Overview & Modelling harm reduction interventions on people who inject drugs in Russia: - PowerPoint Presentation

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Overview & Modelling harm reduction interventions on people who inject drugs in Russia: assessing the dual benefit on HIV and fatal overdose prevention

Javier

Cepeda

UC San Diego

Background to the modelling

Modelling exercises were undertaken to assess the effect of various approaches to improve integration of HIV and non-HIV-related services on HIV and other noncommunicable disease (NCD) outcomes

South Africa

Intervention: mobile multi-disease screening for HIV and NCDs Outcomes: Diagnosis and treatment of HIV, hypertension, and diabetesKenya Intervention: community screening campaignOutcomes: reducing HIV incidence, mortality and diagnosis and treatment of hypertension and diabetesNigeria Intervention: preventing mother-to-child-transmissionOutcomes: expanding access to contraceptives on reducing HIV incidence on infants, unwanted pregnancies, and infant morbidity and mortalityIndiaIntervention: community screening and treatment for HIV and syphilisOutcomes: reducing HIV incidence and mortality, increasing syphilis diagnosis and treatmentRussiaIntervention: integrated harm reduction and ART provision for people who inject drugsOutcomes: reduction in HIV incidence and fatal opioid overdose

Multi-country modelling to study the effect of HIV integration in various settings

Background

HIV in Eastern Europe/Central Asia

Only world region where epidemic expanding

Most new infections occurring in RussiaDriven primarily by injection drug use Particular concern in Siberia and Urals HIV outbreaks occurring in Siberian region with new diagnoses ranging from 130-230 per 100,000 in 20161

1.

Beyrer

, C., et al. (2017). The expanding epidemic of HIV-1 in the Russian Federation. 

PLoS

medicine

, 

14

(11), e1002462.

UNAIDS, Global AIDS Update, 2016

HIV prevention among People who inject drugs (PWID) in Russia

Policies fueling HIV transmission among PWID in Russia

Non-naltrexone medication assisted therapy (MAT) illegal

Needle syringe programs (NSP) legal but coverage minimal 1-3 syringes exchanged/PWID/year1Substantial decline after Global Fund withdrawal in 2010Low ART coverage among PWIDLimited epidemic modeling of HIV among PWID in RussiaOne study indicates scale-up of harm reduction could have large impact on HIV epidemic among PWID in St. Petersburg2Larney

, S., et al. (2017). Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review. The Lancet Global Health, 5(12), e1208-e1220.

Vickerman

, P. et al. (2014). Controlling HIV among people who inject drugs in Eastern Europe and Central Asia: Insights from modelling. International Journal of Drug Policy, 25(6), 1163-1173.

Aim

To model the potential impact of scaling up of HIV prevention interventions (MAT, NSP, ART) on incidence of HIV and fatal opioid overdose among PWID in two epidemiologically distinct settings in

the Siberian and Ural

regions of Russia

Epidemic Model Structure

Dynamic deterministic compartmental model of HIV injecting and sexual transmission among PWID

Stratified by HIV disease stage and ART status, including loss to follow-up

Based on analyses of characteristics associated with prevalent HIV, also stratified by sex and low/high risk (defined by history of incarceration), and harm reduction (on/off)

Susceptible

Acute

Latent

Pre-AIDS

AIDS

ART

ART

ART

HIV-related death

HIV-related death

On ART

Modelled Settings

Omsk, Russia (Siberia)

Increasing HIV prevalence among PWID

9% in 20091, 17% in 20111, 19% in 20152Ekaterinburg, Russia (Ural)Stable, high HIV prevalence among PWID34% in 20013, 63% in 20071, 59% in 20111, 65% in 20144Leonteva A, Pogorila N, Taran Y. Study of HIV and HCV prevalence and associated risk behaviors among injection drug users in Moscow, Ekaterinburg, Omsk, and

Oryel

[

Изучение распространенности ВИЧ и гепатита С, а также поведения, связанного с риском инфицирования, в группе потребителей инъекционных наркотиков г.г. Москвы, Екатеринбурга, Омска и Орла].

Russian Harm Reduction Network [ESVERO] 2011.

Pasechnik

O,

Kalacheva

, GA. Epidemiology of drug addiction and HIV-infection in the Siberian Federal District. Fifth Eastern Europe and Central Asia AIDS Conference; 2016 March 23-25, 2016; Moscow; 2016.

Rhodes T, Sarang A,

Bobrik A, Bobkov E, Platt L. HIV transmission and HIV prevention associated with injecting drug use in the Russian Federation. Int J Drug Policy 2004; 15(1): 1-16.

Russian Health Care Foundation and Centers for Disease Control. Unpublished data.

Scenarios

Base case:

no harm reduction, 26% ART coverage in 2014

NSP only: scaled-up in 2018 to reach 50% coverage MAT only: scaled-up in 2018 to reach 25% coverageMAT only: scaled-up in 2018 to reach 50% coverage NSP+MAT (integrated HR): NSP+MAT intervention scaled-up in 2018 to reach 50% coverage Integrated HR plus ART expansion: NSP+MAT scaled-up in 2018 to reach 50% coverage, triple ART recruitment rate among all HIV-infected PWID

Intervention effects and assumptions

NSP

Reduces injecting HIV transmission risk by 34% and by 58% in high-income settings1MATReduces injecting HIV transmission risk by 44%2Reduces ART loss to follow-up rate by 23%3Reduces overdose mortality by about 80%4 ARTIncreased life expectancyDecreases sexual transmission risk by 90%5Decreases injecting transmission risk by 50%6

Aspinall, E. J., et al. (2013). Are needle and syringe

programmes

associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. 

International journal of epidemiology

, 

43

(1), 235-248.

MacArthur, G. J., et al. (2012). Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis. 

Bmj

, 345, e5945.

Low, A. J., et al. (2016). Impact of opioid substitution therapy on antiretroviral therapy outcomes: a systematic review and meta-analysis. Clinical infectious diseases, 63(8), 1094-1104Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. Bmj 2017; 357: j1550.Cohen, M. S., et al. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. New England journal of medicine, 365(6), 493-505.Vickerman, P., et al. (2014). Controlling HIV among people who inject drugs in Eastern Europe and Central Asia: Insights from modelling. International Journal of Drug Policy

, 25(6), 1163-1173..

Model projections of impact of integrated harm reduction and HIV services on HIV prevalence among PWID

HIV prevalence among PWID (%)

Base case

NSP (50%)

MAT (50%)

MAT (25%)

NSP + MAT (50%)

NSP + MAT (50%) + integrated ART (recruit 3X base case/

yr

)

Omsk, Russia

Ekaterinburg

, Russia

1.

Bekker

LG,

Baral

SD, Cepeda J, et al. Advancing global health and strengthening the HIV response in the era of the Sustainable Development Goals: the International AIDS Society—Lancet Commission. Lancet 2018; published online July 19.

2. Cepeda JA,, et al. Potential impact of implementing and scaling up harm reduction and antiretroviral therapy on HIV and overdose deaths among people who inject drugs in two Russian cities: a modelling study. Lancet HIV. In Press.

Proportion of HIV cases averted in two Russian cities in 10 years

36%

53%

HIV cases averted among PWID, 2018-2028 (%)White boxes: OmskGrey boxes: Ekaterinburg

23%

10%

21%

33%

36%

17%

36%

48%

MAT

(50%)

MAT

(25%)

NSP+ MAT

(50%)

NSP + MAT (50%)

Integrated ART

(recruit 3X base case

per

yr

)

NSP

(50%)

1.

Bekker

LG,

Baral

SD, Cepeda J, et al. Advancing global health and strengthening the HIV response in the era of the Sustainable Development Goals: the International AIDS Society—Lancet Commission. Lancet 2018; published online July 19.

2. Cepeda JA, et al. Potential impact of implementing and scaling up harm reduction and antiretroviral therapy on HIV and overdose deaths among people who inject drugs in two Russian cities: a modelling study. Lancet HIV. In Press.

Scale-up of either NSP

or

MAT to

50% coverage could avert a median of ~35% new HIV infections in Omsk and ~20% in

Ekaterinburg

by 2028.

Scale-up of NSP+MAT to 50% combined with ART scale-up (to 65% coverage by 2028) could avert 53% HIV infections in Omsk and 36% in Ekaterinburg over a decade.

Proportion of opioid overdose deaths averted in 10 years

Overdose deaths averted, 2018-2028 (%)

17%

32%32%

31%

MAT

(50%)

MAT

(25%)

NSP+ MAT

(50%)

NSP + MAT (50%)

Integrated ART

(recruit 3X

base case

per yr)

1. Bekker LG,

Baral

SD, Cepeda J, et al. Advancing global health and strengthening the HIV response in the era of the Sustainable Development Goals: the International AIDS Society—Lancet Commission. Lancet 2018; published online July 19.

2.

Cepeda

JA, et al. Potential impact of implementing and scaling up harm reduction and antiretroviral therapy on HIV and overdose deaths among people who inject drugs in two Russian cities: a modelling study. Lancet HIV. In Press.

High coverage (50%) of non-naltrexone MAT could avert about one-third of fatal opioid overdoses in both settings

Conclusion

Without intervention,

HIV may reach very high levels

among PWID in Omsk (~35%) and remain high in Ekaterinburg (~60%)Legalization of MAT could have substantial impact on new infections and avert one-third of fatal opioid overdoseIn Russia there is an urgent need for legal changes and capacity building to provide basic health services for PWID, ideally in an integrated program, which could reduce HIV, (and HCV), and fatal overdose.

Acknowledgements

University of California,

San Diego

Natasha MartinAnnick BorquezLeo BeletskyNGO Stellit, St. PetersburgKsenia EritsyanAlexandra LyubimovaVeronika OdinokovaRussian Health Care FoundationMarina ShegayUniversity of BristolPeter Vickerman

Matthew Hickman

Johns Hopkins University

Chris

Beyrer

National Institutes of Health

National Institute on Drug Abuse (NIDA)

National Institute of Allergy and Infectious Diseases (NIAID)

Elton John AIDS Foundation

International AIDS Society

For more details, please see supplementary material and our companion paper in The Lancet HIV