This document discusses building a pyramid model for designing HIV prevention and treatment systems for drug users in Eastern Europe. It proposes a pyramid model with multiple levels and types of care services ranging from high to low threshold based on ease of access. The model aims to provide easy access and transfer between services to reach 70-80% of injecting drug users. Priorities should be set based on public health considerations like reducing HIV/AIDS and costs, with low threshold services providing the best coverage for available resources. The pyramid model metaphor emphasizes building services gradually and sustainably from the base up.

1. Building Pyramids:
Designing HIV Prevention and Treatment
Systems for Drug Users in Eastern Europe
Dr. Jean-Paul C. Grund

2. Building Pyramids
Introduction
• While not absent during the days of communist rule, the transition
towards democracy has undoubtedly been followed by an increase in
the availability and use of illicit drugs in all former socialist
countries.
• As a result, injecting drug use, addiction and, as a consequence, HIV
are developing into a serious public health problem.
• Addiction is associated with compromised economic, social and
psychological situations.
• It is increasingly viewed as a complex, multi-causal, chronic
relapsing condition or disease, for which ”to date there is no effective
curative treatment.”
10/18/01, Building Pyramids
J-P Grund

3. Drug Use after Socialism:
Prevalence Russia & Ukraine
Table 1. Registered & Estimated Number of Drug Users in Russia & Ukraine
Russia
Registered Number of Drug Users
Ministry of Internal Affairs:
Ministry of Health:
1 99 0
19 94
19 96
20 01
158.000 249.000
25.000
85.000 450.000 (Users)
270.000 (Addicts)
Estimates:
1996: 600,000
1998: 1-2.5 million
2001: LTP: 3 million
Ukraine
Registered Number of Drug Users:
“Early 1990s”: 20.000; 1997: 80.000
Estimate (MIA):
1997: 600.000 – 700.000 (75 - 80% IDUs)
Sources: Brunet 1996; USAID/CDC 1998; Khodakevich & Dehne 1998; Dehne et al. 1999; MOH, 2001

4. Drug Use after Socialism:
Prevalence in Cities Across the CEE Region
Table 2. Total Number of IDUs and Percentage of Population by City
Sources:
• MSF/H RSAs
• Grund et al. 2001
City
Total IDUs % of Population
35000
2.6
Nizhniy Novgorod
9000
3.6
Novorossiisk
380-440
0.2
Pskov
10000
1
Rostov Na Donu
70-80000
1.7-1.9
St. Petersburg
18000
1.7
Volgograd
25000
2
Odessa
up to 10000
3
Poltava
7000-8000
0.4-0.5
Estonia
2000-3000
0.3-0.5
Vilnius
1416
0.2
Kishineu
15-20000
1-1.5
Sofia
2500
1
Szeged

5. Drug Use after Socialism:
Qualitative Prevalence Assessments
“People drink or inject in this place.”
(Outreach suggest that
Both national and city-level dataWorker, Volgograd) in
several NIS countries more than 1% of the
population is involved in (injecting) drug use.
“It is difficult to find a building in this
town that is not affected by drug use.”
(Epidemiologist, Rostov Na Donu)
10/18/01, Building Pyramids
J-P Grund

6. Drug Use under Socialism: Do It Yourself!

7. Collective Drug
Preparation & Injecting,
Friendship Networks,
& HIV Transmission

8. A Culture of Collective Drug Use
10/18/01, Building Pyramids
J-P Grund

9. A Culture of Collective Drug Use
“It is very seldom when you use alone. At minimum you use with two or
three people. … “Somebody has money for drugs, a second knows where
to get good drugs, a third has some anhydride or a place to cook and yet
another has syringes. … It is also much cheaper to use in groups.”

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87
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71
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40000
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140000
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35
Cumulative number of reported HIV cases
Russian Federation, 1987 - July 1, 2001
80000
60000
0

11. Building Pyramids:
A Model for Policy & Service Development
• Metaphorical model of the development of drug treatment
and health & social care services for drug users.
• The model is essentially a thinking model to support realistic
policy development.
• It includes graphical representations
of key variables and processes,
relevant to decision making.
• It can inform a range of
policy choices, considering and
matching these key variables.
10/18/01, Building Pyramids
J-P Grund

12. Pyramid Model:
Establishing a Typology of Care Services for IDUs
Threshold to Care
High Threshold Services
Medium Threshold Services
Low Threshold Services
‘No’ Threshold Services
10/18/01, Building Pyramids
J-P Grund

13. Pyramid Model
Professional Care Services for IDUs
High Threshold Services
• In-Patient Detoxification
(Reduction, Cold Turkey)
• Mid-Term In-Patient
Treatment
• (Long-Term) Residential
Therapeutic Communities
• Psychiatric Interventions
• After Care, Rehab, Relapse
Prevention, Acupuncture
• (Re-Entry) Housing
10/18/01, Building Pyramids
J-P Grund

14. Pyramid Model
Professional Care Services for IDUs
Medium Threshold Services
• Out-Patient Detoxification
(Reduction, Acupuncture)
• Specialized Medical
Treatment (HIV, HBV,
HCV, Dental Problems)
• Social Work, Counseling,
Case Management
• Job Training, Work
• (Supported) Housing
• Money Management
10/18/01, Building Pyramids
J-P Grund

15. Pyramid Model
Professional Care Services for IDUs
Low Threshold Services
• Out-Patient Opiate Agonist
Treatment: Methadone,
Buprenorphine, Codeine
• Emergency Medical and
General Practice Care
• (Emergency) Psychiatry
• Syringe Access: Exchange,
Distribution, Pharmacy e.a.
Sales (kiosks-coupons?)
• Outreach Work
• Overdose Prevention
10/18/01, Building Pyramids
J-P Grund

16. Pyramid Model
Professional Care Services for IDUs
Low Threshold Services
• Drop-In Centers,
• Safer Consumption Facilities
• Food, Clothing and Shelter
Projects
• Drug Use Management
programs
• Acupuncture, Stress
Reduction
• Safer Drug Use Information
• Chill-Outs @ R@ves
10/18/01, Building Pyramids
J-P Grund

17. Pyramid Model
A Dynamic Model
Key Characteristics
• Easy access @ multiple
entry points.
• Includes all service levels
• (coordinated) transfer
between services.
• Easy use of ancillary services
• Increases demand for high
threshold treatment: develops
naturally with growing contact rates.
• Can reach 70-80% of IDUs.
• Collaborative Model.
10/18/01, Building Pyramids
J-P Grund

18. Pyramid Model
Considerations for Setting Priorities
Public Health Considerations
• Fighting the HIV/AIDS Pandemic
and Other Infectious Diseases
• Reducing Drug-related Morbidity
and Mortality
• Coverage of Populations at Risk
• Treatment Retention
• Treatment of Problem Drug Use
Economic considerations
• Available $$ Resources (Funding)
• Costs of Services
10/18/01, Building Pyramids
J-P Grund

19. Coverage: What proportion of the
IDU Population Needs to be Reached?
Slide: Courtesy of S. Strathdee
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J-P Grund

20. Pyramid Model
Care Services for IDUs: Level & Coverage
Level of Care
Potential Coverage of Population (%)
High Threshold Services
1-20 (?)
Medium Threshold Services
15-40 (?)
Low Threshold Services
70-80
‘No’ Threshold Services
Nx
10/18/01, Building Pyramids
J-P Grund

21. Pyramid Model
Treatment Costs by Type of Modality
Type of Treatment
Relative Costs per Treated Drug User
$$$
High Threshold Services
$$-$$$
Medium Threshold Services
$
Low Threshold Services
Q: Where to Invest Scarce Resources?
A: Where we get the Biggest
10/18/01, Building Pyramids
Bang for the Buck!
J-P Grund

22. Mean Costs Per Year For 1 Heroin Addict (USA)
$
50000
40000
Security
30000
Theft, etc.
20000
10000
Heroin
Jail
or
Prison
and
Court
Costs
0
On Street
Incarcerated
Residential
Drug-Free
Treatment
MMT
Residential
Treatment
Methadone
Maintenance
Treatment
SOURCE: Slide: M. Reisinger, Adapted from NYS DSAS, 1991, by Dole & Des Jarlais.
10/18/01, Building Pyramids
J-P Grund

23. Conclusion
Building Pyramids: A Useful Metaphor for
Development of Drug Policy and Services?
• Pyramids were not built in one
day. Nor are treatment services
for Injecting Drug Users.
• Pyramids were built stone
for stone, layer for layer,
fitting seamlessly on the
preceding layer.
• Pyramids were built to last:
Sustainable Development
• Ancient Architectural Rule:
Start with the Fundament(al)s.
10/18/01, Building Pyramids
J-P Grund