Photo story – Putting people at the centre: integrated treatment for HIV, tuberculosis and drug dependence in Portugal

People who inject drugs are at much greater risk of infection with HIV and tuberculosis (TB). Treatment for drug-dependence, such as opioid substitution therapy (OST), helps such people also maintain treatment for HIV and TB, and improves treatment outcomes.

Services for these 3 problems are usually provided in different locations, so the time and effort required to access them discourage people from seeking and maintaining treatment. The cities of Porto and Vila Nova de Gaia, Portugal, have brought services together, focusing them on people’s needs, not diseases. The photo story describes this model as a good example of integrated services to treat HIV, TB and drug dependence.

WHO assessment of Porto’s model of service integration

Because information is lacking on effective strategies for integrated treatment globally, WHO is encouraging research to identify the best delivery models for collaborative TB/HIV interventions for the most at‐risk populations, including people who inject drugs. In 2011, WHO/Europe commissioned a rapid assessment of the services provided in Porto.

The London School of Hygiene and Tropical Medicine, United Kingdom, in collaboration with local partners from the Institute of Public Health and Faculty of Medicine of the University of Porto, made the assessment. It was part of a joint project with the European Commission (EC) Executive Agency for Health and Consumers entitled “Scaling up access to high quality harm reduction treatment and care for injecting drug users in the European Region (harm reduction)”.

The assessment showed that integrating services for HIV, TB and drug-dependence treatment improves the accessibility and quality of care for people who inject drugs. Key factors in delivering such effective, combined care include:

  • widespread and uninterrupted access to OST in community and specialized health care settings;
  • the involvement of outreach teams;
  • a client‐centred approach; and
  • effective multiagency collaboration.

In addition to integrated treatment services, interventions that provide social support and promote dignity are vital to ensuring access. More broadly, factors influencing the opportunity to introduce integrated care in other settings include:

  • the availability, scale‐up and flexible provision of OST;
  • engagement with civil-society organizations; and
  • the capacity, resources and will for interservice collaboration at the local and national levels.

Portugal’s drug policy

Portugal’s drug policy and approach to integrated care differ from those in many other parts of Europe. In 2001, the country decriminalized personal drug use, moving its focus from criminal justice to public health. Although people who use drugs remain subject to sanctions and are referred to a commission for the dissuasion of drug addiction, the main objectives are to explore treatment options and promote healthy recovery.

Since decriminalization, rates of drug-related morbidity and mortality and of drug injecting have fallen dramatically. Injecting drug use had been an important driver of the HIV epidemic in Portugal, but reported cases associated with this risky behaviour have fallen sharply, from 567 in 2004 to 62 in 2011.

OST became widely available through drug treatment centres early in the HIV epidemic. In 1993, pharmacies started implementing needle and syringe programmes, along with nongovernmental organizations’ outreach efforts. Nevertheless, TB rates in Portugal remain the highest in western Europe: 25 per 100 000 population versus under 10 per 100 000 in most other countries in 2010. Although specialist health programmes typically deliver TB and drug-dependence treatment, concerted efforts have been made in Portugal to integrate HIV, TB, drug-dependence and psychosocial care through collaboration between treatment centres and support services for people who use drugs.