CONFERENCE REPORTS

Scaling up ART for people who use drugs: the Brazilian story

Tracy Swan, Treatment Action Group, NYC

At the 18th International Conference to Reduce Drug-Related Harm, Dr Monica Malta discussed Brazil’s response to the HIV epidemic, and to recent trends in drug use among HIV positive Brazilians.

HIV epidemiology and treatment in Brazil

According to a UNAIDS estimate, 620,000 Brazilian adults and children are living with HIV/AIDS. Brazil was the first developing-world country to provide universal access to HIV treatment, beginning with prophylaxis and treatment for opportunistic infections in 1988, followed by AZT in 1991. Antiretroviral therapy has been provided free of charge since 1996. As of 2007, 180,000 HIV-positive Brazilians are receiving ART.

At least 20% of Brazil’s estimated 800,000 injection drug users (IDUs) are HIV-positive. [1, 2]

Brazil is the largest provider of HIV care and treatment to people who use drugs in the developing world; 30,000 are receiving ART. [3]

HIV and cocaine: the problem and the response

More than 90% of the world’s cocaine is produced in Latin America, and it is widely available in Brazil. Injection drug use in Brazil has decreased; people have switched to smoking crack and snorting cocaine. Several studies have reported that crack cocaine use is associated with high-risk sex, and HIV seropositivity in Brazil. [4, 5, 6, 7]

Since injection drug use has become less common, providing care and treatment for HIV-positive cocaine users has emerged as a key challenge in Brazil. In response, The Pan-American Health Organization (PAHO) and the Brazilian Ministry of Health created a task force to develop guidelines for management of HIV-positive cocaine users, in collaboration with clinicians, researchers, staff from non-governmental organizations and community members. The guidelines were widely distributed, and discussed during a series of meetings with local governments, health care providers, community members and NGO staff. Skills-building workshops were created to support their implementation.

Drug use and adherence to ART

Concerns about poor adherence to ART among drug users were repeatedly raised during guidelines meetings. Dr Malta conducted a comprehensive review of studies on adherence among current and former drug users (Table 1), to address these concerns. She reported adherence rates that ranged from 44-85%. In contrast, an analysis of adherence rates in resource-rich and resource-poor countries from Mills and colleagues reported an overall adherence rate in resource-rich countries of 54.7%, versus 77.1% in resource-poor countries. [8]

How much is enough?

With antiretroviral therapy, an adherence rate of >95% is generally considered necessary to suppress HIV RNA and avoid development of resistance. However, the correlation between adherence and resistance may differ by class of antiretroviral agent. For example, Bangsberg studied adherence and response to ART in the REACH cohort (Research on Access To Care), a group of homeless adults, 65% of whom had a history of injection drug use. A majority of those receiving a non-nucleoside analog (NNRTI)-based regimen achieved an HIV RNA of <400 copies/mL, despite adherence rates as low as 53% (range, 53-100%). In contrast, an adherence rate of >95% was necessary to achieve HIV RNA of <400 copies/mL for protease inhibitor-based regimens. [9]

Conclusion

Dr Malta summarised the key lessons learned:

Drug users can adhere to ART
If the regimen is sufficiently potent, viral suppression can be achieved with adherence rates of <95%
Adherence rates among HIV-positive cocaine users increase when they have access to psycho-social support and drug treatment with their medical care
HIV treatment should not be withheld from people who use drugs, regardless of concomitant diagnoses, such as psychiatric disorders and hepatitis C coinfection.

Brazilian HIV-positive drug users still face several barriers to effective HIV care and treatment. There is no substitution treatment for cocaine. Health care professionals require training to work with people who are using drugs. Lack of resources for comprehensive services, and social problems—racism, poverty, and stigma— continue to limit access.

However, the situation for HIV-positive drug users in Brazil is changing. In Dr Malta’s words, “It is possible to scale up ART and maintain the necessary adherence levels in developing country settings and among HIV-positive drug users. Improved access to HIV treatment is an essential step of any valid attempt to curb the AIDS epidemic, and needs to be faced as a human rights priority. No one should be left behind…”

Table 1. Adherence to ART among people who use drugs and alcohol

Adapted from Dr Monica Malta (abstract 949) Ten Years of universal access to HIV treatment: Learning from the Brazilian Experience. 18th International Conference to Reduce Drug Related Harm. Warsaw, Poland. May 13-17th, 2007.

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Sources for Table 1:

Altice FL, Mostashari F, Friedland GH. Trust and the acceptance of and adherence to antiretroviral therapy. J Acquir Immune Defic Syndr. 2001 Sep 1;28(1):47-58.

Pradier C, Carrieri P, Bentz L, et al. Impact of short-term adherence on virological and immunological success of HAART: a case study among French HIV-infected IDUs. Int J STD AIDS. 2001 May;12(5):324-8.

Bouhnik AD, Chesney M, Carrieri P, et al; MANIF 2000 Study Group. Nonadherence among HIV-infected injecting drug users: the impact of social instability. J Acquir Immune Defic Syndr. 2002 Dec 15;31 Suppl 3:S149-53.

Carrieri MP, Chesney MA, Spire B, et al. MANIF Study Group. Failure to maintain adherence to HAART in a cohort of French HIV-positive injecting drug users. Int J Behav Med. 2003;10(1):1-14.

Palepu A, Tyndall M, Yip B, O’Shaughnessy MV, Hogg RS, Montaner JS. Impaired virologic response to highly active antiretroviral therapy associated with ongoing injection drug use. J Acquir Immune Defic Syndr. 2003 Apr 15;32(5):522-6.

Wagner G. Placebo practice trials: the best predictor of adherence readiness for HAART among drug users? HIV Clin Trials. 2003 Jul-Aug;4(4):269-81.

Wood E, Montaner JS, Yip B, et al. Adherence and plasma HIV RNA responses to highly active antiretroviral therapy among HIV-1 infected injection drug users. CMAJ. 2003 Sep 30;169(7):656-61.

Altice FL, Mezger JA, Hodges J, et al. Developing a directly administered antiretroviral therapy intervention for HIV-infected drug users: implications for program replication. Clin Infect Dis. 2004 Jun 1;38 Suppl 5:S376-87.

Palepu A, Horton NJ, Tibbetts N, Meli S, Samet JH. Uptake and adherence to highly active antiretroviral therapy among HIV-infected people with alcohol and other substance use problems: the impact of substance abuse treatment. Addiction. 2004 Mar;99(3):361-8.

Bouhnik AD, Préau M, Vincent E, et al; MANIF 2000 Study Group. Depression and clinical progression in HIV-infected drug users treated with highly active antiretroviral therapy. Antivir Ther. 2005;10(1):53-61.

References
1. Aceijas C, Stimson GV, Hickman M, Rhodes T; United Nations Reference Group on HIV/AIDS Prevention and Care among IDU in Developing and Transitional Countries. Global overview of injecting drug use and HIV infection among injecting drug users. AIDS. 2004 Nov 19;18(17):2295-303.
2. Aceijas C, Friedman SR, Cooper HL, Wiessing L, Stimson GV, Hickman M. Estimates of injecting drug users at the national and local level in developing and transitional countries, and gender and age distribution. Sex Transm Infect. 2006 Jun;82 Suppl 3:iii10-17.
3. Aceijas C, Oppenheimer E, Stimson GV, Ashcroft RE, Matic S, Hickman M. Antiretroviral treatment for injecting drug users in developing and transitional countries 1 year before the end of the “Treating 3 million by 2005. Making it happen. The WHO strategy” (“3 by 5”). Addiction. 2006 Sep;101(9):1246-53.
4. de Azevedo RC, Botega NJ, Guimarães LA. Crack users, sexual behavior and risk of HIV infection. Rev Bras Psiquiatr. 2007 Mar;29(1):26-30.
5. Dunn J, Laranjeira RR. HIV-risk behaviour among non-heroin using cocaine injectors and non-injectors in São Paulo, Brazil. AIDS Care. 2000 Aug;12(4):471-81.
6. Leukefeld CG, Pechansky F, Martin SS, et al. Tailoring an HIV-prevention intervention for cocaine injectors and crack users in Porto Alegre, Brazil. AIDS Care. 2005 Jun;17 Suppl 1:S77-87.
7. Pechansky F, Woody G, Inciardi J, et al. HIV seroprevalence among drug users: an analysis of selected variables based on 10 years of data collection in Porto Alegre, Brazil. Drug Alcohol Depend. 2006 Apr;82 Supplement 1:S109-13.
8. Mills EJ, Nachega JB, Buchan I, et al. Adherence to antiretroviral therapy in sub-Saharan Africa and North America: a meta-analysis. JAMA. 2006 Aug 9;296(6):679-90.
9. Bangsberg DR. Less than 95% adherence to nonnucleoside reverse-transcriptase inhibitor therapy can lead to viral suppression. Clin Infect Dis. 2006 Oct 1;43(7):939-41.

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Antiretroviral Treatment For Injecting Drug Users