28 September 2022
On September 19th, the INHSU team headed to the ASCEND Symposium (Advancing the health of people who use drugs: hepatitis C and drug dependence), at the Kirby Institute in Sydney, Australia.
The day featured sessions from global experts in public health interventions to improve drug dependence management and progress toward hepatitis C elimination.
The day was full of new research and insights that will help drive forward the health and wellbeing of people who use drugs internationally.
Here are some of our key takeaways from the day:
Drug policy legal reform isn’t necessarily sufficient to create change – training police in public health principles can help
Professor Natasha Martin, Professor of Infectious Disease Modelling, Division of Infectious Diseases and Global Public Health, University of California San Diego. INHSU Vice President.
Professor Martin shared fascinating evidence of how the implementation of drug policy legal reform can impact infectious disease and health harms for people who use drugs.
In Mexico in 2009, possession of small amounts of drugs for personal use were legalised, yet despite this, arrest, incarceration, and mistreatment of people who use drugs remained high.
There is often a gap between how laws are written and how they are operationalized. That discrepancy can be large and in Mexico, and drug policy reform alone was insufficient to change the lived reality of what people were experiencing on the street.
In an attempt to effectively implement positive changes stemming from the legal reform in Tijuana, Mexico, a police education program (Proyecto Escudo, led by Steffanie Strathdee and Leo Beletsky) was implemented, where the entire police force (1,806 police officers from across the city) underwent training that sought to improve attitudes and behaviours towards people who use drugs.
Positioned as an occupational safety initiative (many officers were concerned with issues such as needle stick injuries), the training provided education on the legal reforms, HIV and HCV, prevention interventions and public health.
Among the police offers, the police education program improved education, attitudes, and reduced self-reported drug-related arrests, which were sustained during two years of follow-up. A parallel cohort study of people who inject drugs showed a 68% less chance of being incarcerated post-training compared with pre-training.
Subsequent modelling, led by Javier Cepeda showed that 1.7% and 9% of new HIV infections and overdoses were averted with a two-year intervention effect, and that the police education program was cost-effective.
Recommendations for eliminating HCV In the prison settings
Dr. Nadine Kronfli, Assistant Professor in the Division of Infectious Diseases, Department of Medicine, McGill University. Vice Chair of INHSU Prisons.
Dr. Kronfli shared a presentation on harm reduction services in correctional settings – evidence for HCV elimination.
- Incarceration leads to a 62% increase in HCV acquisition among people who inject drugs.
- To eliminate HCV, the WHO recommends that people who inject drugs have access to a minimum of 300 clean needles/syringes each year, with similar estimates likely needed among those incarcerated.
- There are 10 countries worldwide with a prison needle and syringe program (PNSP), although PNSPs have collapsed due to ineffective implementation, there is low-level evidence for PNSPs for HCV incidence/prevalence reduction
- OAT can reduce the risk of HCV by 50% and has additional benefits such as lower rates of mortality from fatal overdoses post-release and lower re-incarceration rates.
- While landmark studies have shown that treatment as prevention reduces the incidence of HCV in prisons, modelling studies have shown that combination treatment and prevention is necessary for HCV elimination to occur in correctional settings.
Offering harm reduction services should be grounded in a human rights framework and a similar standard of health should be provided to individuals inside and outside of prisons.
What happens if we decriminalise and divert funds into evidence-based interventions instead?
Professor Peter Vickerman, Professor of Infectious Disease Modelling, Bristol Population Health Research Institute, University of Bristol.
Continuing the focus on prison health, Professor Vickerman, discussed the ill effects of incarceration, including how drug use can increase injecting and sexual risk behaviours, reduce uptake and outcomes for HIV and HCV prevention and treatment interventions, and can result in increased likelihood of other structural issues such as homelessness and drug-related mortality upon release.
It was found that incarceration can contribute to 30% of new HIV and HCV infections and the recently released are at the highest risk (2.6-3.8 times higher transmission risk in Australia). Peter’s session explored how decimalisation could help this, as well as assessing what would happen if money saved due to decimalisation was diverted into evidence-based interventions.
Looking at Belarus, Kazakhstan, Kyrgyzstan and St. Petersburg, it was found that decimalisation could save €38-773 million euro over20 years. If diverted, these funds could help achieve up TO 81% coverage of antiretroviral therapy, 30% – 42% coverage of OAT, and could avert 59-84% of HIV infections over 20 years and result in cost savings in all settings.
When it comes to OAT, choice is integral
INHSU’s most recent storytelling project – My Choice – was premiered at ASCEND. My Choice is a participatory storytelling project which explores choice when it comes to Opioid Agonist Treatment (OAT). A panel of people who use drugs, clinicians and researchers discussed the film themes.
The full film will be available online soon.
- “What gets in the way [of people accessing OAT] is the model of care. It’s less about the medications themselves but how they’re packaged up and delivered,” panel participant
- “During COVID we had longer prescriptions and third-party pickups, all things I got told could never happen. Then suddenly, we’re back to five takeaways and back to the doctors. Why? People on the street don’t get it,” panel participant
- “People can also change their mind, and discover what works for them, it [OAT prescription] should be a dynamic process – it needs to be what’s right for the patient and not the clinician,” panel participant
OAT should be treated like any other medication – such as diabetes medicine, with as many barriers as possible taken away or minimised.
Thank you to the ASCEND organisers for such an insightful day and the speakers for sharing their research, knowledge, and expertise.