Global experts called on health and justice officials throughout the world to provide TB and HIV care and treatment for drug users during a press conference at the AIDS 2008 Conference in Mexico City this week.
“Increasingly, the HIV epidemic and its effects, and TB, are being localised to vulnerable groups, in this case drug users, of whom only a small percentage are accessing the services they need,” said Dr Paul Nunn, who coordinates TB and HIV activities of the Stop TB Department at the World Health Organisation (WHO).
Drug users, especially injecting drug users (IDUs) are marginalised, facing discrimination, homelessness, imprisonment and other barriers when trying to access care.
To help make sure that drug users, including those in prison, can receive TB/HIV care, the WHO, UNAIDS and the UN Office on Drugs and Crime (UNODC) have developed the new Policy Guidelines for Collaborative TB and HIV Services for Injecting and Other Drug Users — An Integrated Approach
The drug using population at risk of HIV and TB
“There are about 25 million people [worldwide] who are dependent on drugs, and of them, around 13 million who are injecting drug users — and these people are really very highly vulnerable to HIV and very vulnerable to TB,” said Christian Kroll of UNODC.
Injecting drug use is major route of HIV transmission in most of the world.
“It’s estimated that about 10% of the overall HIV infections are injecting drug users which makes it a figure of 3.3 to 3.5 million people globally,” said Professor Michel Kazatchkine of the Global Fund for AIDS, TB and Malaria. “When it comes to the prevalence of HIV infections among injecting drug users, those figures are fairly low in Western Europe or Australia but as high as 50% in China, Myanmar, Estonia, and a number of other countries.”
Long before the HIV epidemic, drug users have been at a higher risk of TB. However, just as HIV amplified the TB epidemic in sub-Saharan Africa, it has driven an increase in the burden of TB among drug users.
“HIV has lit the fuse of TB on drug users — when it diminishes the immune response, it significantly encourages the development of active TB from latent TB in that it is already present,” said Dr Nunn. People with HIV are up to 50 times more likely to develop active TB in their lifetimes.
The problem has been made more urgent by the increase in multi-drug resistant TB (MDR-TB) and now extensively drug resistant TB (XDR-TB) — which data suggests could be more likely in people with HIV. Exposure to TB in prisons compounds the problem.
“Many drug users end up in prisons. And at any given time, the prison population worldwide is at least 10 million prisoners and there is an annual turnover of 30 million. So, prison situations are situations of overcrowding,” said Kroll.
With poor infection control in most prisons and other facilities providing services to drug users, the risk of TB outbreaks can be extremely high — threatening drug users, other prisoners and contacts and staff working in those facilities.
Drug users have poor access to care
“IDUs just do not access medical services,” said Prof Kazatchkine. “We do not have very solid data, but it’s not unreasonable to say that only about 10% of injecting drug users access proper care for HIV and for injecting drug users in prisons, the figure is lower.”
Barriers are often put in place by the health system itself, which has separate policies and structures for drug users.
“Medical professionals in these countries often talk about drug users failing treatment but in reality, in many instances the health systems are failing the drug users,” said Daniel Wolfe, Director of the International Harm Reduction Development Program (part of the Open Society Institute). “Injection drug users with TB and HIV, for example, are consistently shunted from one clinic to the next with each clinic saying that they should be getting treatment somewhere else,” said Wolfe.
“When injection drug users are forced to choose between HIV treatment and TB treatment and drug treatment, we are clearly failing them,” said Michael Bartos of UNAIDS. “When drug users feel that they are not welcome at an HIV programme or TB clinic, then we are missing major opportunities that we can’t afford to miss.”
“We routinely ask for drug users to make impossible choices regarding treatment. In the Ukraine, for example, where the largest number of AIDS-related deaths are due to TB, you cannot get the detoxification for drug dependence if you have active tuberculosis, and you cannot receive treatment for addiction at the tuberculosis hospital,” said Wolfe.
“If you are among the few lucky enough to be prescribed methadone or buprenorphine, and you also have TB, you have to choose whether to give up that substitution treatment and get the TB treatment or whether to continue on the medication that maintains you and frees you from drug addiction. Obviously many patients are unable to make the choice.”
“In Russia, there is no substitution treatment but you are also ineligible for inpatient drug treatment if you have tuberculosis,” he continued.
“In Vietnam, China and Malaysia, where the largest share of HIV infections are due to injection, the UNODC estimates that there are 200,000 drug users interned at compulsory treatment centres that often offer no treatment at all except compulsory labour, military style drills, etc.. These facilities generally offer no ART despite HIV prevalence of up to 50%. TB testing, treatment and control is inadequate or absent. And with terms of detention stretching for as long as five years, many drug users actually acquire TB in the treatment centres that are supposed to be helping them.”
Effective interventions
Provision of integrated or collocated services can be complicated. It is possible that the absence of guidance contributed to the perception that TB and HIV services are contraindicated in drug users.
“There are standard and simple solutions that need to be implemented — irrespective of the fact that they are drug users or prisoners and have particular difficulties being marginalized or being outside society in some countries,” said Dr Charlie Gilks of the HIV Department of WHO. “From WHO’s perspective, we deal with people’s health problems according to their needs, not according to how they have become at risk of those health problems.”
Drug users need to be provided with HIV services including testing, prevention, treatment and care, including antiretroviral therapy if indicated. In addition, the three I’s, TB intensified case finding, isoniazid preventive therapy and infection control are essential to reduce the burden of TB. Dr Gilks highlighted the importance of infection control.
“In congregate settings — particularly prisons, hospitals or treatment centers where drug users may attend — there is a high risk of person to person transmission of tuberculosis, but the healthcare workers are also at risk. Better infection control (IC) is an absolute priority,” he said.
The complete recommendations are summarised at the end of the article.
Moving to implementation
“The services that drug users require are now laid out; the responsibility now passes to national managers to make sure that they are implemented,” said Dr Nunn.
Indeed, the real challenge may be getting national government to change the way they see their citizens who are drug users.
“I don’t know how these policy guidelines are going to be operationalised in places where discriminatory legislation exists,” said one member in the audience.
“A high degree of coordination will be needed at country level in relation to service provision in relation to different authorities, and there are challenges there: drug control authorities, health ministries, AIDS programmes are not necessarily in the habit of talking to one another,” agreed Bartos.
“If there isn’t a positive policy environment, you can only do very little,” said Stoll. “In countries where you criminalise drug use, where you put drug users in jail, you can have hundreds of guidelines and nothing will happen. And in some cases, it is not necessarily a problem at the national level, but there is often a problem at the local level. In many cases you have a wonderful national policy, but at the local level, you still have a very suppressive, stigmatising environment. Drug users need to be seen as people who have a medical need and a right to services.”
“If these recommendations are to move from paper to practice, it is critical that community organisations, NGOs, and local WHO offices make sure that communities and governments receive this message,” said Wolfe.
Summary of Guidelines for Collaborative TB and HIV Services for Injecting and Other Drug Users
(the complete policy can be downloaded here)
The policy contains thirteen primary recommendations under three headings.
Joint planning
Service delivery will have to be planned to make certain that drug users can access the services they need when and where they need them:
- Multisectoral coordination of TB and HIV services for drug users at the local and national level. Health and criminal justice authorities will need to work together.
- National plans with roles and responsibilities of service providers. National strategic plans for TB, HIV and substance misuse should clearly define roles and responsibilities of service providers, including monitoring and evaluation of services provided.
- Staff training to build effective teams. There should be adequate numbers of personnel as well as education and training to make certain that existing personnel are equipped to deal with HIV and TB in drug users
- Operational research on TB/HIV services for drug users. Support and encourage research to demonstrate how collaborative TB/HIV services are implemented most efficiently and effectively
Key Interventions
Services to reduce the burden of TB and HIV among drug users
- TB infection control in congregate settings including prisons. Every health, drug services or criminal justice facility where drug users congregate should have a TB infection control plan to reduce TB transmission
- Case-finding protocol for TB and HIV for facilities or organisations working with drug users. Any organisation providing services for drug users should train their staff to recognise signs and symptoms of TB and HIV and have protocols to screen for the diseases in their clients, preferably by providing appropriate TB screening and HIV testing and counselling on site.
- Ensure access to all appropriate treatments for drug users. TB is curable with appropriate TB therapy, and HIV is a chronic manageable condition with antiretroviral therapy. Drug users often require multiple concurrent treatment regimens to help manage other common infections such as hepatitis B or C and conditions related to drug dependency. There are established clinical guidelines describing how these can be given together effectively.
- Isoniazid preventive therapy (IPT) to prevent active TB in drug users living with HIV. A course of IPT should be given to all people living with HIV once active TB is reasonably excluded.
- Personnel working with drug users should be aware of HIV risk factors, and provide comprehensive HIV prevention services.
- Sharing injecting equipment and sex are factors for HIV transmission. Personnel should also know how to protect themselves from occupational exposure.
Overcoming Barriers
HIV, TB treatment programmes and services for drug users can organise themselves to overcome the many barriers, such as stigma from health workers, law enforcement personnel and social service workers, which contribute to much poorer health outcomes among drug users.
- Universal access to TB and HIV prevention, treatment and care as well as drug treatment services to drug users. All services for drug users should collaborate locally with key partners to provide universal access to HIV/TB treatment and care and drug treatment in a way that is convenient for the client.
- Quality medical services available to prisoners. Drug users are at high risk of being imprisoned where conditions put them at risk of TB and HIV infection, with poor or irregular access to care and treatment. But prisoners should be able to access (continuous) care equivalent to that received by the civilian population, conforming to internationally accepted standards.
- Treatment adherence support measures for drug users. Adherence support should be tailored to the specific needs of drug users to ensure the best treatment TB/HIV outcomes, reduce the risk of resistance and the risk of transmission to others.
Other infections (e.g. hepatitis) and factors should not prevent drug users accessing HIV and TB treatments. Hepatitis does not contraindicate TB or HIV treatment, and mental health issues and drug or alcohol use are not reasons to withhold treatment.