- Email: [email protected]
Primary health care for people who inject drugs in low and middle income countries
J. Rowe / International Journal of Drug Policy 23 (2012) 103–110
105
Primary health care for people who inject drugs in low and middle income countries Bronwyn J. Myers a,b,∗ a b
Alcohol and Drug Abuse Research Unit, Medical Research Council of South Africa, South Africa Department of Psychiatry and Mental Health, University of Cape Town, South Africa
Much has been written about needle and syringe programmes (NSPs), opioid substitution treatment (OST) and antiretroviral (ARV) therapies as essential components of evidence-based harm reduction initiatives for people who inject drugs (PWIDs) (see for example Mathers et al., 2010). In contrast, significantly less attention has been given to the provision of primary health care (PHC) for people who inject drugs (PWIDs), even though these services may contribute to better outcomes for other harm reduction services such as OST. As PWIDs often face structural barriers to accessing conventional PHC (Day et al., 2011), PHC services targeted at PWIDs specifically have been touted as a way of overcoming these obstacles. The evidence base for these targeted services however has been limited. Islam, Topp, Day, Dawson, and Conigrave’s (2012) synthesis of the literature on PHC services targeted at PWIDs is timely and represents one of the first attempts to establish an evidence base in support of these services. In this synthesis of the literature, the authors provide a summary of factors associated with accessible and acceptable PHC. Accessible services were based at a suitable and accessible location, had flexible appointment scheduling, had needs-based operating hours and were affordable. Services were seen as acceptable when they provided other harm reduction services, provided ancillary social and welfare services, and were not associated with conventional health care. Based on these findings, the authors argue that the best means of ensuring adequate uptake of PHC by PWIDs is to augment existing NSPs and other harm reduction services (which already have a high degree of accessibility and acceptability) to include PHC. Whilst this makes sense for higher income countries that have relatively good NSP and OST service coverage, it makes less sense for low and middle income countries (LMICs). The burning issue for these countries is not whether PHC services targeted at PWIDs have public health benefits, but how these services can be implemented when NSP and OST services are absent or service coverage is poor. Although Islam et al. (2012) acknowledge that contextual influences may shape how PHC services for PWIDs are provided; they fail to discuss the way PHC can be provided in contexts of limited NSP and OST coverage. In LMIC contexts, it might be worth considering how services for other vulnerable and marginalised groups can be expanded to include health care for PWIDs. Surveys of most at risk populations (MARPs) have consistently found significant overlap between various MARPS including men who have sex with men, sex workers, and
∗ Correspondence address: Alcohol and Drug Abuse Research Unit, Medical Research Council of South Africa, PO Box 19070, Tygerberg 7505, South Africa. Tel.: +27 21 938 0350. E-mail addresses: [email protected], [email protected]
PWIDs (Johnston et al., 2010; Parry, Petersen, Carney, Dewing, & Needle, 2008). Often organisations serving these MARPs are located in highly accessible areas and already provide PHC (typically related to sexual and/or reproductive health and BBVI testing) to their clients. Given that some of their clientele will be injecting drugs, it may be possible to expand these services to include PHC related to injection drug use specifically. In contexts where injection drug use is relatively rare and/or harm reduction services limited, this may be an efficient and acceptable way of providing targeted services for PWIDs. Another possibility for LMICs is to mainstream services for PWIDs into conventional PHC. Whilst Islam et al. (2012) mention gradual mainstreaming of targeted PHC services for PWIDs as an end-goal, they do not reflect upon the conditions required to make mainstreaming successful. For lower income countries one of the issues will be around the type of workforce that is needed. Islam et al.’s (2012) review suggests a reliance on health care professionals and it is unclear whether there is space for peer-led services. Peer-led services may be more acceptable to countries facing dire shortages in health care workers. Peer-led services may also improve the acceptability of mainstreamed PHC to PWIDs. Certainly in Africa, there has been growing reliance on peers and (nonprofessional) community health workers to provide basic PHC services, especially relating to HIV/AIDS (Philips, Zachariah, & Venus, 2008). In conclusion, it is clear from this review that there are many unanswered questions about the implementation of PHC for PWIDs. Islam et al. (2012) note the absence of studies comparing the relative effectiveness of PHC targeted at PWIDs and conventional PHC. Without evidence that targeted PHC services are more effective and hold greater cost-benefits than conventional care, I fear that policy makers will ignore evidence provided by this review that targeted services are acceptable to and accessible for PWIDs. References Day, C. A., Islam, M. M., White, A., Reid, S. E., Hayes, S. & Haber, P. S. (2011). Development of a nurse-led primary healthcare service for injecting drug users in inner-city Sydney. Australian Journal of Primary Health, 17, 10–15. Islam, M. M., Topp, L., Day, C. A., Dawson, A., & Conigrave, K. M. (2012). The accessibility, acceptability, health impact and cost implications of primary healthcare outlets that target injecting drug users: A narrative synthesis of literature. International Journal of Drug Policy, 23(2), 94– 102. Johnston, L., Holman, A., Dahoma, M., Miller, L. A., Kim, E., Mussa, M., et al. (2010). HIV risk and the overlap of injecting drug use and high-risk sexual behaviours among men who have sex with men in Zanzibar (Unguja), Tanzania. The International Journal of Drug Policy, 21, 485–492.
106
J. Rowe / International Journal of Drug Policy 23 (2012) 103–110
Mathers, B. M., Degenhardt, L., Ali, H., Wiessing, L., Hickman, M., Mattick, R. P., et al. (2010). HIV prevention, treatment, and care services for people who inject drugs: A systematic review of global, regional and national coverage. Lancet, 375, 1014–1028. Parry, C. D. H., Petersen, P., Carney, C., Dewing, S. & Needle, R. (2008). Rapid assessment of drug use and sexual HIV risk patterns among vulnerable drug-using
populations in Cape Town, Durban and Pretoria, South Africa. Journal of Social Aspects of HIV/AIDS Research Alliance, 5, 113–119. Philips, M., Zachariah, R. & Venis, S. (2008). Task shifting for antiretroviral treatment delivery in sub-Saharan Africa: Not a panacea. Lancet, 371, 682–684. doi:10.1016/j.drugpo.2011.09.014
Primary care is the best place to care for drug users Chris Ford a,b,1 a b
General Practice Principal, London, United Kingdom International Doctors for Healthy Drug Policies, Lonsdale Medical Centre, 24 Lonsdale Road, London NW6, United Kingdom
I have worked with patients who have drug problems in primary care/general practice for over 25 years and feel it is the best place to provide services. I was therefore hopeful and excited to read this paper from its title. However, by the end of it, I felt some disappointment. Throughout myself and my GP colleagues at the Lonsdale Medical Centre, our primary care practice, have always treated the person, not the drug, providing the whole range of general medical services including HIV and hepatitis C care, needle exchange, psychological interventions and opioid substitution treatment in the same environment as all other patients. This is something that Lonsdale has championed with other primary care doctors, through the UK Substance Misuse Management in General practice (SMMGP) network (http://www.smmgp.org.uk/). So I agree with Islam et al.’s (2012) conclusions that providing ‘non-judgmental and cost-free services under a harm reduction framework can increase the accessibility and acceptability of primary healthcare for IDUs.’ But I disagree that this care should be separated out from that of other patients. I concede that we are all often remiss at undertaking rigorous evaluations of Primary Care Centres and hence can’t always show the public health impact of this type of care, and so risk not getting adequate funding. But what we do have testimony to is the hundreds of patients who benefit from this method of care delivery.
E-mail address: [email protected] Clinical Director, International Doctors for Healthy Drug Policies, Lonsdale Medical Centre, 24 Lonsdale Road, London NW6, United Kingdom.
Other problems with this synthesis are language with terms not being clarified (primary care, general practice, office-based practice, etc.) and there is little acknowledgement of the marked variation in primary care and general practice around the world. Comparing even the UK system with the Australian or US primary care, I feel is impossible. This leads me to a comment on the UK literature used in this review, most of which is now out of date (being published in 1992 and 1996). Since then there has been a quiet revolution in the care of people who use drugs in the UK. The number of general practices working with patients with drug problems has gone from 0.2% in 1995 to over 40%, many specialist services are headed up by primary care clinicians and SMMGP provides a support and training network for all those working in primary care, as well as a training programme run by the Royal College of General Practitioners (RCGP Certificate in Drug Dependency Part 1 and 2). Over the 17 years of SMMGP and the 10 years that this training programme have been available and building up, we have undertaken audits, presentations, written reports and the odd paper: we have often talked about the need for robust evaluation of them but somehow caring for the patients has always taken precedence! Perhaps the best response to this paper will be to undertake that work now. Reference Islam, M. M., Topp, L., Day, C. A., Dawson, A. & Conigrave, K. M. (2012). The accessibility, acceptability, health impact and cost implications of primary healthcare outlets that target injecting drug users: A narrative synthesis of literature. International Journal of Drug Policy, 23(2), 94–102.
1
doi:10.1016/j.drugpo.2011.09.013
105
Primary health care for people who inject drugs in low and middle income countries Bronwyn J. Myers a,b,∗ a b
Alcohol and Drug Abuse Research Unit, Medical Research Council of South Africa, South Africa Department of Psychiatry and Mental Health, University of Cape Town, South Africa
Much has been written about needle and syringe programmes (NSPs), opioid substitution treatment (OST) and antiretroviral (ARV) therapies as essential components of evidence-based harm reduction initiatives for people who inject drugs (PWIDs) (see for example Mathers et al., 2010). In contrast, significantly less attention has been given to the provision of primary health care (PHC) for people who inject drugs (PWIDs), even though these services may contribute to better outcomes for other harm reduction services such as OST. As PWIDs often face structural barriers to accessing conventional PHC (Day et al., 2011), PHC services targeted at PWIDs specifically have been touted as a way of overcoming these obstacles. The evidence base for these targeted services however has been limited. Islam, Topp, Day, Dawson, and Conigrave’s (2012) synthesis of the literature on PHC services targeted at PWIDs is timely and represents one of the first attempts to establish an evidence base in support of these services. In this synthesis of the literature, the authors provide a summary of factors associated with accessible and acceptable PHC. Accessible services were based at a suitable and accessible location, had flexible appointment scheduling, had needs-based operating hours and were affordable. Services were seen as acceptable when they provided other harm reduction services, provided ancillary social and welfare services, and were not associated with conventional health care. Based on these findings, the authors argue that the best means of ensuring adequate uptake of PHC by PWIDs is to augment existing NSPs and other harm reduction services (which already have a high degree of accessibility and acceptability) to include PHC. Whilst this makes sense for higher income countries that have relatively good NSP and OST service coverage, it makes less sense for low and middle income countries (LMICs). The burning issue for these countries is not whether PHC services targeted at PWIDs have public health benefits, but how these services can be implemented when NSP and OST services are absent or service coverage is poor. Although Islam et al. (2012) acknowledge that contextual influences may shape how PHC services for PWIDs are provided; they fail to discuss the way PHC can be provided in contexts of limited NSP and OST coverage. In LMIC contexts, it might be worth considering how services for other vulnerable and marginalised groups can be expanded to include health care for PWIDs. Surveys of most at risk populations (MARPs) have consistently found significant overlap between various MARPS including men who have sex with men, sex workers, and
∗ Correspondence address: Alcohol and Drug Abuse Research Unit, Medical Research Council of South Africa, PO Box 19070, Tygerberg 7505, South Africa. Tel.: +27 21 938 0350. E-mail addresses: [email protected], [email protected]
PWIDs (Johnston et al., 2010; Parry, Petersen, Carney, Dewing, & Needle, 2008). Often organisations serving these MARPs are located in highly accessible areas and already provide PHC (typically related to sexual and/or reproductive health and BBVI testing) to their clients. Given that some of their clientele will be injecting drugs, it may be possible to expand these services to include PHC related to injection drug use specifically. In contexts where injection drug use is relatively rare and/or harm reduction services limited, this may be an efficient and acceptable way of providing targeted services for PWIDs. Another possibility for LMICs is to mainstream services for PWIDs into conventional PHC. Whilst Islam et al. (2012) mention gradual mainstreaming of targeted PHC services for PWIDs as an end-goal, they do not reflect upon the conditions required to make mainstreaming successful. For lower income countries one of the issues will be around the type of workforce that is needed. Islam et al.’s (2012) review suggests a reliance on health care professionals and it is unclear whether there is space for peer-led services. Peer-led services may be more acceptable to countries facing dire shortages in health care workers. Peer-led services may also improve the acceptability of mainstreamed PHC to PWIDs. Certainly in Africa, there has been growing reliance on peers and (nonprofessional) community health workers to provide basic PHC services, especially relating to HIV/AIDS (Philips, Zachariah, & Venus, 2008). In conclusion, it is clear from this review that there are many unanswered questions about the implementation of PHC for PWIDs. Islam et al. (2012) note the absence of studies comparing the relative effectiveness of PHC targeted at PWIDs and conventional PHC. Without evidence that targeted PHC services are more effective and hold greater cost-benefits than conventional care, I fear that policy makers will ignore evidence provided by this review that targeted services are acceptable to and accessible for PWIDs. References Day, C. A., Islam, M. M., White, A., Reid, S. E., Hayes, S. & Haber, P. S. (2011). Development of a nurse-led primary healthcare service for injecting drug users in inner-city Sydney. Australian Journal of Primary Health, 17, 10–15. Islam, M. M., Topp, L., Day, C. A., Dawson, A., & Conigrave, K. M. (2012). The accessibility, acceptability, health impact and cost implications of primary healthcare outlets that target injecting drug users: A narrative synthesis of literature. International Journal of Drug Policy, 23(2), 94– 102. Johnston, L., Holman, A., Dahoma, M., Miller, L. A., Kim, E., Mussa, M., et al. (2010). HIV risk and the overlap of injecting drug use and high-risk sexual behaviours among men who have sex with men in Zanzibar (Unguja), Tanzania. The International Journal of Drug Policy, 21, 485–492.
106
J. Rowe / International Journal of Drug Policy 23 (2012) 103–110
Mathers, B. M., Degenhardt, L., Ali, H., Wiessing, L., Hickman, M., Mattick, R. P., et al. (2010). HIV prevention, treatment, and care services for people who inject drugs: A systematic review of global, regional and national coverage. Lancet, 375, 1014–1028. Parry, C. D. H., Petersen, P., Carney, C., Dewing, S. & Needle, R. (2008). Rapid assessment of drug use and sexual HIV risk patterns among vulnerable drug-using
populations in Cape Town, Durban and Pretoria, South Africa. Journal of Social Aspects of HIV/AIDS Research Alliance, 5, 113–119. Philips, M., Zachariah, R. & Venis, S. (2008). Task shifting for antiretroviral treatment delivery in sub-Saharan Africa: Not a panacea. Lancet, 371, 682–684. doi:10.1016/j.drugpo.2011.09.014
Primary care is the best place to care for drug users Chris Ford a,b,1 a b
General Practice Principal, London, United Kingdom International Doctors for Healthy Drug Policies, Lonsdale Medical Centre, 24 Lonsdale Road, London NW6, United Kingdom
I have worked with patients who have drug problems in primary care/general practice for over 25 years and feel it is the best place to provide services. I was therefore hopeful and excited to read this paper from its title. However, by the end of it, I felt some disappointment. Throughout myself and my GP colleagues at the Lonsdale Medical Centre, our primary care practice, have always treated the person, not the drug, providing the whole range of general medical services including HIV and hepatitis C care, needle exchange, psychological interventions and opioid substitution treatment in the same environment as all other patients. This is something that Lonsdale has championed with other primary care doctors, through the UK Substance Misuse Management in General practice (SMMGP) network (http://www.smmgp.org.uk/). So I agree with Islam et al.’s (2012) conclusions that providing ‘non-judgmental and cost-free services under a harm reduction framework can increase the accessibility and acceptability of primary healthcare for IDUs.’ But I disagree that this care should be separated out from that of other patients. I concede that we are all often remiss at undertaking rigorous evaluations of Primary Care Centres and hence can’t always show the public health impact of this type of care, and so risk not getting adequate funding. But what we do have testimony to is the hundreds of patients who benefit from this method of care delivery.
E-mail address: [email protected] Clinical Director, International Doctors for Healthy Drug Policies, Lonsdale Medical Centre, 24 Lonsdale Road, London NW6, United Kingdom.
Other problems with this synthesis are language with terms not being clarified (primary care, general practice, office-based practice, etc.) and there is little acknowledgement of the marked variation in primary care and general practice around the world. Comparing even the UK system with the Australian or US primary care, I feel is impossible. This leads me to a comment on the UK literature used in this review, most of which is now out of date (being published in 1992 and 1996). Since then there has been a quiet revolution in the care of people who use drugs in the UK. The number of general practices working with patients with drug problems has gone from 0.2% in 1995 to over 40%, many specialist services are headed up by primary care clinicians and SMMGP provides a support and training network for all those working in primary care, as well as a training programme run by the Royal College of General Practitioners (RCGP Certificate in Drug Dependency Part 1 and 2). Over the 17 years of SMMGP and the 10 years that this training programme have been available and building up, we have undertaken audits, presentations, written reports and the odd paper: we have often talked about the need for robust evaluation of them but somehow caring for the patients has always taken precedence! Perhaps the best response to this paper will be to undertake that work now. Reference Islam, M. M., Topp, L., Day, C. A., Dawson, A. & Conigrave, K. M. (2012). The accessibility, acceptability, health impact and cost implications of primary healthcare outlets that target injecting drug users: A narrative synthesis of literature. International Journal of Drug Policy, 23(2), 94–102.
1
doi:10.1016/j.drugpo.2011.09.013