IDU in Rehab Centers [Atienza, et al, 2007]

Documentation of IDU Practices and Prevalence of HIV in Drug Rehabilitation Centers in the Philippines
Principal Investigators: J. Atienza, A. Corpuz,G. Belimac, M. Baquilod, D. Agdamag, B. Reyes, N. Dominguez, R. Velasco
Contact Information: Mr. Joel Atienza


SPECIFIC FINDINGS
Socio-demographic Profile of People who Inject Drugs (PWID)

Twenty four (10%) of the 246 respondents were injecting drug users. All were males. Ages ranged from 18 years – 57 years (Median 32 years). Majority (67%) reached college and 62% were single (Table 2). Half were unemployed.

The median age when drugs were first used was 14 years (six years to 21 years).
Twenty of the 24 respondents last injected drug more than a month ago and majority (58%) used nubain. Other drugs injected were shabu, heroin, nubain plus dormicum, demerol, morphine, valium and “sosegon.”

Of the 246 respondents who voluntarily submitted themselves for laboratory testing, none was positive to anti-HIV. Nine of the IDUs were reactive to anti-HCV (Table 6) while only one of the non-IDU was also reactive to anti-HCV. Two of the IDUs were reactive to HBS Ag while 16 of the non-IDU were reactive to HBS Ag.

Description of watering holes, shooting galleries, convergence areas, "safe places", etc.

More than half (58%) divided the drug between those ‘getting high together’ the last time they injected. Majority (88%) injected with other IDUs the last time they injected. Fifty four percent pooled their funds together to purchase and divide the drug among themselves.

Sources of new syringes the last time they injected were pharmacy, ‘shooting gallery’, drug dealer, FBI/police hotline or from a friend. Sixty seven percent ever injected in an IDU “hang-out” and sixty nine percent injected drug in an IDU “hang-out” more than a year ago.

PWID knowledge on STI and HIV transmission, prevention, treatment, etc.

All 24 IDUs have heard of HIV/AIDS. Sixteen said that HIV is a sexual disease. Others said that HIV is contagious, a viral disease, can be acquired from blood transfusion and from injection. When asked if they can tell whether someone is infected with HIV by just looking at him or her, only two responded in the affirmative. Ten of the 24 said that an untreated STI can progress to HIV while all replied that HIV cannot be prevented.
Majority (86%) knew the three correct ways of preventing HIV while forty four percent knew of the misconceptions of HIV transmission.

Thirty eight percent believed that there is a cure for HIV. Most (67%) felt that they are at risk for HIV because of the following reasons: having multiple sex partners, non-condom use during sex, being an IDU and engaging in careless sexual activity. Of the eight who felt that they are not at risk, their reasons were as follows: being faithful to one partner, having a clean partner, abstinence and having his/her own syringe during IDU activities.
More than half (58%) knew of a place in the city where they live where people can have an HIV test (Table 4). One third (38%) had an HIV test at his/her own request from the Social Hygiene Clinic, private laboratory, NGO, Dangerous Drugs Board and from surveillance. Of the nine who had the HIV test at his/her own volition, three received counseling. Five had the test and got the result more than a year ago, two had it just this year while two could not remember.

Of the 24 IDUs, one noticed sore/ulcer, scab in the genital area, two had urethral discharge, one noticed inflammation, pain, swelling/lump in the genital area and two had painful urination in the past 12 months. Only two went for treatment in a barangay health center during the last episode.

Behavior (multiple sex partners, paid sex, condom use, injecting practice, etc)

Four of the 24 IDU respondents (17%) used syringe that has already been used by someone else. Three of these, however, cleaned their syringe either by bleach and water, water alone or by boiling. For the respondent who cleaned the syringe with water, the water was kept in one container where other syringes were cleaned.

The median age of sexual debut was 16 years (six years to 20 years). Half had regular sex partners. Only 17% used condom the last time they had sex with their regular partner. Of the 12, five rarely used condom while another five never used condom with their wife/live-in partner in the last 12 months. None had a wife/live-in partner who injects.
Fifty four percent had sex with a sex worker in the past year. Majority (77%) used condom the last time they had sex with a sex worker. Seventeen percent was given money or drugs in exchange for sex and half of these used condoms during their last sex.
One third (33%) of the IDUs had sexual experience with another man. One paid for sex, five had sex in exchange for money or drugs and four had consensual sexual relations.

Programmatic, including systems issues (service delivery, information, policy, etc.)

Seventy nine percent had previous admissions in drug rehabilitation centers. Only one ever injected drug while admitted. Half of the IDU respondents received HIV information during those admissions.

Majority (67%) was imprisoned due to drugs. Four (out of 24) claimed to have taken drugs while in prison. No one ever tried injecting drug while incarcerated. Nineteen percent received HIV/STI information in prison

In the past 12 months, 29% had a chance to attend a meeting or a discussion on preventing HIV/AIDS/STI sponsored by an NGO and rehabilitation centers. During the current admission, five of the 24 claimed that someone approached him to talk about HIV/STI/hepatitis while two had it more than three times and one had it twice. All eight claimed that condom use as a preventive measure against STI was part of those lectures. Also five respondents said that someone approached him during the current admission to provide information on safe injection to prevent HIV.
All except said that medical doctors regularly visit the rehabilitation centers where they are currently admitted. The frequency of visits vary: from daily to once a week, once a month to “on call” basis. Majority (83%) claimed that the rehabilitation center where they are currently admitted have additional nurses to augment the health staff. More than half ever got sick during the current admission.

RECOMMENDATIONS
For Programme Development; For Policy Formulation; For Further Research


At the Drug Rehabilitation Center Level:
1. At drug rehabilitation centers, advocacy for the development of comprehensive HIV prevention package in closed setting, including drug rehabilitation centers and prisons is needed to comprehensively address drug abuse, HIV and other blood borne diseases.

2. Personnel of the DRC need capacity building to provide HIV and STI services. Orientation on national policies for both drug abuse and HIV prevention and control may be needed within the existing personnel of the DRC.

3. Development of evidenced based ‘harm reduction strategy’ should be complementary to existing demand and supply reduction strategies. Harm reduction as a public health intervention to address HIV and other blood borne disease prevention and control should be considered especially in areas where there are evidences of existing IDU populations. However, multi-sectoral and inter-agency operational mechanisms should be in place to create a more supportive environment to handle both threats.

4. Integrate ‘harm reduction intervention’ for IDUs into the community based program after care, out-patient treatment and rehabilitation program. This will complete the continuum of care approach for IDUs.

At the broader community level:
In areas where injecting drugs users are documented, it is necessary to carry out the WHO recommended comprehensive strategies to achieve more impact. The following strategies should be employed and supported:

1. Needle/Syringe distribution and education to IDUs in areas where evidence of injecting drug behavior exist using scientific research or surveillance. Close partnership with stakeholders is crucial for effective implementation of the strategy.

2. Outreach through peer approach and identification of key advocates who are former IDUs. Development of core messages and other behavior change communication (BCC) strategies that has to be culturally acceptable, such as the following:

1. Don’t use drugs
2. If you use, do not inject
3. If you inject, do not share
4. If you share, clean

3. Voluntary Counseling and Testing for IDUs. Special approaches may be developed to reach and educate IDUs on the benefits of having an HIV tests. Such strategy is complementary to availing the ‘free’ anti-retro viral drugs now being distributed in the public health setting.

4. Antiretro-viral provision to positive IDUs including training of ARV health providers on management of AIDS among IDUs.

5. For involvement of minors, more in depth study on KAP and vulnerabilities of adolescents. A closer look into the implementation of Juvenile Justice Law (RA 9344) should be explored in relation to drug rehabilitation of minors.

6. Health promotion and education should be adapted as a primary strategy for HIV prevention based on the socio-demographic data of this study. Promotion and encouragement of families and individuals in the utilization of rehabilitation services, Advocacy and support for further strengthening of DRCs.

7. Continuous surveillance using both HIV serological and behavioral methods

At the national level:
1. Amendment of existing laws on dangerous drugs and HIV.
2. Higher level advocacy for support in addressing drugs and HIV problem.

Research or Project Information
Title: Documentation of IDU Practices and Prevalence of HIV in Drug Rehabilitation Centers in the Philippines
Start Year: 2007
End Year: 2007

Brief Introduction:
The AIDS Medium Term Plan (AMTP 4) has stated that IDUs should be provided with focused preventive education, skills and services to lessen their vulnerability to HIV infection . At the national level, the Department of Health, Dangerous Drugs Board and other drug enforcement agencies are crucial actors in designing intervention programs that would prevent the explosion of HIV epidemic that has a very high socio-economic cost for the Philippines being a resource constrained economy.
The information on the extent of IDU practices and other risky behaviors among patients admitted in rehabilitation centers are good indicators of the nature of the IDU and HIV infection problem in the Philippines.
The Phase 2 of the project will design an intervention program directed to rehabilitation centers to prevent HIV infection.

General Objective:
To describe injecting drug use among patients of rehabilitation centers in terms of level of behaviors putting them at higher risk of HIV infection.

Specific Objectives:
1. To establish the socio-demographic profile of drug users confined in the Philippine drug rehabilitation centers;
2. To compare the prevalence of injecting drug use among drug users confined in the rehabilitation centers;
3. To identify possible sites where IDU behavior takes place;
4. To compare the prevalence of HIV infection between injecting and non-injecting drug users;
5. To determine prevalence of Hepatitis B and C among rehabilitation patients and more specifically those who admitted to have practiced injecting drugs for recreational purpose;
6. To describe available health programs/services being given to drug dependents at rehabilitation centers;
7. To measure the level of knowledge on HIV/AIDS/STI among drug dependents at rehabilitation centers.

The study is limited to IDU practices among those who are already confined in the rehabilitation centers, which may not truly describe the profile of active injectors and drug users at the community level. No HIV serological re-testing was done to investigate for the ‘window period’.

Key Study Population:
Sampling size (if study): A descriptive study was conducted among the drug users currently admitted in drug rehabilitation centers in the country. Using the Statcalc of EpiInfo software, a sample size of 246 was computed based on simple random sampling with the following assumptions (1) 20% in the study population are IDUs with 25% worst acceptable proportion, (2) 80% B power, and (3) 95% Confidence Interval.
Population size:

Project Sites:
•Shepherd Drug Rehabilitation Foundation Inc. - 3 Scout Albano St. South Triangle QC
•Quezon City Drug Treatment and Rehabilitation Center “TAHANAN” - Diamond Hills Subd. Group II Area B Payatas
•Bureau of Corrections Therapeutic Community Center - New Bilibid Prison Medium Security Compound
•Roads and Bridges to Recovery - 520 EDBEN Bldg. Dr. Sixto Antonio Ave. Maybunga, Pasig
•Bulacan Drug Rehabilitation Foundation,Inc. - De Belen’s Compound Abraham St. Tiaong Baliuag
•Friendship Rehabilitation Foundation Center, Inc. - 3 Bgy. Pinac-Pinacan, San Rafael Bulacan
•Amor Rehabilitation Center Foundation - 12-17 de los Santos St. Ampit Bgy. Gulod Malaya
•Nazareth Formation House - Bo.Lapo-lapo 1st San Jose Batangas
•Drug Abuse Research Foundation - 41 Tagaytay St. Bgy. Osorio Trece Martirez City
•DOH - JP Rizal St. Kaybagal South
•Rising Phoenix Foundation - 62754 Kaybagal South
•Serenity House of Sobriety - 3675 ME Calamba Rd. Bgy.Sungay East
•House of HopeInc. - 888-B,(-A Gun-ob, Lapu Lapu City
•Recovery House - Samson Road Extension, Lahug
•DOH - Candabong, Binlod, Argao Cebu
•DOH - Maitum Upper Puerto,CDO
•Sunshine - Zamboanga City

Principal Investigator: J. Atienza, A. Corpuz,G. Belimac, M. Baquilod, D. Agdamag, B. Reyes, N. Dominguez, R. Velasco
Contact Information: Mr. Joel Atienza
Alternate Phone: hivresearch
Alternate Email Address: hivresearch

Co Investigator/s: National AIDS STI Prevention and Control Program (NCDPC), SACCL San LAzaro Hospital, Office of Special Concerns, National Epidemiology Center
Website: hivresearch