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 nonHIVrelated services on HIV and other noncommunicable disease NCD outcomes ID: 779459
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Slide1
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
Slide2Background 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
Slide3Multi-country modelling to study the effect of HIV integration in various settings
Slide4Background
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
Slide5HIV 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.
Slide6Aim
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
Slide7Epidemic 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
Slide8Modelled 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.
Slide9Scenarios
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
Slide10Intervention 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..
Slide11Model 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.
Slide12Proportion 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.
Slide13Proportion 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
Slide14Conclusion
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.
Slide15Acknowledgements
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