Drug Substitution Therapy in Manipur and Nagaland

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• Drug Substitution Therapy in Manipur and Nagaland

Dr Richard Di Natale Australian International
Health Institute HIV Interventions and Research
in North-East India Recent results from the
field Melbourne 5 July 2007
Implemented by the Emmanuel Hospital Association
in partnership with AIHI Funded by DFID,
Challenge Fund
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EHA Drug Substitution Therapy ProjectYear 1
Evaluation

• Contributors to final evaluation
• EHA
• Charan Sharma
• Rachel Kabi
• Tushimenla Imlong
• Umarani Chanu
• Dr Allen Chiru
• AIHI
• Dr Richard Di Natale
• Kerryn ORourke
• Melissa Yow

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The EHA substitution project

• In February 2006, the UK Department for
  International Development (DFID) funded a drug
  substitution therapy project in northeast India
  for one year
• 1200 treatment places were allocated with a
  further 600 places allocated after six months of
  implementation

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• Goal
• To reduce the rate of HIV transmission in
  Nagaland and Manipur related to injecting drug
  use
• Objective
• To build capacity in Nagaland and Manipur for
  drug substitution therapy
• To implement drug substitution therapy as an
  integrated component of other harm reduction
  services
• Use NACP-III to facilitate take up by the Indian
  government

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Pre-post study design

• Use client surveys to compare outcomes before
  treatment and after treatment
• Allows us to
• to develop a profile of our IDU population
• To analyse factors that affect treatment outcomes
  
• Compare across NGOs, states etc.
• However
• Also need to consider competing explanations

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• Client surveys

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Pre-post study design

• All responses in the client surveys refer to the
  previous one month
• Forms included from May 2006-January 2007
• Treatment defined as a minimum of two days of
  treatment

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Qualitative Data

• Monthly reports
• Monitoring Visits
• Focus Groups
• Case studies

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Inception phase

• March May 2006
• Recruitment of the EHA project team and NGO teams
• Development of clinical protocols
• Orientation and training program
• ME framework

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Staff recruitment and training

• Most positions were filled in March,
• Many staff had worked with IDUs or from an IDU
  background
• Staff turnover low
• Staff training included the following
• Harm reduction
• Drug substitution treatment
• Clinical aspects of DST
• Overview of buprenorphine side effects, dosing
• Roles and responsibilities of project staff
• Outreach and peer education
• Identifying and interacting with KPs
• Counselling

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Staff recruitment and training

• Referral and networking
• Community mobilisation
• OD management
• Abscess management
• Exposure trips
• Monitoring and evaluation
• Focus Group training
• Hep C / HIV/AIDS
• Log book maintenance
• Financial management

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Services offered by NGOs

• Administration of buprenorphine
• Advocacy/community sensitisation
• Health assessment of IDUs
• One-to-one/group counselling
• Referral services
• Education from peer educators and health
  professionals
• Outreach advocacy, recruitment, follow-up and
  some administration of DST
• Provision of medication for SEs (nausea,
  drowsiness, constipation) and vitamins

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Drop in Centres

• Critical function
• Generally adequate but
• Problems with size, too congested and noisy
• Impact on local communities.

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Advocacy

• Some NGOs active in advocacy
• Pressure groups
• Womens groups
• Other NGOs
• Church groups
• Police
• Families and spouses of IDUs
• Youth
• Advocacy was particularly effective when it
  involved people who had directly benefited from
  treatment

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Recruitment of KPs

• Referral mainly through peers and IDU networks
• Large demand for treatment
• All NGOs had clients ready prior to start prior
  to implementation

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• Client profile at intake

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Total Intake Numbers 2267 By state Manipur
73 Nagaland 27 By gender Men 93 Women
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Average age at intake 30.6yrs
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Percentage of polydrug users at intake 55
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• Outcomes following Intake

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Outcomes

• 1. Still in treatment
• 2. Completed Treatment
• Clients have withdrawn from buprenorphine and
  have not returned to their past pattern of drug
  use at the time of discharge
• 3. Relapse
• Clients cease treatment and return to their past
  pattern of drug dependence
• 4. Treatment ceased by NGO
• Assume that clients have returned to past pattern
  of dependence
• 5. Expired

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Relapse

• Craving most common reason
• Some clients unable to meet expenses for daily
  travel
• Of those who relapsed due to side effects, the
  most common SEs were vomiting, headache,
  withdrawal (precipitated), loss of appetite,
  insomnia, drowsiness
• One quarter of who discontinued treatment did so
  in the first week
• Some IDU sex workers were pressured by their
  partners to discontinue treatment.

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• Influences on treatment outcomes

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• Issues and challenges

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Gender

• Most women were treated at dedicated female IDU
  sex worker NGO
• Low intake of women due to a number of factors
• Lower overall prevalence
• Stigma and discrimination - drug use hidden
• Reluctant to attend centres with male clients and
  male staff

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Demand for DST

• One of the most serious problems was high demand
• Some NGOs filled all their available treatment
  places quickly
• Long waiting lists established by June or July.
• Impacted significantly on NGO staff
• Also some demand from non injecting drug users

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Outreach

• Services included
• Recruitment of clients
• Administering buprenorphine to those unable to
  attend the DIC
• Following up lost clients.
• However
• Many NGOs overwhelmed by the demand for outreach
  services
• Follow-up of clients in particular was often
  difficult and time-consuming.

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Take-away doses

• NGOs approached this issue differently
• Given to clients living large distances from DICs
  or sick clients
• Family verification and involvement usually
  required
• Dependent on local capacity for outreach

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Diversion/misuse

• Few reported attempts
• No evidence that buprenorphine is being misused
  in large quantities

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Mixing

• A few clients continued to use small amounts of
  illicit drugs
• Most NGOs tried hard initially to keep clients in
  treatment

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Challenges to client retention

• Time and costs associated with transport
• Population mobility
• Aggressive marketing tactics in response to
  declining drug sales
• Bandhs and strikes
• Peer outreach workers from user background
  regularly exposed to illicit drugs

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Income generation

• Making equipment for the DIC
• Art and craft
• Kite making
• Envelope making
• Paper bag making

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Unheard voices

• One day I sent him to the shop to buy something
  for the kitchen. It was a test to see if he will
  do the job. He bought everything I told him to
  buy and returned home with an amount of five
  rupees in change. I was very happy that he came
  back home with the change. This was the first
  time he had ever done this. My son is a new
  person.
• Clients Mother

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Unheard voices

• Buprenorphine is like gold really more
  precious than gold .
• Clients wife
• the Drop in centre (DIC) is a place of God.
  Clients wife
• Because of treatment my fiancée has agreed to
  marry me after treatment is over
• Clients wife
• I cant remember having more rice than I did
  this morning. I feel great.
• Client
• There are no more thefts and fighting in the
  family. The family atmosphere is much better
  now.
• Clients mother

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• Thank-you