Fundao Oswaldo Cruz FIOCRUZ Oswaldo Cruz Foundation The

Fundação Oswaldo Cruz (FIOCRUZ) Oswaldo Cruz Foundation The comprehensive management of people living with AIDS who misuse cocaine in the context of universal access to highly active antiretroviral therapy in RJ, Brazil Francisco Inácio Bastos & Mônica Malta

Figure 1. Coca growing regions, 2003 – 2007 Andean countries produce 95% of the world’s cocaine Source: UNODC 2007 World Drug Report Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Figure 2. Accumulated AIDS incidence among IDUs (per 100, 000 inhab. ) Brazil, 1984 -2000. Source: Hacker et al. , 2006 (Cad Saude Pública) Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

HAART in Brazil n In 1996 Brazil became the first developing country to provide full access to combination ARV therapies and laboratory monitoring at no cost. n As of June 2007, ~180, 000 patients (80% of people in need of treatment) in the country were receiving HAART. Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

The dynamics of cocaine use and treatment in Brazil Shift from cocaine powder to crack cocaine. n Binge use common, with high frequency of injections. n Limited use of heroin, so negligible importance of methadone maintenence therapy. n Treatment dropout and readmission common. n Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Challenges? Providing care and support to PLWHA who use drugs in Brazil presents special challenges because of the combined effects of addiction, poverty, stigma, and discrimination. Challenges include: § Dynamic and changing nature of cocaine use and HIV infection. § Limitations of most drug treatment centers and ARV dispensing units. § Lack of well-trained and motivated staff to manage and care for patients with various comorbidities. Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

FIOCRUZ Model n Partnership with Alcoholics Anonymous (AA) n Partnership with a therapeutic community n Support from stakeholders n Waiting room debates: a successful but brief intervention n Provision of food and hygiene Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Case Management Individualized care and support. n Self-help groups. n Initial evaluation by a physician, a psychologist, and a social worker. n Cases demanding special management and support personally reviewed by a management team member and discussed with other staff. n n Beds and showers on site. Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Results Optimal management of drug users living with HIV/AIDS is feasible and does no require large amounts of money/large staff n Staff can be motivated and trained on-site n People with different backgrounds, affiliations and points of view about management of “drug addiction” (from harm reduction to strictly-abstinence oriented) can work together, cooperatively n Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Lessons Learned Open collaboration, mutual trust, and respect for different viewpoints key for a large and diverse staff. n Important both in terms of services offered (eg. injection equipment) and communication to address complex issues facing an impoverished clientele. n Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Beyond Provision n Providing ARVs involves much more than simply offering them. n Evaluation is key. Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Much to be Done n n Training of staff to work with drug users still badly needed in most setting in Brazil. Better coordination at national, state, and municipal levels is necessary. Key players include: n n n Research projects Religious institutions Federal government (provision of ARV) Municipal government (provision of medicines for the management of opportunistic infections) Professionals who donate their time and effort on a voluntary basis Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Prospects for the Future n n n Specific projects targeting people who use illicit drugs and alcohol should be a top priority in this setting. Success is possible with a well-integrated team, modest funds, and good collaboration with government institutions. Replication in poorer contexts and communities affected by much larger epidemics may be difficult, but we hope this model paves the way for other groups to implement similar initiatives. Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ