Pharmaceutical Journal Vol 263 No 7065
p544-545
October 2, 1999 International
World Congress of Pharmacy and Pharmaceutical Sciences
Drug addiction treatment in the fight against AIDS
The 1999 World Congress of Pharmacy and Pharmaceutical Sciences — the 59th international congress of the International Pharmaceutical Federation (FIP) — took place in Barcelona, Spain, from September 5 to 10. Our coverage continues this week with reports of a forum on AIDS and drug addiction and presentations on pharmacy and the internet
An increasingly important way in which pharmacists can help in the global fight against AIDS/HIV infection is to become more effectively involved in combating the spread of infection among injecting users, the congress heard on September 7. Participants at a forum organised by the FIP working group on AIDS and drug addiction heard that in many parts of the world injecting drug use was now the main mode of HIV transmission.
Discussing the scale of the problem, Dr ANDREW BALL (substance abuse department, World Health Organisation) said that heterosexual transmission was the driver for the AIDS epidemic in sub-Saharan Africa, where two-thirds of all people with HIV/ AIDS lived, but injecting drug use was now the main mode of transmission in Eastern Europe, Central Asia, East Asia, North Africa, the Middle East, Southern Europe, North America and parts of South America.
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Andrew Ball: injecting drug use has become the main transmitter of HIV
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The role of injecting drug use in regional epidemics varied greatly. For example, in the Indian state of Manipur, three-quarters of HIV infections were among injecting drug users, whereas for the rest of India, three-quarters arose from heterosexual transmission.
City epidemics
A series of explosive HIV epidemics among injecting drug users had been witnessed in different cities over the past 15 years, starting with New York in about 1980, followed by Edinburgh in 1984 and Bangkok in 1988. However, by the late 1980s evidence had been growing that HIV epidemics associated with injecting drug use could be prevented, slowed, stopped and even reversed. Examples were Glasgow, London and Sydney. But despite this knowledge and experience, new and explosive epidemics among injecting drug users were still being witnessed 10 years later. The most dramatic recent examples were in various cities in former states of the USSR — most recently in Moscow during the first half of 1999.
International research had played a critical role in understanding the factors that influenced the spread of HIV in drug-using populations. Cities that had managed to contain the epidemic among injecting drug users had three features in common: early implementation of prevention initiatives while HIV prevalence was low; community outreach to provide information and help develop trust between injecting drug users and health care providers; and the widespread availability of sterile injection equipment. At an individual level, there was evidence that, given the opportunity, injecting drug users would reduce their risk of HIV infection by changing drug injecting practice and in certain circumstances by modifying sexual behaviour.
Multiple behaviour interventions had been developed and tested for reducing HIV risk behaviours among drug users. To be effective, HIV prevention interventions needed to be implemented early, offer multiple strategies and multiple levels, be implemented in multiple settings to ensure greater cover and penetration, target multiple risk behaviours and provide opportunities for repeated exposures.
Pharmacies and pharmacists had a critical role to play in supporting a comprehensive and sustained strategy for preventing and responding to HIV epidemics among injecting drug users. Networks of pharmacies provided excellent opportunities for reaching injecting drug users and providing a broad range of HIV interventions, including: dispensing methadone, buprenorphine and other opioid agonists; providing sterile injection equipment; needle and syringe disposal; providing bleach and information on sterilisation procedures; providing information and education on risk reduction strategies; referral to other health services; providing condoms and advice on sexual risk practices; providing care and advice for those living with HIV/AIDS; and treating and preventing sexually transmitted infections.
In some countries, pharmacies had taken a strong active role in expanding HIV prevention efforts, such as through pharmacy-based needle and syringe exchange programmes in the United Kingdom and Australia, and the development of official policies such as that of the American Pharmaceutical Association on the sale of sterile syringes. In particular, the valuable work of the FIP's working group on AIDS and drug addiction was noted, which had included mapping of pharmacists' experiences in HIV prevention from all global regions.
Pharmacist intervention
In the first of several papers on pharmacists' interventions, Ms CRISTINA MENOYO (Spain) described the setting up of pharmacy-based programmes to help reduce the spread of AIDS among intravenous drug users in Spain. The programmes involved health education, distribution of "anti-AIDS kits", syringe and needle exchange, and methadone maintenance schemes to wean drug users away from injection. Pharmacists who had agreed to participate were given six hours' training. More than 1,100 pharmacists had been trained at courses organised by 20 pharmacy schools.
Mr RAFAÉL BORRÁS (Spain) told the forum that pharmacists had had considerable success in managing detoxification programmes for drug users in Catalonia, where 65 per cent of AIDS transmission was among IV drug users. Action to reduce the risk of infection included methadone maintenance programmes, syringe exchange schemes and encouragement of drug users to sign on for detoxification courses. Pharmacists were members of the multidisciplinary health care teams that managed the risk reduction programmes and participated in the detoxification programmes, being in a good position to monitor compliance. Patients who signed up for a detoxification course could choose whether the programme would be controlled by the drug centre, a pharmacy, a family member or the drug user himself. A pilot study had found that the chance of success was greatest when the programme was controlled from a pharmacy, with 67 per cent of patients successfully completing the treatment. This compared with 33 per cent for control by a family member or the addict himself and only 16 per cent for control by the drug centre.
Mr ENRIQUES ORDIERES (Spain) described a scheme in Spain's Basque area in which pharmacists directly supervised the treatment of IV drug users for tuberculosis, which was one of the first indicators of AIDS in that area. Treatment was difficult because of the need for multidrug therapy and because the social and other problems of injecting drug users led to poor compliance. After a working group had investigated ways of improving tuberculosis therapy compliance, the Basque health department and the Basque association of pharmacists had signed an agreement in March this year to introduce a scheme in which tuberculosis treatment was supervised in the pharmacy under the direct observation of the pharmacist. Pharmacists willing to take part had been given training by pharmacologists, AIDS specialists, etc. The pharmacists provided monthly reports on their patients' progress, giving information on such matters as side effects and compliance. A committee was evaluating the results of the programmes.
Mr OLIVIER BUGNON (Switzerland) said that in his country AIDS/HIV prevention was part of the routine activity of most community pharmacists. More than 70 per cent of pharmacies were involved in the distribution, exchange and disposal of needles and syringes. A similar proportion supplied methadone to addicts, and 20 per cent carried out urine testing for drugs. About half of all Swiss pharmacies also took part in a programme of health promotion activities to prevent the sexual transmission of AIDS and other diseases. The campaign was aimed particularly at women between the ages of 15 and 20, who were offered a free information pack in the form of a colourful toilet bags containing leaflets and condoms. As part of the scheme, more than 500 pharmacists and about 700 assistants had been given AIDS prevention training in special seminars.
Ms JANINE MATTE and Ms LOUISE PETIT (Canada) told the forum that a methadone substitution programme provided from their pharmacy in Quebec City, Canada, had reduced by two-thirds the use of injections as the means of administering psychoactive substances. Their pharmacy had been chosen for the project because it had two private consultation areas, was open for 75 hours a week, offered a 24-hour on-call service,5 and was willing to integrate the methadone maintenance clientele into its regular clientele. Clients had to sign a contract agreeing to keep to the programme for two years. They agreed to psychological and medical evaluations, daily visits to the pharmacy and weekly urinary detection tests in the pharmacy. They also agreed to obtain all their prescription drugs and self-medication products from that pharmacy. An evaluation of the programme after 12 months had found that only 33 per cent of participants were still injecting drugs, compared with 94 per cent at the time of admission to the programme. No patient was found to be HIV positive other than one who had been positive on admission.
Room for improvement
Pharmaceutical care of AIDS patients in the community could be improved, suggested Dr FOPPE VAN MIL (the Netherlands), summarising the results of a recent questionnaire survey of Dutch community pharmacists.
The survey had found that only a third of respondents sold needles and syringes to drug addicts - a figure that Dr van Mil found "amazingly low". In the field of AIDS prevention, only 60 per cent had health education material visible to customers in their pharmacies and a similar proportion sold condoms. Questioned about patient counselling, only a third of respondents had said that they gave AIDS patients any special attention.
The results were disappointing, said Dr van Mil, since AIDS patients needed a special approach for their drug treatment, and often needed specially targeted counselling. Providing them with pharmaceutical care required special tools, knowledge and skills.
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Developing pharmacies as AIDS care centres
The International Pharmaceutical Federation's working group on AIDS and drug addiction has announced a project designed to establish pharmacies as "AIDS/HIV care centres". The project has the support of the World Health Organisation.
Announcing the project during the AIDS forum at the congress, Ms ANNICK DULION (director of professional affairs, Conseil National de l'Ordre des Pharmaciens de France) said that the objective was to develop manuals outlining practical ways for pharmacists to implement guidelines on an AIDS role for pharmacists that were contained in the joint declaration signed by the FIP and the WHO at the 1997 FIP congress in Vancouver (PJ, September 13, 1997, p148).
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Jean Parrot and Annick Dulion: the project will help pharmacists develop an AIDS role and make an impact
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She said that the manuals would be tailored to specific geographical and epidemiological areas. The manuals would be modular and would include modules on intravenous drug injection, on the safe and effective use of antiviral drugs and on prevention strategies.
Implementation of the project would be based on experiences gathered from countries around the world. The manuals would be tested in community pharmacies in different parts of the world to determine their effectiveness in improving patient health outcomes in countries with different health care systems, cultures, etc.
The final manual would be published in English, French, German and Spanish to maximise its usefulness in various countries around the world. It would be used in starting up new projects in collaboration with non-governmental associations, health authorities and pharmaceutical companies or other partners. The project would be financed partly through FIP and WHO, but external sponsors were also being sought.
Mr JEAN PARROT (president, Conseil National de l'Ordre des Pharmaciens de France) said that the project was an exemplary one for a number of reasons: it obliged pharmacists to face ethical and moral considerations as well as scientific, medicinal and therapeutic approaches; it involved pharmacists as health professionals in contact with people's realities; it called for a range of pharmaceutical skills, including prevention, information detection, patient care and risk reduction; it demonstrated the need for, and pharmacists' commitment to, interprofessional collaboration; it would create cohesion and confidence among individual pharmacists and reduce their isolation; it would motivate others to greater involvement in the fight; and it could stimulate a broader use of pharmacists in an ever growing array of public health issues.
Concluding, Mr Parrot said that the effort was justified because of the size of the AIDS pandemic and because of pharmacists' potential to make an impact. Successful completion of the project would allow it to be expanded beyond AIDS, putting pharmacies world-wide at the front line of combating public health problems and making every pharmacist a WHO correspondent for health priorities.
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