在俄羅斯獲得阿片類藥物激動劑治療:改革的時候

 

在俄羅斯獲得阿片類藥物激動劑治療:改革的時候

資料來源:刺胳針愛滋病毒醫學期刊。www.thelancet.com/hiv Vol 5 October 2018

 

俄羅斯是一個擁有1.44億人口的國家,亦是世界上愛滋流行增長最快速的國家其中之一。儘管全球愛滋的死亡率和傳播率均有所下降,但俄羅斯的愛滋病毒感染率則是增加,估計有110萬人感染了愛滋病毒和每年新感染病例數則超過103,000例。據聯合國愛滋病規劃署估計,在2015年東歐和中亞80%的新感病例發生在俄羅斯,更受到了藥物注射使用方式所助長。阻止愛滋病毒傳播的努力遭受到俄羅斯政府政策的阻礙,這方面除已縮減了減害計畫的努力更否定了俄羅斯為數180萬的注射藥癮者獲得阿片類藥物激動劑的治療,他們當中有許多人是注射阿片類藥物。 

在剌胳針愛滋病毒醫學期刊中Javier Cepeda及其同事,針對俄羅斯政府對使用阿片類藥物激動劑治療(OAT)以更有效地阻斷愛滋流行的零容忍之藥物政策上,提供了重新評估的有力論據。阿片類藥物激動劑治療(OAT)使用美沙酮和丁基原啡因在治療阿片類藥物使用障礙和預防愛滋病毒上,是一種極具效率和成本效益的治療方法。聯合國愛滋病規劃署和世衛組織已將OAT建議為在減少或消除非法藥物使用上係經證實且具實證基礎的介入措施。 OAT一直在導致減少犯罪和監禁方面上、社會穩定和增加就業上以及促進病患更積極參與醫療照護上,被如此地證明是安全和可被接受的。

Javier Cepeda及其同事提供的分析是及時和具說服力的。作者在俄羅斯兩個著名城市,西伯利亞地區的鄂木斯克和烏拉爾區的葉卡捷琳堡,針對注射藥癮和性行為導致愛滋病毒傳播上開發了一個複雜的數學模式。在整個俄羅斯的許多城市中,鄂木斯克和葉卡捷琳堡掌握了很多影響生活的趨勢。在舊蘇聯年代鄂木斯克和葉卡捷琳堡都已經成為重要的的工業和技術中心,在文化和科學領域蓬勃發展。兩個城市也都經歷了在過渡到市場經濟後其經濟財富的下降,而兩個城市更都提供了俄羅斯在愛滋病毒和阿片類藥物共同流行所造成的破壞上生動的證明。在葉卡捷琳堡佔人口總數的1.8%被認已感染了愛滋病毒,而鄂木斯克的愛滋盛行率則正在上升。

配備著詳細的流行病學和行為科學上的數據,Cepeda和其同事使用建模來顯示擴大減害計畫規模可以對愛滋預防有重大影響。他們發現了在擴大阿片類藥物激動劑治療( OAT )和針具交換計畫之覆蓋率達到50%,並且增加招募病患加入抗反轉錄病毒療法,在往後的十年間於注射藥癮者中,在鄂木斯克具有防止58 HIV新感病例(95%信賴區間為46-69)的潛力,以及在葉卡捷琳堡則可有38%的新感病例(26-50)可避免 。繼擴大這三種減害的方案後,隨著時間的推移兩個城市藥物過量使用案例預計將減少約三分之一 。作者未來的預測亦顯示俄羅斯目前所實施的政策將無法承受並將導致巨大的社會成本。作者令人信服地表明了正確的組合相關政策,可以在解決愛滋發生率和藥物過量致死的頻率上大大地改變其結果。

雖然是區域性之模型,例如這個由Cepeda及其同事之研究案例,仍在擴大介入措施規模以防治愛滋病毒上提供了有用的見解,後續針對全球和俄羅斯在指導愛滋預防工作上的努力,亦需要有更進一步的研究。首先,需要有更好的監測數據,不僅可衡量愛滋病病毒的傳播率和藥物過量致死的盛行率,且更可讓我們全面地了解在跨越不同的場域中族群風險的異質性。這些數據應包括人口混雜的樣態和網絡結構的變化,以便可以用來制定更具目標性的介入措施以提高模型的有效性。評估減害計畫在減少疾病傳播的因果影響上的改進也極需要。當公共資源缺乏有效的實施和承諾之情況時,包括俄羅斯在內,減害計畫的有效性並無法保證可以轉換到其他場域上去。

來自其他的國家如烏克蘭的證據,OAT在當地十多年來雖一直是合法的,但建議在擴大OAT規模之道路上亦充滿了額外的挑戰。由烏克蘭注射藥癮者的研究建議,在個人層面的障礙,包括患者認知上認為治療無效、害怕執法單位、社會羞辱等導致個人不願意開始執行OAT,而這些障礙也可能出現在俄羅斯。而擴大OAT執行規模也需要關注個案於照護體系內之存留率,包括適當的劑量和服藥之順從性以減少藥物使用的再次復發。在對抗成癮上OATs並不是魔法子彈,但它們可以透過讓病患更能好好地控製其藥癮狀態、減緩愛滋病毒感染的傳播並預防致命性的藥物過量等方面來防止問題之惡化。承諾去支持和擴展減害計畫,包括OAT,是朝向正確方向的關鍵步驟。沒有政策上之改革和承諾,俄羅斯目前停止愛滋流行之前景似乎很慘淡。

 

作者:阿列克謝澤列夫

耶魯大學醫學院內科部感染科愛滋病項目,美國康乃迪克州紐哈芬市,CT 06511alexei.zelenev@yale.edu

 

Access to opioid agonist therapy in Russia: time for reform

Russia, a country of 144 million people, has one of the fastest growing HIV epidemics in the world. Although HIV

mortality and transmission have decreased globally, the incidence of HIV has increased in Russia, where more than

1.1 million people are infected with HIV and the number of new infections exceeds 103,000 cases per year.UNAIDS

estimates that 80% of new infections in eastern Europe and central Asia occurred in Russia in 2015, fuelled by injection drug use.The efforts to halt the spread of HIV are hindered by the policies of the Russian government, which has scaled back harm reduction efforts and denied access to opioid agonist treatment to 1·8 million people who inject drugs in Russia, many of whom inject opioids.

In The Lancet HIV, Javier Cepeda and colleagues5 provide a compelling argument for the Russian government to reevaluate their zero-tolerance drug policy toward the use of opioid agonist therapy (OAT) to better disrupt the HIV epidemic.5 OAT with methadone and buprenorphine is a highly effective and cost-effective treatment for opioid use disorder and prevention of HIV.6 UNAIDS and WHO recommend OAT as a proven evidence-based intervention for reducing or eliminating illicit drug use.7 OAT has been shown to be safe and tolerable, and leads to a reduction in crime and incarceration, increased social stability and employment, and better engagement in care among patients.

    The analysis provided by Javier Cepeda and colleagues is timely and persuasive. The authors develop a sophisticated mathematical model for injection and sexual transmission of HIV for two prominent cities in Russia: Omsk in the Siberian district and Ekaterinburg in the Ural district. Omsk and Ekaterinburg capture many trends that shape life in many cities across Russia. Both Omsk and Ekaterinburg had emerged as important industrial and technological hubs during the Soviet era, thriving in the realms of culture and science. Both cities saw their economic fortunes decline after the transition to a market economy and both cities provide a living testament to the devastation caused by the HIV and opioid co-epidemics in Russia. 1.8% of the total population of Ekaterinburg is thought to be infected with HIV, and HIV prevalence in Omsk is increasing.

Armed with detailed epidemiological and behavioural data, Cepeda and colleagues use modelling to show that scale-up of harm reduction programmes can have a substantial effect on HIV prevention. They found that scaling up of OAT and needle and syringe exchange programmes to 50% coverage, combined with increased recruitment to antiretroviral therapy, has the potential to prevent 58% (2·597·5 percentile interval 4669) of new HIV infections in Omsk and 38% (2650) of new HIV infections in Ekaterinburg among people who inject drugs over the next 10 years. Following expansion of these three harm reduction programmes, the overdoses are projected to decrease by about a third in both cities over time. The future projections made by the authors show that the policies currently implemented by Russia are not sustainable and effect large social costs. The authors convincingly show that a correct combination of policies could substantially alter the outcomes in addressing the incidence of HIV and frequency of fatal overdose.

Although compartmental models, such as the one by Cepeda and colleagues, provide a useful insight into the scaling up of interventions to treat HIV, further studies are needed to guide HIV prevention efforts in Russia and globally. First, better surveillance data are required that would not only measure the rate of HIV transmission and prevalence of fatal overdose, but would allow us to understand population risk heterogeneity better across the different settings. These data should include population mixing patterns and changes in network structures that could be used to develop more targeted interventions and improve the validity of models. Improved estimates of the causal effects of harm reduction programmes in reduction of transmission are also needed. The effectiveness of harm reduction programmes is not guaranteed to translate to other settings, including Russia, without effective implementation and commitment of public resources.

The evidence from countries such as Ukraine, where OAT has been legal for more than a decade, suggests

that the road to OAT scale-up is fraught with additional challenges. Studiesof people who inject drugs in

Ukraine suggest that individual-level barriers, including perceived ineffectiveness of treatment among patients, fear of law enforcement, and social stigma have contributed to individuals unwillingness to start OAT, and these barriers are also likely to be present in Russia. Scaling up of OAT also requires a focus on retention in care, which includes adequate dosing and adherence to medication to reduce concurrent drug use.OATs are not a magic bullet against addiction, but they might prevent exacerbation of the problem by allowing the patients to better manage their addiction and to slow down the transmission of HIV infections and to prevent fatal overdose. A commitment to support and expand harm reduction programmes, including OAT, is a crucial step in the right direction. Without policy reform and commitment, Russias current prospects for stopping the HIV epidemic appear bleak.

Alexei Zelenev

Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, Yale University,

New Haven, CT 06511, USA. alexei.zelenev@yale.edu,   www.thelancet.com/hiv Vol 5 October 2018