May OF

REPORT

BlREGIONAL INFORMAL TECHNICAL CONSULTATION ON THE DEVELOPMENT OF CLINICAL PROTOCOLS ON HIV TREATMENT AND

CARE FOR INJECTING DRUG USERS

15-17 May 2006 Kuala Lumpur, Malaysia

Convened by World Health Organization

Regional Offices for South-East Asia and the Western Pacific

Not for sale

Printed and distributed by:

World Health Organization Regional Office for the Western Pacific

Manila, Philippines

NOTE

The views expressed in this report are those of the participants in the Biregional Informal Technical Consultation on the Development of Clinical Protocols on HN Treatment for Injecting Drug Users and do not necessarily reflect the policies of the Organization.

This report has been prepared by the World Health Organization Regional Offices for South-East Asia and the Western Pacific for governments of Member States in the Regions and for those who participated in the Biregional Informal Technical Consultation on the Development of Clinical Protocols on HN Treatment for Injecting Drug Users from

15 to 17 May 2006 in Kuala Lumpur, Malaysia.

ABBREVIATIONS ... 1

1. INTRODUCTION

1.1 Objectives ... · .. ··· ...

1.2 Participants ... ··.··· .. ··· ... 1

1.3 Organization of the meeting ... , ... 1

1.4 Opening ceremony ... 2

2. PROCEEDINGS

2.1 Plenary session I. ... , ... ' .... , ... 2

2.2 Plenary session II ... " ... , ... .3

2.3 Plenary session 111. ... '" ., ... , ...

2.4 Plenary session IV ... 5

2.5 Plenary session V ... , ... 7

2.6 Plenary session VI. .. , ... '" ., ... 8

3. CONCLUSIONS

3.1 Outcomes ... 9

3.2 Next steps for adaptation ... , ... 9

ANNEXES:

ANNEX 1 - LIST OF P ARTICIP ANTS, TEMPORARY ADVISERS, OBSERVERSIREPRESENTATIVES AND SECRETARIAT ANNEX 2 - TIMETABLE

Keywords: Clinical protocols! Anti-HIV agents-therapeutic use/ Antiretroviral therapy, Highly active/ HIV infections-drug therapy! Substance abuse, Intravenous! Asia, Southeastern!

Western Pacific

AIDS

ART ARV

ddI d4T DOTS FHI HAART

HIV ICDIO IDU IDUs IRIS LAAM MSF MMT

OI PLHA TB UNAIDS UNODC WHO

ABBREVIATIONS

Acquired immunodeficiency syndrome Antiretroviral treatment (therapy) Antiretroviral

Didanosine Stavudine

Directly observed treatment, short-course Family Health International

Highly active antiretroviral therapy Human immunodeficiency virus

International Classification of Disease lOIb revision Injecting drug use

Injecting drugs users

Immuno-reconstitution inflammatory syndrome Levo-alpha acetyl methadol

Medecins Sans Frontieres

Methadone maintenance treatment Opportunistic infection( s)

People living with HIV/AIDS Tuberculosis

Joint United Nations Programme on HIV/AIDS United Nations Office on Drugs and Crime World Health Organization

1. INTRODUCTION

Antiretroviral therapy offers an opportunity to improve the prognosis and quality of life of people living with HNIAIDS. However, the restricted availability of antiretroviral therapy and discrimination against injecting drug users often result in inequities in access and treatment. Many countries still have few or no facilities or services for injecting drug users.

Various stakeholders have requested WHO technical support in this area.

WHO, the Joint United Nations Programme on HN/AIDS (UNAIDS) and other international and national partners have committed to provide universal access to antiretroviral treatment to all those in need, including specific at-risk groups. This biregional informal technical consultation was held to reach a consensus on clinical protocols and an essential HIV/AIDS care and treatment package for injecting drug users for adaptation and use in the WHO Regional Offices for South-East Asia and the Western Pacific. The process was based on a draft document, WHO Clinical Protocol on HIV, which was reviewed and revised in an expert consultation held in Lisbon, Portugal, in June 2005, focusing on the needs of Europe and Central Asia.

1.1 Objectives

(1) To review the draft clinical protocol on HNIAIDS care and treatment for injecting drug users prepared by the WHO Regional Office for Europe for adaptation and use in the South-East Asia and Western Pacific Regions;

(2) to agree on the revised clinical care and treatment protocols for injecting drug users; and

(3) to define an essential HIV/AIDS care and treatment package for injecting drug users.

1.2 Participants

Eleven participants attended the meeting, including country participants from Cambodia, China, Malaysia, the Philippines and Viet Nam, and partner organizations, including the Family Health International (FHI), Klinik Kesihatan Sembilan in Malaysia and the United Nations Office on Drugs and Crime (UNODC). The WHO secretariat included staff from WHO Regional Offices for South-East Asia and the Western Pacific, and from country offices in Indonesia, Malaysia and Thailand. Temporary advisers for the meeting were experts in the areas of antiretroviral therapy and/or treatment and care of injecting drug users.

The list of participants, temporary advisers, observers/representatives and secretariat staff is attached under Annex 1.

1.3 Organization ofthe meeting

The meeting was held at the Mahkota Room, Ballroom Level of Hotel Istana in Kuala Lumpur, Malaysia, from 15 to 17 May 2006. Methods used in the meeting included plenary sessions, presentations and small group discussions. The timetable is attached as Annex 2.

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1.4 Opening ceremony

Dr Michel Tailhades (Medical Officer, HSI, WHO Regional Office for the Western Pacific), welcomed the meeting participants to Kuala Lumpur. He introduced Dr Jai P. Narain (Director, Department of Communicable Disease, WHO Regional Office for South-East Asia).

Dr Narain delivered the opening address on behalf of the WHO Regional Directors for South-East Asia and the Western Pacific. He welcomed the participants and representatives of the Family Health International (FHI) Asia and Pacific Division and the United Nations Office for Drug Control (UNODC) for East Asia and the Pacific. He spoke of the importance of the meeting and the commitment of the WHO Regional Offices to the efforts to scale up antiretroviral therapy to people who use injection drugs. He wished the participants well for the meeting.

Dr Ying Ru-Lo (Regional Adviser, HN/AIDS Unit, WHO Regional Office for South-East Asia) also addressed the meeting. She welcomed all of the participants and presented her expectations for the meeting.

2. PROCEEDINGS

2.1 Plenary session I: General considerations ofHN organization and management

Dr Penny Miller (Family Health International) reviewed the epidemiology ofHN among injecting drug users, both globally and in Asia. It is estimated that there are 5.6 million injecting drug users (IDUs) in South-East Asia. There are also very high HN rates in the region. Some country-specific data were presented to illustrate the various challenges throughout the region. For example, Bangladesh and Pakistan were described as early concentrated epidemics that are poised to accelerate. Nepal was also given as an example of an early concentrated epidemic among IDUs, with an estimated 30 000 IDUs and an HN prevalence of 40%-68%. Myanmar represents a more mature epidemic with spread to lower risk populations. There are an estimated 90 000 to 300 000 injecting drug users in the country, with an HN prevalence of 45%-80%. Even in countries with concentrated epidemics driven largely by injecting drug use, resources are extremely limited and there is a real risk that many countries could move into a more generalized epidemic, which is much more difficult to control.

Dr Fabio Mesquita (Indonesia HN/AIDS Prevention and Care Project) gave a presentation on "Comprehensive services for injecting drug users: situation in Asia".

Dr Mesquita used the programme in Indonesia as an illustrative example of how programmes directed towards IDUs could be organized. The core components are needle and syringe programmes, treatment of drug-related problems, and HN-related support and treatment of injecting drug users. This is a multidisciplinary model, with wide access across the country.

The initiative also includes the first prison programme in Asia.

The question and discussion period that followed plenary session I was moderated by Ms Boum Ranumas. The main points of discussion were:

•

•

•

•

•

•

There are a number of explosive epidemics in the region.

HIV transmission within closed settings is a serious concern (i.e. Indonesia has 480 prisons).

For antiretroviral scale-up, the injecting drug use community needs to be engaged.

Overdose management and other injection-related complications should be considered.

A continuum of care must be established and services harmonized.

Ms Bourn Ranumas read a prepared statement from the Thai Drug Users Network that focused on the serious legal issues surrounding drug use that pose major obstacles to HIV care and treatment.

2.2 Plenary session il: WHO clinical protocol on HIV / AIDS treatment and care

Ms Manuela Moeller (Technical Officer, HSI, WHO Regional Office for the Western Pacific) introduced the WHO Clinical Protocol and outlined the objectives for the small group work. The three groups were instructed to review the draft document, WHO Clinical Protocol on HIV, which was revised in an expert consultation in Lisbon, Portugal, in June 2005. Chapter 1 (introduction and general issues) and Chapter 2 (services for injecting drug users and models of comprehensive care) were to be reviewed during the first session. The groups were instructed to make recommendations regarding:

• regional situations and requirements;

• the structure of the protocol;

• the practicality of the document; and

• its user-friendliness; and

• to identify any areas that are missing or require further research

2.2.1 Group work I

The working groups discussed their particular sections and returned to the large group to report on their suggestions.

Group 1 reported on the background and general considerations and services in the document. There were a number of observations.

• Avoid statements that are stigmatizing or patronizing.

• Make use of points that are applicable across the region.

• Be specific about regional drug-use patterns that may be very different from country to country.

• There is a need to consider other drugs - especially crystal methamphetamine and other stimulants.

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o Principles should include services for injecting drug users and their regular sex partners.

o Involve injecting drug users in the programmes to reduce stigma.

o Emphasize that the use of compulsory treatment/prisons is not effective and actually increases the risk ofHN transmission.

Group 2 reported on the drug substitution section of the document. There were a number of observations.

o The current programmes are driven by pUblic-security issues.

o Methadone and Buprenophrine are not widely available.

o China has plans for a major methadone scale-up programme and WHO is playing a proactive role in this.

o Hong Kong also has some good scale-up programmes for substitution therapy.

o The document makes the use of methadone with antiretrovirals seem difficult when it is not.

o The chart with methadone dosing needs more detail.

o Detoxification programmes and antiretroviral programmes should be strongly linked.

o The psychosocial interventions outlined in the document are very good.

o Remove Levo-alpha acetyl methadol (LAAM) as it is not available.

o Adverse reactions to methadone are very rare and this should be stated in the document.

Group 3 reported on the clinical management of patients on antiretrovirals. There were a number of observations.

o HN confirmation by Western Blot is not necessary.

o GD4 counts and plasma viral-load testing are still too costly and may not be available.

o The screening annex is not very useful.

o Urine screening is not necessary.

o Highly active antiretroviral therapy (HAART) recommendations should be the same for injecting drug users and non-injecting drug users.

o Discussions regarding country-by-country situations illustrated wide variations in services and antiretroviral availability across the region (i.e. Malaysia - two drugs free and the third needs to be purchased; Southern China - no methadone currently;

the Philippines - reported 2000 on treatment and only seven injecting drug users;

Thailand - reported about 50 000 on antiretrovirals, but few injecting drug users;

Indonesia - most antiretrovirals must be purchased).

2.3 Plenary session ill: Clinical management ofHN-positive injecting drug users

Dr Hillary Kunins (Albert Einstein College of Medicine, New York, United States of America) reviewed issues regarding the initial evaluation of the injection-drug-using patient with HN. Dr Kunins presented the-experience of a New York setting where 4500 patients are being followed in 12 clinics that offer methadone and a multidisciplinary approach to addiction care, HIV treatment and hepatitis C treatment. Formal instruments are used to "open the door"

to further discussion around stigmatized behaviours or problems, evaluate progress in treatment, and promote quality care. Screening for psychiatric illness is an important component of the evaluation, using standardized evaluation tools. The programme also provides a range of social supports in order to optimize adherence to antiretroviral therapy.

Dr Suresh Kumar (Hospital Kuala Lumpur, Malaysia) gave a presentation on

"Surveillance programme for antiretroviral treatment compliance, outcomes and side-effects".

Dr Kumar used the Malaysian hospital-based experience to illustrate some of the challenges to providing HN care and treatment. He emphasized that effective treatment programmes must consider the multiple needs of the individual and not just drug-use issues. He discussed the data collection procedures at his institution and the challenges to collecting consistent information on adherence, side-effects and treatment outcomes. The main challenges were poor response from the treating sites, incomplete data entry forms, time lag, expense of data collection, difficulty assessing outcomes and lack of information on adherence.

The question and discussion period following plenary session ill produced a number of important points.

• Not all drug users are drug-dependent and therefore not everyone needs to be put on drug-dependency treatment.

• In some countries, the use of mandatory drug treatment wrongly identifies people who are not drug-dependent.

• Detox for opiate withdrawal should be used to alleviate discomfort, prevent the development of complications, interrupt a pattern of heavy drug use and facilitate linkages to services.

• Detox should not be seen as a treatment but rather as an entry into treatment.

• Relapses are very common and relapse-prevention strategies are critical.

• Co-morbid disorders must be addressed separately.

• Psychiatrists can improve the quality of addiction care.

• In China, the early results of a programme for daily methadone pick-up show it is problematic, as transportation is often difficult and people are reluctant to fill out surveys as it may be hard to guarantee confidentiality.

2.4 Plenary session IV: Management of addictions and supporting HIV -positive patients on antiretroviral therapy

Dr David Jacka (WHO, Indonesia) focused on opiate substitution therapy (OST) - both methadone and buprenorphine. He reviewed the programme that he is working with in Victoria, Australia. The history and uptake of methadone and buprenorphine in Australia was described. When assessing a patient for opiate substitution therapy, the key features to be

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considered are: engaging the patient in the treatment process, presenting the addiction problem, determining the pattern of drug use and the severity of the dependency, risk practices, and finding goals for the patient. Dr Jacka also described emerging opiate substitution therapy programmes in Asia, with a focus on China, Hong Kong and India.

Dr Emanuele Pontali (Casa Circondariale di Marassi, Prison of Genoa, Italy) covered the approach to antiretroviral therapy for injecting drug users. The principles outlined included:

antiretroviral therapy is effec~ve for injecting drug users; given appropriate support, IDUs adhere well to treatment; current or past drug use is not a criterion for denying treatment; and special attention is required in relation to substance dependency and co-morbidities. There also needs to be special attention paid to monitoring for hepatoxicity because of the high rates of hepatitis B/C co-infection. Adherence can be enhanced by social stability, a reduction in illicit drug use, a low pill burden, and once-daily treatment regimens.

The question and discussion period was moderated by Mr Lenny Ng following plenary session N and produced a number of impo$nt points.

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•

•

•

•

2.4.1

Discussion ensued regarding age limits for methadone in various countries. It was agreed that methadone should be offered as early as necessary, but there may be country-specific age restrictions.

Programmes that combine opiate substitution therapy and antiretroviral therapy should be promoted.

If multidisciplinary programmes are to be promoted, then all of the components must be in place. Unfortunately, this is not always the case and programmes for antiretrovirals should not be delayed due to the lack of opiate substitution therapy

and other supports. .

Immuno-reconstitution inflammatory syndrome (IRIS) should always be considered when starting antiretrovirals.

Many countries in Asia still have very limited access to opiate substitution therapy and there remains a major problem with stigma and discrimination.

Group work II

The working groups discussed their particular sections and returned to the large group to report on their suggestions.

Group I reported on the organization and management considerations.

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•

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•

•

Ensure that consistent wording is used throughout the document.

Medical care should be widely available, accessible and affordable.

Medical care should also be available to partners ofIDUs.

Reference to prisons should be replaced by "closed settings".

Drug maintenance therapy should be emphasized over abstinence.

Mobile services should be considered.

Group 2 reported on drug interactions with antiretrovirals and also on the section on chronic pain management. There were a number of observations.

• Interactions should be covered in tabular form.

• Chronic pain management presents many challenges in Asia due to the lack of available analgesic medications and trained medical staff.

Group 3 reported on adherence, co-infections and co-morbidities, as well as minimum indicators for clinical monitoring.

• Daily dispensing may be practical for some locations, but would not be a practical approach in many others.

• The ability to diagnose tuberculosis is important.

• Hepatitis C treatment is beyond the scope of most countries at this time.

• The cost of hepatitis C treatment remains prohibitive.

• CD4 counts and plasma viral-load testing are still too costly and may not be available.

2.5 Plenary session V: Clinical management ofHIV-infected injecting drug users - highly active antiretroviral therapy

ffiAART)

Dr JOrg Golz (Centre for Infectious Diseases and Drug Addiction, Berlin, Germany) provided a comprehensive overview of antiretroviral therapy and its potential side-effects. He described a range of adverse effects from a body system perspective, ranging from dermatological effects (abacavir), GI effects (Protease inhibitors), central nervous system effects (efavirenz), hematologic effects (zidovudine) and metabolic effects (d4T and ddl). He also covered a range of drug interactions when using ARVs, including methadone and anti-TB medications.

Dr Mark Tyndall (University of British Columbia, Canada) covered co-infections and co- morbidities. The main co-infection seen in the injecting drug use population is hepatitis C, where essentially all HIV-positive injecting drug users have also been exposed to hepatitis C.

This can complicate antiretroviral treatment by resulting in higher rates of hepatotoxicity.

Treatment of hepatitis C prior to antiretroviral therapy may be an option in some settings, although hepatitis C treatment is extremely costly, requires injections, lasts for 12 months, is poorly tolerated and is not always effective. The ultimate efficacy of therapy is somewhat dependent on the hepC viral genotype. Hepatitis B co-infection is also extremely prevalent in much of Asia and has implications for HIV therapy. The management of tuberculosis was also discussed. Tuberculosis must be treated and is a common pathogen associated with immuno- reconstitution syndrome. It also can complicate tolerability to HIV therapy.

The question and discussion period following plenary session V produced a number of important points:

• Diagnostic testing for hepatitis viruses may not be available.

• Hepatitis B vaccine, although very effective, is not part of routine vaccination in Asia.

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• In Thailand, 50% of HIV -positive patients present with tuberculosis.

• Alcohol use should be strongly discouraged in those with hepatitis B/C. This is not as much of a problem in Indonesia and Malaysia.

2.6 Plenary session VI: Clinical management ofHIV -infected injecting drug users

Mr Umesh Sharma (International HIV/AIDS Alliance) reviewed adherence support for mus on antiretroviral treatment. He described some important challenges to antiretroviral adherence including: the distance and time to travel to services, the poor availability of methadone, the attitudes of health care providers towards mus, the cost of monitoring treatment and other diagnostic testing, the fear that confidentiality cannot be assured, and the fact that patients are not well informed or prepared to begin treatment. Mr Sharma emphasized the importance of family and partners to support therapy in the Asian setting. For the most part, programmes are just beginning in Asia and many challenges remain.

Dr Guogan Lu (Medecins Sans Frontieres Clinic, China) described an existing antiretroviral programme in Nanning, China. This is in the province of Guangxi and has the third highest HIV prevalence in China. In the injecting drug use population, HIV prevalence is estimated to be 40%-60%. The Medecins Sans Frontieres (MSF) project was established in December 2003 and provides a comprehensive programme of HIV treatment and care to over 500 patients. Dr Guogan presented outcome data for the first 316 patients registered in the programme. The overall adherence was estimated to be about 88%. Medications are provided for two weeks at a time and the role of family members is critical to enhance adherence. This programme does not currently provide methadone treatment, although this is planned.

The question and discussion period following plenary session VI produced the following points:

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•

•

•

2.6.1

Monitoring systems are important to evaluate antiretroviral programmes.

Confidentiality remains a very important consideration in all substance dependency and HIV programmes.

Directly observed treatment (DOT) programmes are not practical in many settings and family members are very important to optimizing adherence.

Law enforcement is still a major obstacle to HIV care and treatment.

Group work III

The working groups discussed their partiCUlar sections and returned to the large group to report on their suggestions.

Group 1 reported on initial patient evaluation, managing HAART in injecting drug users, and side-effects and toxicity management.

Group 2 reported on adherence, co-infections and minimum standards for monitoring.

Group 3 reported on gaps and identified other potential country-specific data sources.

The fInal discussion focused on some remaining obstacles in the Asian setting. Although it was recognized that there is a lot of variation from country to country, some consistent obstacles remain:

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•

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•

MethadonelBuprenorphine is not yet widely available.

Compulsory drug-treatment centres (COTC) are still a very common approach to managing drug users, despite the lack of evidence to support them.

Second-line antiretroviral treatments are not generally available and this leaves people with few options if resistance develops.

Capacity to monitor the effectiveness of treatment through CD4 counts and plasma viral loads is not generally available.

3. CONCLUSIONS

The participants reached the following conclusions:

3.1 Outcomes

The meeting brought together a group of HN and substance dependency experts to produce a guide for physicians and health care workers providing HN / AIDS care and treatment for people who inject drugs in Asia. The meeting led to a list of specifIc recommendations that will be used to fmalize a published guide, to be distributed by WHO.

3.2 Next steps for adaptation

The fIrst draft document will be produced by Dr Mark Tyndall and then circulated to some of the meeting participants for comments. Dr Tyndall will incorporate the suggestions and submit a final draft of the revised document to WHO.

ANNEXl LIST OF PARTICIPANTS, TEMPORARY ADVISERS, OBSERVERSIREPRESENTATIVES

AND SECRETARIAT

CAMBODIA

CHINA

MALAYSIA

1. PARTICIPANTS

Dr Sam Sop han, Paediatrician for HIY/AIDS Care Unit (CHIC), National Paediatric Hospital, #100, Blvd. Russian, Khan Toul Kork, Phnom Penh. Tel: (85512) 931 290. Email: [email protected] Dr Moeng Sumanak, Medical Practitioner in AIDS Ward

Khmer-Soviet Friendship Hospital, 35 Phum Prek Torl, Sangkat Stoeng Mean Chey, Khan Mean Chey, Phnom Penh.

Tel: (011) 768 007. Email: m [email protected] Dr Zhang Fujie, Director, Division of Treatment and Care

National Centre for AIDS/SID Control and Prevention, China CDC No 27 Nan Wei Road, 100050 Beijing. Tel: (8610) 630 39086.

Fax: (8610) 630 39087; 630 39074.

Email: [email protected]

Dr Wei Jianan, Yice Director of AIDS Research Centre of China Academy ofT.C.M.

No 5, Beixian Ge St., Xuan Wu District, Beijing. Tel: (8610) 88001225.

Fax: (8610) 63014195. Email: [email protected] Dr Huang Xiao Jie, Attending Physician,

Department of Infectious Diseases,

Beijing You an Hospital, No 8 Xi Tou Tiao, Feng Tai District, Beijing~

Tel: (8610) 8114 4481. Fax: (8610) 6329 4417.

Email: [email protected]

Dr Anuradha AlP P.Radharkrishnan, 4 Jalan Udang Gantung 1, Taman Cuepac, Segambut, 52000 Kuala Lumpur.

Tel: (6012) 6256614. E-mail: [email protected].

Dr Rosnah Mat Isa, Family Physician, Klinik Kesihatan Serendah 48200, Hulu Selangor, Selangor. Tel: (603) 60812500.

Fax: (603) 60812503. E-mail: [email protected]

VIETNAM

Dr Rosario Jessica Tactacan, Medical Specialist ill, San Lazaro Hospital Quiricada St., Sta. Cruz, Manila. Tel: (632) 309 9528.

Fax: (632) 711 6979; 711 4117. Email: [email protected] Dr Le Van Kham, Expert/State Official, Department of Therapy Ministry of Health, 138A Giang Vo Street, Ha Noi.

Tel: (844) 8464416 Ext 422. Fax: (844) 846 0966.

Email: [email protected]

Dr Nguyen Tien Lam, Secretary ofHIV/AIDS Treatment Sub-committee Ministry of Health, National Institute of Infections and Tropical Diseases (NIID), 78 Giai Phong Road, Dongda District, Ha Noi.

Tel: (090) 410 9999. Fax: (844) 576 3491. Email: [email protected]

2. TEMPORARY ADVISERS

Dr Jorg Hendrik GOIz, General Practitioner, Kaiserdamm 24, 14057 Berlin, Germany.

Tel: (04930) 301 1390. Email: [email protected]

Dr Suresh Kumar, Senior Consultant in Psychiatry, 12 Vaidyaram Street, T. Nagar, Chennai 600 017, India. Tel: (91 44) 24332285. (91 98) 400 31559. Email: [email protected]

Dr Hillary Kunins, Assistant Professor of Medicine and of Psychiatry and Behavioural Sciences Montefiore Medical Center/Albert Einstein College of Medicine, Division of General Internal Medicine, 211 East 210th Street, Bronx, New York 10467,_United States of America. Tel: (1718) 944-3861.

Fax: (1718) 944 3841. Email: [email protected]; [email protected]

Dr Bertrand Lebeau, Clinician/Consulting Physician in a specialized centre in drug addiction Andre Gregoire Hospital, La Mosaique, 89 bis rue Alexis Pesnon 93100, Montreuil, France.

Tel: (01 48) 973 297. Fax: (01 48) 575 522. Email: [email protected]

Dr Guogan Lu, HNIAIDS Clinician, MSF Clinic, No 80 Tao Yuan Road, Nanning, Guangxi People's People's Republic of China. Tel: (86 13) 8781 77830, Email: [email protected]

Dr Fabio Mesquita, Harm Reduction and IDU Adviser, Indonesia HNIAIDS Prevention and Care Project (IHPCP), Jalan Merdeka Barat No 3, Jakarta Pusat 10110, Indonesia. Tel: (6221) 350 5561.

Fax: (6221) 350 5564. Email: [email protected]; [email protected]

Mr Yoon Chong Lenny Ng, Programme Manager, Ikhlas Drug User Programme, 30A, Lerong Haji Taib 4, 50350 Kuala Lumpur,_Malaysia. Tel: (603) 404 51404. Fax: (603) 404 51405.

Email: [email protected]

Dr Samiran Panda, Society for Positive Atmosphere and Related Support to HIV/AIDS (SPARSHA), AE-35, Rabindra Pally, Prafulla Kanan, Kestopur, Kolkata 700 1001, West Bengal, India.

Tel: (91 33) 259 10334. Email: samiran [email protected]

Dr Emanuele Pontali, Consultant (Infectious Diseases), Casa Circondariale di Marassi, Prison of Genoa, 16142 Genoa,Jtaly. Tel: (39339) 599 0771. Fax: (391010) 563 4474.

Email: [email protected]

Ms Hathaikant (Bourn) Ranumas, Project Officer, Asia Pacific Network of People Living with HIV/AIDS (APN+), 170171 22nd Floor, Ocean Tower 1, Sukhumvit 16, Ratchadapisek Road,

Klongtoey, Bangkok 1011O,_Thailand. Tel: (662) 2591908 to 9. Fax: (662) 2591910.

Email: [email protected]

Mr Umesh Sharma, Technical Advisor and Consultant, The International HIV/AIDS AJliance 47, SantisukRoad, Changpuer, Muang, Chiang Mai 50300, Thailand. Tel: (66 53) 211 632.

Email: [email protected]@loxinfo.co.th

Dr Somsit Tansupaswadikul, Senior Medical Officer, Bamrasnaradura Institute

Department of Disease Control, Ministry of Public Health, Tiwanon Road, Nonthaburi 11000.

Thailand. Tel: (662) 590 3515-6. Fax: (662) 590 3520. Email: [email protected] Dr Mark Tyndall, Associate Professor of Medicine, BC Centre for Excellence in HIV I AIDS St Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia, V6H lY6, Canada.

Tel: (604) 806 8535. Fax: (604) 806 9044. Email: [email protected]

INTERNATIONAL (FBI)

KLINIK KESIHATAN SEMBILAN, MALAYSIA

UNITED NATIONS OFFICE ON DRUGS AND CRIME

WHOIWestern Pacific Region

Care and Treatment, 19^th Floor, Tower 3, Sindhom Building, 130-132, Wireless Road,

130-132, Wireless Road, Kwaeng Lumpini, Khet Phatumwan Bangkok, Thailand. Tel: (662) 263 2300. Fax: (662) 2632114.

Email: [email protected]

Dr Salmiah Mb Sharif, Ministry of Health, Malaysia

(Family Health Specialist), 43200 Cheras, Selangor Darnl Ehsan Malaysia. Tel: (603) 9075 8046. Fax: (603) 9075 8048.

Mobile: 6012-2242045. Email: [email protected] Dr Manjul Khanna, Project Coordinator, Regional Centre for East Asia and the Pacific, Rajdamnem, Nok Avenue, Bangkok 10200, Thailand. Tel: (662) 288 2100.

Fax: (662) 2812129. Email: [email protected] Ms Sonia Bezziccheri, Demand Reduction Associate and Interim Coordinator of the UN Regional Task Force on Injecting Drug Users, Regional Centre for East Asia and the Pacific, Rajdamnem Nok Avenue, Bangkok 10200, Thailand. Tel: (662) 288 2100. Fax: (662) 2812129.

Email: [email protected]

4. SECRETARIAT

Dr Michel Tailhades, Medical Officer,

HN / AIDS and STI Unit, W orId Health Organization Regional Office for the Western Pacific

United Nations Avenue, 1000 Manila, Philippines Tel. No.: (632) 528 9719. Fax No.: (632) 521 1036.

E-mail: [email protected]

Mr Reginald Gray Sattler, Technical Officer, HN / AIDS and STI Unit, W orId Health Organization, Regional Office for the Western Pacific

United Nations Avenue, 1000 Manila, Philippines Tel. No.: (632) 528 9731. Fax No.: (632) 521 1036.

E-mail: [email protected]

WHOIWestern Pacific Region (continued)

WHOlMalaysia

WHO/South-East Asia Region

WHOlIndonesia

WHOlThailand

Ms Manuela Moeller, Short-term Professional, HSI Unit HN/AIDS and STI Unit, World Health Organization, Regional Office for the Western Pacific

United Nations Avenue, 1000 Manila, Philippines.

Tel: (632) 528 9759. Fax: (632) 521 1036.

Email: moellerm@,wpro.who.int

Dr Han Tieru, WHO Representative in Malaysia, Brunei Darussalam and Singapore,

World Health Organization,

l,t Floor, Wisma UN, Block C, Komplek Pejabat, Darnansara, Ialan Dungun, Damansara Heights, 50490 Kuala Lumpur, Malaysia. Tel: (603) 209 39908. Fax: (603) 20937446.

Email: [email protected]

Dr Balan Venugopalan, Technical Officer

World Health Organization, 1st Floor, Wisma UN, Block C, Komplek Pejabat, Damansara, Ialan Dungun, Darnansara Heights 50490 Kuala Lumpur. Tel: (603) 2093 9908.

Fax: (603) 20937446. E-mail: [email protected] Dr Jai P. Naraln, Director,

Department of Communicable Diseases,

World Health Organization, Regional Office for South-East Asia, World Health House, Indraprastha Estate, Mahatma Gandhi Road, New Delhi 110002, India. Tel: (91 11) 23370804.

Fax: (91 11) 23370197. Email: [email protected] Dr Ying-Ru Lo, Regional Adviser, HN/AIDS,

World Health Organization, Regional Office for South-East Asia, World Health House, Indraprastha Estate, Mahatma Gandhi Road, New Delhi 110002, India. Tel: (91 11) 23370910.

Fax: (91 11) 23370197. Email: loyCmsearo.who.int

Dr David Jacka, Short-term Professional (Harm Reduction), World Health Organization, Bina Mulia I, Floor 9. I!. HR., Rasuna Said Kav 10-11 Kuningan, Jakarta 12950, Indonesia.

Tel: (62-21) 5204349. Fax: (62-21) 520 1164.

Email: [email protected]

Dr Myat Htoo Razak, Short-term professional, Medical Officer (HIV/AIDS), World Health Organization, Permanent Secretary Building 3, 4th Floor, Ministry of Public Health, Tiwanon Road, Nonthaburi 11000, Thailand. Tel: (662) 590 1524.

Fax: (662) 591 8198. Email: [email protected]

Plenary 111: Clinical management of HIV~nfected IDUs Plenary V: Clinical management of HIV-Infected IDUs -

• ^Weloome Presentation: ^HAART

·

Introduction of participants • Drug dependence treatment • ^Sid~, toxicity, drug interactions

• • C~nIections, co-mo!bidity

• Objectives and expected outcomes Questions and discussion

Questions and discussion

• Administrative annoUncements

1000-1030 Coffeellea break 1030-1100 Coffeellea break 1030-1100 CoffeeIIea break

1030-1200 Plenary I: Background and general considerations of HIV 1100-1230 Plenary IV: Clinical management of HIV~nfected IDUs - MMT and HMRT 1100-1230 Plenary VI: Ctinical management of HIV~fected IDUs organisation and management considerations

Presentation: Presen1atlon:

Presentation: • Substitution therapy (Methadone and Buprenorphine) • Adherence support

• Epidemiological situation on HIV and IDU • ARV treatmeot for IDUs, regimens • Monitoring ART services

• Comprehensive sel1lices for tDUs; situation in Asia

Questions and discussion Questions and discussion

Questions and discussion Statement

Statement Statement

1200-1400 Lunch 1230-1400 Lunch 1230-1400 Lunch

1400-1500 Plenary II: WHO clinical protocols on HIVIAIDS Treatment 1400-1545 Group work II 1400-1530 Group work 111 (to follow up and to define oonsensus and open

and Care for Injecting Drug Users 1) ClIganisation and management considerations questions)

2.1 Services for IDUs 1) Principles, background and general considerations of

•

·

• Introduction ofwortdng groups 3.7 Management of acu1e and chronic pain 3) Clinical management of HIV ~fected IDUs (HMRT)

3) CUnical management of HIV~fected IDUs (HMRT) 3.6 Adherence

3,8 Co-Infections and oo-morbidities of HIV In IDUs 4. Suggesied minimum set of Indicators for mcnitoring at

clinical level

1500·1515 Coffeellea break 1545-1600 Coffeellea break 1530-1545 CoffeeIIea break

1515-1700 Group worK I 1600-1700 Continuation of group worK 1545-1700 Plenary VII: Feedback from working groups, discussion on

1) Principles, background and general oonsiderations recommendations, next steps for adaptation, development of

1,1 HIVand IDU Epidemiology trainings, etc.

1.2 Heallh and social oonsequences of IOU

2) Clinical management of HIV~fected IDUs 1700-1800 Group work presentation, discussion and wrap up 1700-1730 Closing (Substitution)

3.2 Managing oploid dependence

3) Clinical management of HIV~fected IDUs (HMRT) 3.1 Initial patient evaluation

3.3 Managing HAART in IDUs with HIV/AIDS 3.4 Side-effects and toxicity management 1700-1800 Group worK oresentation, discussion and wrao up

1800 End of the day 1800 End of the day 1800 End of the day

Secreiariat meeting Secreiariat meeting Secreiariat meetinQ