1. Key Components of Good HIV/AIDS Policy
Targeting The Drugs-HIV Nexus with
Pragmatic Health interventions
Dr. Jean-Paul C. Grund
UNAIDS Vienna

2. The Drugs
and HIV
Nexus

3. The Micro Risk Environment
of Drug Injecting: Drug Culture

4. Tradition of Self Preparation of Drugs

5. Use of Cooking Utensils, Nizhniy Novgorod

6. Frontloading Cheornaya, Nizhniy Novgorod

7. Group Injecting, Nizhniy Novgorod

8. Group Injecting, Nizhniy Novgorod

9. Group Injecting, Rostov Na Donu

10. Group Injecting of Heroin, Volgograd

11. Group Injecting, Volgograd

12. Drug Use Soviet Style: Do It Yourself!

13. IDUs’ Relationships with Law Enforcement

14. IDUs’ Relationships with Law Enforcement

15. Needle Exchange Programs

16. Slide:Courtesy of S. Strathdee

17. Global Expansion of Needle Exchange Programs
(December 2000)
Countries with at Least One Existing Needle Exchange Program N=
(46)

18. NEPs in the Russian Federation
• Recent, explosive epidemic of injection
and blood borne infections
• ~ 1 million IDUs
• At least 42 NEPs
• 58% of NEPs surveyed in Dec 2000 had
opened in the last year
Source: D. Burrows, 2001

19. Injection-Related HIV Risk Behaviors of Russian
Syringe Exchange Participants1 N = 1,076
N. N.
Pskov
R-N-D St. Petersb.
Russian syringe exchange program=participants Volgograd
N = 236 N = 201 N 199
N = 221
N = 219
reported a strong pattern of risk reduction, associated
Daily Injection of at
withleast one drug (%) in the program. In particular
participation
30 Ds. Prior to SEP
64
25
52
66
74
substantial andDays
statistically significant decreases in
Last 30
64
11
36
77
71
P
.7237
.2009
“receptive syringe sharing” <.0001 reported. .0031
were <.0001
Receptive Sequential
Syringe Use (%)
30 Ds. Prior to SEP
Last 30 Days
P
Injected @ Anonym.
Injecting Venue (%)
30 Ds. Prior to SEP
Last 30 Days
P
Total
N = 1,076
53
53
.0001
41
9
<.0001
26
4
<.0001
39
9
<.0001
48
29
<.0001
37
3
<.0001
38
11
<.0001
62
47
<.0001
25
9
<.0001
54
28
<.0001
37
19
<.0001
45
33
<.0001
45
28
<.0001
Single-digit percentages of respondents reportedly engage
in receptive syringe sharing fororthe recent 30 days in four
1
Totals may not equal 100% due to rounding
missing data.
out of five cities.

20. Drug Use Characteristics of Russian
Syringe Exchange Participants N = 1,076
N. N.
Pskov R-N-D St. Petersb. Volgograd
N = 236 N = 201 N = 199
N = 221
N = 219
Age First IDU1 (Mean/SD)
Total
N = 1,076
19 (4)
21 (5)
21 (5)
18 (3)
19 (4)
20 (4)
< 3 years
3+ – 6 years
6+ – 10 years
>10 years
22
33
33
12
47
31
10
12
18
22
25
35
43
27
16
14
26
41
26
6
30
32
23
15
Powder Heroin
Amphetamine
47
9
53
61
5
24
96
9
90
4
59
20
Reported Secondary Exchange (%)
40
46
40
43
48
44
Years Injecting1 (%)
Almost half of Russian Syringe Exchange Participants
reported Secondary Exchange (40-48%), whether the
Drug Injected
program (%)
encouraged it or not. 84
Homemade opiates
83
15
6
21
42
1,2
1
2
N differs because results are derived from intake questionnaires that linked with risk assessment questionnaires, only, so that N
for
Nizhny Novgorod = 165; N for Pskov = 153; N for Rostov-na-Donu = 109; N for St. Petersburg = 56; N for Volgograd = 160;
and the total N for the five programs = 643.
Percents may sum to > 100; more than one response may apply.

21. Methadone Maintenance Programs
Why Do We Need Them?

22. Great Need for New Scientific Treatment Concepts

23. When Substitution Treatment is Unavailable

24. Do Methadone Maintenance
Programs Work?
YES! There is evidence from around
the world showing the efficacy of
Methadone Maintenance Programs

25. Effect of Methadone Treatment
on Level of Heroin Use

26. Heroin Use in Past 30 Days
407 MM Patients by Current Methadone Dose
Percentage Heroin Use
100
90
80
70
60
50
40
30
20
10
0
0
1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 90+
Methadone Dose
SOURCE: Ball and Ross 1991, p. 248.

27. Effect of Methadone Treatment
on Injecting Drug Use
and Syringe Sharing

28. IDU And Needle Sharing Practices Among 507
Methadone Maintenance Patients In Six Programs
IN TREATMENT SAMPLE
(n=402)
IV USERS
(no needle
sharing)
29%
DROPOUT SAMPLE
(n=105)
Needle
Sharing IV
USERS
8%
NO IV USE
in the past
year
63%
SOURCE : J.C. Ball, University of Maryland, Baltimore, 1987.
IV USERS
(no needle
sharing)
51%
NO IV USE
since
treatment
29%
Needle
Sharing IV
USERS
20%

29. Effect of Methadone Treatment
on HIV Prevalence and Incidence

30. Absence of HIV Antibodies in Long-term, Socially
Rehabilitated Methadone Maintenance Patients
• Patients Entering MMT Before 1983 (N = 58):
0% HIV+ in 1990
• Out of Treatment IDUs in New York:
55-60% HIV+ in 1990
Source: D. Novick, H. Joseph, et al., Archives of Internal Medicine, Vol 150, Jan. 1990

31. Eighteen-month HIV Seroconversion By Methadone
Maintenance Treatment Retention
30
22%
20
Percent of
Seroconversion
Rate
10
3.5%
4.4%
0
In Treatment
(N = 85)
Adapted from Metzger et al., 1993
Partial Treatment
(N = 45)
Treatment Status
No Treatment
(N = 55)

32. Effect of Methadone Treatment
on Prevalence of Hepatitis

33. Increased Methadone Maintenance Census
And Decreased Hepatitis Cases: NYC, 1971-1973
Patients in
Methadone
Maintenance
Treatment
40000
2400
2000
30000
1600
20000
1200
800
10000
400
0
0
1971
1972
1973
3-Year Increase (19,900 Additional Patients)
Source: Dole, Joseph, and Des Jarlais, 1981
1971
1972
1973
3-Year Increase (1,500 Fewer Cases)
Reported
Cases of
Serum
Hepatitis

34. Effect of Methadone Treatment
on Crime and Incarceration

35. CRIME BEFORE AND DURING Methadone
Methadone TREATMENT AT 6 PROGRAMS
(Ball and Ross, 1991)
Last Addiction Period, "On Street"
CrimeDays Per
Year at
Risk
300
300
282
264 273
250
224
189
200
In Methadone Maintenance Treatment
210
250
200
150
150
100
100
50
50
Program:
0
37
27
15
14
A
B
C
19
21
E
F
Program:
0
A
B
C
D
E
F
Before Treatment Crime
D
In-Treatment Crime
Red bars = crime days per year when addicted. Blue bars = crime days per year after 6 months
or more in treatment. (N = 491)

36. Time of Incarceration Before and
During Methadone Treatment
Days in prison
per year 45
40
35
44,3 Days
(100%)
30
Reduction of 92% of
time spent in prison
25
20
15
3,4 Days
(8%)
10
5
0
Days in prison per year of heroin
addiction
Days in prison in the last 12
months

37. HIV is not the only harm

38. Harm Reduction and Overdose

39. Overdose Deaths: Frankfurt/M, 1969-1998
160
140
120
100
80
60
40
20
0
69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99
No. Of ODs under "No Tolerance" Policy
No. Of ODs under "Harm Reduction" Policy

40. State Repression vs. Community Integration

41. Conclusion: Good AIDS Policy
• Multi-Sectoral Approach: HIV/AIDS policy is a
matter of all areas and levels of government and
civil society;
• Evidence-Based Interventions;
• Biggest Bang for the Buck: Direct funding to
where the Epidemic is and goes;
• Keep Your Priorities Clear;
• Pragmatism is Essential:

42. “In Essence, a Policy of Harm Reduction
Requires an Approach of Pragmatism
Rather Than Purism – an Acceptance That
It May Sometimes Be Better to Go for a
Probable Silver Than a Possible Gold.”
John Strang

43. Photo Credits
Black & White Photographs:
© John Ranard
Color Photographs:
© Jean-Paul Grund