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Dr. Jean-Paul C. Grund
Building Pyramids: Designing HIV Prevention and Treatment
Systems for Drug Users in Eastern Europe
10/18/01, Building Pyramids J-P Grund
Building Pyramids Introduction
• While not absent during the days of communist rule, the transition
towards democracy has undoubtedly been followed by an increase in
the availability and use of illicit drugs in all former socialist
countries.
• As a result, injecting drug use, addiction and, as a consequence, HIV
are developing into a serious public health problem.
• Addiction is associated with compromised economic, social and
psychological situations.
• It is increasingly viewed as a complex, multi-causal, chronic
relapsing condition or disease, for which ”to date there is no effective
curative treatment.”
Drug Use after Socialism: Prevalence Russia & Ukraine
RRuussssiiaa
RReeggiisstteerreedd NNuummbbeerr ooff DDrruugg UUsseerrss
MMiinniissttrryy ooff IInntteerrnnaall AAffffaaiirrss::
MMiinniissttrryy ooff HHeeaalltthh::
11999900 11999944 11999966 22000011
115588..000000 224499..000000
2255..000000 8855..000000 445500..000000 ((UUsseerrss))
227700..000000 ((AAddddiiccttss))
EEssttiimmaatteess:: 11999966:: 660000,,000000
11999988:: 11--22..55 mmiilllliioonn
22000011:: LLTTPP:: 33 mmiilllliioonn
UUkkrraaiinnee
RReeggiisstteerreedd NNuummbbeerr ooff DDrruugg UUsseerrss:: ““EEaarrllyy 11999900ss””:: 2200..000000;; 11999977:: 8800..000000
EEssttiimmaattee ((MMIIAA)):: 11999977:: 660000..000000 –– 770000..000000 ((7755 -- 8800%% IIDDUUss))
Table 1. Registered & Estimated Number of Drug Users in Russia & Ukraine
Sources: Brunet 1996; USAID/CDC 1998; Khodakevich & Dehne 1998; Dehne et al. 1999; MOH, 2001
City Total IDUs % of Population
Nizhniy Novgorod 35000 2.6
Novorossiisk 9000 3.6
Pskov 380-440 0.2
Rostov Na Donu 10000 1
St. Petersburg 70-80000 1.7-1.9
Volgograd 18000 1.7
Odessa 25000 2
Poltava up to 10000 3
Estonia 7000-8000 0.4-0.5
Vilnius 2000-3000 0.3-0.5
Kishineu 1416 0.2
Sofia 15-20000 1-1.5
Szeged 2500 1
Drug Use after Socialism: Prevalence in Cities Across the CEE Region
Table 2. Total Number of IDUs and Percentage of Population by City
Sources: • MSF/H RSAs • Grund et al. 2001
10/18/01, Building Pyramids J-P Grund
Drug Use after Socialism: Qualitative Prevalence Assessments
“People drink or inject in this place.” (Outreach Worker, Volgograd)
“It is difficult to find a building in this
town that is not affected by drug use.” (Epidemiologist, Rostov Na Donu)
Both national and city-level data suggest that in several NIS countries more than 1% of the
population is involved in (injecting) drug use.
Drug Use under Socialism: Do It Yourself!
Collective Drug
Preparation & Injecting,
Friendship Networks,
& HIV Transmission
10/18/01, Building Pyramids J-P Grund
A Culture of Collective Drug Use
A Culture of Collective Drug Use
“It is very seldom when you use alone. At minimum you use with two or
three people. … “Somebody has money for drugs, a second knows where
to get good drugs, a third has some anhydride or a place to cook and yet
another has syringes. … It is also much cheaper to use in groups.”
23 70 338
441
523
609
717
875
1071
2617 70
1626
054
8035
110
3,02
415
0,00
0
1059
2
0
20000
40000
60000
80000
100000
120000
140000
160000
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Apr-
01
Jul-0
1
Cumulative number of reported HIV cases
Russian Federation, 1987 - July 1, 2001
10/18/01, Building Pyramids J-P Grund
Building Pyramids:
A Model for Policy & Service Development
• Metaphorical model of the development of drug treatment
and health & social care services for drug users.
• The model is essentially a thinking model to support realistic
policy development.
• It includes graphical representations
of key variables and processes,
relevant to decision making.
• It can inform a range of
policy choices, considering and
matching these key variables.
10/18/01, Building Pyramids J-P Grund
‘No’ Threshold Services
Pyramid Model:
Establishing a Typology of Care Services for IDUs
High Threshold Services
Medium Threshold Services
Low Threshold Services
Threshold to Care
10/18/01, Building Pyramids J-P Grund
• In-Patient Detoxification
(Reduction, Cold Turkey)
• Mid-Term In-Patient
Treatment
• (Long-Term) Residential
Therapeutic Communities
• Psychiatric Interventions
• After Care, Rehab, Relapse
Prevention, Acupuncture
• (Re-Entry) Housing
Pyramid Model Professional Care Services for IDUs
High Threshold Services
10/18/01, Building Pyramids J-P Grund
• Out-Patient Detoxification
(Reduction, Acupuncture)
• Specialized Medical
Treatment (HIV, HBV,
HCV, Dental Problems)
• Social Work, Counseling,
Case Management
• Job Training, Work
• (Supported) Housing
• Money Management
Pyramid Model Professional Care Services for IDUs
Medium Threshold Services
10/18/01, Building Pyramids J-P Grund
Pyramid Model Professional Care Services for IDUs
• Out-Patient Opiate Agonist
Treatment: Methadone,
Buprenorphine, Codeine
• Emergency Medical and
General Practice Care
• (Emergency) Psychiatry
• Syringe Access: Exchange,
Distribution, Pharmacy e.a.
Sales (kiosks-coupons?)
• Outreach Work
• Overdose Prevention
Low Threshold Services
10/18/01, Building Pyramids J-P Grund
Pyramid Model Professional Care Services for IDUs
• Drop-In Centers,
• Safer Consumption Facilities
• Food, Clothing and Shelter
Projects
• Drug Use Management
programs
• Acupuncture, Stress
Reduction
• Safer Drug Use Information
• Chill-Outs @ R@ves
Low Threshold Services
10/18/01, Building Pyramids J-P Grund
Pyramid Model A Dynamic Model
• Easy access @ multiple
entry points.
• Includes all service levels
• (coordinated) transfer
between services.
• Easy use of ancillary services
• Increases demand for high
threshold treatment: develops
naturally with growing contact rates.
• Can reach 70-80% of IDUs.
• Collaborative Model.
Key Characteristics
10/18/01, Building Pyramids J-P Grund
Pyramid Model Considerations for Setting Priorities
• Fighting the HIV/AIDS Pandemic
and Other Infectious Diseases
• Reducing Drug-related Morbidity
and Mortality
• Coverage of Populations at Risk
• Treatment Retention
• Treatment of Problem Drug Use
• Available $$ Resources (Funding)
• Costs of Services
Public Health Considerations
Economic considerations
10/18/01, Building Pyramids J-P Grund
Slide: Courtesy of S. Strathdee
Coverage: What proportion of the
IDU Population Needs to be Reached?
10/18/01, Building Pyramids J-P Grund
Pyramid Model Care Services for IDUs: Level & Coverage
‘No’ Threshold Services
High Threshold Services
Medium Threshold Services
Low Threshold Services
Level of Care
Nx
15-40 (?)
70-80
1-20 (?)
Potential Coverage of Population (%)
10/18/01, Building Pyramids J-P Grund
Type of Treatment
Low Threshold Services
High Threshold Services
Medium Threshold Services
Pyramid Model Treatment Costs by Type of Modality
$$$
$$-$$$
$
Relative Costs per Treated Drug User
Q: Where to Invest Scarce Resources?
A: Where we get the Biggest Bang for the Buck!
Low Threshold Services
10/18/01, Building Pyramids J-P Grund
Mean Costs Per Year For 1 Heroin Addict (USA)
0
10000
20000
30000
40000
50000
On Street Incarcerated Residential
Treatment
Methadone
Maintenance
Treatment
$
Security
Theft, etc.
Heroin
Jail
or
Prison
and
Court
Costs Residential
Drug-Free
Treatment MMT
SOURCE: Slide: M. Reisinger, Adapted from NYS DSAS, 1991, by Dole & Des Jarlais.
10/18/01, Building Pyramids J-P Grund
Conclusion Building Pyramids: A Useful Metaphor for
Development of Drug Policy and Services?
• Pyramids were not built in one
day. Nor are treatment services
for Injecting Drug Users.
• Pyramids were built stone
for stone, layer for layer,
fitting seamlessly on the
preceding layer.
• Pyramids were built to last:
Sustainable Development
• Ancient Architectural Rule:
Start with the Fundament(al)s.