amfAR, The Foundation for AIDS Research

amfAR Think Tank on Implementation Science for PWID

amfAR, The Foundation for AIDS Research, hosted a two-day think tank on implementation science for people who inject drugs (PWID) on June 4th and 5th in Washington, DC. Below are key points and questions resulting from this consultation.

There are highly effective interventions for preventing HIV transmission and acquisition among people who inject drugs, but coverage levels remain low, stymied by counterproductive policy and legal frameworks as well as a lack of access to those in need of services. Implementation science could address some of these barriers by helping us better understand how to reach and retain PWID with currently available programs and technology.

Priority Implementation Science Questions for PWID
What are the most effective models for reaching and retaining PWID while providing them the programs they want and need? How do integrated services, such as needle and syringe programs, medication assisted therapy, and HIV treatment programs impact access and retention? How can we increase knowledge and uptake of interventions, such as low dead space syringes and Naloxone among PWID?

Key Points

  • Though the HIV epidemic among PWID continues to expand in many countries, coverage of effective evidence-based prevention and treatment programs remains low. Basic epidemiological surveillance of this population is lacking throughout the world and political barriers continue to impede data collection and program implementation.  
  • Most PWID with HIV are co-infected with Hepatitis C (HCV). Comorbidity and prevention of HCV transmission and acquisition rarely receive the attention required. In many settings where PWID are the majority of people living with HIV, their access to treatment for either HIV or HCV is low.
  • Opioid substitution therapy and needle and syringe programs remain highly effective interventions for preventing the spread of HIV among PWID. Modeling has shown that these two interventions, in combination with ART for persons living with HIV, can reduce new infections over five years by as much as 40%.
  • Studies have shown that low dead space syringes (LDSS) could reduce HIV and HCV transmission among PWID. Successful distribution efforts have included social marketing and partnership with the private sector to better understand user preference, demand generation for LDSS and working with manufacturers to increase availability.
  • In addition to needle and syringe programs, there are other key priorities for HIV prevention among PWID: keeping drug users out of prison, preventing the transition from smoking to injection (including making methadone available for those who smoke), and promoting overdose prevention with Naloxone.  All of these efforts would also serve as a means of retaining PWID in other HIV programs.
  • Addressing mental illness and social issues surrounding drug use (e.g. homelessness) are essential to the effectiveness of programs for PWID. These services should be readily available to PWID but should not be a prerequisite for accessing other drug treatment or HIV prevention, treatment, and care programs.
  • PEPFAR’s Key Population Implementation Science (KPIS) program offers an opportunity to identify key priorities and knowledge gaps for PEPFAR, answer essential programmatic questions related to improved programming, expanded coverage, and linkage and referral to comprehensive services, and match these questions to a funding mechanism. The $15 million funding opportunity was made available for application to PEPFAR country teams in Brazil,  Cambodia, Ghana, Guatemala, Kenya, Nicaragua, South Africa, Tanzania, Thailand, Ukraine, Vietnam, and Zimbabwe

The second half of this consultation was dedicated to describing implementation science questions related to three topics:

  • Needle and Syringe Implementation Science Questions
    • How do we explore the feasibility of switching users and sellers from current syringe use to LDSS?
    • How do NSP programs impact linkage and retention to other health services including ART and drug treatment? How does distribution of Naloxone (including as part of take-home MAT) impact linkage and retention as well?
    • How do we increase knowledge of Naloxone and LDSS among drug users? What are the appropriate venues for reaching them?
    • Can we develop a formative toolkit that helps establish and scale up LDSS programs? Suggested components include tools to conduct a market assessment, understand user preference and demand, and develop procurement guidelines.
  • MAT Implementation Science Questions
    • How do we implement high volume, low burden, and high quality MAT programs for injectors and non-injection drug users?
    • Identify and implement strategies to more effectively and efficiently access harder to reach PWID (e.g., female injection drug users) with MAT programs.
    • How do we encourage all major donors to use the WHO, UNODC, and UNAIDS indicators to ensure comparability of MAT programs across countries and programs?
    • How do centralized versus decentralized models impact recruitment and retention to MAT?
    • What other changes to the model would increase recruitment and retention (e.g. hours of operation, provider or pharmacist centered delivery)? How do we define PWID preference?
    • How does access to MAT impact retention and recruitment to other services, particularly ART for PWID?
  • ART for PWID Implementation Science Questions
    • What is the impact of immediate versus CD4-dependent access to HIV treatment among PWID?
    • What level of ART coverage do you need among PWID to achieve viral suppression and a prevention effect in the population? How can we use modeling to define the ‘tipping point’?
    • What are innovative strategies for earlier recruitment into ART: multi-disease service delivery (TB, HCV, STIs), community led services, Naloxone distribution?
    • How do we better target subpopulations of PWID such as women, MSM, and sex workers?
    • How do mobile technologies impact PWID adherence to ART and other services such as MAT and NSP?
    • How can Pre-Exposure Prophylaxis for PWID be implemented in conjunction with increased access to and up-take of HIV Testing & Counseling?
    • How can we better target epidemiological “hot spots” (places where increased HIV transmission occurs on a sub-national level) to increase the effectiveness of HIV prevention, treatment, and care programs?
    • What is the ideal model for service integration (such as MAT and ART) for PWID? What are the advantages and disadvantages of one-stop shop models, and what are the best models for different situations encountered by PWID?
    • How is access to ART impeded by criminalization?
    • What is the optimal model for delivering PWID program in prisons? How do you keep a continuum of care for HIV, HCV, and TB while people are incarcerated and once they are discharged?