The forgotten group: a new HIV outbreak amongst people who inject drugs. Patricia Anderson Lead CNS BBV Brownlee Centre
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1 The forgotten group: a new HIV outbreak amongst people who inject drugs Patricia Anderson Lead CNS BBV Brownlee Centre
2 No conflicts to declare
3
4 Potted History 1981 Modern wave of drug misuse Glasgow soared from (heroin) 1983 outbreak of HIV among IV drug users in Edinburgh: over 60%infected in 6 months 1987 First needle exchange set up in Edinburgh Glasgow 1988 Methadone prescribing introduced in Edinburgh by GP s 1992 Glasgow
5 Needle exchange 1989 Pharmacy needle exchange rejected by Scottish Health Minister Hospital gate 2 half days inaccessible Easterhouse drug project evening 5 months later moved to Easterhouse Health Centre 100 clients daily Replicated in other parts of the city 5 needles on first visit 15 subsequent visits
6 Opened 1994 Glasgow Drug Crisis Centre City Centre accessible to all comers One stop facility, homelessness, physical and mental health, legal and child care issues 24 hour needle exchange In1997/1998 over 3,000 individuals used the service
7
8
9 New HIV diagnoses among people who inject drugs GGC
10 PWID HIV outbreak 120 new infections since November 2014 amongst PWIDs in Glasgow city 2015= = = =5 (to May) Extensive use of IEP services Epidemiologically and virologically linked Clade C virus
11 PWIDs - Socially excluded Homelessness Addictions Criminalisation Drugs/sex work Financial Barriers to accessing healthcare traditional model of care High rates of violence (*women) drug/debt related
12 What happened? We Took our eye off the ball
13 Brownlee Centre
14 Awareness / Education Spreading the word by all services in contact with the population group is essential 14
15 Broader context...anthrax, botulism, Staph aureus bacteraemia, drug deaths...
16 Daily priorities Accommodation Opiate replacement therapy Finance Drugs/alcohol Avoiding others Health needs
17 Healthcare attitudes Drug/alcohol intoxication Difficult patients Present in crisis Adherence to medication Drug-drug interactions Non attendance for investigations Multiple co-morbidities Complex co-morbidities 16 Deaths 12% of cohort Stigma
18 What to do? Effective HIV Prevention Interventions and the Need for Rapid Mobilization to Address HIV Outbreaks Among At-Risk Populations Philip et al The Journal of Infectious Diseases, Volume 215, Issue 10, 15 May
19 Accessing healthcare In and out of prison Sleeping rough on streets Drug & alcohol use affects priorities A&E IP Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sep Oct Prison clinic HIV service DNA DNA DNA DNA DNA Attended
20 Change model of service?
21 Adapting to need Adapt services to meet the needs of the vulnerable Alternative service model in reach model homeless health services addictions services, mental health, homeless health combined GUM/ID expertise to provide input to sexual, reproductive and medical issues Links with other services, voluntary sector, ED HIV medication dispensed in community outreach model nurse led a holistic approach to providing HIV/BBV care
22 A day in the life of
23 Does it work? HIV medication 102/104 (98%) have ever received ART 95/104 (91%) are currently receiving ART 45/104 (42%) currently receiving via community pharmacy Adherence varies from 10% to 99% 72/104 (69%) have an HIV viral load <40 copies/ml Nurse-Led BBV clinic in homeless health service 43/104 (41%) have attended (NMP)
24 What still needs to be done? 100% engagement in care Needs adequate dedicated nursing staff Multiagency integration Prisons Addictions Mental health Third sector Treatment of hepatitis C At least 40 requiring treatment Ongoing care and support...lifetime risks Other possibilities Injectable treatment (+/- PrEP) PrEP
25 HIV testing
26 DRUG CONSUMPTION Place where problem drug users are allowed to bring their illegally-obtained drugs and take them in a supervised, hygienic environment. Sterile injecting equipment. Closely observed, in order to give medical assistance should they overdose. c. 90 DCRs operating in 10 countries: Switzerland, Germany, the Netherlands, Spain, Norway, Luxembourg, Australia, Canada, Denmark and Greece. Advanced plans in France
27 DCR There is no legal framework for the provision of drug consumption rooms in the UK and we have no plans to introduce them, the Home Office said. Operating an injection facility would be likely to mean committing a range of offences including encouraging or assisting the possession and supply of controlled drugs, it added
28 Vancouver
29 Zurich
30 Summary Hard to reach groups Much more than managing HIV Risk vs benefit clinical decisions Multidisciplinary and multiagency approach Building relationships/trust Outreach work invaluable Develop and adapt service models to suit cohort Communication is key HIV prevention is complex
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