Substance Abuse Treatment and HIV in Iran Azarakhsh Mokri MD Iranian National Center for Addiction Studies (INCAS) Tehran University of Medical Sciences Tehran, Iran

I. Iran suffers from an intriguing duality of narcotic abuse! IV Heroin Users; 175,000 Opium Ingestion Heroin Smoking; 250,000 Opium Smoking

Afghanistan produces 3,200 tons each year!

Results: Heroin vs. Opium Abusers Opium Users (n=215) Heroin Users (n=158) Age 36.09 ± 11.49 35.23 ± 9.73 Duration of addiction 7.39 ± 6.37 8.81 ± 7.57 Money spent daily on drugs 3.6 ± 2.4 $ 9.5 ± 8.4 $* Marital status 54% married 5.3% divorced 51% married 6% divorced Employment rate 58% 62% Years of formal education 9.12 ± 3.58 9.59 ± 3.34 First drug of abuse 97% opium 95% opium History of IDU 14% 71%* History of incarceration 33% 63%* HIV infection rate 4% (n=4 /107) 17%* (n=12/69) *P<.01

Results: Heroin vs. Opium Abusers Opium Users (n=215) Heroin Users (n=158) Age 36.09 ± 11.49 35.23 ± 9.73 Duration of addiction 7.39 ± 6.37 8.81 ± 7.57 Money spent daily on drugs 3.6 ± 2.4 $ 9.5 ± 8.4 $* Marital status 54% married 5.3% divorced 51% married 6% divorced Employment rate 58% 62% Years of formal education 9.12 ± 3.58 9.59 ± 3.34 First drug of abuse 97% opium 95% opium History of IDU 14% 71%* History of incarceration 33% 63%* HIV infection rate 4% (n=4 /107) 17%* (n=12/69) *P<.01

Results: Heroin vs. Opium Abusers Opium Users (n=215) Heroin Users (n=158) Age 36.09 ± 11.49 35.23 ± 9.73 Duration of addiction 7.39 ± 6.37 8.81 ± 7.57 Money spent daily on drugs 3.6 ± 2.4 $ 9.5 ± 8.4 $* Marital status 54% married 5.3% divorced 51% married 6% divorced Employment rate 58% 62% Years of formal education 9.12 ± 3.58 9.59 ± 3.34 First drug of abuse 97% opium 95% opium History of IDU 14% 71%* History of incarceration 33% 63%* HIV infection rate 4% (n=4 /107) 17%* (n=12/69) *P<.01

We know (or think we know) 2 other facts about opium versus heroin enigma; Heroin and opium users show similar relapse rates after detoxification Opium dependence can be pharmacologically as severe as heroin dependence!

Detoxification of opium versus heroin abusers

II. HIV is highly related to IDU More than 11,200 cases of HIV/AIDS have been registered and estimated 30,000-40,000 HIV/AIDS cases are in the country. Around 60% of the cases are infected through needle sharing in IDUs. If cases with unknown route are omitted 85% and 10% are through IDU and sexual contact, respectively.

HIV knowledge Approximately 97% of drug users (n=61) stated that HIV could be contracted via sharing needles. Engaging in unprotected sex was seen as an HIV transmission route by slightly more than 80% of individuals. A high percent of opium and heroin users (20%-30%) believed that casual contacts were transmission paths for HIV as well.

Needle/syringe availability Syringes have been available at low price (<4 cents!) for many years. Pharmacies are local, widespread and cooperative. No ban on selling or carrying syringes.

Zamani et. al. Prevalence of and factors associated with HIV-1 infection among drug users visiting treatment centers in Tehran, Iran. AIDS 2005, 19:709–716

Drug abuse is a crime and drug abusers are arrested! In some years up to 400,000 people are convicted because of drug related charges. Most convicts stay 45 days to 6 months in prison. 65% of prisoners are convicted because of drug related charges! Total prisoners in Iran; 130,000

IV Heroin users Infected with HIV & HCV Opium users

Decriminalizing drug use?! IV Heroin users Infected with HIV & HCV Opium users

Meanwhile IV Heroin Users Implementing other treatments for IV drug users; Need for more than abstinence models Governmental specialized centers for IDUs Free of charge MMT for street drug users NGO based needle exchange and condom distribution programs IV Heroin Users Opium Abusers

Specialized Governmental MMT Centers Offer MMT and MH care for high-risk, high comorbidity clients; Psychiatrists GP Psychologists Social workers Independent funding Satellite distribution center Governmental MMT center

??? MH/SA/STD/HIV joint specialized centers MH/SA joint specialized centers Low-risk, low comorbidity High-risk, high comorbidity

Patients in MMT and methadone consumption

Patients in MMT and methadone consumption

Patients in MMT and methadone consumption Where is the lost methadone?

Where is the lost methadone? Methadone is consumed by opium users for detox and short-term replacement. Both clients and physicians favor such approach. Such practice has little proven value. IV heroin users are excluded at expense of opium smokers!!

The Utmost Critical Question Should opium dependent individuals receive substitution treatment?

Methadone: global manufacture and consumption, 1983-2002

PHC abstinence oriented interventions Office-based MMT PHC abstinence oriented interventions X Office based buprenorphine Tincture of Opium??? SR morphine Low-risk, low comorbidity High-risk, high comorbidity

Starting with office-based MMT GP + (social worker+ psychologist + nurse) Spend 15 days training in academic centers Get certificate and start work So far 130 but by end of 2005 planned 300 and next year 600.

For more specialized centers Psychiatrists+ (GP + social worker+ psychologist + nurse) Psychiatry residents spend 1-3 months rotation at INCAS. Medical students part time for a month. Chance to interact with patients, other staff, even police and judiciaries

MMT Bleach IV Heroin users Infected with HIV & HCV Opium users Needle exchange Condoms Bleach IV Heroin users Infected with HIV & HCV Opium users Drug courts Alternates to prison

But the true wonderful trend! Massive demand thus large scale supply. Mobilizing resources and training staff Providing diversity Self-organization Intelligent decision making and control