Recomendados
Recomendados
Mais conteúdo relacionado
Mais procurados
Mais procurados (20)
Semelhante a Harm reduction atma jaya
Semelhante a Harm reduction atma jaya (20)
Mais de Herrupribadi77
Mais de Herrupribadi77 (8)
Último
Último (20)
Harm reduction atma jaya
- 1. HIV, harm reduction and the right to the highest attainable standard of health Adeeba Kamarulzaman
- 2. Estimated numbers of IDUs and regional prevalence of HIV in people who inject drugs, 2010 * No countries have a prevalence of 5% to <10% Copyright, The Lancet 16 million people in 148 countries inject drugs 3.3 – 6 million people inject drugs and are HIV+ve
- 5. Current Response Where 3 programmes work together, at all levels : Negative consequences of drug use can be reduced Long term problem of drug use can itself be addressed Supply Reduction Supply Reduction Demand Reduction Harm Reduction
- 13. Evidence of Effectiveness of Needle Syringe Program
- 15. HIV seroprevalence in cities with and without NSPs Hurley Lancet 1997
- 18. Evidence of Effectiveness of Drug Dependence Treatment in HIV Prevention
- 21. HIV infection rates in and out of substitution treatment (Metzger et al. 1993) Out % In %
- 28. Intervention coverage – crucial, but often inadequate Coverage of target population is critical for HIV prevention
- 29. NSP Coverage in Malaysia * assuming 400 injections per IDU/year COVERAGE IDU population No. of NSP IDUs in contact % IDUs contact Syringes distributed (year) % all injections with a syringe from a NSP* 135 000 9 (110) 5500 4% 750 000 1.3 %
- 32. Harm Reduction IS Effective What Are the Obstacles?
- 33. What Are The Obstacles? Political will – lack of are there votes in harm reduction? Denial national immunity myths Legal restriction laws against outreach, needle distribution, ST drugs classed as ‘narcotics Prejudice – medical, political, societal HR, ST ‘condones drug use’, Lack of concern and compassion drug users ‘have selves to blame’, ‘God’s punishment’ Disinformation campaigns misuse of science Reliance on law enforcement… … rather than public health Imbalance between prevention and care too much emphasis on, excitement about, clinical issues
- 38. Harm reduction 20 years of experience Human rights Public health Two strands, shared ethos Evidence based Assessment based Pragmatic Targeted Realistic goals Rights to: Life and security Health protection Medical care Protection against hurts from community and state Ethos: Facilitative Non-coercive Non-punitive Cooperative
Notas do Editor
- Harm minimisation refers to policies and programs aimed at reducing drug-related harm. Harm minimisation aims to improve health, social and economic outcomes for both the community and the individual and encompasses a wide range of integrated approaches, including • supply-reduction strategies designed to disrupt the production and supply of illicit drugs; • demand-reduction strategies designed to prevent the uptake of harmful drug use, including abstinence-oriented strategies to reduce drug use; • a range of targeted harm-reduction strategies designed to reduce drug-related harm for particular individuals and communities.’ National Drug Strategic Framework 1998-99 to 2002-03 15 These strategy areas are not mutually exclusive – some activities will relate to more than one strategic area.
- So moving onto the findings from the review of the evidence for whether drug treatment is effective in preventing HIV in IDUs. During the course of this review, effectiveness has been considered in terms of seroprevalence in injecting drug users - (both in and out of treatment) and rates of seroconversion. However, studies that have measured these aspects of effectiveness are few in number – so the review places most emphasis on the effect of treatment on behaviours associated with high risk of HIV transmission namely: injecting drug use, sharing of injecting equipment number of sexual partners unprotected sexual activity
- The authors identified two studies that reported lower prevalence of HIV in Injecting Drug Users in methadone maintenance treatment. However, it is important to note that the extent to which the lower seroprevalence is actually due to participation in treatment is unclear. For example, Tidone and colleagues clients commencing MMT showed a significantly higher incidence of HIV infection than others already in treatment - suggesting that methadone treatment may help in preventing HIV diffusion. There were also very few studies of HIV seroconversion rates. This is probably because large numbers of participants and long periods of time are needed in order for such studies to achieve statistical significance. However, a study by Metzger reported seroconversion rates of 3.5% for drug users in treatment, compared to 22% for those not in treatment over an 18 month period.
- This slide illustrates data from this study showing differences in HIV infection rates among IDUs in and out of substitution treatment. As you an see the rates of infection were much higher in those not in treatment.
- The authors also examined a number of other key treatment outcomes relating to risk– particularly around injecting practices and sexual behaviours. 11 studies that examined treatment outcomes in terms of injecting drug use were identified: 8 focusing on methadone maintenance treatment, 1 on Buprenorphine maintenance, 1 Naltrexone study and 1 Drug Free. Overall there were lower rates of injecting drug use among those in treatment and in particular, all the methadone maintenance studies showed a reduced frequency of injecting together with an increased likelihood of NOT injecting. In terms of sharing injecting equipment, all 11 studies showed evidence linking treatment with reduced risk. Those in treatment were more likely to use effective methods to clean their injecting equipment and were less likely to share equipment with other users.
- Eight studies addressed sex-related risks for HIV infection. These mainly examined continued work in the sex industry and the total number of sexual partners reported by drug users. Overall, seven of these studies showed a reduction in sex-related risks associated with treatment. Finally three studies examined overall HIV infection risk. All of these were outcome studies of Methadone Maintenance Treatment and all three showed reduced global risks in terms of drug and sex-related behaviours.
- Now, the studies that have tended to have the BIGGEST impact on social policy are descriptive outcome studies and so the authors included these in their review. These sorts of observational studies are particularly important because they measure the impact of treatment in real life settings in different geographical areas and across different types of treatment. Two such studies are the Drug Abuse Treatment Outcome Study (DATOS) in the United States and the National Treatment Outcome Study (NTORS) in the United Kingdom . Both are major multi-site pre-post studies of treatment impact. Overall these studies consistently report a significant impact of treatment on injecting behaviours. - while for some individuals injecting is eliminated , for many, the impact of the treatment is to reduce the frequency of the behaviour and to reduce the rate of equipment sharing . For example, DATOS found that all modalities of treatment reduced injecting risk significantly. NTORS reported that injecting rates fell from 60% at intake to 37% at 4-5 years follow up and the rate of self reported sharing was reduced by two thirds.
- Now the review contains a lot of detail on a range of treatment types which I’ve had to condense considerably. KEY findings concerning the effectiveness of methadone maintenance treatment include the following: First of all, there is strong evidence that increasing methadone doses result in better retention in treatment and less heroin use. Secondly, it seems that there is moderate evidence that the most effective methadone maintenance treatment programs use doses of at least 60mg/day and are oriented towards maintenance rather than abstinence.
- Thirdly, there is strong evidence to support the assertion that methadone maintenance substantially reduces heroin use. And that this type of treatment is more effective than no treatment or placebo at reducing rates of imprisonment, reducing heroin use, retaining clients in treatment, and supporting employment or return to further education. Overall, the key finding for both buprenorphine and LAAM were very similar to those for MMT – so higher doses were associated with better retention in treatment, lower rates of heroin use and use of other illicit drugs.
- Generally, the evidence found for the effectiveness of abstinence -based treatments was less compelling. There was SOME evidence to suggest that rates of dropout from residential rehabilitation programs are very high in the early stages of treatment but then decline. There was also SOME evidence that at least three months of treatment is required in order to achieve change. Those who complete residential rehabilitation programs, are subsequently less involved in drug use and criminal behaviour, and report increased legal employment And finally there was a LITTLE evidence to suggest that Treatment PROGRESS , NOT just time in treatment, is predictive of good outcomes.