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Task shifting redefined: removing social and structural barriers to improve delivery of HIV services… Ti, Lianping; Kerr, Thomas Oct 4, 2013

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COMMENTARY Open AccessTask shifting redefined: removing social andstructural barriers to improve delivery of HIVservices for people who inject drugsLianping Ti1 and Thomas Kerr1,2*AbstractHIV infection among people who inject drugs (IDU) remains a major global public health challenge. However,among IDU, access to essential HIV-related services remains unacceptably low, especially in settings where stigma,discrimination, and criminalization exist. These ongoing problems account for a significant amount of preventablemorbidity and mortality within this population, and indicate the need for novel approaches to HIV program deliveryfor IDU. Task shifting is a concept that has been applied successfully in African settings as a way to address healthworker shortages. However, to date, this concept has not been applied as a means of addressing the social andstructural barriers to HIV prevention and treatment experienced by IDU. Given the growing evidence demonstratingthe effectiveness of IDU-run programs in increasing access to healthcare, the time has come to extend the notionof task shifting and apply it in settings where stigma, discrimination, and criminalization continue to posesignificant barriers to HIV program access for IDU. By involving IDU more directly in the delivery of HIV programs,task shifting may serve to foster a new era in the response to HIV/AIDS among IDU.Keywords: Task shifting, People who inject drugs, Stigma and discrimination, HIV servicesThe HIV/AIDS epidemic among people who inject drugs(IDU) remains a major public health challenge globally.This epidemic persists despite the fact that a range of ef-fective preventive interventions and treatments exist [1]. Areview by the Reference Group to the UN on HIV andInjecting Drug Use concluded that access to HIV preven-tion, treatment and care among IDU globally was extremelylow and that urgent action was needed to rectify this situ-ation [2]. Various factors contributing to low access to HIVprevention and treatment among IDU have been identified,including the unavailability of programs, as well as anoverreliance on drug law enforcement, incarceration, andmandatory drug detention programs as primary responsesto the harms of injection drug use [3–6].A growing body of literature highlights a range of down-stream social and behavioural impacts of the global em-phasis on drug law enforcement. For example, fear ofconfrontations with police perpetuates unwillingnessamong IDU to access essential HIV-related services [7,8].The emphasis on punishment of IDU for their behavioursalso fuels negative public opinion of this population, includ-ing among healthcare workers, which makes ensuring ac-cess to prevention and treatment of HIV challenging if notimpossible [8,9]. For example, throughout the Asia-Pacificregion, many IDU encounter delays in the provision ofhealthcare services, refusal of treatment by healthcareworkers, as well as breaches of confidentiality, includingsharing of information between healthcare workers and po-lice [10,11]. In some settings, individuals are registered asdrug users within national or regional databases upon seek-ing care or treatment [8]. Negative physician attitudes to-wards HIV-positive IDU have also led to suboptimal ARTtreatment and care for this subpopulation due to concernsover non-adherence and antiretroviral resistance [11–13].Pervasive stigma and the associated self-imposed isolationthat often results can also render individuals reluctant toaccess services due to fears that family, community mem-bers, and employers may shun them for their drug usingbehaviours [14–16]. Collectively, these barriers to HIV* Correspondence: uhri-tk@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada2Department of Medicine, St. Paul’s Hospital, University of British Columbia,608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada© 2013 Ti and Kerr; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Ti and Kerr Harm Reduction Journal 2013, 10:20http://www.harmreductionjournal.com/content/10/1/20prevention and treatment highlight the urgent need fornovel methods of healthcare delivery for this population.One concept that has been applied to improve the deliv-ery of HIV services in African settings is that of taskshifting. Defined as the systematic delegation of tasks fromspecialized cadres to cadres with less training such asnurses or lay workers, task shifting has been used as an ef-fective strategy to address the current healthcare workershortage in many African countries [17–20]. A body of lit-erature supports the use of task shifting as a successful ap-proach in delivering healthcare services including HIVtesting, counseling, and ART treatment by lay workers[21–24]. In addition to the success of this model amongheterosexual populations within resource limited settings, asystematic review has revealed that task shifting can also beapplied effectively to more marginalized populations, in-cluding men who have sex with men [25]. In addition tothe role of task shifting as a means to improve coverage ofHIV services, this concept has also been applied to alleviatethe economic burden imposed on many developing coun-tries [18]. Due to recent financial cutbacks made by theGlobal Fund to Fight AIDS, Tuberculosis and Malaria, theorganization is now considerably more limited in its abilityto respond to the global HIV pandemic [26,27]. In a timewhen resources are scarce, task shifting may help to relievethis situation and attempt to avert the HIV/AIDS crisis.In light of the ongoing problems in ensuring access to es-sential HIV prevention and treatment services for IDU,there may be an opportunity to reconceptualize taskshifting as a way of overcoming social and structural bar-riers to HIV-related services. A large body of evidenceindicates that peer-run initiatives can extend the reach andeffectiveness of conventional public health programsby reaching high-risk IDU [28–30]. Accordingly, the WHO,UNODC, UNAIDS Technical Guide recommendcommunity-based outreach methods as an essential ap-proach for service delivery [1]. However, the involvement ofIDU in providing HIV services need not be limited to thoseefforts that aim to extend the reach of existing programsand may have value in other areas. Shifting HIV servicesfrom professional healthcare workers to peers may alsoserve to address the existing stigma that IDU experiencewithin healthcare settings, thereby improving access tothese services, especially in the Asia-Pacific region wherethe annual prevalence of HIV testing among IDU is as lowas 20% [31]. By creating peer-involved HIV testing clinicsand pairing physicians with peers, IDU may be more likelyto use these services without fear of being discriminated byhealthcare workers or fear of being registered as drug userswithin official registries. Indeed, past research has shownthat drug-user led interventions are more acceptable toIDU than conventional public health programs,[32–34] andthat this is due in part to perceived acceptance of their druguse behaviors by their peers [28,29]. In this sense, theremay also be potential for peer-delivered HIV services thatdo not involve healthcare professionals, as many IDU mayprefer to have their peers deliver these services to avoid fre-quent interactions with healthcare workers.Additionally, task shifting may avert some problemscaused by police in countries with a heavy reliance onlaw enforcement. By shifting delivery of care fromhealthcare professionals to peers, or by incorporatingpeer workers into professionally-led services, a reductionin stigma and discrimination in these settings may beachieved [32]. Likewise, this type of shift in service deliv-ery may address some concerns among IDU about infor-mation sharing between public health systems andenforcement officials.While there is potential for task shifting to reducestigma and discrimination in these settings and thus pro-vide greater coverage of HIV prevention and treatmentservices, it is important to recognize the political bar-riers that may restrict the wide implementation of theseprograms; particularly, the lack of governmental andpublic support for harm reduction programs. Therefore,in order for task shifting to be successfully and sustain-ably implemented within these settings, there is still aneed to shift public and policy thinking towards harmreduction practices through the collective involvementof the community, researchers, service providers, advo-cates, and policy makers.HIV/AIDS among IDU has taken a massive toll in termsof human suffering and economic impacts in countriesthroughout the world. High rates of preventable HIV infec-tion, HIV-related morbidity and mortality among IDU, aswell as increasing expenditures on HIV-related care andtreatment services are major consequences of suboptimalHIV prevention and treatment. There is now an obviousneed for innovation in the delivery of programs and ser-vices for IDU. Given the evidence indicating positive bene-fits of peer-led interventions for IDU, as well as the successof task shifting in settings with human health resourceshortages, shifting the delivery of conventional HIV/AIDSprograms and services to IDU themselves may serve to ad-dress the severe stigmatization and discrimination thatcharacterizes the existing healthcare context in many set-tings hard hit by IDU-driven HIV epidemics. In turn, thisnovel approach to task shifting may foster a new era in theresponse to HIV among IDU.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsThe specific contributions of each author are as follows: LT prepared the firstdraft of the manuscript; TK provided critical comments on the first draft ofthe manuscript; Both authors approved the final version to be submitted.Received: 23 August 2012 Accepted: 24 September 2013Published: 4 October 2013Ti and Kerr Harm Reduction Journal 2013, 10:20 Page 2 of 3http://www.harmreductionjournal.com/content/10/1/20References1. WHO, UNODC, UNAIDS: WHO, UNODC, UNAIDS technical guide for countriesto set targets for universal access to HIV prevention, treatment and care forinjecting drug users. Geneva: WHO; 2009.2. Reference Group to the UN on HIV and injecting drug use: ConsensusStatement of the Reference Group to the United Nations on HIV and InjectingDrug Use 2010. New South Wales: Reference Group to the UN on HIV andinjecting drug use; 2010.3. Mathers B, Degenhardt L, Ali H, Wiessing L, Hickman M, Mattick R, Myers B,Ambekar A, Strathdee S: HIV prevention, treatment, and care services forpeople who inject drugs: a systematic review of global, regional, andnational coverage. Lancet 2010, 375:1014–1028.4. Csete J, Kaplan K, Hayashi K, Fairbairn N, Suwannawong P, Zhang R, WoodE, Kerr T: Compulsory drug detention center experiences among acommunity-based sample of injection drug users in Bangkok, Thailand.BMC Int Health Hum Rights 2011, 11:11.5. Wolfe D: Paradoxes in antiretroviral treatment for injecting drug users:Access, adherence and structural barriers in Asia and the former SovietUnion. Int J Drug Policy 2007, 18:246–254.6. Small W, Wood E, Betteridge G, Montaner J, Kerr T: The impact ofincarceration upon adherence to HIV treatment among HIV-positiveinjection drug users: a qualitative study. AIDS Care 2009, 21:708–714.7. Beyrer C, Malinowska-Sempruch K, Kamarulzaman A, Kazatchkine M, SidibeM, Strathdee S: Time to act: A call for comprehensive responses to HIV inpeople who use drugs. Lancet 2010, 376:551–563.8. Human Rights Watch, Thai AIDS Treatment Action Group: Deadly denial.Thailand: Barriers to HIV/AIDS treatment for people who use drugs inThailand; 2007.9. Chan K, Stoove M, Sringernyuang L, Reidpath D: Stigmatization of AIDSpatients: Disentangling Thai nursing students’ attitudes towards HIV/AIDS, drug use, and commercial sex. AIDS Behav 2008, 12:146–157.10. Paxton S, Gonzales G, Uppakaew K, Abraham K, Okta S, Green C, Nair K,Parwati Merati T, Thephthien B, Marin M, Quesada A: AIDS-relateddiscrimination in Asia. AIDS Care 2005, 17:413–424.11. Ding L, Landon B, Wilson I, Wong M, Shapiro M, Cleary P: Predictors andConsequences of Negative Physician Attitudes Toward HIV-InfectedInjection Drug Users. Arch Intern Med 2005, 165:618–623.12. 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Bemelmans M, Van Den Akker T, Ford N, Philips M, Zachariah R, Harries A,Schouten E, Hermann K, Mwagomba B, Massaguoi M: Providing universalaccess to antiretroviral therapy in Thyolo, Malawi through task shiftingand decentralization of HIV/AIDS care. Trop Med Int Health 2010,15:1413–1420.24. Selke H, Kimaiyo S, Sidle J, Vedanthan R, Tierney W, Shen C, Denski C,Katschke A, Wools-Kaloustian K: Task-shifting of antiretroviral deliveryfrom health care workers to persons living with HIV/AIDS: clinicaloutcomes of a community-based program in Kenya. J Acquir ImmuneDefic Syndr 2010, 55:483–490.25. Pedrana A, Guy R, Bowring A, Hellard M, Stoove M: Community models ofHIV testing for men who have sex with men (MSM): Systematic Review 2011.Burnet Institute: Melbourne; 2011.26. Boseley S: Crisis looms as Global Fund forced to cut back on Aids,malaria and TB grants. The Guardian 2011.27. York G: Economic crisis hits health aid that has helped millions as donorscut back. The Globe and Mail 2011.28. Kerr T, Hayashi K, Fairbairn N, Kaplan K, Suwannawong P, Zhang R, Wood E:Expanding the reach of harm reduction in Thailand: Experiences with adrug user-run drop-in centre. Int J Drug Policy 2010, 21:255–258.29. Hayashi K, Wood E, Wiebe L, Qi J, Kerr T: An external evaluation of apeer-run outreach-based syringe exchange in Vancouver, Canada.Int J Drug Policy 2010, 21:418–421.30. Smyrnov P, Broadhead R, Datsenko O, Matiyash O: Rejuvenating harmreduction projects for injection drug users: Ukraine’s nationwideintroduction of peer-driven interventions. Int J Drug Policy 2012,23:141–147.31. WHO, UNODC: Guidance on Testing and Counselling for HIV in SettingsAttended by People Who Inject Drugs: Improving Access to Treatment, Careand Prevention. Geneva: WHO; 2009.32. Broadhead RS, Heckathorn DD, Altice FL, Van Hulst Y, Carbone M, FriedlandGH, O’Connor PG, Selwyn PA: Increasing drug users’ adherence to HIVtreatment: results of a peer-driven intervention feasibility study.Soc Sci Med 2002, 55:235–246.33. Irwin K, Karchevsky E, Heimer R, Badrieva L: Secondary syringe exchange asa model for HIV prevention programs in the Russian Federation.Subst Use Misuse 2006, 41:979–999.34. Snead J, Downing M, Lorvick J, Garcia B, Thawley R, Kegeles S, Edlin BR:Secondary syringe exchange among injection drug users. J Urban Health2003, 80:330–348.doi:10.1186/1477-7517-10-20Cite this article as: Ti and Kerr: Task shifting redefined: removing socialand structural barriers to improve delivery of HIV services for peoplewho inject drugs. Harm Reduction Journal 2013 10:20.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitTi and Kerr Harm Reduction Journal 2013, 10:20 Page 3 of 3http://www.harmreductionjournal.com/content/10/1/20

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