The U.S. President’s Emergency Plan for AIDS Relief The Evolving HIV Prevention Strategy for IDUs in PEPFAR Amb. Eric Goosby US Global AIDS Coordinator

Topical Outline PEPFAR Background Burden of HIV Disease among IDUs Service Coverage for IDU PEPFAR Plans to Increase Access, Expand Coverage and Reduce Disease Burden Challenges Ahead

PEPFAR: The US Response to the Global AIDS Crisis 2003: PEPFAR launched 2008: PEPFAR reauthorized through 2013 US accounts for 58% of all global AIDS investments (USD $32 billion through FY2010) Interagency coordination model PEPFAR as cornerstone of US Global Health Initiative

PEPFAR Builds on first phase Emphasis on supporting country ownership for sustainability Continue to support countries with both generalized and concentrated epidemics to scale up treatment (more than 4 million), prevention (more than 12 million) and care (more than 12 million) Includes focus on HIV prevention, treatment and care in countries with concentrated epidemics of HIV Person who inject drugs MSM Female sex workers

IDUs in Countries with PEPFAR Programs 5.3m IDUs living in countries with PEPFAR programs Concentrated in Russia, Ukraine Central Asia, and China

Gender Distribution of Injection Drug Use

IDUs Living with HIV in Countries with PEPFAR Programs Estimated 800k HIV- positive IDUs in countries with PEPFAR programs Injection drug use is leading driver of HIV/AIDS in Asia and Eastern Europe

HIV Cases Attributable to Injection Drug Use * Cambodia, Tanzania, Kenya, and South Africa do not have data available. Still, there are ~4.5m million IDUs who are HIV-negative in countries with PEPFAR programs

Coverage of Core Interventions in Countries with PEPFAR Programs Low Coverage Medium Coverage High Coverage Current Coverage NSP<20%20-60%>60%10% 533k/5.3m MAT<20%20-40%>40%4% 104k/3.2m ART for IDU<25%25-75%>75%? Access to core interventions is believed to be extremely low in countries with significant IDU populations and PEPFAR programs

NSP Coverage in Countries with PEPFAR Programs Needle & Syringe Access Programs (NSPs) Of 5.3m IDUs in PEPFAR countries, only 533k (10%) receive NSP assistance from any source. Those who do access 44m needles, or just over 80 needles per injector, per year.

MAT Coverage in Countries with PEPFAR Programs Of 3.2m opioid injectors in these countries, only 104k (~4%) are on MAT. Tajikistan and Cambodia recently began MAT. Tanzania is starting in July 2010.

Alignment of U.S Drug, Domestic HIV/AIDS and PEPFAR Prevention Strategies Coordination between PEPFAR and the White House Offices of National Drug Control Policy and National AIDS Policy Obama Administration’s National Drug Control Strategy: comprehensive approach based on a balanced public health and public safety model Main goals: (1) curtail illicit drug use and (2) reduce the consequences of drug use, including those imposed by HIV/AIDS

PEPFAR’s Prevention Goals Goal : Support the prevention of more than 12 million new HIV infections “Evidence-based combination HIV prevention” Structural/policy changes to create supportive enabling environments Biomedical Behavioral

PEPFAR’s Evolving Prevention Strategy for IDUs PEPFAR: Provides a comprehensive package of evidence-based interventions Creates enabling environments and a human rights- based approach to prevention for IDUs Secures commodities to reduce the risk of HIV transmission Coordinates an efficient international response Links to international indicators

Evidence-Based Interventions Evidence-based Comprehensive Package of Interventions (WHO, UNODC, UNAIDS, 2009) 1. Needle and syringe programs (NSPs) 2. Medication-Assisted Treatment (MAT) and other drug dependence treatment 3. Antiretroviral therapy (ART) 4. HIV testing and counseling (T & C) 5. Prevention and treatment of sexually transmitted infections (STIs) 6. Condom programs for IDUs and their sexual partners 7. Targeted information, education and communication (IEC) for IDUs and their sexual partners 8. Vaccination, diagnosis and treatment of viral hepatitis 9. Prevention, diagnosis and treatment of tuberculosis (TB).

Access to Services & Protection of Human Rights PEPFAR programs should seek to create safe spaces for IDUs to access services and ensure that services are based on: Equity Nondiscrimination Voluntariness Collaboration and involvement of affected populations Combat stigma or discrimination Do not increase risk for violence or incarceration

Optimizing Global HIV Prevention Impact PEPFAR will: Formalize, strengthen and coordinate our responses with key multilateral and bilateral organizations With multilateral and bilateral partners: Provide critical in-country technical support Bring significant resources for prevention Build political will to bring civil society into the process. Improving health outcomes for IDUs is a shared responsibility

Challenges Ahead Rapid scale-up of services Increase capacity of health care systems Ensure that programs are: Available Accessible High-quality Sustainable Achieving high coverage Monitored and evaluated Impacting the epidemic

Conclusions There is a mismatch between the current burden of disease among IDUs and coverage rates. PEPFAR is working with partner governments and civil society to address this imbalance PEPFAR guidance supports country-driven interventions that are evidence- and human rights- based and reach populations who are most at risk PEPFAR seeks to ensure that country-owned and -led programs and interventions are developed and implemented with respect for human rights of IDUs

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