Pangaea Program Brief: Injection Drug Using Populations

General Background

Pangaea has a long-standing history of work in the field of injection drug use and the overlap with HIV/AIDS. Positioned in San Francisco, Pangaea board and staff members have been involved in and led efforts to bring appropriate care and treatment to IDU populations with a particular emphasis on providing complementary HIV prevention and treatment services. Most recent work has focused on the on-going development of HIV and drug treatment programs for IDUs in both China and Ukraine through a partnership with the Clinton Foundation HIV/AIDS Initiative.

Pangaea’s primary focus in working in regions with IDU-driven HIV epidemics is to develop HIV related program delivery that allows IDUs to have access to a comprehensive range of HIV prevention and treatment services, including ART, with high retention rates. In past and current initiatives this has meant taking HIV prevention and treatment strategies proven effective in general populations and tailoring services to the meet the specific needs of IDU populations. To do this effectively, the fields of substance use and HIV have been brought together to deliver a full range of services from both domains, but in an integrated manner. Linkages with available social services and engagement of law enforcement have also been used to reduce barriers to services and to increase the range of services provided beyond medical interventions.

Core Competencies in IDU Populations

Pangaea is committed to seeing HIV transmission among IDU populations limited and to raising the general standard of care for HIV-infected IDUs. The following are areas of focus in which Pangaea has direct experience.

a. Technical assistance to national and regional governments.

At the national level, Pangaea has worked with governments to develop and implement countrywide plans for providing HIV/AIDS care and treatment for injection drug users. Pangaea’s role has been to work with the national and regional ministries of health to define plans for expanding care and linking prevention with treatment. Program plans build on existing health care and public health infrastructure and support the development of human resource capacity to implement treatment. Pangaea professionals are also capable of providing assistance in the development of national ARV treatment guidelines, clinical training, development of regional systems of care; special programs targeted most at-risk populations, and development of systems for monitoring and evaluation.

b. Integrated drug treatment and HIV care service delivery.

Effective drug treatment programs, including opiate substitution therapy (OST), provide an opportunity to bring stability to a drug user allowing for effective treatment and prevention of communicable diseases including HIV and TB. Pangaea has developed integrated treatment services to provide a single point-of-care for drug users. This has meant identifying clinical service delivery sites for both methadone and HIV and finding ways to combine these services. This includes bringing methadone into an HIV clinic and HIV treatment services into a methadone/drug treatment center designed to help scale up services and increase coverage for IDUs to ensure that opportunities are not missed to reach IDUs who may enter either the methadone treatment or HIV treatment system. Implementing this plan has required:

facilitating discussions between different areas within the MoH and regional governments to allow for integration of services;
review and amendment of national methadone prescribing procedures and standard protocols;
installing controls for methadone storage and accountability and design of patient selection and preparation procedures;
identifying access points to IDUs both clinical and social and developing partnerships with IDU peer networks;
reducing barriers to counseling and testing, implementing highly accessible counseling and testing, and developing methods to track referral of HIV positive persons to treatment facilitates;
combining HIV treatment and drug treatment in a single venue to increase patient retention and reduce loss of follow-up;
providing substitution therapy to stabilize drug use and provide an option for initiation of ART strong adherence support;
cross training of health care providers in the fields of HIV and drug treatment;
providing on-going HIV prevention services to HIV negative IDUs; and
establishing treatment programs within correctional/detention facilities with mechanisms for transfer of care once persons are released back into the community.

Although fully integrated HIV and drug treatment services may be desirable from an efficiency perspective, in some contexts where this has not been possible Pangaea has been able to facilitate necessary connections across bureaucracies, developing new working relationships between hospital clinicians and methadone-trained public health doctors. In several settings Pangaea has taken hospital-based clinicians to the methadone centers to provide patient consultation and hands-on training. In such circumstances we look to develop virtual integration with improved communication between providers.

c. Health care provider training and civil society engagement.

In collaboration with in-country partners Pangaea has developed and/or led in the following activities:

Sensitization training for civil society and public leaders in the utility of methadone and an overview of program purpose to reduce opposition and acquire support or acceptance of OST program.
Training for nurses and counselors in how to approach a drug-using patient to increase patient retention and appropriate treatment planning. This has included discussions on the reasons for drug use, patterns of use, and the impact of drug use on the life and family of a drug user. Panel discussions with drug users and interactive sessions have raised awareness of the hardships of addiction. Clinical training includes introduction of addiction assessment tools, questions to use in history taking and how to deal with an aggressive client.
Clinical training on methadone alone and on methadone/HIV combined. This has included dosing, treatment of overdoses, appropriate monitoring, how to find appropriate levels of methadone for an individual client to stabilize cravings, and assessment of other clinical problems (infections, abscesses, TB, STIs etc). Combined HIV/TB includes drug-drug interactions, drug switches, adherence strategies and how to initiate ART for a person on OST.
Training on the presence and effect of psychological disorders.

Training is always conducted as a combination of didactic and on-site mentoring sessions at set intervals. The strategy is to identify more senior and/committed clinical leaders in a region and build up their capacity to lead and continue to train in their region. Bringing the fields of drug treatment and infectious diseases together is also a main point of focus given that the fields tend to be organized separately and do not necessarily share the same approach to patient care.

d. Continuum of service delivery into the community

Pangaea has experience in developing connections with community groups or services that can provide social support to IDUs to enhance adherence and treatment outcomes. This social support may be in any of the following:

Navigating health systems to receive additional care for health problems outside but related to drug use;
Preparing to re-enter the workforce – job application assistance and preparing for interviews
Job searches and placements;
Family relationships – rebuilding and making connections; and
Securing housing and food.

In settings where HIV and methadone treatment are not or cannot be co-located, engaging community-based organizations to provide outreach and support to help track patients for both the HIV and methadone programs has been shown to enhance patient retention and treatment outcomes.

Program Examples – Working with IDUs

HIV and drug treatment among IDUs in Ukraine

The aim of the Ukraine program is to increase access to comprehensive HIV/AIDS and drug treatment to attain improved health outcomes for infected populations, lessen the risk of spread of HIV to non-injection drug user (IDU) populations, and ultimately, to reduce AIDS related deaths. The main program target population is IDUs. As the treatment partner for the Clinton Foundation in Ukraine, Pangaea has provided the over-all direction for the focus and scope of the program and continues to provide oversight for planning and implementation of treatment activities. All activities are implemented through a partnership with Ukraine Ministry of Health. The core components of the Ukraine program are:

introduction of rapid HIV testing targeting IDUs; focus on ease of access, quick results and strategies to make effective HIV treatment referrals;
registration and procurement of methadone for substitution therapy;
design and implementation of methadone substitution therapy for both HIV (+) and (-) IDUs;
development of a combined, highly integrated HIV and drug treatment program for IDUs;
training and mentoring of nurses, doctors and counselors on HIV treatment and methadone substitution therapy with emphasis on methadone and ART interactions; and
development of regional laboratory capacity to support HIV and drug treatment services.

Each of these components are requirements for the implementation of a robust treatment program for IDUs which produces high ART and methadone substitution therapy adherence leading to a reduction in risk behaviors and ultimately, HIV transmission.

HIV/AIDS treatment in rural China – bringing treatment to IDUs and incarcerated populations

Since 2004, as a partner with the Clinton Foundation China HIV/AIDS Program, Pangaea has been providing technical assistance to the China Ministry of Health in support of expanding a national HIV/AIDS treatment program. Initial efforts focused on developing national treatment guidelines for ART, and working with provincial authorities in Anhui and Yunnan to provide clinical training and mentoring of health care professionals, and to develop and scale up comprehensive HIV/AIDS treatment models linked with community based support services and referral conduits from voluntary counseling and testing, tuberculosis and mother/child health programs.

More recent activities have been directly related to the role that injection drug use plays in the HIV epidemic in China and bringing HIV treatment services to incarcerated populations. Activities with IDUs and incarcerated populations have included linking methadone treatment programs with HIV clinical care, and developing a treatment model for persons in drug detention centers where prevalence of HIV is high. Pangaea is assisting Yunnan Provincial authorities to develop a model for comprehensive HIV treatment for incarcerated IDU populations as an extension of services currently provided in hospital based AIDS clinics. The aim is develop a model for treatment that ensures services for persons while in drug detention centers that will continue upon their return to the community. Integration of HIV care into the detention centers has included broader attention to issues of TB within enclosed settings, and working collaboratively with guards and law enforcement personnel on health and safety issues.

For more information contact:

Pangaea Global AIDS Foundation
995 Market Street, Suite 200
San Francisco, California 94103
1.415.581.7000
1.415.581.7009 – fax
www.pgaf.org