Scientific Justification of the Effectiveness of Implementing HIV/AIDS Risk Reduction Programs Among Drug Users (Exemplified by Sverdlovsk Oblast)

The dissertation by Kanarsky I.A. is dedicated to the scientific justification of the effectiveness of the implementation of HIV/AIDS risk reduction programs and other hemocontagious infections among drug users, exemplified by Sverdlovsk Oblast. The investigation is conducted at the National Scientific Research Institute of Public Health of the Russian Academy of Medical Sciences and encompasses the analysis of epidemiological dynamics of drug addiction and HIV infection morbidity during the period 1992–2002, the study of socio-hygienic risk factors, and the evaluation of the effectiveness of medical-social prevention based on a harm reduction strategy. The work contains original questionnaire data, focus group results, and expert evaluations, as well as a developed model of interdepartmental interaction in the sphere of hemocontagious infection prevention.

Relevance of the Problem

For Russia, as for other countries of the world, the HIV/AIDS pandemic at the present time represents a global danger and one of the most serious threats to the socio-economic development and national security of the country. The fight against the spread of HIV/AIDS is one of the urgent problems in many countries of the world (Declaration of the Special Session of the UN General Assembly on Commitment to the Fight against HIV/AIDS, 2001). In Russia, over the past fifteen years, cardinal changes have taken place in the public order, in the way of life, which have led to the stratification of society, the strengthening of social tension, and a sharp increase in socially conditioned diseases, including drug addiction and hemocontagious infections: hepatitis B and C, sexually transmitted infections (STIs), HIV infection (Ovcharov V.K., 2000, Pokrovsky V.V., 2000, Starodubov V.I., 2003, Chicherin L.P., 2000, Shchepin O.P. et al., 2001, Shchepin V.O., 2001).

At the present time, drug addiction represents a real threat to the health of the population of Russia (Koshkina E.A. 2002) and directly contributes to the increase in morbidity from HIV/AIDS and parenteral hepatitis. The fight against HIV infection, hepatitis, and drug addiction is an urgent problem of the health care sphere, and its main activity must include the struggle against diseases of a social character (Gerasimenko N.F., 2002; Shevchenko Yu.L. 2002).

An analysis of the dynamics of morbidity from drug addiction shows that a rapid increase occurred in Russia beginning in the 1990s, and by the end of 2002 the number of patients with drug addiction under dispensary supervision amounted to approximately 323 thousand people, or 225.3 per 100 thousand population (State Report on the Health Status of the Population of the Russian Federation in 2002, Ivanets N.N., 1997, 2002, Koshkina E.A., 1998, 2001, 2002). The true figures are 8–10, and sometimes even 100 times, higher than the recorded data. More than 2 million people in Russia regularly take drugs (Savelyev S.A. 2001; Kesselman I.E. 1999; Materials of Parliamentary Hearings. Drug Addiction in Russia: A Threat to the Nation, 1998; Vyalko A.I. 2002).

Following drug addiction, the Russian Federation experienced an explosive increase in morbidity from hemocontagious infections and sexually transmitted infections. Morbidity from hepatitis B in Russia in 1999 amounted to 35.7 per 100 thousand population, hepatitis C — 14.2, and in the case of hepatitis C, a direct correlational link is observed between the level of prevalence of drug addiction and the intensity of the epidemic process (Zhebrun I.V., Mukomolov S.Dzh. 1999). According to data from the Ministry of Health of the Russian Federation, in 2002 approximately 1 million cases of sexually transmitted infections (STIs) were registered (651.4 per 100 thousand population), with particularly high registration rates observed among children and adolescents, especially of the female sex. In turn, STIs increase the risk of transmission of HIV infection during sexual contacts, primarily among women of reproductive age from sexual partners, and measures to reduce STI morbidity also reduce the prevalence of HIV/AIDS (Laga M. Et al: 1993; Mertenes T.E. et.al. 1990).

By mid-May 2002, in Russia, since the beginning of registration, 194 thousand cases of HIV infection had been registered, more than half of which occurred in 2001–2002. The main route of spread of HIV infection (90% of cases) is the shared use of injection equipment during the consumption of narcotic substances. The bulk of those infected are people aged 18 to 25 (Shevchenko, Yu.L. 2002). Drug addiction is the main source of the modern epidemic of HIV infection, parenteral hepatitis, and sexually transmitted infections in Russia, and one of the main in the world: HIV infection among drug users has been noted in more than 100 countries of the world (A.V. Kolganov, V.V. Bogach, 2002; G.G. Onishchenko, M.I. Narkovich, 2000).

The HIV/AIDS epidemic is a serious threat to the national security of the country. The spread of HIV infection inflicts significant economic damage, which is associated both with material costs for the treatment of patients and with the loss of a large portion of the able-bodied population. At the same time, traditional measures for the prevention and counteraction of hemocontagious infections have proven ineffective, especially among injection drug users and persons engaged in prostitution.

Sverdlovsk Oblast is a typical industrial region of the Russian Federation. The total number of persons registered with a diagnosis of drug addiction in Sverdlovsk Oblast, according to data from the Ministry of Health of the Russian Federation as of January 1, 2003, amounted to 12,381 people, of whom approximately 85% consume drugs by injection. The increase in the number of drug-consuming persons over the last 5 years amounted to 4.7 times. Year by year, the share of drug users with HIV-positive status increases. At the same time, persons beginning to consume drugs — mainly adolescents and young people — are most at risk of hemocontagious infections. In these groups in Sverdlovsk Oblast, since 1996, there has been a sharp surge in morbidity from HIV infection, parenteral hepatitis B and C. As of December 31, 2002, 17,718 cases of HIV infection had been registered in Sverdlovsk Oblast, with 78% of cases of infection occurring through injection drug use, and by the cumulative number of HIV-infected persons as of December 31, 2003, Sverdlovsk Oblast held first place in Russia. The spread of hemocontagious infections inflicts damage on the health of citizens, primarily of young and working age, and leads to significant social and economic losses associated with the treatment of patients, the loss of their ability to work, and premature mortality. Effective treatment for AIDS does not exist in the world, therefore prevention is decisive (Pokrovsky V.V. 2000). However, since 1999, in a number of territories of Sverdlovsk Oblast, interdepartmental programs for the prevention of the spread of hemocontagious infections among drug users have been introduced (Khalfin R.A. 2000). This determined the necessity of a scientific evaluation of the effectiveness of the implementation of these programs in Sverdlovsk Oblast.

Goal of the Investigation. Scientific justification of organizational approaches to the evaluation of the effectiveness of medical-social prevention of hemocontagious infections, including HIV infection, including programs for harm reduction from injection drug use among their consumers.

Tasks of the Investigation:

1. To conduct a comparative analysis of the dynamics of the spread of drug addiction and morbidity from HIV infection in the territory of Sverdlovsk Oblast based on official data.

2. To study the socio-hygienic characteristics, the level of awareness of the problem of drug addiction and hemocontagious infections, the features of drug consumption and sexual behavior of injection drug users.

3. To test and evaluate the effectiveness of programs of medical-social prevention of hemocontagious infections among injection drug users based on the principles of a harm reduction strategy from drug use.

4. To study effective forms of interaction between medical-social services and public organizations in the implementation of harm reduction programs.

5. To develop proposals and practical recommendations for the implementation and evaluation of the effectiveness of medical-social prevention of hemocontagious infections for territorial structures and services combating the HIV/AIDS epidemic.

Scientific Novelty and Theoretical Significance of the Investigation.

For the first time, the medical-social and organizational aspects of the implementation of a harm reduction strategy from drug consumption in the conditions of a large industrial region of Russia have been studied and scientifically justified. It has been established that the participation of drug users in harm reduction programs reduces the probability of their transmission of hemocontagious infections. The absence of an increase in drug addiction and HIV infection morbidity as a result of the introduction of preventive measures for harm reduction from drugs has been substantiated. For the first time, a model of interdepartmental interaction in the problem of prevention of hemocontagious infections among youth and drug-dependent persons has been introduced into practice.

Practical Significance.

Scientifically grounded recommendations have been proposed for the introduction of harm reduction measures from drug use into the system of interdepartmental prevention of hemocontagious infections, including HIV/AIDS. For the first time, a unified system of evaluation, accounting, and reporting of harm reduction programs has been implemented in Sverdlovsk Oblast. The results of the investigation may be used by health care institutions, educational institutions, and law enforcement agencies for the development and implementation of state and regional comprehensive programs for the prevention of hemocontagious infections in target groups (drug users).

Expected Results.

• Improvement of the interdepartmental system of prevention of hemocontagious infections;

• Reduction of social and economic losses through the containment of the spread of hemocontagious infections, including HIV/AIDS, through the introduction of new preventive technologies.

Implementation of the Results of the Work.

• 16 scientific articles based on the results of investigations of international, regional, and Russian level have been published;

• The main provisions of the dissertation work were presented at 2 international scientific-practical conferences on harm reduction (New Delhi, India, May 1–5, 2001; Ljubljana, Slovenia, March 2–6, 2002); 3 regional conferences dedicated to HIV infection prevention (Yekaterinburg, January 29–30, 2001; Saint Petersburg, May 27–June 1, 2001; Yekaterinburg, February 20–21, 2002), 2 scientific-practical conferences of UGMU (Yekaterinburg, 2000, 2001); at the interdepartmental conference of the NII SGiUZ named after Semashko RAMN, 2003.

• During the investigation, a special computer program for monitoring the activity of primary care points for drug users and the work of outreach workers, i.e., in the environment of drug users inaccessible for contact, for attracting them to prevention, "Database of Primary Care Points for Drug Users, 2.0", based on MS Access 97, was developed and introduced in Sverdlovsk Oblast;

• An educational program has been developed and seminars are conducted for specialists of various services on the harm reduction strategy;

• Based on the results of the investigations, methodological recommendations on the prevention of infectious diseases among drug users have been published and introduced into practical health care: "Organization of the Prevention of the Spread of Infectious Diseases among Injection Drug Users", approved by the Ministry of Health and the CGESN of Sverdlovsk Oblast in 2001, 2002.

Propositions to be Defended:

1. Features and analysis of the dynamics of drug addiction and HIV infection morbidity among the population of a large industrial region of Russia.

2. Results of the medical-sociological investigation: socio-hygienic characteristics, level of awareness of the problem of drug addiction and hemocontagious infections, and features of drug consumption and sexual behavior — risk groups for hemocontagious infections, including HIV infection.

3. Evaluation of the effectiveness of programs of medical-social prevention of hemocontagious infections among injection drug users based on the principles of a harm reduction strategy from drugs.

4. Justification and proposals to territorial structures and services for HIV/AIDS prevention of organizational forms for the prevention of the spread of hemocontagious infections within the framework of the introduction of harm reduction measures from drug addiction into the system of interdepartmental prevention.

Volume and Structure of the Work.

The dissertation consists of an introduction, a literature review on the research topic, a research methodology, and 4 chapters of original research, a conclusion, findings and proposals, a bibliography containing 182 domestic and 83 foreign sources, documents confirming the introduction of the results of the investigation into the practice of health care, and appendices. The text is presented on 194 pages of typed manuscript, illustrated with 40 tables and 9 figures.