Monitoring of the implementation of UNGASS Commitments HIV

Monitoring of the implementation of UNGASS Commitments: HIV Prevention among IDUs by Karl L. Dehne, UNAIDS, Vienna Senior Advisor on HIV and Drug Use March 2003 slide number 1

Presentation overview l UNGASS on HIV/AIDS commitments regarding IDUs l Original behavioural IDU indicator l Proposed (supplementary) service coverage indicator l First round results l Advantages and disadvantages of the two indicators l Conclusions March 2003 slide number 2

UNGASS ON HIV/AIDS DECLARATION OF COMMITMENT TARGETS l Reduce by 2003, HIV incidence for groups with high/increasing rates of infection l Develop/strengthen, by 2003, national strategies to promote health of groups with high rates of HIV infection, e. g. injecting drug users l Ensure, by 2005, a wide range of prevention programmes, including efforts to reduce drug use related harm March 2003 slide number 3

10 Areas of Commitment l Leadership Prevention Care, support and treatment Human rights Reducing vulnerability l Orphans l l l l Social and economic impact Research and development Conflicts and disasters Resources IDU commitment interpreted as “prevention” March 2003 slide number 4

Behavioural indicator (1) • Definition: • Percentage of injecting drug users who have adopted safe behaviours (avoided equipment sharing last 30 days and used condom on last intercourse). • Purpose • To assess progress in preventing IDU associated HIV transmission • Applicability • Countries where injecting drug use is a significant mode of HIV transmission • Frequency • Biennial March 2003 slide number 5

Safe injecting and sexual practices (2) • Method of measurement: • Cluster sample or targeted snowball sample survey (BSS style) • Sequence of 4 questions (injected? shared? had sex? Used condoms? ) • Score of those replying yes for denominator (1+3) and numerator (2+4) • Interpretation: • Gaining access to IDUs a challenge (especially where there are no services!), survey data rarely representative nationally • Extent of IDU related HIV epidemic also dependent on size of vulnerable population March 2003 slide number 6

Coverage indicator (1) • Definition: • Percentage of injecting drug users reached during last month with either (outreach) prevention services or drug dependence treatment, either longer-term drug-free or substitution therapy • Purpose • To assess progress in the implementation of programmes and services for the prevention of HIV transmission associated with injecting drug use • Applicability • Countries where injecting drug use is a significant mode of HIV transmission • Frequency • Biennial March 2003 slide number 7

Coverage indicator (2) • Measurement • • Denominator (estimated number of regular IDUs): • Multipliers, as many as possible • If possible, other methods (e. g. capture-recapture) • Extrapolate from cities, regions/provinces • In reality, often multiplier “guesstimate Numerator • Inventory of outreach projects and treatment sites • Service statistics (No. of individual clients last month) • Interpretation • Denominator data will have a considerable margin of error: best available estimates • Different types of services (outreach with provision of advice, counselling only, needle-syringe programmes, various types of treatment) all be weighted the same March 2003 slide number 8

Coverage indicator, definitions (1) • Outreach • Any designated programme activity through which injecting drug users have contact (face-to-face interaction) with service providers, including, for example, outreach workers, trust points, counselling centres or clinics, mobile services, etc. , and are provided with one of the following • Information on HIV/AIDS • Counselling on safer injecting methods • Clean needles, syringes and condoms • Outreach can be conducted by professional health care workers as well as by volunteer peer workers (current or ex-drug users). Outreach does not include activities, where there is no face-to-face contact between service provider and drug injector, e. g. media campaigns March 2003 slide number 9

Supplemental IDU indicator, definitions (2) • Substitution treatment • Any activity, in which daily* and for a longer period of time (more than 6 months) a substitute for opiates is provided; most common substitution therapies include methadone maintenance and provision of buprenorphine. Note that drug-assisted detoxification is not considered substitution therapy • Drug-free dependence treatment • Any residential treatment lasting more than four weeks with the goal of total abstinence, including for instance, therapeutic communities; any longer-term (designed for 6 months and more) drug -free outpatient treatment, in which the individual has had contacted at least once during the last 30 days • For the purpose of estimating the numerator, detoxificationonly in whatever form is not considered treatment March 2003 slide number 10

Some preliminary results l 20 countries approached, in extra effort to obtain IDU UNGASS indicator results l Coverage indicator results obtained from 9 countries (plus some in-official results) l Behavioural indicator results obtained from 3 countries March 2003 slide number 11

IDU Service Coverage in Selected Countries COUNTRY Belarus Estimated No. of IDUs % IDUs reached with prevention services in last month 50, 000 1. 8 Brazil 800, 000 10. 5 China* 400, 000 5. 0 Indonesia 160, 000 1. 5 Iran* 135, 000 0. 6 Nepal 20, 000 21. 9 Pakistan 60, 000 0. 4 Romania 30, 000 2. 2 Viet Nam 84, 000 62. 7 *reported by UN staff March 2003 slide number 12

Other important countries Coverage indicator results not reported COUNTRY Estimated No. of IDUs % IDUs reached with prevention services Ukraine 540, 000 10 -15 Russian Federation 1. 5 -2. 5 million India March 2003 slide number 13 0. 5 -1. 6 million < 10 ?

Behavioural indicator results COUNTRY Ukraine Kazakstan Surinam March 2003 slide number 14 No. of IDUs sampled 600 % IDUs reporting safe behaviours 65 1365 14. 5 9 0

Summary of differences and commonalities l Impact (like young people’s behaviour) versus service coverage (like MTCT) l Both composite (IDU & sexual behaviours and different type of services respectively), requiring analysis by individual component l Both would require aggregation or extrapolation from local sites to national level March 2003 slide number 15

Differences & commonalities (2) l Measurement of both indicators requires extra efforts beyond existing data compilation in most countries, but…. . l Promotion of coverage indicator measurement process may be more beneficial for program development (e. g. inventories, intersectoral consultations on IDU population size) than series of behavioural surveys l Political commitment versus commitment of IDUs March 2003 slide number 16

Additional interpretation issues l Behavioral indicator: – Safe behaviours: only those reached? Consistent over time? Definition of sharing – Unsafe behaviours: risk of blaming the addicted l Coverage indicator – Official underestimates of No. of IDUs – Quality of services – Definition of treatment (e. g. Vietnam) March 2003 slide number 17

Issues related to current patterns of IDU epidemics and responses l IDU population size crucial (and important vulnerability factor) l Drug dependency tends to make a significant “spontaneous” reduction in risk behaviours, in the absence of face-to-face service contacts, unlikely, and …. l … prevention service currently coverage low (care service coverage virtually non-existent) March 2003 slide number 18

Conclusion l Prevention service coverage indicator currently most appropriate l Behavioural and/or HIV prevalence indicator to be used in addition, where either – epidemic is recent, or – service coverage is significant and likely to have an impact March 2003 slide number 19