone

maintenance and syringe exchange

programs’. Des Jarlais, Paone, Friedman,

Peyser Newman. 1995

Summary

•             Effectiveness methadone HIV control now well established

•             Current focus implementation

•             Coverage critical: setting, achieving targets

•             Many examples of rapid expansion without problems

•             Achieving high retention critical

Summary: 2

•             Less known about good quality control

•             Methadone Rx in prisons critical for HIV control

•             Need extensive primary health care to achieve coverage

•             ARV with methadone effective, ARV without  methadone ineffective

•             Cardinal principal: ‘never let the best be the enemy of the good’

 

‘Current policy puts too much

emphasis on protecting society from

methadone and not enough on

protecting society from the epidemics

of addiction, violence and infections

that methadone can help reduce’.

Institute of Medicine, 1995

 

While drug users find it easier and

more attractive  to get help from a drug

dealer than from a drug treatment

centre, the drug epidemic will continue

to expand and HIV will continue to

spread