An innovative programme in which peer outreach workers use a
case management approach to help HIV-positive people who inject drugs to engage
with medical services and to begin antiretroviral therapy appears to be paying
off, according to early results presented to the 24th International
Harm Reduction Conference in Kuala Lumpur yesterday.
The approach involves experienced harm reduction peer outreach
workers shifting their focus from needle exchange to helping HIV-positive
clients engage with HIV treatment services. The aim is to improve the HIV
treatment cascade for this key group in Ukraine’s HIV epidemic.
Having provided harm reduction services and HIV testing for
several years, the International HIV/AIDS Alliance in Ukraine was concerned
that despite referral to government-run HIV treatment services, few people who
inject drugs were effectively linked to and retained in care.
One analysis found that of just under 11,000 injecting drug users
diagnosed with HIV by Alliance projects, fewer than 6000 were engaged with
medical care and 2252 had begun HIV treatment. Individuals frequently
registered with a medical clinic and then dropped out, only returning when
severely ill and immunocompromised.
“Some people do not like doctors and hospitals, especially
stigmatised people such as our clients,” commented Pavlo Smyrnov of the
International HIV/AIDS Alliance in Ukraine. “But we were also hearing of doctors
telling users they must come off drugs first before they can think about
receiving ART. In more extreme cases, we have even heard of doctors asking drug
users to give a written statement saying they don’t want to begin ART until
they have stopped using drugs.
“It became clear to us that referrals were not really
working, so we decided to make treatment our responsibility.”
The ‘community initiated treatment intervention’ aims to use
principles of peer navigation, case management and community support to help
active drug users start HIV treatment and adhere to it. Those using the
programme have either just been diagnosed with HIV or have been diagnosed for
some time but have dropped out of care. Support is for up to six months.
The outreach workers – who already have a relationship with
the service users and are generally highly trusted – are able to explain the
benefits of starting HIV treatment promptly and to help with the bureaucratic
processes of health services. They take on a mediating role between the patient
and the doctor, advocating to ensure that patients receive the services they
are entitled to. Doctors often appreciate the outreach workers’ ability to
respond to the non-medical needs of the service users.
Two years on, outreach workers have supported 8623 clients.
Preliminary data on a subset of clients suggests a better treatment cascade
than normally achieved for HIV-positive drug users in the country.
|
Project clients
|
All HIV-positive people who inject drugs
|
Total
|
2058 (100%)
|
66,960 (100%)
|
Registered in care
|
1698 (82%)
|
46,872 (70%)
|
Active medical care
|
1535 (74%)
|
23,436 (35%)
|
Receiving HIV treatment
|
545 (26%)
|
6007 (9%)
|
Nonetheless the cascade remains less than ideal. Some of the
shortfall in numbers receiving HIV treatment is because people with a CD4 cell
count above 350 cells/mm3 (41% of project clients) are not eligible
under the country’s treatment guidelines. Further, significant barriers remain
in the health system – an unwillingness to treat people who continue to use
drugs and interruptions in the provision of antiretroviral drugs.