加拿大溫哥華地區成功地遏止愛滋病毒在藥癮者間的蔓延

 

加拿大卑斯省溫哥華地區結合減害計畫設置的"Insite設施"與提供"Treatment as prevention"服務極為成功地遏止愛滋病毒在藥癮者間的蔓延

 

護士在具爭議性的抗HIV診所中協助成癮者注射海洛因

編者按:本影片報導內容包涵藥癮者靜脈注射的描繪,可能會對某些觀眾造成干擾。

 

WILLIAM BRANGHAM(訪問者):加拿大卑斯省(BC省,不列顛哥倫比亞省) 的溫哥華,常被認為是在北美地區中最美麗最適宜居住城市之一。

但是在市區中有一小部分地區卻以令人震驚的不同方式呈現。鬧區東側鄰近區域無情的提醒著因吸毒導致的損失。

環顧四週,瘦弱的成癮者走在街上,一般看不到警方有封鎖的行動。藥物在光天化日之下公然交換,婦女在街上賣淫。在行經幾個集中街區的過程中,你會看到有人就在人行道上吸食快克(crack,一種純度極高的古柯鹼),或在一條小巷中為自己注射海洛因或古柯鹼。

毫不稀奇,這鄰近區已被另一個瘟疫造訪:回溯至上世紀90年代,這裡曾是世界上愛滋疫情增長最快的流行中心之一。

THOMAS KERR醫師:溫哥華曾經歷了被稱為所謂除了在非洲撒哈拉以南地區之外,被觀察到HIV最爆發性流行的區域。

訪問者:但現在已經改變,這要歸功於一項計劃,戲劇性地減低了疾病的傳播。計畫的支持者說,它的發生是透過提供共用針具的藥癮者獲取免費的HIV藥物;此外他們也引導成癮者到這個頗具爭議的設施當中,在此處醫務人員會真正協助他們注射非法藥品。

在BC省所執行的策略現正被美國、中國和歐洲等地仔細研究中,肇因於此計畫是如何在非常難以觸及的人群中成功地對抗了一場疾病之流行。

那麼它是如何工作的呢?有時,它開始呈現在像翠西一樣大步地走在人行道上的人之身上,翠西是一名合格護士,隸屬於在這附近工作的一個小護理團隊。

訪問者:嗯,我還以為護士都穿著白色的鞋子,這是怎麼回事?

翠西(護士):[笑]你不會在市中心東側穿白色的鞋子,(笑)這是肯定的!

訪問者:她攜帶著背上的藥物與用具,翠西正前往探望十多位他所照顧的HIV陽性患者中的一人,無論他們在哪裡。

翠西:不論是否要我走在巷子裡找到你的?沒問題;如果需要我來你家服務?那也沒問題。

科林(患者):嗯,我覺得好像是一個傻瓜。

翠西:你的元氣如何?

訪問者:翠西今天的工作是替科林服務,一個她認識了好幾年可能因透過共用針具而感染H.I.V. 之病患。而且即使他仍然使用毒品,他仍會與翠西或其他護士每隔幾個星期碰面,並努力地自己把每天應服用的抗H.I.V.病毒藥劑準時服用。

翠西:只因為人們在使用毒品或賣淫,他們就不會關心自己的健康,我認為這是一種謬誤。我覺得他們其實是很在乎的,而更因為他們在心理健康和成癮上的問題,它可能是更加困難的。

訪問者:這種及早並持續的HIV治療是卑斯省的整体愛滋防治策略的核心支柱,而此計畫也是一個因這個團隊的重要發現而開始的。

蒙塔內爾醫師:......我說,哦!我的上帝!這是龐大的,這個結果超乎我想像。實際上這可以把整体的疫情翻轉。

訪問者:蒙塔內爾醫師是全球治療HIV的專家中之一員,出生在阿根廷,現在加拿大服務,蒙塔內爾醫師協助在卑斯省建立了卓越的HIV和愛滋病防治中心。

回溯到上世紀90年代中期,他的團隊也是最早證實在當時仍極具爭議的想法之團隊中的一員:「積極的治療HIV不僅在個人上可以幫助病人,更能防止疾病在整個社會中蔓延」。

具體方法如下:這是眾所周知,一個未經治療的愛滋病人體內充滿病毒,如果他們與其他人共享針具,就很可能會感染他人並傳播疾病。但是以抗HIV病毒藥物治療這些源頭的患者,顯著地會抑制他們在血液中病毒量,因此,由相關的研究顯示,會使得他們更不容易傳播給他人。 (根據蒙塔內爾醫師估計,更不易傳播的可能性超過90%以上。)

蒙塔內爾醫師:其實,要預測注射藥癮者傳播愛滋病毒的一個最強大的指標是在社區中循環流傳的病毒量,在社區中帶來治療的影響下,社區整體病毒量降低,同步地新感染的人數也併行下降。換句話說,重點不是針,笨蛋,是病毒。

護士:我要繼續前進...

訪問者:這些發現激發了更積極行動即盡可能檢測越多的人越好的,讓任何檢測呈陽性的人儘可能納入治療中盡快吃藥。此一總體策略即是現在所謂的“治療即為預防” 。

但在卑斯省之公共健康倡導者並沒有就此停止:蒙塔內爾醫師和許多人一起努力,推動所謂的“InSite” 此一設施的創立。

托馬斯·克爾醫師:所以說 "InSite "是一個非常獨特的設施。這也是在北美地區唯一的一個此類的設施。

訪問者:托馬斯·克爾醫師是一名在蒙塔內爾醫師的中心進行愛滋病研究的研究人員,並且已發表了數篇在InSite中進行的研究。

托馬斯·克爾醫師:這是一個任何人都可在此注射非法藥物的地方,如海洛因和古柯鹼,他們可以進來此地帶著已在大街上獲得藥物,在一名護士的監督下施打。

訪問者:每天早上當門打開的第一分鐘開始,一群吸毒者便魚貫的進入 - 最初超過700人,每天到這裡來施打。所有的注射用具公開陳列供應,並免費使用。

在一個專門培訓的護士團隊的注視下,成癮者一一入席在十幾個不同的分隔位置上,進行他們已經取得在街上能夠買到的任何非法藥物的施打。

InSite於2003年開幕,由加拿大開明的政府授予的豁免權,允許藥癮者在部分由納稅人資助的設施中使用違禁藥物。

今天上午,一個叫喬迪的女士同意當她注射時讓我們拍攝她。她說她是一個吸毒者,在街道上超過十年......她一直注射了這麼久,因此她的許多靜脈倒塌或佈滿疤痕,今天上午,經過反復嘗試,她仍無法找到一條血管可以施打。

護士:你找到了嗎?

喬迪女士:沒有。

訪問者:所以...InSite裡的一個護士過來幫她。

喬迪女士:就在那裡。

護士:這是極小的,它真的很小。

訪問者:自從這個地方開張後,批評者一直在試圖去關閉此一設施。現在保守的中央政府說InSite賦予藥物的使用,而不是阻止它們。它試圖關閉這個設施,並防止他人在加拿大其他地方開設。

訪問者:在2005年,加拿大總理斯蒂芬·哈珀說:“我們作為政府不會動用納稅人的錢資助吸毒......這不是我們追求的策略。”

但在2011年,加拿大最高法院裁定Insite可以繼續開放存在。

InSite的支持者則認為,它不僅減少藥物施打過量導致之死亡,減少該地區之疾病,並獲得更多的吸毒者進入到治療方案......他們甚至認為:「它更是防治愛滋病毒系列活動中的關鍵措施」。

吸毒者到這裡來可以得到疾病的檢測和轉診治療服務,如果他們是陽性的個案......他們沒有共用污染的針頭......他們在此可與想要幫助他們的護士和醫務人員定期的聯繫。

托馬斯·克爾醫師:如果這個設施是不存在,這些人將被趕入小巷中施打,並被警察追著跑,並將繼續與醫療系統斷絕聯繫。但是,我們現在已經發現了一種機制與這些人聯繫,並為他們提供了更多急需的照護。

訪問者:(面向蒙塔內爾醫師),我聽到你所說的一切。但你的批評者會說,在Insite現場,一名護士甚至可以幫助藥癮者找到靜脈,這部分是縱容,使他們使用上更容易。對於這些批評你有什麼說法呢?

蒙塔內爾醫師:你知道嗎,我過去也曾以你剛才所描述同樣的方式思考,這所有的一切都是協助用藥。你的意思是,我將要去問我的基層員工或我的住院醫師是否實際目睹他人注射?天啊!我是否瘋了。事實上你知道,問題點在,這並不是所謂的在做正確的事或做錯誤的事,成癮者每天都在注射,讓我們面對現實吧- 

訪問者:無論如何他們還是會這樣做。

蒙塔內爾醫師:這種情形正在發生,這正發生在美洲的每一個城市當中。因此,透過假裝這種情形沒有發生,那麼你正在採取了如我國總理所採的相同做法且只會說:“這不應該發生!”。 然而事實上?它仍然是發生了,他想給他們定罪為刑事犯罪。然而,你知道嗎?他反而是導致讓情況變得更糟。

訪問者:數據顯示此一策略一直在發揮效果:通過在卑斯省大幅增加正在接受治療的愛滋病毒感染人數,新診斷出愛滋病毒感染的人數已減少 - 減少超過了一半以上。

即使他們更難看到疾病出現,他們發現個案確實減少了。

蒙塔內爾醫師說,他們不僅是幫助別人,而且他們也為政府省錢。如果卑斯省的每個人都能不接觸到H.I.V. 病毒,政府就可節省了大約25萬美元而不必花費在治療的那個人身上的費用。

蒙塔內爾醫師:在此一策略上投資更多反而是節約成本;這不僅是符合成本效益,它更是避免成本的花費。

訪問者:所以等一下,你是在爭辯說,如果你花更多的錢在治療具活動性的HIV感染者身上,終了時你會節省更多的錢,因為在整體感染者的儲存池中並沒有新增的病人。

蒙塔內爾醫師:威廉,我不是爭論!我是告訴你,事情就是這樣的。我並不意味著去太挑釁它,但數據是一切。你知道,我們隨機分派的臨床實驗現在證明,治療幾乎停止了傳播。我們知道,它阻止疫情的惡化。我的意思是,還有什麼是我們所需要的?這是顯而易見的。

訪問者:卑斯省的成功防止愛滋病毒的蔓延,促使中國衛生官員(也正在與HIV感染和靜脈注射藥癮問題同步流行疫情拼搏)承諾一個在此同樣策略的基礎上之全國性的“治療即為預防”的防治模式。美國也正在做兩件類似的試點研究,“治療即為預防”目前已被世界衛生組織、聯合國愛滋病預防署和國際愛滋病防治社群廣泛接納作為主要的HIV防治策略。

Nurses help addicts inject heroin at controversial clinic battling HIV

Editor’s note: This video report contains depictions of intravenous drug use that may be disturbing to some viewers.

WILLIAM BRANGHAM: Vancouver, British Columbia is considered one of the most beautiful, livable cities in North America.

But there’s a small part of the city that’s stunning in a different way. The downtown east side neighborhood is a grim reminder of the toll drug addiction takes.

Everywhere you look, emaciated addicts walk the streets. Police generally don’t see the point of locking them up. Drugs are exchanged openly in broad daylight. Women on the street prostitute themselves. Over the course of a few concentrated blocks, you’ll see people smoking crack right on the sidewalk, or injecting themselves in an alley with heroin or cocaine.

Not surprisingly, this neighborhood has been visited by another plague: back in the 1990s, this was the epicenter for one of the fastest growing AIDS epidemics in the world.

DR. THOMAS KERR: Vancouver experienced what has been described as the most explosive epidemic of H.I.V. ever observed outside of Sub-Saharan Africa.

WILLIAM BRANGHAM: But that’s changed now, thanks to a plan that’s dramatically reduced the spread of the disease. It’s happening, supporters say, by getting free H.I.V. medication to addicts who share needles.  They’re also steering addicts to this controversial facility where medical staff actually help them inject illegal drugs.

The strategy being deployed in British Columbia is being studied closely – by the U.S., by China and by Europe – for how it’s successfully fought an epidemic among a very hard-to-reach population.

So how does it work? Sometimes, it starts with people like Tracy D’Souza pounding the pavement. D’Souza’s a registered nurse, one of a small army of nurses working this neighborhood.

WILLIAM BRANGHAM: Now, I thought nurses wore white shoes. What’s the deal?

NURSE TRACY D’SOUZA: [laughs] You don’t wear white shoes in the downtown eastside. [laughs] that’s for sure.

WILLIAM BRANGHAM: With her medical kit strapped to her back, D’Souza’s off to see one of the dozen or so H.I.V.+ patients she cares for, wherever they are.

NURSE TRACY D’SOUZA: If I have come in the alley to find you? No problem. If I have to come to your home? No problem.

COLIN: Well, I feel like a nut.

NURSE TRACY D’SOUZA: How’s your energy?

WILLIAM BRANGHAM: D’Souza’s working with Colin today, who she’s known for several years. He likely contracted H.I.V. through sharing a needle. And even though he’s still using, he’s seeing D’Souza or other nurses every few weeks, and he diligently takes daily HIV retroviral drugs on his own.

NURSE TRACY D’SOUZA: I think it’s a fallacy that just because people are using drugs, or selling sex that they don’t care about their health. I think they care very much — I think because of their mental health and addiction issues, it might be tougher.

WILLIAM BRANGHAM: This early and consistent H.I.V. treatment is a central pillar of British Columbia’s strategy, and it’s one that began with important discoveries by this man’s team:

DR. JULIO MONTANER: … and I said, oh, my god, this is huge. This is bigger than I thought. This actually can turn the epidemic around.

WILLIAM BRANGHAM: Dr. Julio Montaner is among the world’s experts on treating H.I.V. Born in Argentina, now a Canadian, Montaner helped found the British Columbia Centre for Excellence in H.I.V. and AIDS.

Back in the mid-1990s, his team was one of the first to demonstrate what was then a contested idea: that aggressively treating H.I.V. in individuals not only helps them, but can prevent the spread across an entire community.

Here’s how: it’s well-known that people with untreated H.I.V. are full of the virus, and if they share a needle with others, they’ll likely infect them and spread the disease. But treating those original patients with HIV medicine dramatically suppresses the amount of virus in their blood, which, research has shown, makes transmission to others much less likely. (According to Dr. Monatner, it’s more than 90% less likely.)

DR. JULIO MONTANER: In fact, the single most powerful predictor of you as an injection drug user to contract H.I.V. was the amount of virus that was circulating in the community, which, upon bringing treatment to that community, came down. And so the number of new infections came down in parallel. In other words, it’s not the needles, stupid. It’s the virus.

NURSE: I’m gonna go ahead and poke…

WILLIAM BRANGHAM: These findings triggered an even more aggressive campaign to test as many people as possible, and to get anyone who tests positive onto the meds as quickly as possible.  This overall strategy is now called “treatment as prevention”

But public health advocates in British Columbia didn’t stop there: Dr. Montaner – along with many others – pushed for the creation of this facility, which is called “InSite.”

DR. THOMAS KERR: So InSite is a very unique facility. It’s the only one of its kind in North America.

WILLIAM BRANGHAM: Dr. Thomas Kerr is an AIDS researcher who works at Dr. Montaner’s center and has done several published studies of InSite.

DR. THOMAS KERR: It is a place where people who inject illicit drugs, such as heroin and cocaine, can come with drugs that they’ve obtained on the street, and inject under the supervision of a nurse.

WILLIAM BRANGHAM: Every morning, the minute the doors open, a group of addicts file in – the first of more than 700 who come here every day to shoot up. All the paraphernalia is laid out, free for the taking.

Under the watchful eye of a team of specially trained nurses, addicts take a seat at one of a dozen different booths to do whatever drugs they’ve been able to buy on illegally the street.

InSite opened in 2003, granted an exemption by the then Liberal government of Canada to allow the use of illegal drugs in a facility partly funded by taxpayers.

On this morning, a woman named Jody allowed us to film her as she injected. She says she’s been an addict, on the streets for more than a decade… She’s been shooting up for so long that many of her veins are collapsed or covered with scars, and this morning, after repeated tries, she can’t find one that’ll work.

NURSE: You finding it?

JODY: No.

WILLIAM BRANGHAM:  So…one of the InSite nurses comes over to help her. 

JODY: Right there—

NURSE: It’s itty bitty. It’s really tiny.

WILLIAM BRANGHAM: Ever since this place opened, critics have been trying to shut this facility down. The now Conservative national government says InSite enables drug use, not prevents it. It’s tried to close this facility, and prevent others from opening in Canada:

WILLIAM BRANGHAM: In 2005, Canadian Prime Minster Stephen Harper said, “We as a government will not use taxpayers’ money to fund drug use … that is not the strategy we will pursue.”

But in 2011, the Supreme Court of Canada ruled Insite can stay open.

InSite’s supporters argue that not only does the facility cut drug overdose deaths, reduce disorder in the area, and get more addicts into treatment programs… but they argue: its crucial in the campaign against H.I.V.

Addicts who come here can get tested for the disease and referred for treatment if they’re positive… they’re not sharing infected needles… and they’re in regular contact with nurses and medical staff who want to help them.

DR. THOMAS KERR: If this facility wasn’t there, these people would be injecting in alleyways, running from the police, and would continue to be disconnected from the health care system. But we’ve now found a mechanism to connect with these people, and provide them with much needed care.

WILLIAM BRANGHAM: (to Dr. Montaner)  I hear everything that you’re saying. And your critics would argue that having someone on site, a nurse who could even help someone find a vein, that is partly condoning and making it easier for them. What is your argument against that?

DR. JULIO MONTANER: You know, I used to think the same way as you just described, that all of this was enabling. You mean that I’m going to ask my junior staff, my residents to actually witness somebody injecting? Jeez, i’m out of my mind. Well, you know, the problem is that this is not about doing the right thing or the wrong thing. The addicted person is injecting. Let’s face the music–

WILLIAM BRANGHAM: They’re going to do it regardless.

DR. JULIO MONTANER: This is happening. This is happening in every single city in America. So by pretending that this is not happening, then you’re taking the same approach that the Prime Minister of my country is taking saying, “This shall not happen!” And so what? This is still happening, and he wants to criminalize them. And, you know what? He’s making the situation worse.

WILLIAM BRANGHAM: The data show their strategy has been working: by dramatically increasing the number of people being treated for H.I.V. in British Columbia, the number of new diagnoses of H.I.V. has been decreasing – cut by more than half.

Even as they’re looking harder for the disease, they’re finding less of it.

Dr. Montaner says, not only are they helping people, but they’re saving money. For every person who doesn’t contract H.I.V. in British Columbia, the government saves an estimated quarter-of-a-million dollars it doesn’t have to spend treating that person.

DR. JULIO MONTANER: Investing more on this strategy is cost saving. It’s not just cost effective. It’s cost averting.

WILLIAM BRANGHAM: So wait, you’re arguing that if you spend more money on treating active H.I.V.cases in the end you will save more money because you’re not adding new patients to the pool of infected people.

DR. JULIO MONTANER: William, I’m not arguing. I’m telling you. This is the way it is. And I don’t mean to be too provocative about it but the data is all in. You know, we have randomized clinical trials that now show that treating virtually stops transmission. We know that it stops disease progression. I mean, what else do we need? It’s obvious.

WILLIAM BRANGHAM: British Columbia’s success preventing the spread of H.I.V. has prompted Chinese health officials (who’re also grappling with twin epidemics of H.I.V. and IV-drug addiction) to commit to a nationwide “treatment as prevention” model, based on this same strategy.  The U.S. is doing two similar pilot studies, and “treatment as prevention” has now been adopted as the principal H.I.V. strategy by the World Health Organization, U.N. AIDS, and the International AIDS Society.