Primary health care for people who inject drugs in low and middle income countries

Abstract

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 eduction initiatives for people who inject drugs (PWIDs) (see for xample Mathers et al., 2010). In contrast, significantly less attenionhas beengiven to theprovisionof primaryhealth care (PHC) for eople who inject drugs (PWIDs), even though these services may ontribute to better outcomes for other harm reduction services uch as OST. As PWIDs often face structural barriers to accessing onventional PHC (Day et al., 2011), PHC services targeted at PWIDs pecifically have been touted as a way of overcoming these obstales. The evidence base for these targeted services however has een limited. Islam, Topp, Day, Dawson, and Conigrave’s (2012) ynthesis of the literature on PHC services targeted at PWIDs is imely and represents one of the first attempts to establish an evience base in support of these services. In this synthesis of the literature, theauthorsprovidea summary f factors associated with accessible and acceptable PHC. Accessile services were based at a suitable and accessible location, had exible appointment scheduling, had needs-based operating hours nd were affordable. Services were seen as acceptable when they rovided other harm reduction services, provided ancillary social nd welfare services, and were not associated with conventional ealth care. Based on these findings, the authors argue that the best eans of ensuring adequate uptake of PHC by PWIDs is to augment xisting NSPs and other harm reduction services (which already ave a high degree of accessibility and acceptability) to include HC.Whilst thismakes sense for higher income countries that have elatively good NSP and OST service coverage, it makes less sense or low and middle income countries (LMICs). The burning issue or these countries is not whether PHC services targeted at PWIDs ave public health benefits, but how these services can be impleented when NSP and OST services are absent or service coverage s poor. Although Islam et al. (2012) acknowledge that contextual nfluences may shape how PHC services for PWIDs are provided; hey fail to discuss the way PHC can be provided in contexts of imited NSP and OST coverage. In LMIC contexts, it might be worth considering how services PWIDs (Johnston et al., 2010; Parry, Petersen, Carney, Dewing, & Needle, 2008). Often organisations serving theseMARPs are located inhighly accessible areas andalreadyprovidePHC (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 contextswhere 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 servicesmaybemore acceptable to countries facingdire shortages inhealth careworkers. Peer-led servicesmayalso improve theacceptabilityofmainstreamedPHCtoPWIDs.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 unansweredquestionsabout the implementationofPHC forPWIDs. 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.