Most services for drug users in the four case studies are fully engaged with scaling up harm reduction and HIV prevention. But while some of the key activities to reduce the burden of TB/HIV are being introduced, they sometimes seemed added on as an after thought, if at all.
TB infection control
Without implementing good TB infection control practices, people who use drugs are at high risk of being exposed to TB in health services or in other settings where they are congregated (prisons, homeless shelters, injecting sites/crack houses, drop in centres and support groups).
Most clinical services in the countries visited are well aware of the risks of TB transmission to their clients and staff, and most of the facilities visited in these case studies claimed to be making some effort to introduce good TB infection control. The HIV facilities in Brazil had infection control plans and advanced ventilation systems, while CAPS AD sites, such as PROSAM in Sao Paolo had used their own funds to install ventilation systems. Similarly, according to Dr Konstantin Lezhentshev of the All-Ukrainian Network of People Living with HIV, they secured funding and took whatever steps were necessary to improve TB infection control in most facilities treating people with HIV in Ukraine — including remodelling some of them. However, he noted that it is not clear that TB infection control has consistently been considered within the OST units.
Indeed, in most settings, good TB infection control is not happening in drop-in centres or other facilities (including prisons) where people using drugs gather, nor are clients and staff of these facilities being educated about how to protect themselves from TB (except to some extent in Ukraine and Brazil).
In Zanzibar, people who attend support groups are afraid of being exposed to TB.
“We know that if you have TB, it is easy to give it out to another person. As you see, the room where we meet is small. The door is not open, and the windows are closed. Last week, one person came with TB and somebody said to him that you are not allowed to come into the room,” said one support group member.
“It was the right thing to do because his TB was still active, he had been on treatment for only five days,” said Ms Sukwa. “So allow him to stay home until the time he cannot infect others. But, yes we know this is not a good place — not only for the clients but for the staff here. Because when they are inside here, they close the door and there is no air circulation.”
In India, the National Framework For Joint HIV/TB Collaborative Activities recommend introducing ‘simple and feasible’ TB infection control practices into health facilities frequented by high numbers of HIV-infected persons — but, other than vague recommendations that drop-in centres for drug users should be ‘well-ventilated,’ TB infection control is not reaching the targeted interventions.
“What about TB infection control? We know this is a problem, but we don’t have the funding to do anything about it,” said Mr Shabab Alam, Project Director for the Sharan TI-1 site in New Delhi. “The government and NACO needs to think and talk about this — and the nurses and other healthcare staff also have their health rights to be considered.”
Intensified case finding for TB & HIV testing and counselling
Detection of TB and HIV in drug users is the first step to accessing treatment, and reducing mortality and disease transmission from both diseases. HIV testing and counselling can and should be available to people using drugs, preferably at the service sites where they first present, including the specialised services which countries develop to reach them.
Likewise, routine TB screening is a simple activity that could help flag possible TB cases. The guidelines recommend, at a minimum, that trained counsellors or other lay health workers can administer a brief questionnaire on TB symptoms to screen for active TB, referring those who screen positive to a microscopy centre. Identifying TB suspects is also an important activity to protect workers at community-based organisations and health facilities from TB.
The site visits found that HIV testing and counselling were more widely available, offered at clinical sites and the specialised services in Zanzibar, Ukraine and Brazil. However, in India, people using drugs who are clients of the Targeted Interventions must be referred to a testing and counselling centre.
TB screening tends to only be provided at clinical facilities. In Zanzibar and most of India, outreach workers provide accompanied referrals to get the client to a facility that can screen for and/or diagnose TB. If they make it there, there is a high likelihood that they will be screened in Zanzibar — ICAP supported sites in Tanzania report routinely screening 99% of their clients using a simple TB symptom checklist (see annex ?).
However, with the exception of a couple of sites in Northeast India, CBO staff and outreach workers are not routinely screening for TB. Another problem in India is that the TB programme is oriented towards diagnosing smear positive TB — people with HIV often have smear-negative or extrapulmonary TB, and have to pay out of pocket for further tests to get diagnosed — which means many cases may be missed.
Treatment for TB, HIV and co-management of TB/HIV
People using drugs have the right to effective TB and HIV treatment in accordance with international clinical guidance — and even though treatment can sometimes be complex when people have multiple concurrent illnesses (including TB/HIV and hepatitis), standard treatments, including OST, can be given concurrently.
Programmes visited are attempting to improve access to medical care for drug users — which is a positive first step — and having some limited success at getting people who use drugs onto TB or HIV medication.
In Zanzibar, increasing numbers of drug users are being referred for treatment, but there are no data yet on how effective referrals to TB or HIV care are — but without OST, which encourages people to come in for care, URRAP concedes that keeping drug users in care long enough to get on treatment is a challenge.
“It’s not easy for the drug user to stay on TB treatment because most of them want to get the next fix,” said one outreach worker. “To treat an active drug user for TB, you also need to provide him with shelter and counselling.”
In India, site visits found a number of people who inject drugs who were on HIV or TB treatment, usually together with OST. Even though it is policy in India, it was harder to find people with TB/HIV coinfection on simultaneous treatment. Better funded TI sites in the Northeast, where the TI sites are closer to referral centres — and which sometimes can directly provide TB treatment — seem to be having more success at this. Elsewhere, however, people have to pay out of pocket for transport to referral facilities that can be several kilometres from the TI or OST sites.
Many never reach care. TB care in India is more decentralised than ART and so in theory, should be more accessible but the TB programme requires that people have an address to get treatment, putting drug users who live on the streets at a disadvantage.
A couple of NGOs serving people who use drugs have reached an understanding with local TB officers to get around this requirement, but this in only happening on a site-by-site basis and similar understandings need to be reached nationwide. Finally, although it is against policy, many doctors still resist prescribing antiretrovirals to drug users, even when the client is on substitution therapy and thus could use better training.
In Ukraine, the intensive phase of TB treatment can still only be delivered by a TB facility, but some have begun offering OST in order to keep people using drugs in the hospital and on TB treatment. As for antiretroviral therapy (ART), some integrated care sites have placed an infectious disease doctor on staff who can deliver treatment. Co-management of TB/HIV during the intensive phase of TB treatment is only possible at TB facilities with an infectious disease doctor on the team. The integrated care sites at TB dispensaries visited for these case studies were only beginning to put people on both TB treatment and antiretrovirals.
Finally, in Brazil, antiretrovirals are only available by referral to specialised facilities but if coinfected, clients should receive co-treatment.
A related issue is the availability of cotrimoxazole, which is an essential and lifesaving medication for people with active TB who are co-infected with HIV, but sites visits found that this wasn’t always prescribed in Ukraine and India, despite international and national guidelines.
TB prevention using isoniazid preventive therapy (IPT)
People with HIV who have been exposed to TB are at high risk of developing active TB disease — but studies show that a course of isoniazid preventive therapy (IPT) can significantly reduce this risk. In some countries, such as India, it is not yet national policy to provide IPT to people with HIV. In others, IPT may be policy but is rarely done.
A case in point is Brazil, where it is policy to offer IPT to people known to be latently infected (shown by a positive tuberculin skin test). Some HIV centres have had more success than others at putting people with HIV onto IPT. However, some doctors are reluctant to prescribe the drug, while the requirement to have a positive skin test (which means coming to the clinic once to receive the test, and then a few days later to have the test read). Many people do not make it through this process to get onto treatment, and, at present, there are no data on the number of drug users who actually receive IPT.
Preventing HIV transmission
Drug users need access to HIV prevention services to protect themselves and their contacts from HIV. Although sharing contaminated injecting equipment is the most common means of HIV transmission among drug users, in many settings drug users are also at high risk of sexual transmission. For instance, drug users in India are far more likely to report unprotected sex with sex workers — and many have passed HIV on to their wives. Meanwhile, in Brazil, people who use drugs frequently, such as crack users, are also at high risk of HIV, presumably by sexual transmission. Dr Bastos reported that in his studies, there appeared to be a significant overlap between crack use and sex work (for drugs or money).
Most of the programmes in these case studies are geared to do HIV prevention work. In India, CBOs focus on condom distribution and clean syringe/needle exchange — although there are complaints from some TI’s that they were not receiving enough needles for their clients. India’s programme also promotes universal precautions to protect staff from needlestick injuries.
Clean needle kits are widely available in most Brazilian states, even though drug injecting is no longer common. Other community based organisations in Brazil are now more focused on how to reduce sexual transmission among crack users, and some are offering clean sniff kits and crack pipes to reduce the risk of hepatitis transmission from sharing.
Outreach workers report challenges promoting harm reduction and condom distribution in Zanzibar’s conservative Islamic society. However, even though the community does not yet support needle exchange, the CBOs have sensitised pharmacists to at least sell syringes to drug users (which they would not do previously).
In Ukraine, the National Law on AIDS that endorses a harm reduction approach to prevention and the package of preventive services is widely available to drug users. In addition, scaling up access to OST is partly to reduce the demand for injecting opiates and to prevent transmission of HIV and other infections via unsafe injection practices.