INTERVIEW: HIV epidemic in the stage of concentration, or How to help drug users

The problem of injecting drug use directly affects the epidemiological situation of HIV infection. Since the maximum number of HIV-infected people is concentrated among drug users, it is this group that is the main source of infection for others, through which the epidemic continues to spread. The problem of HIV infection among injecting drug users is the subject of a scientific work, one of the leaders of which is the head of the Department of Epidemiology of the Belarusian State Medical University, Candidate of Medical Sciences, Associate Professor Irina Valchuk. In an interview with BelTA, she told what the concept of a concentrated epidemic means, what is the social portrait of a drug addict living with HIV infection, and whether it is worth continuing the methadone substitution therapy program.

- How common is HIV infection in the world and in Belarus? Can you compare the epidemiological situation in our country and other countries of the WHO European Region ?

- The spread of HIV infection remains an important problem for the HEALTH care systems of states around the world. The incidence in different regions has its own distinctive features. The differences relate to the level and dynamics of morbidity, the gender and age structure of the sick, the dominance of certain routes of infection transmission, the mortality rate among those infected, the level and availability of clinical and laboratory diagnostics, medical care, and access to antiretroviral therapy. All this significantly affects the forecast for the development of the HIV epidemic in the respective regions.

According to the Joint United Nations Program on HIV/AIDS (UNAIDS), about 38 million people are currently living with HIV, with 1.7 million new infections in particular in 2019. 75 people have been infected with HIV since the beginning of the epidemic .7 million people died from opportunistic diseases (diseases that can occur in the late stages of HIV infection with a weakened immune system. - Approx. BelTA) According to experts, HIV infection is one of the 10 most significant infectious diseases for humanity, representing a real threat to health and national security.

Despite the fact that the total number of detected cases of HIV infection in the world is declining, in the European Region of the World Health Organization, especially in its eastern part - the Eastern Europe and Central Asia (EECA) region, there is an increase in new cases of the disease. Thus, in the last 5 years, the number of new HIV infections in the WHO European Region has reached an average of 141.5-160 thousand people.

Over the past 10 years, the number of people newly infected with HIV in the EECA region has increased by 29%, with the majority of those infected (84%) living in the Russian Federation and Ukraine. The HIV prevalence rate in the EECA region reached 9% in 2018, which is a very high figure.

Belarus ranks third among the countries of the WHO European Region in terms of the number of newly diagnosed cases of HIV infection - the incidence rate in 2020 was 15.1 cases per 100,000 population.

Scaling up antiretroviral therapy has saved millions of lives and prevented millions of new infections. Yet 690,000 people died from AIDS-related illnesses last year, and 12.6 million of the 38 million people living with HIV lacked access to life-saving treatment.

- On a global scale, has the UNAIDS 90-90-90 global target been achieved?

- An important direction in the fight against the HIV / AIDS epidemic was the achievement of the 90-90-90 targets by 2020, which were announced at the 20th International AIDS Conference in 2014 in Melbourne (Australia). Let me remind you what these numbers mean. The point is that 90% of all people living with HIV should know their status; 90% of all people diagnosed with HIV infection should be on stable antiretroviral therapy; 90% of people on antiretroviral therapy should be virally suppressed (undetectable viral load).

In 2020, the UNAIDS report on the global AIDS epidemic set new targets for 2030 - 95-95-95. The report also stated that "over the next decade, decisive action will be required every day to put the world back on track to achieve the goal of ending the AIDS epidemic by 2030." However, the covid-19 pandemic has had a negative impact on various areas of activity, including slowing down active measures to combat HIV/AIDS.

Currently, the focus is no longer on the total number of HIV-infected people, the emphasis is on the timeliness and effectiveness of their antiretroviral therapy and the achievement of an undetectable viral load. This will not only protect HIV-positive patients from the development of late stages of the disease and opportunistic infections, but also reduce the risk of transmitting the virus to other people, which is extremely important from an epidemiological standpoint.

The problem of HIV infection, unfortunately, is associated with such a negative social phenomenon as stigmatization and discrimination by society of people with a positive HIV status. Public opinion survey shows high levels of HIV-related stigma in the EECA region: at least 40% of respondents in three countries of the region indicated that children living with HIV should not attend the same schools as other children, at least 70% of people four countries said they would not buy vegetables from a shopkeeper living with HIV.

- In general, which groups of the population are most often involved in the epidemiological process and why?

- In accordance with the Political Declaration on HIV and AIDS adopted by the UN General Assembly, it is people who inject drugs (PWID) who are recognized as a key population with an increased risk of HIV infection and subsequent spread of this infection. Since members of this group in different countries often face stigma, discrimination and legislation that hinders access to HIV prevention and treatment services, the declaration called on UN Member States to take all appropriate measures to ensure that 90% of PWID are provided with comprehensive prevention services.

The results of a number of studies indicate that the level of quality of life is significantly reduced in people living with HIV, with opportunistic infections, mental illness and disorders, which suggests the need for a comprehensive approach to the treatment of HIV-infected patients, including psychosocial support.

- According to UNAIDS experts, the HIV epidemic in our country is in the stage of concentration. What does this mean?

- According to generally accepted criteria, we speak of the concentrated stage of the epidemic when the prevalence of infection in the key group of PWID exceeds the 5% threshold. The prevalence of HIV infection among people who inject drugs in MINSK, according to epidemiological surveillance, reaches 33%. Consequently, this contingent is the very group where the maximum number of HIV-infected people is concentrated, who are sources of infection for others and through which further spread of the infection occurs.

In addition, according to the results of our scientific study, it was found that the incidence of HIV infection among PWID is 230 times higher than the incidence of the general population and plays a decisive role in the development of the epidemic process among the population as a whole.

- How would you describe the social portrait of a drug addict living with HIV infection?

- Based on the results of scientific research conducted by Margarita Shilova, senior lecturer at the Department of Epidemiology of the Belarusian State Medical University, a socio-epidemiological portrait of PWID living with HIV was compiled. This is a man aged 36 years and older, with more than three convictions, infected with the hepatitis C virus, not married, not officially employed, with an average experience of using opioid drugs of 21 years, having up to three periods without using drugs due to serving imprisonment (conviction) or undergoing rehabilitation.

Thus, we see that this category includes quite young people of working and reproductive age, but due to drug addiction and a positive HIV status, they are left out of our society. The need to constantly acquire drugs pushes them onto the path of antisocial and even often criminal behavior, which leads to a break in relations with their close environment, loss of family, job, serving sentences in places of deprivation of liberty.

- In your work, serious attention is paid to the program of substitution methadone therapy. What is its essence?

- For the treatment and medical rehabilitation of people who inject drugs, there are a number of harm reduction programs that help fight drug addiction, minimize the negative social consequences associated with drug use, and control the spread of HIV infection in key populations. First of all, we are talking about the program of opioid substitution therapy. Another direction is the cabinets for the safe use of narcotic drugs, but so far they do not operate on the territory of our country.

In Belarus, opioid antagonist substitution therapy, or the so-called methadone substitution therapy (SMTA), was first organized in the Gomel Regional Narcological Dispensary in 2007 as part of a WHO pilot project, and in 2009 at the City Clinical Narcological Center in Minsk.

Today, there are 19 substitution therapy rooms in our country. Three of them are located in Minsk: on the basis of the MOKC "Psychiatry-Narcology" - this is a regional one, two more - substitution therapy rooms in Minsk, and the second room was opened relatively recently, in 2020. In the regions, almost all large cities, for example, in Soligorsk, Zhodino, Orsha, in all regional centers, there are such offices, but their occupancy (the number of people in the substitution therapy program) is much less.

The essence of the program is that people with an established diagnosis of narcotic opioid addiction are prescribed drugs from the group of narcotic analgesics, which they take under the supervision of medical professionals. In Belarus, methadone hydrochloride Molteni (in the form of syrup) is primarily used for these purposes.

Methadone blocks opioid receptors, as a result of which in such patients the dependence syndrome is successfully eliminated and at the same time there is no euphoria and withdrawal syndrome (withdrawal) when transferring from opioid drugs. As a result of long-term methadone substitution therapy, the frequency of use of "street" opioids and other psychoactive substances is significantly reduced. The patient can completely refuse the parenteral route of drug administration, which in turn dramatically reduces the risk of transmission of viral hepatitis B, C, D and HIV.

However, it must be remembered that methadone does not reduce dependence on ALCOHOL, tranquilizers, sleeping pills, narcotic drugs from other groups (not belonging to the group of opioid drugs). Methadone substitution therapy is a widely researched treatment with proven efficacy. There is now strong evidence that methadone substitution therapy is effective in reducing illicit drug use, reducing mortality and the risk of HIV transmission, improving physical and mental health, improving social functioning and reducing crime.

The duration of such therapy is determined by the attending narcologist in agreement with the patient, it can continue for an indefinite period of time. However, research shows that the longer substitution therapy is given, the better the outcome in terms of illicit drug use reduction, medical and social rehabilitation.

Methadone replacement therapy is prescribed for patients over 18 years of age, however, in the presence of somatic or infectious diseases, such as chronic viral hepatitis B or C, HIV infection, tuberculosis, the appointment of MMT can be recommended from the age of 16. Pregnant women are included in the program for the duration of their pregnancy and for six months after delivery. A history of viral hepatitis B, C, D, HIV infection, tuberculosis, schizophrenia, bipolar affective disorder, epilepsy are indications for inclusion in MTM in the first place.

The maximum level of involvement in the opioid substitution therapy program in Minsk was reached in 2018 and amounted to 5.3%. Today it is somewhat smaller. The main barrier on this path is the very strict regulation of participation in the program. Patients must be registered with a narcological dispensary, provide an impressive number of documents, including the results of examinations for comorbid pathology. Also, one of the fundamental reasons is the fear of falling into the field of view of law enforcement agencies. However, to achieve a clinical, social and epidemiological effect, the involvement of people who inject drugs in the program should be at least 40%.

It is worth noting that HIV-infected PWID who want to participate in substitution therapy, like people living with HIV, generally need support and support. The problem is that many people reach the consultative and diagnostic departments for HIV infection long after they find out about their status. In some cases, they need psychosocial support, which is expressed in the help of non-profit public organizations.

Outreach workers can provide advice, talk about antiretroviral therapy, possible side effects, accompany the patient to the HIV consultative and dispensary departments. Such accompaniment and support is very important for this key group, because often, seeing a large queue at the office, fearing adverse reactions and not having the necessary information about the importance of starting antiretroviral therapy early, patients do not seek medical help, do not receive the necessary therapy and remain sources of infections in the population. This practice - advisory assistance and escort of this contingent - is generally accepted in the world.

- What results indicate the effectiveness of the methadone substitution therapy program?

- Research conducted by Shilova Margarita Alexandrovna scientifically substantiated the effectiveness of the methadone substitution therapy program for people who inject drugs living with HIV in our country. The positive impact of the program on the processes of socialization and adaptation of such people was noted. First of all, this is entering into an officially registered marriage (37% of such patients created a family). Also, an important parameter of social adaptation of such difficult patients is their official employment (54% of the participant in the substitution therapy program found a permanent job). Improved relationships with family members, friends and close associates of 96% of program participants. The vast majority of people in the program noted an overall significant improvement in their quality of life. Besides,

According to a survey of people who inject drugs, it was the improvement in the quality of life that became the main motivation for participating in the methadone substitution therapy program. Due to the strict conditions of enrollment and being in the program, the most motivated patients for socialization and adaptation to life in society are included in it. This explains both the high retention rate in the substitution therapy program and the achievement of improved quality of life indicators.

BELTA.