 |
Continuum of care for IDUs HIV Imphal Manipur Study PFI |
|
|
1 Pages 1-10 |
▲back to top |
|
|
1.1 Page 1 |
▲back to top |
|
|
1.2 Page 2 |
▲back to top |
Research report
Continuum of Care for Injecting Drug Users (IDUs),
including IDUs living with HIV,
in Imphal city, Manipur:
Current Situation, Needs and Gaps
A Mixed Methods Study
March 2009
Population Foundation of India
|
|
1.3 Page 3 |
▲back to top |
Acknowledgements
Population Foundation of India thank the study participants for openly sharing their personal experiences,
perspectives, and opinions on the various services available for injecting drug users, including those living with
HIV, in Imphal city.
Population Foundation of India would like to thank and appreciate the help of Manipur State AIDS Control Society
(MSACS), Emmanuel Hospital Association (EHA) – Project ORCHID, United Nations Office of Drugs and Crime
(UNODC) - Northeast regional office, India, and all the non-governmental organizations and community-based
organizations who served as our study partners. We thank them for their active participation in the two consultation
2
meetings related to this study that helped us in fine-tuning the study tools and preparing a participatory action
plan for ‘continuum of care’ for IDUs, including those living with HIV, in Imphal city.
PFI would like to acknowledge the efforts of Dr. Venkatesan Chakrapani, M.D., principal investigator of this research
study for his contribution to the design, data collection, data analysis and writing of this report, along with his
research team – Dr. Ram Kamei, Ms. Honeilam Kipgen, and Mr. Kh. Jayanta Kumar (Bobby). We thank Dr. Lucy
Pickering, Research Fellow, Oxford Brookes University, UK, and Ms. Karyn Kaplan, Director of Policy and Advocacy,
Thai AIDS Treatment Action Group, for their helpful comments on an earlier version of this report.
Contact details:
Population Foundation of India (PFI)
Program Management Unit – The Global Fund Project
B-28, Qutub Institutional Area, Tara Crescent,
New Delhi – 110016
Phone: +91-11-42899770
Fax: +91-11-42899795
Website: www.popfound.org E-mail: popfound@sify.com
|
|
1.4 Page 4 |
▲back to top |
Prelude
The Population Foundation of India is implementing the project “Access to Care and Treatment” in six high HIV
prevalence states in India funded by The Global Fund To Fight AIDS, Tuberculosis and Malaria under Round 4 grant.
On the basis of programme needs and experiences, PFI identifies issues that need attention and conducts special
studies to provide possible solutions. These special studies are seen as integral elements of the programme and
the results are expected to feed the programme to improve coverage, effectiveness and ultimately profit the
beneficiaries.
The study entitled “Continuum of Care for Injecting Drug Users (IDUs), including IDUs living with HIV, in Imphal
city, Manipur: Current Situation, Needs, and Gaps” is one such study that PFI conducted during the phase 2 of the
3
programme. Hope the findings would be of significant use to the People Living with HIV/AIDS and key stakeholders
in Imphal, Manipur, and ultimately benefit Injecting Drug Users (IDUs), including IDUs living with HIV.
|
|
1.5 Page 5 |
▲back to top |
Table of Contents
Executive Summary
7
1. Introduction
15
2. Methodology
18
3. Findings & Discussion
22
Quantitative Component
22
Qualitative Component
24
4
Existing Services
- Drug dependence treatment related services
24
- Infections-related services for IDUs
30
Barriers to accessing services
34
Referral Mechanisms
38
4. Recommendations
40
5. References
45
6. Glossary
47
Tables
Table 1. Profile of the focus group participants
21
Table 2. Profile of key informants and in-depth interview participants
21
Table 3. Characteristics of the service agencies for IDUs and PLHIV in Imphal city
23
Table 4. HBV, HCV and STI-related services in Imphal city
23
Table 5. Coverage: Unique individuals covered by services in the past year
24
Boxes
Box 1. Details of qualitative methods
19
Box 2. Study-related consultation meetings with key stakeholders in Imphal
20
Box 3. Components of Targeted Intervention project among IDUs in Manipur
22
Box 4. Major gap in drug dependence treatment services: Lack of ‘continuum’
29
Box 5. Gaps in addressing the needs of female IDUs
33
Box 6. Criminal drug laws, Police interference in harm reduction services,
37
and Human rights violations against IDUs
Box 7. Purpose of the referrals among various service providers
38
Diagrams
Diagram 1. Potential pathways to ensure ‘continuum’ in drug dependence treatment
29
Diagram 2. Existing linkages & referrals across various service agencies in Imphal city
39
|
|
1.6 Page 6 |
▲back to top |
Acronyms and Abbreviations
AIDS
Acquired immunodeficiency syndrome
ART
Antiretroviral therapy or treatment
ARVs
Antiretrovirals
CBO
Community-based organization
CCC
Community Care Centre
CD4
Cluster of Differentiation
5
CoC
Continuum of Care
DAC
Drug De-addiction Centre
DIC
Drop-in Centre
EHA
Emmanuel Hospital Association
FGD
Focus Group Discussion
HCV
Hepatitis-C Virus
HBV
Hepatitis-B Virus
HIV
Human Immunodeficiency Virus
ICTC
Integrated Counselling and Testing Centres
IDI
In-depth interview
IDU
Injecting Drug User
INP
Indian Network for People living with HIV/AIDS
JNH
Jawaharlal Nehru Hospital
KII
Key informant in-depth Interview
MSJE
Ministry of Social Justice and Empowerment
MSACS
Manipur State AIDS Control Society
NACO
National AIDS Control Organization
NGO
Non Governmental Organisation
NACP
National AIDS Control Program
NSP
Needle Syringe Program
OIs
Opportunistic Infections
ORCHID
Organised Response on Comprehensive HIV/AIDS Intervention in the Districts of
Manipur and Nagaland
ORW
Outreach Worker
OST
Opioid Substitution Therapy
|
|
1.7 Page 7 |
▲back to top |
PCR
PE
PLHIV
PPTCT
RIMS
RIAC
SP
STI
6
TCC
TI
UNODC
VCTC
Polymerase Chain Reaction
Peer Educator
People living with HIV
Prevention of Parent to Child Transmission
Regional Institute of Medical Sciences
Rapid Intervention and Care
Spasmoproxyvon
Sexually Transmitted Infection
Treatment Counselling Centre
Targeted Intervention
United Nations Office on Drugs and Crime
Voluntary Counselling and Testing Centre
|
|
1.8 Page 8 |
▲back to top |
Executive Summary
7
1. Background
Manipur is one of the high HIV prevalence states in
India, with 1.13% of the general population estimated
to be HIV-infected. As of May 2008, there were 29,602
HIV-positive cases reported in Manipur; and of these,
42.09.% were categorized as having contracted HIV
through injection drug use (MSACS, 2008). In Imphal,
the capital city of Manipur, the estimated number of
injecting drug users (IDUs) is about 9,000-12,000, with
an estimated HIV seroprevalence of 19.8% (NACO,
2006).
IDUs require a range a services – those related to drug
use (such as sterile needles and injection site abscess
management) and those related to infections such
as HIV, HCV and HBV – and rarely are these all found
under one roof. Hence, at least in the city/district level,
all the required services need to be available and
linked effectively to ensure continuum of prevention
and care for IDUs.
Continuum of care (CoC) at the city/district level means
that a full range of services catering to all the needs of
IDUs are available within a city/district; with adequate
coverage of the IDUs who need such services; with
no barriers to access or utilization; and well linked to
other services in that city/district through strong and
effective referral mechanisms.
2. Study Objectives
To move towards the goal of having continuum of care
for IDUs (including those living with HIV) in Imphal
city, this study was conducted with the following
objectives.
To assess the current situation of the various drug-
and infections-related medical/non-medical services
(Govt./NGOs/CBOs/PLHIV Networks/Private sector)
available for IDUs, including those living with HIV, in
Imphal.
To identify gaps in existing prevention/care services;
and identify unmet and emerging service needs.
3. Methodology
A mixed methods (qualitative & quantitative) study
design was used. Data collection and analysis were
conducted in the second half of 2008.
Quantitative component: A survey was conducted
using a semi-structured questionnaire among 36
agencies (NGOs, CBOs, government hospitals, private
clinics and laboratories) in Imphal city about the type
of services they offer to IDUs/PLHIV. SPSS version-14
was used for statistical analysis.
Qualitative component: 7 focus group discussions
(n=46 participants – former or current IDUs), 16 in-
depth interviews (with IDUs, targeted intervention and
drug de-addiction program staff ) and 7 key informant
interviews (with health care providers and NGO
leaders) were conducted.
Consultation meetings: In a first consultation meeting
with key stakeholders in Imphal (May 2008), the study
plan and draft study tools were shared. Stakeholders’
suggestions helped in refining the study tools. Once
the study was completed, the draft report was shared
with the key stakeholders in another consultation
meeting (September 2008). Their comments/feedback
helped in further refining this report.
|
|
1.9 Page 9 |
▲back to top |
4. Key Findings
DACs provided services to 2,260 IDUs (1,863
Out of the 36 agencies surveyed in Imphal city, 23
agencies implement major projects: 15 implement
males and 397 females).
Key gaps and needs
RIAC (MSACS-supported) projects; one agency
- Limited number of DACs and less
implements ORCHID (BMGF-supported) project; and
capacity.
7 agencies run de-addiction centres (MSJE-supported).
- Insufficient space or congestion within
Twenty-four agencies provide only free services;
DACs.
8 agencies provide both free and charged services;
3 agencies provide subsidized services; and one
agency provides only charged services. Charged
services include food/admission fees for clients
8
in de-addiction centres (DACs). All DACs offer de-
addiction treatment for heroin, dextropropoxyphene
- Lack of relapse prevention plan after de-
addiction/rehabilitation.
- No formal facility for child care in
rehabilitation centres (Unmet need of
female IDUs).
(spasmoproxyvon or ‘SP’) and alcohol.
d.OST
I.Existing drug use related services
a.
Needle Syringe Programs (NSPs)
Currently, 25 RIAC partners and an ORCHID
project partner implement NSP in Imphal
city. Syringes, injecting paraphernalia such
as distilled water and cotton swab, and
education on safer injecting practices are
provided under NSP.
Key gaps and needs
- Inadequate number of syringes
distributed and inappropriate size of
needles/syringes for ‘SP’ users.
- No proper syringe disposal mechanisms.
b. Detoxification
Detoxification is conducted in 3 ways – home-
based detox, community-based detox and
detoxification in de-addiction/rehabilitation
centres. Lobain and diazepam are used for
detox.
Key gaps and needs
- Quantity and types of detox medicines
supplied are limited.
- Interruption in the availability of detox
medicines to NGOs.
c. De-addiction Centres (DACs)
Among the eight DACs in Imphal, 7 are
supported by MSJE and one is privately run.
The capacity of each centre ranges from 15
to 30 clients. During the last year, these eight
OST program supported by NACO through
Emmanuel Hospital Association (EHA) is
implemented by three NGOs - MNP+, Care
Foundation and SASO with a target of 200,
120 and 400 IDUs respectively; and at the end
of September 2008, they had covered 295,
174 and 426 IDUs respectively.
Key gaps and needs
- Limited coverage.
- Lack of plan for people who relapse after
a ‘full course’ (1–2 years) of OST
e. Overdose Management
Naloxone, the antidote for heroin overdose,
is sold at very high prices (Rs.2000 to 4000
per ampoule) by the pharmacies while the
price fixed by the pharmaceutical companies
ranges from Rs.50 to Rs.130 per ampoule.
Only one NGO provides free overdose
medicine.
Key gaps and needs
- Overdose treatment medications are not
available under TI projects.
- Insufficient education/training on
overdose prevention and management.
f.
Narcotics Anonymous (NA)
Nine NA groups in Imphal have about 1,000
members, with ‘active’ membership estimated
to be around 300 to 400. Meetings are held
thrice-a-week at designated places and on
an average 30 members attend a group
meeting.
|
|
1.10 Page 10 |
▲back to top |
Key gaps and needs
c. Abscess management
Though NA groups are for abstinence,
possibilities need to be explored to link them
up with other drug use related services so that
there can be referrals from NA groups to these
services if their members require.
MSACS-supported RIAC projects and
intervention programs supported by ORCHID
provide services for abscess management.
Key gaps and needs
Medicines for treatment of infections are
g. IDU/PLHIV support groups
provided free but interrupted supply of
Self-help groups and support groups for
different categories of IDUs such as IDUs on
dressing material (esp. in RIAC projects) was
reported.
OST and IDUs living with HIV are formed by
d. Investigations support and facilities
NGOs. IDUs are also associated with IDU
and PLHIV networks as members, staff or Under the projects such as H13 project
9
supported by UNODC and TI projects of
volunteers.
ORCHID and RIAC, investigations for IDUs
Key gaps and needs
living with HIV are mainly supported through
- No linkage of the support groups of IDUs
cost-sharing. Only for some critically ill clients,
(including women) with the Social Welfare
financial support for full investigations is
Department that accepts proposal for
provided.
supporting self-help groups.
- Lack of concept clarity and marketing
skills among the support groups in
relation to ‘self-help groups’.
Key gaps and needs
- No support for pre-ART investigations
(except free CD4 count test) at
government hospitals.
II. Existing infections-related services
a.
Condoms
Condoms are supplied under RIAC and
ORCHID projects and can be obtained
from DICs and outreach workers. Condom
demonstration is conducted by peer
educators, outreach workers and care
workers.
Key gaps and needs
- Lack of free female condoms.
- Lack of adequate free water-based
lubricants.
b. Voluntary Counselling and [HIV] Testing
Centres (VCTCs)
- Financial support (full or partial) provided
by NGOs for laboratory tests is inadequate
to meet the requirements of all clients.
- Non-availability of testing facilities: HIV
and HCV viral load, ART drug resistance,
and HCV genotype testing.
e. Antiretroviral treatment (ART)
In Imphal city, two ART centres in two
government hospitals (RIMS & JNH) provide
free first-line ART. Treatment counselling
centres (managed by PLHIV networks),
that provide counselling/education on
ART adherence, are attached to both ART
Centres.
Two major HIV testing centres in Imphal are
located within two government hospitals:
RIMS and JNH. Apart from these, HIV testing
is also available through ICTCs and PPTCT. HIV
testing is conducted free-of-cost. Pre-test and
post-test counselling are provided.
Key gaps and needs
- Current users living with HIV face several
barriers in getting first-line ART (see the
‘barriers’ section below).
- Non-availability of free second-line ART.
Key gaps and needs
f.Opportunistic Infections (OIs) Management
Lack of comprehensive and competent Minor OIs are managed by doctors at the
counselling for IDUs in some centres.
NGOs with antibiotics supplied by MSACS
|
|
2 Pages 11-20 |
▲back to top |
|
|
2.1 Page 11 |
▲back to top |
or supported by projects. For TB, NGOs refer
• To private laboratories for investigations
clients to DOTS centres. Intravenous fluids and
(screening / diagnostic testing)
antibiotics are provided at the government
hospitals.
Key gaps and needs
There is inadequate or no support for OI
diagnostic testing from the NGOs and
government hospitals.
• To de-addiction centres for drug
abstinence (informal)
b. From government hospitals
• To PLHIV networks for psychosocial
support (limited referrals)
g. HBV & HCV
• To NGOs for detox (mostly informal)
Key gaps and needs
c. From de-addiction centres
- Inadequate knowledge of HCV/HBV
• To private labs for investigations
10
among IDUs
• To Narcotic Anonymous groups for
- Non-availability of free screening or
relapse prevention
confirmatory testing for HCV/HBV
- Lack of free HBV vaccination for IDUs
5. Recommendations
- Free or affordable treatment is not
available for HCV and HBV infections
III. Barriers in accessing existing services
Individual barriers: Withdrawal symptoms supersede
rational thinking; reluctance to visit DIC on a daily-
basis; lack of adequate knowledge about ART; lack of
financial support for pre-ART investigations; lack of
adequate knowledge of programs and services; lack of
self-efficacy in continuing to be‘clean’; and not trusting
the effectiveness of detox.
Health care system barriers: Stigma/discrimination in
health care settings; and long waiting hours.
Social, legal and policy barriers: Police harassment;
stigma and discrimination by the society; lack of
family support; problems faced from ‘anti-drug’
organizations.
Programmatic barriers: Insufficient budget for care/
support services for PLHIV under RIAC; limited capacity
of current OST projects (in terms of enrolling IDUs);
and mismatch between DICs and ‘hot spots’.
IV. Existing referrals and linkages
a. From NGOs
• To govt. hospitals for investigations
related to HIV, HBV, HCV (Liver/Kidney
function tests)
• To PLHIV networks for psychosocial
support
A. Recommendations that can be
implemented over a short-term period
(A few months to a year)
1. Improve the quality of existing services
Ensure that harm reduction training is provided
to all service providers – service providers of
drug dependence treatment and HIV prevention
intervention services as well as health care
providers – to promote better understanding
of drug use/dependence as a health (rather
than a criminal) issue and to treat drug users as
equal human beings who deserve appropriate,
competent and comprehensive care.
a. De-addiction services [Primarily directed to
MSJE]
• Strengthen the follow-up of discharged
clients and ensure a tailored
(individualized) relapse prevention plan.
• Develop guidelines for the enrolment
of clients in the various treatment
modalities (community-based detox,
home-based detox, residential
rehabilitation program) and ensure
referral to the next level of care after
detoxification.
• Establish long-term vocational training
programs that are useful to and in-
demand from the clients – within the
existing drug rehabilitation programs
|
|
2.2 Page 12 |
▲back to top |
as well as connecting with vocational
• Ensure proper matching of the location of
training programs of relevant ministries
DICs and hotspots used by IDUs.
such as Ministry of Labour and
Employment.
• Develop mechanisms to maintain
confidentiality of clients when they pick-up
b.OST [Directed to NACO and MSJE]
• Develop pragmatic measures for providing
OST medicines to out-station clients or those
who need to move out of the locality for some
period.
syringes at DICs - by providing unique identity
code/number (and not insisting on writing
their names).
• Provide quality condoms along with water-
based lubricants at hotspots. (Educate IDUs
that government condoms such as ‘Nirodh’
• Ensure proper understanding of OST
are of high quality).
program by clients prior to enrolment to
• Intensify promotion of condom use among
11
minimize drop-out. i.e. prepare the patient
IDUs and their sexual partners (male/female).
for committing to long-term OST (‘treatment
readiness or preparedness’ or pre-enrolment
• Intensify efforts to improve partner screening
counselling/education). And once enrolled,
and treatment for HIV and STIs.
provide adherence support and ensure proper
monitoring.
d.ART and Management of opportunistic
infections (OIs) [Directed to SACS/NACO]
• Ensure proper implementation of NACO’s
enrolment criteria (e.g., not to enrol oral drug
users in OST program).
c.Targeted Interventions for IDUs [Directed to
NACO/SACS]
• Train government doctors in ART centres on
proper clinical management of IDUs living
with HIV (especially ART management;
screening and treating co-infections such as
HBV and HCV; and OST) as well as sensitization
about drug users and drug dependence.
• In NSPs under RIAC projects, consider
distributing syringes/needles through
shopkeepers or influential persons in
a locality who understand about harm
reduction programs (referred to as ‘secondary
distributors’ in ORCHID project) to reach more
IDUs.
• Ensure adequate supply of different sizes of
syringes and needles to meet the needs of
drug users who use different drugs (Heroin
and ‘SP’)
• In NSPs, ensure supply of packaged distilled
water, alcohol-soaked cotton swab, and
cooker.
• Develop appropriate mechanisms to remove
used syringes from the hotspots.
• Establish
centralized
procurement
mechanisms for buying detox medications in
targeted interventions (because of frequent
shortages and inexperience in procurement
among some NGOs).
• Impart correct and complete knowledge
about ART through NGOs (outreach workers,
NGO counsellors), counsellors at government
ART and HIV testing centres, and through
mass media.
• Ensure appropriate ART regimens are provided
for IDUs who are co-infected with HBV/HCV
and/or TB as well as who are current users
(and who may be on OST).
• Ensure adequate and uninterrupted
supply of necessary free OI medications
(antibiotics, anti fungal and antiviral drugs –
such as Flucanozole, Acyclovir, Ganciclovir,
Amphotericin-B) at the government
hospitals.
• Ensure access to appropriate information
concerning ART/street drug/prescription
drug (OST) drug-drug interactions.
• Intensify promotion of condom use among
IDUs on ART.
|
|
2.3 Page 13 |
▲back to top |
2. Improve access to existing services [Directed to
adherence and ART adherence.
SACS, State Health Department and MSJE]
• Provide housing support and night shelter for
• Ensure financial coverage for comprehensive
homeless/needy female and male IDUs.
health care services and laboratory
investigations for needy IDUs and IDUs living
with HIV.
• Ensure available social welfare schemes
(income generation programs, vocational
training, micro-credits and small loans) in the
• Provide free or affordable residential drug
State Department of Social Welfare also cover
treatment and rehabilitation care for IDUs and
IDUs and PLHIV.
IDUs living with HIV.
• Establish specific schemes catering to the
• Provide free or subsidized lab tests (e.g., liver
needs of IDUs (male and female), and spouse/
and kidney function tests) to be done before
children of IDUs/PLHIV including provision of
12
starting ART and while on ART at government
legal aid, housing assistance, and employment
and private hospitals/labs as well as lab tests
assistance.
for diagnosing and monitoring OIs.
• Provide free medications for managing
3. IEC materials / Communication [Directed to
SACS/NACO]
overdose at NGOs and Government Hospitals
and train emergency room physicians and
• Involve stakeholders including IDUs at all
paramedical staff on overdose management.
stages of development of IEC materials.
• Provide water-based lubricants along with
• Field test IEC materials before dissemination
and post-dissemination evaluation to find out
effectiveness.
• Impart proper and adequate knowledge
on HCV/HBV prevention, diagnosis and
treatment.
high quality condoms at all suitable places –
ART centres, DICs, outreach sites, etc.
• Provide female condoms for female IDUs –
especially those who engage in sex work.
• Quicken the process of providing free second-
line ART regimens in Manipur.
• Develop IEC materials on prevention, early
diagnosis and management of abscess
management and drug overdose.
• Publicize information about OST to IDUs and
general public.
• Develop guidelines for diagnosing and
treatment of psychiatric disorders among
PLHIV and IDUs, and train health care providers
on the same.
• Provide nutritional supplements for IDUs
living with HIV as well as for those IDUs who
B. Recommendations that can be
are malnourished (especially women and
implemented over a medium-term period
homeless IDUs).
(~ 2 years)
• Initiate training on self-care and home-based
1. Initiate new services [Directed to SACS/NACO,
MSJE, and Department of Social Welfare,
care for family members by caregivers/field
workers when they make home visits.
Manipur]
• In prisons, introduce harm reduction services
• Ensure that specific needs of various sub-
groups of drug users (oral drug users,
and ensure treatment, including ART, for
people living with HIV, including IDUs
adolescents/children using drugs, Female
IDUs) are met in de-addiction centres
HIV/HCV/HBV-related lab tests and treatment
(Example: Separate spaces for adolescents,
• Install HIV-DNA PCR machine at the
Recreation for children/youth, Childcare
government hospitals to diagnose HIV
services for female IDUs)
infection among children born to PLHIV.
• Develop strategies for improving the self-
efficacy of IDUs in relation to drug treatment
• Install adequate number of CD4 machines to
reduce the waiting period.
|
|
2.4 Page 14 |
▲back to top |
• Establish test facilities for HIV and HCV viral
used by any service agency.
load, antiretroviral drug resistance test, and
free/subsidized screening and confirmatory
testing facilities for HCV/HBV infections.
• Provide subsidized or free treatment for IDUs
• Develop follow-up mechanisms and ensure
continuum of care – discharge/transition plan
from one level of service to another.
and IDUs living with HIV who have HCV/HBV
• Ensure to keep priority on delivery of services
infections.
based on clients’ needs rather than focusing
• Provide free HBV vaccination for IDUs,
on achieving project targets.
including those living with HIV.
• Develop a resource directory of service centres
2. Improve coverage of the existing services
to help users and service providers.
[Directed to MSJE, and SACS/NACO]
4. Capacity building and Training [Directed to SACS
13
• Scale-up the availability of residential detox/
and Dept. of Social Welfare/MSJE]
rehabilitation centres (Increase the capacity
of existing DACs and increase the number of
DACs).
• Hands-on training for physicians and other
service providers managing OST programs.
And training on prevention of injection-
• Establish long-term and replicable vocational
related abscess and its management.
training programs.
• Provide training on overdose prevention and
• Rapidly scale-up OST program to ensure
management for doctors, IDUs and outreach
adequate coverage.
workers and peer educators of TI programs.
3. Strengthen linkages and referral mechanisms
[Directed to SACS/NACO, and MSJE]
• Develop guidelines on when and how to refer
IDUs from one service to another service. For
example, from NSP to OST or DACs.
• Develop and strengthen linkages among
NGOs, DACs and NA groups.
• Strengthen referrals from NA groups to other
services like OST, de-addiction - depending
upon the need of NA group members.
(Educate NA members about the various drug
treatment options and harm reduction).
• Build linkages with Imphal Municipal Council
or institutions which have incinerators for
proper disposal of used syringes.
• Link to PLHIV networks for adequate treatment
education and adherence counselling
support.
• Develop detailed mechanisms for proper
networking and coordination among the
various service providers.
• Develop a standard referral slip (without
compromising confidentiality) that can be
• Strengthen existing NA networks in Imphal.
• Support formation of more self-help groups
for self-employment and income-generation
programs and build the capacity of the
communities to accomplish these.
• Provide vocational training depending upon
the skills, enthusiasm and background of IDUs
and PLHIV.
• Create and strengthen monitoring and
evaluation mechanisms to ensure all
services for drug users are of high quality,
and accessible and acceptable to drug users
community.
C. Recommendations that need to be
implemented over a long-term period and
on an ongoing basis
1. Create enabling environment
[Directed to SACS/NACO and MSJE]
• Clarify any misunderstandings about OST
and harm reduction programs among various
stakeholders at all levels (including those who
run DACs).
|
|
2.5 Page 15 |
▲back to top |
• Sensitize police (at all levels) and anti-drug
agencies on drug dependence and need for
NSP and OST.
drug users are not undermined by the current
overemphasis on drug control rather than
drug user health.
• Take stigma reduction measures in the 2. Create evidence-base
health care settings and sensitize health care
[Directed to SACS/NACO and MSJE]
providers on the health and human rights
issues of IDUs and PLHIV.
• Conduct evaluation of detox and rehabilitation
programs to find out what make them
• Support the formation and strengthening
effective or less effective.
of community organizations of drug users –
empowering them to understand their human
• Commission
sociobehavioral
and
rights and advocate for themselves.
epidemiological studies among IDUs and
14
• Involve drug users in the development and
PLHIV to develop an evidence-base and
design evidence-informed interventions
implementation of all government HIV/drug
to meet their unmet and emerging service
programs.
needs.
• Harmonize public health and public security
policies to ensure programs and services for
|
|
2.6 Page 16 |
▲back to top |
1. Introduction
15
M anipur is an ancient state with more than
2,000 years of history and civilization.
Historically, it has occupied an important
place as the gateway to South-East Asia. According to
2001 Census, Manipur has a population of 2,293,896
out of which 354,993 reside in the urban areas of
Imphal districts. Imphal is the capital of Manipur
and lies within both the Imphal-East and Imphal-
West districts but the majority of the city area is
under Imphal West district. Imphal city is highly
heterogeneous in terms of ethnicity and linguistic
groups. It has Meiteis, Kukis, Nagas, Meitei Pangals
(Muslims) and migrant populations from neighbour
states. Imphal has a high literacy rate (75-80%) but
unemployment is high with only about 40% of the
population engaged in some form of work for a given
period in a year (Economic Survey - Manipur, 2007-
08). About two-thirds of the Imphal East and West
districts’ population is in the age group of 15 to 59
years.
According to a Rapid Situation Assessment conducted
in 2000, there were approximately 12,667 IDUs in
Imphal city; gender disaggregated data is not available
(Oinam, 2008). Multiple factors play a role in making
Imphal a hotspot of drug abuse. Main reasons are its
proximity to the ‘Golden triangle’, the area where the
borders of Myanmar, Laos and Thailand meet. Most
of the eastern boundary of Manipur is formed by
Myanmar, which is the second largest illicit opium
producer in the world (UNODC, 2007). High levels of
unemployment, large number of young people, and
insurgency are some of the important contextual
factors for high drug use prevalence in Manipur.
Manipur state is one among the high HIV prevalence
states in India, with 1.13% of the general population
estimated to be HIV-infected. Among the injecting
drug users (IDUs), HIV prevalence has come down
from about 70% (Beyrer et al., 2000; Sarkar et al., 1997)
in the early 1990s to 20.67% in 2006 according to the
HIV serosurveillance data of the government (NACO,
2006). Studies have shown very high risk behaviours
among IDUs in Manipur with more than 90% sharing
needles and equipment (Eicher et al., 2000). As of May
2008, there were 29,602 HIV-positive cases reported
in Manipur; and of these, 42.09% were categorized
as having contracted HIV through injection drug use
(MSACS, 2008). A study documented that among 77
HIV-positive IDUs, Hepatitis-B virus (HBV) prevalence
was 100% and Hepatitis-C virus (HCV) prevalence was
92% (Saha et al., 2000).
Several models of continuum of care that are
internationally accepted are available for non-drug
using people living with HIV (PLHIV) (Osborne et al,
1997; WHO, 2004), including a toolkit for scaling up
continuum of care (CoC) in a particular geographical
area (FHI, 2007). There are some treatment models
in relation to drug-dependence treatment for IDUs
(NTASA, 2002; Simpson, 2004) and continuum of care
models are being developed in relation to the various
treatment services for alcohol/drug addiction (Ohio
State Department, undated), and substance abuse
and mental health (County Alcohol and Drug Program
Administrators of California, 2005). However, there
are no continuum of care models for IDUs (including
those living with HIV) in relation to the various service
needs such as HIV prevention and treatment, HBV/
|
|
2.7 Page 17 |
▲back to top |
HCV prevention and treatment and drug-dependence CoC action plan is available, it would be easy for the
treatment services. An earlier ‘Continuum of care state and union government to define what does CoC
project’ in Manipur (UNAIDS, 2001), though focused for IDUs mean and how to ensure that CoC for IDUs
on improving the referrals among the various HIV/ are available in specific geographical areas.
AIDS related services, operated in a different climate.
For example, at that time there were no needle While we currently do not have any CoC model at
syringe programs or opioid/oral substitution therapy. the city/district level, we do have information about
Also, that project did not explicitly link the HIV-related what should be the range of services required for
services with drug-dependence treatment services. IDUs, including those with HIV (WHO, 2005 & 2006).
The current situation in Manipur requires that any For example, UNODC emphasizes the importance
model of CoC for IDUs should also address linking of having a ‘comprehensive package approach’
HIV/HBV/HCV-related services with drug-dependence (UNODC, undated) for IDUs that include: outreach
16
treatment services.
education; needle syringe exchange programs; oral
substitution treatment (sublingual buprenorphine);
Models of continuum of care can be seen at several
levels: One is at the institutional level – whether
a particular institution is catering to the various
service needs of a particular clientele. For example,
Antiretroviral treatment (ART) and treatment of
opportunistic infections (OI) for HIV-positive IDUs;
drug-dependence (de-addiction) treatment and
rehabilitation programs; abscess management;
there is an institutional level care and support model
from Social Awareness Service Organisation (SASO),
Imphal, which is available for IDUs (India HIV/AIDS
partners screening/treatment; and treatment for co-
infections (STIs, HBV, HCV, etc.).
Alliance, 2008). The services provided by SASO Prior to this study, informal discussions with activists
include: one-to-one interactions, group sessions with and NGO staff from Manipur revealed the following in
IDUs; STI treatment (including partner treatment); relation to the drug-related and HIV/HBV/HCV-related
counselling and information on HIV prevention medical and other services for IDUs in Manipur.
through counsellors and part-time doctors; referral
and linkages with various public healthcare services;
needle-syringe exchange programme (NSP); training
• Lack of full range of services and treatment options
for IDUs.
and capacity building for community members; and
opioid substitution therapy (OST). Though SASO
provides several services, it does not (and could not)
• Inadequate coverage of IDUs in the existing
services.
offer all the services listed in the ‘comprehensive • Lack of effective referral mechanisms or linkages
package approach’ of UNODC (see below).
of existing services for PLHIV.
IDUs require a range a services – those related to drug
use (such as sterile needles and injection site abscess
management) and those related to infections such
as HIV, HCV and HBV – and rarely are these all found
under one roof. Hence, at least in the city/district level,
all the required services need to be available and
linked effectively to ensure continuum of prevention
and care for IDUs. Thus, continuum of care (CoC)
at the city/district level means that a full range of
services catering to all the needs of IDUs are available
within a city/district; with adequate coverage of the
IDUs who need such services; with no barriers to
access or utilization; and well linked to other services
in that city/district through strong and effective
referral mechanisms.. Once such a city/district level
• Lack of comprehensive and effective strategies for
reducing stigma and discrimination against drug
users and people living with HIV.
All these shortcomings mean that an integrated
comprehensive and continuum of care for IDUs is not
available in Imphal city. Consequently, these gaps can
ultimately affect the effectiveness of HIV prevention
and drug dependence treatment programs for IDUs.
Given the high HIV prevalence among IDUs in Manipur,
it is critical that any CoC for IDUs should also include
people living with HIV. Thus, in order to ensure that
IDUs (including PLHIV) in Imphal city have access to a
range of services during various phases in their drug
careers and infection status (HIV/HBV/HCV), there is
|
|
2.8 Page 18 |
▲back to top |
a need for an integrated continuum of care at least at
the city level.
To move towards the goal of having an integrated
continuum of care for IDUs (including those living with
HIV) in Imphal city, this study was conducted with the
following objectives:
• To assess the current situation of the various
drug and infection-related medical/non-medical
services (Govt./NGOs/CBOs/PLHIV Networks/
Private sector) available for IDUs, including those
living with HIV, in Imphal.
• To identify gaps in existing prevention and care
services; and identify unmet and emerging service
needs.
17
|
|
2.9 Page 19 |
▲back to top |
18 2. Methodology
T his mixed methods study included a
quantitative survey and qualitative in-depth
interviews and focus groups. This study
received ethics approval from the ethics review
committee constituted by the Population Foundation
of India (PFI) and an independent community
advisory board.
Quantitative component
A survey instrument was developed to assess the
range and type of services for IDUs including those
living with HIV in Imphal city (including Greater
Imphal areas) in Manipur. The survey tool assessed
the following areas: type of agency, types of services
available, existing referral mechanisms, and coverage.
The instrument was pre-tested and refined. Based on
Manipur SACS’s resource directory (2000) and updated
list of NGOs/CBOs working on HIV-related issues,
thirty-six agencies were identified and surveyed. The
agencies included NGOs, CBOs, and public/private
clinics and hospitals providing services to IDUs and
PLHIV in Imphal city (including Greater Imphal areas).
SPSS version-14 was used for analysis of quantitative
data.
Qualitative component
Seven focus group discussions (n=46 participants), 16
in-depth interviews and 7 key informant interviews
were conducted with male and female IDUs, care
givers, health care providers and community leaders.
The common eligibility criteria were: being 18 years
of age or older and ability to give informed consent.
Purposive sampling was used to recruit the study
participants for focus groups. All recruitment was
conducted only by word of mouth in order to avoid
potential risks to participants.
Socio-demographic questions were asked of all focus
group and in-depth interview participants. These
included questions about age, level of education,
occupation, marital status, and current status of drug
use. For purposes of recruitment in this study, the
term ‘current IDUs’ or current users is used to refer to
those who have had injected in the previous 3 months
- consistent with NACO’s definition of IDUs (NACO,
2007), and those who did not inject in the previous
past 3 months but have had injected prior to 3 months
were regarded as ‘former’ IDUs. (For more details – see
glossary.)
Focus group venues were chosen according to
the convenience of participants and the safety of
participants and research staff. Written informed
consent was obtained from all participants, including
consent for audio taping of the interview. Focus
groups and in-depth interviews were conducted using
a semi-structured focus group/interview guide with
scripted probes. Questions were modified or added
over the course of the study in an iterative process to
explore and reflect on emerging findings, a technique
called ‘progressive focusing’ (Schutt, 2004). Focus
groups facilitators were well versed in speaking the
local Manipuri language, and they received extensive
training in interviewing and research ethics. All
interviews and communications with participants were
conducted in Manipuri, except some of the interviews
with key informants that were in English. The duration
of focus groups ranged from 60 to 120 minutes and
|
|
2.10 Page 20 |
▲back to top |
Box 1: Details of qualitative methods
Focus Group Discussions (FGDs)
[7 FGDs - 46 participants]
10. Project Coordinator of NGO implementing Project
ORCHID in Imphal
1 FGD among care givers (n=6 participants)
6 FGDs among IDUs (n=40 participants)
• Male IDUs living with HIV
• ‘SP’ (spasmoproxyvon) Users
• IDUs living with HIV on ART
• IDUs living with HIV with HBV/HCV co-infections
• IDUs on sublingual buprenorphine (Opioid
substitution therapy)
11. Project Coordinator of OST program in Imphal East
12. Project Coordinator of OST program in Imphal West
13. Project Director of DAC for male IDUs
14. Project Director of DAC for female IDUs
15. Private medical doctor providing services to IDUs and
PLHIV
16. Senior Medical Officer, Government hospital, Imphal
• Female IDUs living with HIV
Key Informant Interviews (KIIs)
19
In-depth Interviews (IDIs)
(n=7 participants)
(n=16 participants)
1. An spasmoproxyvon (‘SP’) injector
1. Program staff of an NGO
2. An IDU living with HIV with HBV/HCV co-infections
2. Senior leader of an NGO
3. IDU with polydrug abuse
3. Leader of PLHIV Network
4. A young IDU in DAC
4. Board Member of an NGO
5. Female IDU in sex work
6. Female IDU living with HIV
5. A researcher (who has conducted studies among IDUs
in Imphal)
7. Widow of an IDU
8. Wife of an IDU
6. Official of Manipur State AIDS Control Society
(MSACS)
9. Project Manager of an NGO implementing RIAC
project
7. Program staff of a funding agency
key informants interviews approximately 60 minutes.
As recommended by the community advisory board,
an honorarium of 250 Indian rupees was given to the
study participants who attended focus groups and
in-depth interviews. Key informants did not receive
honoraria. Focus groups and interviews were tape-
recorded and transcribed verbatim in Manipuri and
translated into English for data analysis.
Line-by-line review of the transcripts was conducted
and first-level codes (descriptors of important
components of the focus groups and interviews),
including in vivo codes, were noted in the margins
(Charmaz, 2006; Glaser, 1978). Using focused coding
and a constant comparative method (Charmaz, 2006;
Glaser & Strauss, 1967), first-level codes were refined
and organized into categories. Finally, theoretical
coding was undertaken to identify higher level
codes, relationships among categories, and to ensure
saturation of categories (Charmaz, 2006). Member
checking was conducted with key informants to
increase credibility of the findings (Lincoln & Guba,
1985). Peer debriefing (Lincoln & Guba, 1985) was
undertaken with community leaders to increase
trustworthiness of the findings. The results correspond
to the emergent categories; all quotations are drawn
from the focus groups and key informant interviews.
The study findings were discussed in a consultation
meeting with key stakeholders (including drug users
and PLHIV) and their suggestions were analysed as
‘feedback data’. (See Box 2)
Characteristics of the participants
Characteristics of the FGD participants
A total of 46 people participated in the 7 FGDs: 6
among IDUs and one among caregivers.
FGDs among IDUs
Participants ranged in the age group from 24-41 years
(Mean=33.6) and 87.5 % (n =35/40) have completed
high school. Of those who were employed (n=11/40)
|
|
3 Pages 21-30 |
▲back to top |
|
|
3.1 Page 21 |
▲back to top |
27.5% were staff of voluntary organizations. About
one-fourth (n=12/40) of the participants were
currently married and lived with their spouse. Three of
the participants were separated and 62.5% (n=25) of
the participants were never married. About one-third
(n=13/40) were current users.
FGD among caregivers
Participants ranged in the age group from 27-65 years
(Mean=51.6). Four never went to school and one
person had completed high school. All of them were
unemployed. Four participants were living with their
spouse and 2 were widows.
Characteristics of the key informants (n=7)
Key informants ranged in the age group from
33-45 years (Mean=40.1). Three have completed
undergraduate college education and 4 have
completed post-graduation. Six were associated
with non-governmental organizations. Two were
former IDUs.
20
Box 2: Study-related consultation meetings with key stakeholders in Imphal
Two consultation meetings were held with key stakeholders (such as NGOs/CBOs providing services to IDUs and PLHIV,
PLHIV networks, Manipur SACS, and Department of Social Welfare, Manipur) – one before starting the study and another
before finalizing the study report. Here, we summarize how these consultation meetings helped in strengthening the study
design and fine-tuning this research report.
First consultation meeting (May 2008): To get stakeholder inputs on the study design and data collection instruments
This meeting was held on May 2 & 3, 2008, at Imphal. On the first day (May 2), Project Director, Manipur SACS, presented on
the targeted interventions among IDUs in Manipur, and emphasized the need for holistic approach in providing services
to IDUs. And in the presentation from the Department of Social Welfare, various schemes available for women (including
people who use drugs and PLHIV) and children were summarized. Then, the ‘continuum of care’ study plan was presented
by the principal investigator of the study. It was followed by discussions with the audience to get their suggestions on fine-
tuning the study plan. Participants provided several useful suggestions. For example, they suggested collecting information
about the service needs of female IDUs, and to assess the impact of anti-drug agencies on service access and utilization
among IDUs. Presentations from the key stakeholders as well as discussion about the current situation of HIV-related and
drug use-related services available for IDUs in Imphal helped the research team to understand what areas need to be
explored in the study.
On the second day (May 3), the draft versions of the data collection instruments such as survey questionnaire for the
agencies and qualitative guides - focus group guide, in-depth interview guide, and key informant guide - were shared with
the participants to get their inputs. Participants provided several useful suggestions and comments that helped in refining
the data collection instruments.
Second consultation meeting (September 2008): To get feedback on the study findings and recommendations
Once the draft research report was prepared, PFI organized a two-day consultation meeting with key stakeholders to get
their feedback on the study findings and recommendations. The principal investigator presented the key findings and
recommendations. The presentation highlighted the quality and coverage of the existing services, pointed out the gaps
and needs, and proposed evidence-informed recommendations to improve existing services, to initiate new services and
to improve service linkages. In the subsequent discussion session, participants including key persons from Manipur SACS,
Department of Social Welfare, Manipur, and UNODC, provided comments on the study findings and recommendations.
In the afternoon, the participants discussed in groups about the study recommendations, and provided suggestions to
fine-tune and prioritize the recommendations. Some participants expressed that this ‘exercise’ also helped them to better
understand the issues in areas other than their own work area and the need for continuum of care for drug users in Imphal.
The suggestions from the participants were considered as “feedback data” and analysed, and those suggestions were
helpful in fine-tuning the study recommendations.
|
|
3.2 Page 22 |
▲back to top |
Table 1: Profile of the focus group participants
n=46 participants in 7 FGDs)
Table 2: Profile of key informants and in-depth
interview participants
Items
Age, Mean years
Range
IDUs (n=40) Care givers
(n=6)
33.6
24-41
51.6
27-65
Items
Key
informants
(n=7)
In-depth
interview
participants
(n=16)
Education,
- Less than high school
5 (12.5%) 1 (16.6%)
Age, Mean years
Range
40.1
33-45
34.9
18-46
- High school
8 (20%) 1 (16.6%)
Education,
- Higher secondary
17 (42.5%)
- High school
---
4 (25%)
- College
7 (17.5%)
- Higher secondary
---
1 (6.25%)
- University
- Illiterate
2 (5%)
1 (2.5%) 4 (66.6%)
- College
- University
3 (42.85%) 10 (62.5%)
21
4 (57.15%)
1 (6.25%)
Occupational status/
Primary source of income
- Unemployed
- Self-employed
- Daily-wage labourer
- NGO staff
- Sex work
- Housewife
17 (42.5%)
4 (10%)
1 (2.5%)
11 (27.5%)
6 (15%)
6 (100%)
Occupational status/
Primary source of
income
- Unemployed
- NGO staff
- Sex work
- Govt. Employee
---
6 (85.72%)
---
1 (14.28%)
4 (25%)
9 (56.25%)
1 (6.25%)
2 (12.5%)
- Govt. Employee
1 (2.5%)
Marital status
Marital status
- Ever married
4 (57.15%) 10 (62.5%)
- Ever married
15 (37.5%) 6 (100%)
- Never married
3 (42.8550
6 (37.5%)
- Never married
25 (62.5)
Injecting drug use
Injecting drug use
- Current user
- Former user
13 (32.5%)
27 (67.5%
0 (0%)
0 (0%)
- Current user
- Former user
- Non User
0 (0%)
2 (28.58%)
5 (71.42%)
3 (18.5%)
5 (31.5%)
8 (50%)
Characteristics of the in-depth interview
participants (n=16)
Participants ranged in the age group from 18-46
years (Mean age = 34.9). Four (25%) have completed
high school and 10 (62.5%) have completed
undergraduate college education. Of those who were
employed (n=12), 56.25% (n=9) were staff of voluntary
organizations. Ten (62.5%) of the participants were
currently married and living with their spouse and
six (37.5%) were never married. Three (18.5%) were
current IDUs, and five (31.5%) were former IDUs.
Consultation meetings (See Box 2)
In a first consultation meeting with key stakeholders
in Imphal (May 2 & 3, 2008), the study plan and draft
study tools were shared. Stakeholders’ suggestions
helped in refining the study tools. Once the study
was completed, the draft report was shared with the
key stakeholders in another consultation meeting in
September 17 & 18, 2008. Their comments/feedback
helped in further refining this research report.
|
|
3.3 Page 23 |
▲back to top |
22 3. Findings & Discussion
Quantitative Component (Survey of
agencies)
A total of 36 agencies offering a range of services for
IDUs including those living with HIV were surveyed.
Table 1 represents the characteristics of services
available for IDUs, including those living with HIV, in
Imphal city. Of these 36 agencies, 86% (n=31/36) were
non-governmental organizations, 8% (n=3/36) were
government hospitals and 6% (n=2) were private
hospitals.
Most agencies have more than one funding source
though nearly 86% receive funds from government
(central/state). About 40% receive funding from various
foundations, membership fees and donations. Forty-
two per cent (n=15/36) implement Manipur State AIDS
Control Society (MSACS)-supported HIV prevention
and care/support project. Among the 8 de-addiction
centres (DACs) within the Imphal city, 7 receive support
from UNODC/MSJE and all offer treatment for heroin,
spasmoproxyvon and alcohol dependence.
HIV programs
In Imphal, HIV prevention and care/support programs
are implemented through support of MSACS (RIAC
projects) and BMGF-supported ORCHID project
(One TI in Imphal and 3 OST sites). HIV programs of
MSACS and ORCHID are similar (see box 2) and has
the following components: community outreach
education, needle syringe programs (NSP), drop-in
centers, STI screening and treatment (in most drop-
in centers), and referral services - HIV testing, ART,
Box 3: Components of Targeted Intervention project among IDUs in Manipur
A. Rapid Intervention and care Project (RIAC)
[Source: Manipur SACS]
1. Risk reduction education including free supply of
educational materials
2. Voluntary confidential HIV antibody testing (with pre-
and post-test counseling)
3. Counselling services and behavioural skill training
4. Exchange of sterile needles/syringes for used ones
5. Free supply of bleach (5% solution)
6. Referral services to drug treatment and other
supportive networks
7. Free supply of condoms
8. Home care for IDUs who developed opportunistic
infections/AIDS
9. Drop-in-Centre
10. Health Clinic
11. Home detox
12. STI / Abscess / Overdose management
B. Project ORCHID [Source: EHA, Imphal unit]
1. Drop-in-Centre: Recreation: Indoor games, TV;
Condom and syringe supply; Home detox
2. Outreach activities: NSP; Condom promotion; Home
visit; One-to-one interaction for STI & HIV prevention;
One-to-group interaction for STI & HIV prevention
3. Health/STI Clinic: General health check-up;
STI treatment; STI testing (Syphilis); Abscess
management
4. Advocacy (to create an enabling environment):
with respective local stakeholders such as Churches,
women groups, Youth clubs, and Panchayats
5. Referral services: ICTCs; ART centres; Hospitals/
Laboratories; NGOs
|
|
3.4 Page 24 |
▲back to top |
and opportunistic infections treatment. With support
from NACO, three sites provide OST (sublingual
buprenorphine) services – Care Foundation, Manipur
Network for People living with HIV (MNP+), and SASO.
Table 3. Characteristics of the service agencies for IDUs
and PLHIV in Imphal city
Characteristics
Available Services
(n = 36, %)
Availability of on-site testing and treatment
facilities for HBV, HCV, and STIs
Almost half (50%) of the agencies offer one or more
STI related services. Of these, 50% (n=18/36) of the
agencies screen for STIs and 41.6% (n=15/36) offer
treatment for STI related symptoms. Of the 36 agencies,
only 7 agencies offer HBV/HCV screening test services
(See Table 4).
Nature of the agency
Government Hospital
NGO-Trust
NGO-Society
Private hospital
Funding¹
National Govt.
State Govt.
Foundations
3 (8.3%)
2 (5.5%)
29 (80.5%)
2 (5.5%)
11 (31.4%)
19 (54.2%)
23
15 (42.8%)
Referral services
Donations
14 (40%)
Since de-addiction centres do not have any testing
Membership fees
15 (42.8%)
facilities they refer their clients for HIV, HBV, and HCV Implementers of key programs
testing to either government hospitals (RIMS and JNH)
RIAC
15 (41.6%)
or to private hospitals. Sometimes, DACs share the costs
of some of the lab tests (up to 85% of the costs) for
selected number of HIV-positive people. Referrals from
government hospitals to other centres (HIV NGOs and
DACs) are minimal. NGOs implementing HIV prevention
and care/support programs (MSACS- or BMGF-
supported) refer their clients for HIV, HBV, HCV and CD4
testing as well as ART to government hospitals (RIMS
and JNH). Some NGOs might refer their clients to private
clinics for screening infections (HIV, HBV, HCV).
ORCHID
UNODC/MSJE
Others
Staff
Medical staff²
0
1-5
6+
Nonmedical staff
1 (2.7%)
7 (19.4%)
18 (50%)
6 (16.6%)
23 (63.8%)
7 (19.4%)
0
6 (16.6%)
Staffing
1-5
7 (19.4%)
Table 1 summarizes the staffing patterns of these
agencies. The mean number of medical staff (medical
doctors and nurses) is 3.19 (median=2). The mean
number of the non-medical staff (project coordinators,
counselors and outreach workers) is 8.33 (median=7).
6 – 10
10+
9 (25%)
14 (38.8%)
¹ Percentage will add to more than100 due to multiple
responses
² Refers to physicians and nurses
Coverage
We asked the agencies how many unique individuals
they reached out through their various services
within the last one year – fiscal year or annual year
(depending upon the data they have). It was to find
out what proportion of IDUs in Imphal in one year are
accessing the various services – assuming that most, if
not all, service users of these agencies in Imphal to be
residents of Imphal. The number of unique individuals
(males and females) reached out as reported by the
agencies are summarized in Table 3.
Table 4. HBV, HCV and STI-related services in Imphal city
Types of
infection-
related
Services
Infections
HBV
(n=36)
HCV
(n=36)
STI (n=36)
Screening
6 (16.6%) 7 (19.4%) 18 (50%)
Confirmatory
2 (5.5%) 2 (5.5%) 4 (11.1%)
Treatment
4 (11.1%)
-- 15 (41.6%)
|
|
3.5 Page 25 |
▲back to top |
Table 5. Coverage: Unique individuals covered by
services in the past year (That is, one year prior to the data
collection period – July/August 2008)
Types of
Services
Males Females
Total
NSP
18633
318
18951
OST (Buprenor-
550
20
570
phine)
(Ongoing)
Secondary distributors could be shopkeepers or
influential persons in a locality who understand
about harm reduction programs. (In some
countries, the term ‘secondary distribution or
exchange’ means involving people – usually
peers but could be partners or friends – acquiring
needles from formal needle syringe services and
redistributing them to IDUs) (Bryant & Hopwood,
2008; Lorvick et al., 2006)
Home-based
Detox
1378
22
1400
Gaps and Needs
a.Limited time for interactions with IDUs
24
Community-
820
25
845
based Detox
means inadequate education and
demonstration of safer injecting practices
Residential care
1863
397
2260
Qualitative Component
Existing Services (including gaps and needs)
A. Drug dependence treatment-related services
I. Needle Syringe Programs (NSP)
[Note: Although NSP is usually grouped under harm
reduction services, it is included here to discuss
how NSP can be connected to OST and Drug de-
addiction services in the context of ‘continuum of
care in drug dependence treatment’ (See Box 3)]
Outreach Workers complained about the
limited time to interact and demonstrate safer
injecting practices to IDUs when they were in
outreach sites. Even in the DICs, IDUs come
in a hurry and there is no adequate time to
discuss about safer injecting practices. Thus,
outreach workers were concerned that at
least some significant proportion of IDUs do
not have in-depth knowledge about safer
injecting practices and even if they do have
knowledge, certain situations may compel
them to share syringes.
NSP was launched in Manipur in November
1998. Currently, there are 25 RIAC partners
implementing NSP in Imphal district. Project
ORCHID is also implementing NSP through SASO
in Imphal. The number of IDUs targeted in Imphal
district under RIAC projects is 12,600 and Project
ORCHID is 1,500. However, in the Imphal city,
among the agencies surveyed, the cumulative
number of IDUs covered so far under both RIAC
and ORCHID are 18,951 (18,633 males and 318
females). Given the estimated number of IDUs in
Imphal being 12,667, this ‘high’ coverage could be
because of certain number of IDUs accessing NSP
services from more than one agency.
Syringes and injecting paraphernalia such as
distilled water and cotton swab are provided
under NSP – through DICs and outreach services.
Outreach Workers (ORWs) and Peer Educators (PEs)
distribute syringes at the hotspots, drug dealers’
places and at other places frequented by IDUs.
Under project ORCHID, “secondary distributors”
are given syringes from whom IDUs can collect.
b. Inadequate number of syringes and
inappropriate syringe/needle size
Concerns about potential ‘misuse’ of syringes
(referring to the possibility of selling free
syringes received from NSPs for money) by
IDUs have made NGOs to limit the number of
syringes to not more than 2 to 4 syringes per
day. Thus, it is inadequate for high frequency
injectors, especially SP injectors, who inject
10 to 15 times per day. Limited distribution
of syringes also compels IDUs to reuse old
syringes. The needles of old syringes are
blunted and thus are difficult to puncture
the skin and result in painful injections, with
increased chances of cellulitis (bacterial
infections below the skin).
Syringes supplied for NSP are 2ml and 1 ml
syringes. Heroin users prefer 1 ml syringe; and
SP users prefer 2 ml syringe since the injection
volume is more. Abscess and blocked veins are
more common among SP injectors. When the
|
|
3.6 Page 26 |
▲back to top |
drug is injected in a hurry, it is difficult for SP
medicine. In exceptional cases where the IDU does
users to get access to vein with the 2 ml syringe
not want his family to know about his drug use or
needle. But under the current NSP, there is no
if the IDU has left his house, a friend is allowed to
option of providing needles of smaller bore
serve as the caretaker and to monitor that person.
size along with the 2 ml syringes.
Our survey found that in the last year, 1,400 (1,378
c. No proper mechanisms for disposing used
needles/syringes from NSP
males and 22 females) were provided with home
detox medications by RIAC Partners in Imphal city.
Proper disposal mechanisms for used syringes
Some NGOs organize community detox camps
are absent. Most NGOs implementing NSP do
in collaboration with local organizations such as
not have needle destroyers. They generally
youth clubs and anti-drug organizations. Christian
dispose by burning and burying. Once in a
organizations such as the Don Bosco Social
while, NGO volunteers collect syringes from
Service Scheme (DSSS) provide logistic support
25
the dumping sites in the hot spots and burn
to such camps. Furthermore, MSJE-supported
them.
de-addiction centres organize community detox
camps on a regular basis. As per MSJE guidelines,
d.Lack of monitoring
each camp can accommodate up to 15 clients.
In theory, in NSP new syringes are ‘exchanged’
for used syringes. However, return rate of
But due to large number of IDUs who could not
afford treatment in rehabilitation centres, the
syringes was reported to be about 50%.
Currently mostly syringes are just supplied
without insisting on returning the used
syringes. Also, currently there is no proper
number of IDUs in a camp is always more than 15
– sometimes even up to 100. In the last one year,
845 IDUs (820 males and 25 females) were covered
by community detox camps (survey finding). In
way to find out whether adequate numbers
of syringes are obtained by IDUs that suit their
injection frequency; whether they continue to
share syringes; and how do they dispose of the
de-addiction centres, detox is usually first of the
several stages in the rehabilitation process. But,
sometimes, the clients may wish to go after the
completion of detox stage, and thus do not go
used syringes. Due to a variety of reasons (for
through all the stages.
example, police frisking), IDUs do not want to
carry sterile or used syringes, thus one could
expect the low return rate of used syringes. NSP
should ensure that IDUs get adequate number
and appropriate size of syringes/needles;
they do not reuse or share syringes; and they
properly dispose of used syringes or bring
those used syringes for exchange. Without
these measures, it might be difficult to further
bring down HIV prevalence among IDUs.
Gaps and Needs
While it is necessary to use different detox medicines
for drug users using different drugs, often only
‘Lobain’ and Diazepam are used for all (Heroin,
SP, Alcohol). And key informants complained of
difficulties in purchasing detox medicines due to
limited funding, restriction on such drugs by anti-
drug organizations, inexperience of the NGOs, and
pressure from the police.
II. Drug Detoxification
In Imphal, detoxification (treatment of withdrawal
symptoms) services are available in three ways -
home detox, community detox and detoxification
in drug rehabilitation centres. The medicines
used for detoxification are ‘Lobain’ and Diazepam.
Detoxification duration varies from a week to three
weeks – depending on the severity of withdrawal
symptoms. For home detox, it is mandatory that
a family member accompanies the IDU to get the
Same detox medicines for drug users
who use different drugs
“[Detox] procedures will be different for heroin
users, SP [spasmoproxyvan] users, Nitrozepam
users. But in Manipur, due to limited range of detox
medicines, the same kind of medications are used
for treating both heroin and SP users.”
(A Project Director of de-addiction centre)
|
|
3.7 Page 27 |
▲back to top |
Some service providers complained that certain
agencies give detox medications to the drug users
without involving their family members, thus
giving opportunities for diversion of those detox
medicines into injecting use. They expressed the
need to review the effectiveness of home detox
and ways to improve the effectiveness.
educational sessions on HIV, de-addiction &
relapse prevention. DAC support their clients for
buying some medicines and share the costs of
certain lab tests (only for female IDUs who lack
monetary support). However, if the clients fall sick
and require costly medicines and investigations,
costs for those are borne by clients themselves.
III. De-addiction centres (DACs)
Among the eight DACs in Imphal city, seven are
Gaps and Needs
a.Limited number and less capacity
supported by MSJE and one is privately-owned.
As noted, eight DACs with a bed capacity of
The in-patient capacity of these centres ranges
15 to 30 clients are insufficient in meeting the
26
from 15 to 30 clients. None of these centres offer
high demand for residential rehabilitation
treatment on an outpatient basis. Except for Sneha
services.
Bhawan, run specifically for female drug users, and
Centre for Social Development (CSD) that caters to
b. Insufficient space or congestion
both male and female drug users, the rest of the
centres cater only to male IDUs. During the last
year, these 8 DACs provided services to 2,260 IDUs
(1,863 males and 397 females).
Most centres’ dormitories or rooms are
congested making it an unpleasant staying
experiences for the ‘inmates’ (the term used
by some NGOs to refer to the clients who stay
The main reason behind enrollment in DAC
in DACs).
is because IDUs are forced by their family
members, ex-drug user friends, and sometimes
even by anti-drug agencies. Some FGD
participants claimed that they willingly got
“It was a tough time for me. Thirty of us were put in
the same room and sometimes I felt like suffocating.
It was very difficult to stay in that small room.”
enrolled in DACs to achieve drug abstinence.
(An IDU who had recently stayed in a DAC)
The course of treatment in DACs ranges from
three to six months. Clients admitted in these
centres go through three phases: detoxification,
c.Lack of Relapse Prevention plan after de-
toxification or Rehabilitation
de-addiction and rehabilitation. Detoxification
phase is usually 5 days but can be up to 2 or 3
weeks depending on the severity of withdrawal
symptoms. De-addiction phase is about 45
days and rehabilitation phase is for another 45
days. After completion of these 3 phases, some
clients choose to stay in the centre for ‘after-care’
– though otherwise they are fit for discharge.
After discharge, DACs usually refer their clients
to Narcotic Anonymous (NA) groups. During
rehabilitation phase, some centres provide
vocational training on handicrafts (e.g., ‘meiphu’
and ‘mora’ making) to selected clients.
DACs and NGOs providing home detox do
not have a formal relapse prevention plan
for persons who have completed residential
rehabilitation program or detox, other
than referring to NA groups and assisting
in formation of support groups. Study
participants (IDUs and their caregivers)
suggested that employment and assurance of
livelihood for recovered drug users might help
in relapse prevention since unemployment
and idling away the time increase the chances
of relapse into drug use.
Each DAC has a part-time doctor and nurse
to provide health care to the clients, and
has a counsellor who provides psychosocial
support counselling. Counsellors also conduct
|
|
3.8 Page 28 |
▲back to top |
Interconnections between lack of employment,
vocational training, and relapse
Motives for enrolling in OST program found
from FGD among IDUs with co-infection and
that among IDUs on OST are contradictory.
“It’s best to keep them [recovering drug users]
While some participants of the first FGD shared
occupied doing productive work. It would be
that some clients enrol because they don’t have
the best way to help them. Regardless of the pay
money to buy drugs, participants who are in OST
whether it is Rs. 200/300 or 1000, the underlying
program told that they got enrolled because they
idea is to make them utilize their time doing better
wanted to discontinue injections and wanted to
things. If they have free time on their hands, they
be drug-free. However, participants from other
are tempted to start using drugs again.” (Mother of
FGDs and some key informants felt that IDUs get
an IDU talking about the need to offer training and
enrolled in OST not with the aim of abstinence
employment)
but because they do not have money to pay for
treatment in DACs; unwilling to get admitted in
27
d.Limited and inappropriate vocational
training for IDUs
DACs; and failure of several cycles of home detox
and residential rehabilitation care.
Vocational training is provided to only a
selected number of clients. Participants
complained that many clients may not see
their training as meaningful for their future
employment opportunity since some of
them are also relatively higher education.
Key informants suggested the need for a
range of vocational training and choosing the
trainees based on their skills, enthusiasm and
educational background.
The DIC for OST is open on all days from 9:30
am to 4:30 pm with slight change in timings on
holidays. Buprenorphine tablet is crushed and
placed under the tongue. Client is observed
for five minutes until it dissolves completely.
This is to prevent ‘diversion’ (in to injection) of
buprenorphine. The dose is given only once
in a day. Generally clients are given 4-6 mg at
initiation under the supervision of a psychiatrist.
If dosage is inadequate, dosage amount is
increased. Dose tapering is done in consultation
IV.Opioid Substitution Treatment (OST)
In Imphal, NACO-supported OST program is
overseen by the Emmanuel Hospital Association
(EHA) and implemented through MNP+, Care
Foundation, and SASO, with a target of 200, 120
and 400 IDUs respectively. These agencies have so
with doctor after 5 to 6 months and if the client is
willing for it. Being a relatively new program, the
effectiveness of this program has not yet been
formally assessed. However, participants and key
informants reported that only a few IDUs have
become ‘clean’ after OST course completion.
far covered 295, 174 and 426 IDUs respectively (as
of the end of September 2008).
Gaps and Needs
a.Limited coverage
NACO’s guidelines regarding client selection are
usually followed. Clients are identified through
peer educators and outreach workers. Criteria for
enrolment include: clients should be injecting
drug users (not users of oral drug alone); clients
should have been injecting for >2 years. For
enrolment, the history of a client (type of drugs
used and frequency of use) is taken and referred
to the doctor who decides the substitution dose.
Clients who drop-out can be re-enrolled by filling
up a continuation form, if the drop-out time is less
than a week.
Out of the estimated 12,667 IDUs in Imphal
city, only 895 IDUs have been enrolled in
OST program (<10% coverage) at the end of
September 2008. Program staff of an NGO
implementing OST program stated that
many IDUs approach their office asking to get
enrolled but because of limited targets, they
could not enrol them.
b.Limited duration and discontinuity
Participants shared that cases of relapse are
high when dose is tapered abruptly due to
|
|
3.9 Page 29 |
▲back to top |
premature termination of OST projects due to
e.Lack of clear plan for clients who relapse
lack of funding. Thus, they desired continuity
after a ‘full course’ of OST
in the OST program and adequate time period
before winding up funding support.
A project coordinator of OST program stated
that, “We do not know what to do if a client
c.Lack of proper monitoring mechanism for
detecting ongoing injecting drug abuse
who has completed one- or two-year course
of OST relapses. Whether to restart the OST
course again?” Thus, clear guidelines on after-
Key informants complained about the lack of
care of OST and relapse prevention plan are
biological monitoring systems (such as urine
needed.
test) to detect injecting drug abuse among
clients on OST since they are aware of some V.Overdose Management
28
OST clients using heroin or spasmoproxyvon
Participants have personally heard of many deaths
injections or some take alprazolam before
due to heroin overdose. SASO is the only NGO that
they come to take buprenorphine to get
provides free overdose medicine. Naloxone, the
high. A project co-ordinator of OST program
antidote for heroin overdose, is sold at exorbitant
stated:
prices (Rs. 2000 to 4000 for an ampoule) by
the pharmacies though the prices fixed by the
“It is not possible to monitor all of them
pharmaceutical companies range from only Rs. 50
individually. But if they had used [injected]
to Rs. 130 per ampoule.
something the night before, it can be found
out when they come to get their [daily
Gaps and Needs
buprenorphine] dose. If such cases happen,
Naloxone is not available in any of the major
the counsellor properly counsels them.”
government hospitals such as RIMS or JNH in
d. Inadequate pre-enrolment / adherence
counselling and lack of attention to mental
health issues
Imphal. Even pharmacies near RIMS reportedly
do not stock naloxone. And those pharmacies
that have this medicine often sell them at very
high prices. Key informants and participants
In the FGD among IDUs on OST, participants
were critical about the lack of adequate
information before one gets enrolled in
OST program and lack of attention to other
suggested buying naloxone through RIAC
and ORCHID projects as well as asked for
capacity building of NGO staff on overdose
management.
issues faced by clients. They also suggested
increasing the number of counselling staff
since the increased client load might be the
reason for not giving enough attention to
the clients. They felt that the staff, especially
counsellors, need to pro-actively ask the
clients about the problems they face. A
FGD participant stressed the need for
comprehensive counselling:
VI. Narcotics Anonymous (NA)
Imphal city has 9 NA groups with about 1,000
members, with ‘active’ membership limited to
about 400. Members of NA groups comprise of
IDUs discharged from DACs, former IDUs, and
clean IDUs referred by peers or NGOs. Apart from
these NA groups, no specific support mechanisms
exist for relapse prevention. Meetings are held
thrice-a-week at designated places and about
“Apart from giving medication, there is need
30 members attend each meeting. Until recently,
of providing counselling on a frequent basis.
NA groups were not interacting with the public
It is not going to bring any solution by giving
but recently they started carrying out public
some medicine and entertaining through
information campaigns through posters – to
watching TV at DIC. Whatever experiences
popularise and dispel misconceptions about
the service provider gained it should be
NA among the families of IDUs and the larger
shared among the clients.”
society.
|
|
3.10 Page 30 |
▲back to top |
Box 4. Major gap in drug dependence treatment services: Lack of ‘continuum’
Various drug dependence treatment modalities available in Imphal include: 1. detoxification (home-based detox,
community-based detox, and center-based detox offered in the residential rehabilitation/de-addiction centres - DACs); 2.
Abstinence-based ‘de-addiction’ treatment offered in DACs after the detox phase; and 3. Opioid Substitution Treatment
(OST).
Current pathways into various treatment modalities do not seem to be based on a particular rationale (or evidence-base).
Among the service providers, there exists an apparent hierarchy and emphasis on certain treatment modalities (based on
moral grounds / ideology) excluding exploring other options that might be suitable for that particular client at that point
in time. For example, emphasis on abstinence leads to people getting referred/admitted to DACs and not being referred to
OST or NSP, though they would have been benefited
by those options.
Diagram 1: Potential pathways to ensure ‘continuum’
Many IDUs have followed treatment pathways that in drug dependence treatment
show the following utilization patterns:
29
• H – H – H – H – H (innumerable times of home-
Relapse
based detox)
Prevn
& NA
• H – C – H – H (several times of mix of home-
based and community-based detox)
• H – DAC – DAC (several combinations of home-
based and rehabilitation)
• H – H – OST (this pattern is recent since the
introduction of OST)
Detox*
DAC/
Rehab
OST
• NSP – OST (this pattern is recent since the
introduction of OST)
IDU
(H = Home-based detox; C = Community-based
detox NSP- Needle Syringe Program)
Diagram-1 shows some of the potential pathways
for establishing ‘continuum’ in drug dependence
treatment. However, key challenges include
providing options for IDUs that include explaining
pros and cons of the available treatment options/
pathways, and assisting them in making informed
decisions to choose an option/pathway - based
on objective criteria and client preferences/
situations.
Maintenance
NSP
Therapy**
Psychological
Interventions**
* Here, ‘detox’ refers to home-based and community-based detoxification
** Maintenance therapy (such as methadone maintenance therapy) and
psychological interventions are currently not available in Imphal (and in
most parts of India)
Gaps and Needs
NA groups usually operate without any external
funding support. However, as they now seem
open to getting external support, strengthening
NA groups as a relapse prevention strategy can be
considered. Though NA groups are for sustaining
abstinence, possibilities need to be explored to
link some of their members who might benefit
from other drug dependence treatment and HIV
prevention services.
VII. IDU/PLHIV Support Groups and agencies
In spite of the difficulties of sustaining support
groups, NGOs have initiated formation of
support groups for different subgroups of IDUs
such as IDUs on OST and IDUs living with HIV.
These support groups are mainly for psycho-
social support related to HIV infection and thus
not in a sense ‘self-help groups’. Key informants
were concerned about the need to clarify the
concept of self-help groups and support groups
to NGOs as well as the target populations since
lack of clarity results in miscommunication and
unrealistic expectations among the donors and
the target populations.
In addition to the support groups initiated by
NGOs, there are IDU and PLHIV networks with
specific visions, missions, goals and objectives.
IDUs including those living with HIV get
associated with these networks as a member,
staff or volunteer.
|
|
4 Pages 31-40 |
▲back to top |
|
|
4.1 Page 31 |
▲back to top |
B. Infections-related services for IDUs
(including harm reduction)
their partners are referred for HIV testing by
NGOs.
I. HIV-related services
a. Condoms
Condoms are supplied under RIAC and
ORCHID projects and can be accessed from
drop-in centres and from the outreach
workers. Condom promotion is actively
pursued through the mass media and public
awareness campaigns. Demonstration on
using condoms is given by peer educators,
HIV testing is conducted free of cost. Pre-test
counselling is provided both by NGO staff
and at the HIV testing centres. During post-
test counselling, if the clients become too
depressed due to a HIV-positive result, VCTC
counsellors refer them to NGOs or PLHIV
networks for psycho-social support.
Gaps and Needs
30
and outreach workers. Key informants and
Focus groups and key informants pointed out
participants informed that IDUs have good
that the counsellors at the ICTCs need to be
understanding about the effectiveness of
well trained especially on issues specific to
condoms in preventing HIV and sexually
IDUs. Also, they reported irregular supply of
transmitted diseases. Female IDUs who
OI medicines and condoms from MSACS to
engage in sex work admitted that the level
the ICTCs.
of condom use with their paid partners is not
satisfactory.
c. HIV treatment and care/support services for
IDUs
Gaps and Needs
i.Abscess management
Both male and female participants felt that
condoms supplied through RIAC projects
are of inferior quality. Female IDUs based
this complaint on their observations that
condoms frequently burst while using them
with alcoholic clients and sex happens in a
hurry due to fear of police. Thus, it is possible
that these situations might be responsible
Increasing number of SP injectors also
has resulted in increase in the number of
IDUs with cellulitis/abscess with serious
cases requiring limb amputation. Abscess
management is part of the services
provided through RIAC and ORCHID
projects.
for the breakage of condoms rather than
Gaps and Needs
the quality of condoms per se. However, it
points out the need to gain the trust of the
target populations that condoms supplied
to them are of good quality. Some service
providers are of the opinion that the quality
of condoms is good but one needs to focus
on changing the perceptions of the clients
as well as by having attractive packaging for
condoms.
Participants stated that medicines for
abscess management are given free
but often IDUs need to buy dressing
materials on their own (especially in RIAC
projects), which some cannot afford.
Lack of dressing materials made the
participants to question the relevance of
daily visits made by outreach workers to
see IDUs with abscess.
b. VCTC/ICTC
Two main HIV testing centres in Imphal are
located at RIMS and JNH. Besides these,
HIV testing is also provided through ICTCs
and PPTCT centres. Also, Manipur Voluntary
Health Association (MVHA) has a mobile
HIV testing unit. Most of the IDU clients and
ii. Investigations support and testing
facilities
In government hospitals, certain tests are
prerequisite before initiating antiretroviral
treatment (Liver and kidney function tests,
complete haemogram, chest X-ray, CD4
Count and blood sugar test). Only CD4
|
|
4.2 Page 32 |
▲back to top |
Count test is free at government hospitals.
Cost-sharing for some lab tests for IDUs
living with HIV are available under projects
such as UNODC-supported H13 project
and target interventions supported by
MSACS and ORCHID. Sometimes, NGOs
support lab costs for some clients from
their organization funds.
Gaps and Needs
Some clients could not afford to share
the lab costs and some require support
for those lab tests that are not supported
by NGOs and those tests that are not
available in government hospitals. Viral
load and antiretroviral drug resistance
testing facilities are unavailable in Imphal.
For viral load tests, samples are sent to
other states.
No support for investigation costs for HIV-
negative (or unknown HIV status) IDUs
“We want every IDU to be treated equally
irrespective of whether they are HIV positive or not.
When we approach NGOs to get services such as
LFT [liver function tests], they ask us about our HIV
status and if we are [HIV-] negative, then they don’t
support us [cost-sharing of lab tests] …we don’t
get any financial support from our families.”
(A male IDU participant in a FGD)
iii.Antiretroviral Treatment (ART)
In Imphal, ART Centres at RIMS and JNH
provide free first-line ART as per NACO
ART guidelines. Eligibility of patients
for initiating ART is determined by CD4
Count in addition to clinical status. If
the client is not yet eligible (CD4 >200/
cubic millimetre), a CD4 test is done
every six months to monitor their
eligibility. For clients on ART, CD4 Count
Test is done every six months to monitor
the effectiveness of ART. Treatment
Counselling Centres (TCC) that provide
counselling and education on ART
adherence are located within the two
ART centres. First line ART drugs are
provided on monthly basis.
Gaps and Needs
Second-line ART
Though there are no official data on how
many people require second line ART in
Manipur, experiences of key informants
and service providers show that a
significant number might require it. As a
physician key informant mentioned:
“Before the supply of ART came from
WHO, many people were on ART from
around 1997… From my clients records,
there is a probability of 5-10% of them
31
having developed resistance to first-line.
Currently 15 of my clients are on second
line of ART. There are many more that
need second-line but could not afford.
Some of them have expired.”
Nutritional support
PLHIV, especially those on ART, require
proper nutrition. Participants pointed out
the lack of nutritional support for PLHIV
and also wanted adequate information
on nutrition for PLHIV.
iv.Opportunistic Infections (OIs)
Management
Patients are treated for OIs at government
hospitals – especially for TB, diarrheal
diseases, and severe infections such as
brain infections. Minor OIs are managed
by doctors at the NGOs. For TB, NGOs
refer their clients to Directly-observed
treatment centres (DOTS).
Gaps and needs
Providers and participants complained
about the lack of availability or
interrupted supply of costly medications
such as Flucanozole, Amphotericin-B,
Aciclovir, and Ganciclovir. Also, lab tests
for diagnosis and supplemental tests for
OIs are charged at government hospitals
which could not be afford by many
PLHIV.
v. Psycho-social support and Counselling
In Imphal, only a few doctors and
|
|
4.3 Page 33 |
▲back to top |
psychiatrists address mental health
issues of PLHIV and IDUs. Except the OST
program where psychiatrists visit thrice a
week to assess OST clients, there are no
mental health services for IDUs and PLHIV.
Until recently, RIAC projects did not even
have counsellors.
vaccination is not available for IDUs, except for
some one-time initiatives by some NGOs.
Knowledge about HBV
“I do not know whether HBV is spread through air
or water. I do not know …what kind of disease it
is.” (A female IDU in an IDI)
Gaps and needs
Knowledge about HCV
Participants expressed the need
for providing psychosocial support
“Knowledge of Hep B and C is there among IDUs
counselling on an ongoing basis from
but it is not much. About Hep C, they know that
32
both government hospitals and NGOs.
treatment is expensive, not many know that
Most government and NGO counsellors
IDUs are very vulnerable to Hep C and that it is
are inadequately trained on mental health
transmitted through sharing of syringes and other
status assessment and psychological
paraphernalia such as cotton, swab, and cooker”.
counselling. A key informant opined that
(A service provider key informant)
for the Christian community psycho-
social support should also come from
the Churches. Also, a health care provider
Non-availability of confirmatory testing facility for
HCV and other related investigations support
pointed out the lack of adequate number
While HCV antibody testing for HCV is available,
of mental health specialists to diagnose
confirmatory testing is not available. For
and treat mental health problems/illnesses
confirmation, the blood sample is sent out of
among drug users and PLHIV
the state – a costly and time consuming process.
vi. Home Visits
Under RIAC and ORCHID projects,
outreach workers, care workers, and
nurses visit the home of bed-ridden
Key informants mentioned that though HCV
prevalence is high among IDUs living with HIV
(>90%), there is limited support for screening for
HBV/HCV among IDUs and PLHIV.
PLHIV but the frequency of visits was
not felt sufficient by the participants.
They provide medicines, counselling
and psycho-social support to the clients
and their family members. They educate
the family members on care giving and
universal precaution.
No viral load testing facility for HCV
“We have only antibody testing for HCV. We
support selected clients through medical health
care and support component of some projects.
When it comes to the qualitative, quantitative
[confirmatory] testing part, we don’t [support].”
II. HBV & HCV
(A program staff of an NGO)
Gaps and Needs
Near lack of knowledge/education about HCV/HBV
Free or affordable treatment for HCV/HBV is not
available
Participants admitted their lack of or inadequate
knowledge about HBV/HCV infections in relation
to diagnosis, prevention (HBV vaccination)
and treatment. Key informants attributed this
inadequate knowledge on HBV/HCV to lack
of awareness programs on HBV/HCV by the
government and NGOs, and lack of training of
outreach staff of HIV programs. Also, free HBV
Except for a few IDUs who are employed or
who have financial support for treatment from
their family, HCV treatment is beyond the reach
of majority of IDUs. Certain pharmaceutical
companies (Fulford and Roche) provide free
HBV/HCV diagnostic testing to clients who come
forward to get HCV treatment but HCV treatment
cost is prohibitive.
|
|
4.4 Page 34 |
▲back to top |
“Mortality rate of PLHIV has come down due to
ART. But still, premature deaths occur due to liver
complications like Cirrhosis and hepatocellular
carcinoma – arising from Hep-C co-infection.”
(A physician key informant)
Free treatment or HBV is not available in the
government centres for all IDUs. If HBV co-infected
IDUs living with HIV are receiving lamivudine-
based first-line ART regimens then that regimen
also acts against HBV.
“The majority of the mortality cases among IDUs III. IEC Materials
now can be attributed to complications arising out
of Hepatitis C and B infection. So there is an urgent
need to address it… Its treatment cost is very
expensive, it’s not easily affordable.”
a. Near lack of IEC materials on issues of importance
to IDUs and IDUs living with HIV from the
government
(A medical officer in government ART centre)
IEC materials published are mostly on HIV
33
Box 5. GAPS IN ADDRESSING THE NEEDS OF FEMALE IDUs
Female IDU participants and key informants felt that existing services for IDUs do not cater to the specific needs of
female drug users.
“There is a need to design a special program based on the needs of female drug users…. Most services like DIC,
home detox, rehab etc. have all been designed keeping the male drug users in mind, so they have no problems
in accessing those. There is a need to re-evaluate these services from the point of view of female drug users as
there is a huge gap in making women-friendly services available.”
(A woman key informant NGO service provider)
a. Night shelter and housing support
Many female IDUs, especially those who engage in sex work, have left their homes or do not want to stay at their
homes due to discrimination. During daytime, some come to drop-in centres of NGOs providing services to female
sex workers but they face problems during night. Hence some expressed their desire for having a night shelter or
housing support.
An in-depth interviewee who is a Project Director of a female DAC also shared that once the female IDUs complete
their treatment course in the rehabilitation centre, they do not want to go back to their family members or do not
have support for housing and hence come to the streets. Thus, she pointed out the need of providing temporary
housing support as well as providing vocational training for an adequate period.
b. No safe detox measures during pregnancy
There are female IDUs who continue to use drugs even during pregnancy. Even if they want to stop using drugs, it’s
not possible for them because detox cannot be done during pregnancy and without the help of detox medicine
it is not feasible to just stop taking drugs as it is difficult to bear the withdrawal symptoms. So, left with no option,
such women continue to use drugs until delivery. Thus participants felt that it is important to find out ways to assist
pregnant female IDUs who want to give up drugs.
c. No formal provision/facility for child care in rehab centres
DACs prefer the female IDU client to come for treatment alone without her child (infants or school-going children)
due to lack of child care services. While some female IDUs have relatives who are willing to take care, others do not
have that option.
“One client has a 3-month old child. When she attends classes, others look after her baby. Now, there are 3
sisters in (name of the rehabilitation centre). They are also very attached to the children and they sometimes
look after them. We prefer our clients to have no children coming along with them but we sometimes have to
take their condition into account and accept both mother and child.” (A woman program leader of DAC)
d. Need for female condoms
RIAC and ORCHID projects provide only male condoms and not female condoms. Because of problems with
condom negotiation with male clients, female IDUs who engage in sex work and key informants expressed the
need for female condoms.
e. Vocational training and income generation programs for female IDUs
Female IDU participants expressed the need for income generating programs and vocational training. And they
felt that such training programs would help them in using their time more productively and will help them to
discontinue drug use.
|
|
4.5 Page 35 |
▲back to top |
awareness and prevention. There are no exclusive
physical withdrawal symptoms made getting
IEC materials on drug-related issues.
and fixing the drug as their priority. In spite of the
b.Existing IEC materials are not up-to-date
knowledge about the risks involved in sharing
syringes, many IDUs still share. They know about
Existing IEC materials were published many years
the availability of NSP service; drop-in centre, from
back. Thus, though they were relevant at the
where they can collect syringes. After getting
time of their preparation, they are losing their
the drugs, IDUs inject with whatever syringes
relevance now as new developments take place.
are available at the dealer’s place and/or shared
As drug use pattern and HIV risk behaviours
syringes with others. (Note: As we will see later,
change from time to time, IEC materials should
sharing within the dealer’s place is also indirectly
be revised taking into account those factors.
due to not wanting to be carrying syringes in the
street due to police harassment.) A male IDU living
34
c.Existing IEC materials are available only in
with HIV said:
Manipuri or English
“When I was in withdrawal due to non availability
IEC materials are published only in Manipuri
of drugs, I did not want to go to DIC* [drop-in
or English. As drug use and HIV infection cut
centre] (because of fear of arrest by police) and
across various communities that speak different
besides that I had no money to buy new syringe.
languages, it is important to publish IEC materials
In spite of knowing everything when we buy drug
in major local dialects as well so that all concerned
from peddler’s place we had to inject it there and
can have awareness and appropriate knowledge
leave immediately.”
on such issues.
Another participant mentioned that, “Even if IDUs
d. Near lack of IEC materials on HBV/HCV and
have some money, their priority will be drugs and
overdose prevention
they will neglect going for [drug dependence]
IEC materials regarding HBV and HCV are lacking.
treatment.”
Only a handful of NGOs have prepared IEC
materials on HCV/HBV and overdose prevention.
Practical difficulties in visiting drop-in centres
(DICs) on a daily basis
Barriers to Accessing Services
In spite of the range of services available for IDUs in
Imphal, IDUs face many barriers in accessing and using
those services. Barriers differ according to: the type of
services; the subgroups of IDUs who are at different
stages of their drug use; and infection status (HIV/
HBV/HCV). Here, we summarize the barriers that were
identified based on the participants’ perspectives and
insights. Most findings are similar to studies conducted
among IDUs in Chennai, and Delhi (Chakrapani et al.,
2008a; 2008b; 2008c).
A. Individual level barriers
B. Health care system barriers
C. Social, policy and programmatic barriers
NSP and OST programs require clients (IDUs) to
drop-in daily at the centre for using the services.
Daily visit to the DICs for getting new syringes or
taking buprenorphine was not a practical option
for some IDUs. Some reused the same syringes
again and again increasing the chances of cellulitis
and abscess formation.
“I took only one syringe in a day and used
the same syringe repeatedly for about 2/3
days after cleansing it properly. I didn’t want
to go again and take new syringe [due to
inconvenience in frequent travel and money
spent for travel] so I used it repeatedly.”
(A male IDU in a FGD among IDUs with co-
infections)
A. Individual Level Barriers
Precedence to drugs and withdrawal symptoms
supersede
Several participants stated that craving and
Lack of adequate knowledge of services
It is a general perception that IDUs in Imphal
access various types of services and are aware
about the developments relating to drug and HIV
services. But, it was understood participants and
|
|
4.6 Page 36 |
▲back to top |
key informants felt that only a section of IDUs
and thus they want to control their withdrawal
have adequate knowledge on accessing the range
symptoms. Some also questioned the seriousness
of services available in Imphal. But many IDUs
of service providers in providing effective detox
especially those who are not actively associated
services.
with NGOs have little or incomplete knowledge
about available services. For example, relatively
new programs such as OST do not seem to be
properly understood by IDUs.
“Actually home detox is not successful even 1%.
Home detox is mostly done when they do not have
any money to buy [detox] drugs and physically very
weak due to non-availability of detox drugs. NGOs
“On an average, out of every 100 drug users in
are providing this detox service just for namesake;
Imphal, only about 40% have knowledge of what
they too know that it is not going to work out.”
services are available where…IDUs not sure about
(Perception of a male IDU living with HIV – in a
OST program. Not much details are known [about
FGD)
35
it] to some.” (A male IDU in a FGD)
Low self-esteem
Key informants from NGOs commented that even
NGO staff and government health care providers
do not have adequate knowledge about the
various services available for IDUs and PLHIV in
Imphal.
Participants and key informants were of the
view that some IDUs feel that they are worthless
and there is no point in using drug dependence
treatment or HIV treatment services. Consequently
they do not seek health care services:
Lack of self-efficacy in ART adherence
‘“Most of the drug users feel that as they are drug
Some IDUs do not have adequate knowledge
users, they have no use to go on living and don’t
about ART. Since ART once initiated has to be
seek treatment for themselves.” (A male IDU
taken for life long, they prefer not to be on ART
participant)
since they feel they could not adhere to ART if they
relapse into drug use or they may forget to take B. Health Care System Barriers
the medication on time.
Waiting hours
“Even if ART is prescribed after their CD4 count,
they prefer not to have it. They do not want because
it has to be taken life-long” (A Project Director of a
de-addiction centre)
At government ART centres, long waiting time and
withdrawal symptoms during their waiting period
deter current IDUs to visit. Also, some expect NGOs
to take care of all their needs and hence expect
Distrust on the effectiveness of drug treatment
many services through NGOs.
services
Participants and key informants stated that since
relapse rate is apparently so high among IDUs,
many have lost trust in the effectiveness of detox
“IDUs especially current users find it difficult to
wait for doctor check-ups because of their craving
for drugs.” (A male IDU in a FGD)
services and rehabilitation programs that some no
longer want to enrol for those services. Peers also
Stigma and Discrimination by Health Care
Providers
discourage some IDUs who go for detox services.
As a polydrug user said, “Even my friends said that
even if I am planning to go for detox, I’ll get back
to my same old habit. So [they said] there is no use
of [detox].”
Participants and key informants narrated several
recent incidents of stigma and discrimination in
the government hospitals. Many have personally
experienced discrimination. In many cases, IDUs
have informed doctors about their HIV-positive
Participants mentioned that one reason could be
the lack of motivation behind enrolling in detox
services. IDUs may ‘choose’ to use detox services
when they do not have money to buy drugs
status so that health care providers could take
necessary precautions. But participants reported
that some doctors either purposefully delay the
treatment or refer them somewhere else and
|
|
4.7 Page 37 |
▲back to top |
usually provide them substandard treatment after
knowing their HIV status and/or drug use history.
Some IDUs especially female IDUs expressed
not to go to government hospitals because of
discrimination.
peddler place is also not going to work out as the
peddler himself does not want to keep it because
police scold and beat them up.” (A former IDU in
an IDI)
Fear of stigma and shame
Delay in treatment, denial or referring
somewhere
Participants reported that some IDUs do not want
their drug use behaviour or HIV-positive status
“In government hospitals, if we approach them
to be known to others and hence hesitate to visit
for family planning and if they know we are (HIV)
service agencies to use their services. Similar
positive, we are discriminated against. They ask us
reason also prevented outreach workers from
36
to consult other clinics saying we cannot avail of the
making home visits to PLHIV. Sometimes, family
necessary equipments which are used by others as
members may prevent them from using services
it would lead to sterilization again. They say consult
since the HIV-positive status of their IDU family
others…and they delay doing such procedures.”
member will then be known others and thus
(A female HIV-positive IDU in an IDI)
bringing shame to the family.
Discriminatory attitude among health care
providers
“I was once referred to [govt. hospital] by [an NGO].
The NGO staff told the doctor about my condition
so that they could be careful. Following that,
six to seven doctors came in, looked at me with
abhorrence and passed my treatment chart among
them. I felt ashamed upon hearing them say that I
was a drug user and a sex worker….they continued
talking thus and nobody wanted to treat me. I felt
very dejected. I cried and said that they need not
treat me……….I felt very angry at the doctors. We
revealed everything to them so that they could take
up their necessary precaution and they behaved
like that.” (A current female IDU in a FGD)
C. Social, Policy And Programmatic
Barriers
Police harassment (see Box 6)
Participants expressed apprehensions in carrying
syringes and visiting drop-in centres to collect
and drop off syringes, because of fear of arrest by
police. Key informants reported that though various
advocacy programs with police have helped in
reducing the police harassment, it is still present and
poses a barrier for IDUs to access services.
“There are some who don’t allow us to enter or
visit them. Some clients do not want to come
out or don’t want us to enter their house as
we are already identified with some mark”.
(Female peer educator, H-13 project: Talking about
the difficulties in making home visits)
“In Manipur, IDUs face many hurdles in the path
of getting access to treatment as they do not have
money..….No family supports for the money to
treat.” (A doctor)
Fear of anti-drug organizations and pressure
groups
Until recently, anti-drug organizations detained,
beaten, and took photos of IDUs. They had
called media people and flashed the photos of
IDUs in local dailies. Participants mentioned that
though these things have happened in the past,
these activities have decreased to a great extent.
Fear of actions perpetrated to them (IDUs) by
these organizations also makes IDUs a hidden
population.
“Earlier the underground used to apprehend drug
users and shot them in the leg to pressurize them
to give up drug use.” (A male IDU in an FGD)
“There are two DICs at [name of the place] but we
cannot go there and take syringes since we think
that police will apprehend us. Keeping syringes at
Insufficient budget for PLHIV and care/support
services under RIAC
NGO service providers complained that the
|
|
4.8 Page 38 |
▲back to top |
Box 6. Criminal drug laws, Police interference in harm reduction services, and Human rights violations against IDUs
In India, both illegal drug users and illegal drug dealers are penalized. According to the Narcotic Drugs and Psychotropic
Substances (NDPS) Act, a drug user found guilty of possessing a small quantity of a drug is liable for six months of
imprisonment. If they are found guilty of consumption, they could be sentenced to either six months or one year in prison,
depending on the substance consumed (Lawyers Collective, 2007). While not using the NDPS Act per se, there are reports
from major cities in India that police interfere with HIV prevention activities among drug users (Chakrapani et al., 2008b &
2008c; Chakrapani & Kumar, 2009; Lawyers Collective, 2007). Here, from this study, we have summarised relevant evidence
in relation to human rights violations against IDUs and police interference in harm reduction services.
IDU participants and program staff stated that fear of arrest by police often prevented IDUs from carrying sterile syringes.
Police usually extort money from IDUs if they found syringes with them and threaten to arrest them if they do not give
money. A female IDU in sex work said:
“Earlier when the drop-in centre of [NGO] was at [place], we used to go by rickshaw. [Police know we are IDUs] …and they
check us once in a while. If they found any syringe with us, they ask for money and also beat us occasionally.”
37
Even former drug users are not spared by police. As stated by a former IDU:
“Once I came across some police in an area of drug peddling. I was passing through that area in relation to some other work.
Police knew that I formerly used drugs. But I have been clean for over a year. They stopped me because of my past history [of
drug use] and let me go only after they took the small amount of money I had. That was an unpleasant experience for me.”
Female IDU participants who engage in sex work stated that they need to earn money to pay for their drugs as well as
paying “tax” to the police in addition to earning money to run their family. Furthermore, police demand “free sex” and
threaten to arrest them if they do not agree to their “wishes”.
“Sometimes a woman does not have money and can able to get [heroin] only at night - after some money has come in. If
they meet the police at that time [after they are returning with heroin], police want to touch and feel those women so that
they can let them go. Such incidents happen frequently.” (A female IDU in sex work)
Program staff of targeted interventions stated that even now police interfere with the activities of the outreach workers
who distribute syringes and condoms to male and female IDUs – although in a less intense manner compared to a few years
ago. Some participants also felt that police harassment has decreased. A female IDU said, “Earlier [female IDUs] were afraid
to go the DIC [drop-in centre] and police used to snatch syringes from them if they found ….such things has come down
now.” However, some key informants argued that a relative decrease in police harassment is not enough, there is a need
to intensify advocacy with the police and other law enforcement agencies. A government official agreed that sensitization
of the police should occur at all levels and government has plans to intensify their work with the police department and
army/paramilitary personnel.
“[Police harassment] is decreasing now; it was very high 4 or 5 years before. It is because of our advocacy with police. We
were advocating with, during the last 1 or 2 years, higher level policemen and now we are going to the police and security
[army] personnel working at the ground level [lower-rung]. Once we do that [sensitized all levels of police], I think the
harassment will be further reduced. Police advocacy is being taken up as a special, separate program.” (A government official
in-charge of the HIV/AIDS program in Manipur)
budgeted amount for monthly care and support
for clients enrolled in an organization is too little.
Thus, NGOs could not support all the IDUs who
require financial assistance for care and support
services.
Unsuitable location of services and Distance
Participants felt that some DICs are located in
places that are not considered safer by IDUs since
there is a fear of possible detention by the police,
anti-drug groups.
“Most of the DICs are located at unsuitable places
where they feel uncomfortable to go and take
new syringes. Therefore the number of IDUs turn
up at DIC is very low. Distance is also a barrier and
there are two DICs at [place] but we cannot go
there and take syringes since we think that police
will apprehend us.” (A former IDU in an IDI)
“Going there and take the [OST] drugs everyday
is a problem because of the distance. So I would
rather like to do detox with lobain at the nearby
NGO.” (A male IDU in a FGD)
|
|
4.9 Page 39 |
▲back to top |
OST services that are started recently can be
accessed from only four centres in Imphal. A client
enrolled in the OST program complained that he
need to go every day to a centre that is located far
from his residential place.
Lack of harm reduction and treatment services
within prisons
HIV/AIDS NGOs/DACs to Private clinics/labs
NGOs refer their clients to private clinics/labs usually
for tests that are not available at the government
hospitals. NGOs that have projects for supporting
laboratory tests usually tie up with private labs to get
discount for tests.
NGOs to Government Hospitals
Participants who were former prison inmates
and key informants stated that harm reduction
services such as NSP, condoms, and OST are not
NGOs refer their clients to Government Hospitals such
as RIMS and JNH mainly for free first-line ART and free
CD4 count.
available within prisons. They also narrated the Government Hospitals to NGOs
38
difficulties in accessing detoxification treatment Referrals from government hospitals to NGOs seem
and antiretroviral treatment for IDUs living with less frequent. Some doctors and counsellors may refer
HIV within prisons. (For more details, refer to PLHIV to PLHIV networks.
Chakrapani & Kumar, 2009)
Private Clinics/Labs to NGOs
Referral Mechanisms
Referrals are made from HIV/AIDS NGOs to other HIV/
AIDS NGOs; HIV/AIDS NGOs and DACs to government
hospitals; and DACs to HIV/AIDS NGOs. See diagram
2 that summarizes the existing referral mechanisms
among various service providers in Imphal.
Private clinics referring their patients to NGO is also rare
and happens only in a few cases - when the patients
require services for drug dependence treatment or
want to access free services.
Referrals – informal and formal (referral
slips)
HIV/AIDS NGOs to other HIV/AIDS NGOs
Some NGOs refer their clients to other NGOs when the
services needed by the clients are not available with
them (such as support for lab investigations). They
also refer when the services required by the clients are
available with them but are too limited to cater to the
needs of all the clients (e.g. support for medicines).
“When we send clients with the [referral] letter, they
[referred NGO] accept it because we have networked
with them before in this regard … they give good care
to the client.” (Director of an HIV/AIDS NGO)
Referral is done through both word-of-mouth and by
using referral slips. For organizations having two or
more related projects, there is intra-agency referral
as well as inter-agency referral. A service provider key
informant said:
“There is a difference between referring by using
referral slip and referring through word of mouth.
When referral slip is taken, the doctor examines
it and provides the medicines written there but in
word of mouth referral, only one or two important
medications from among the named five are given.”
There is no uniform referral format among the NGOs;
referral slips used differ from one agency to another.
Box 7. Purpose of the referrals among the various service providers
1. From NGOs
- To government hospitals for
a. Investigations on HIV, HBV, HCV (liver/kidney
function tests)
b. Antiretroviral treatment (ART)
c. OI treatment
- To PLHIV networks for psychosocial support
- To private laboratories for investigations
- To DACs (informal)
2. From government hospitals
- To PLHIV networks for psychosocial support (limited
referrals)
- To NGOs for detox (informal and minimal referral)
- To DACs for drug abstinence (informal)
3. From DACs
- To private labs for investigations
- To Narcotic Anonymous (NA) for relapse prevention
|
|
4.10 Page 40 |
▲back to top |
Clients accompanied by NGO staff
Need for supporting travel costs
When referring to other agencies, usually NGO staff Support for travel is given by NGOs only to a small
accompany the clients when the clients do not know number of clients. Thus, many clients do not have the
that place or when the clients have serious health means to go to the agencies where they are referred.
problems. In most referrals, clients go by themselves
to the referred place. If accompanied by NGO staff, the
referral slip is taken back to the organization by the staff.
In cases where the client is not accompanied, a referral
slip is given to the patient who takes it along and he
returns to the NGO with the signed referral slip. When
NGO staff accompany clients, the travel expenses are
“We only go to (name of two NGOs) as we have no
money to go to the other places. We don’t have money
for travel fare, doctor consultation fees and for buying
medicines. As it’s impossible for us, we don’t go.”
(A female IDU in a FGD)
Lack of knowledge of available services
almost always borne by the NGOs. Travel support is Participants and key informants told that many IDUs
39
provided only for those clients who are seriously ill and still do not know the range of services available for
not accompanied by staff. Most organizations do not IDUs and PLHIV in Imphal and NGOs refer their clients
have formal mechanisms to follow-up those whom they only to a selected group of service agencies.
have referred. In some organizations, follow-up is done
by field staff who check whether clients have received Reluctance to reveal drug use habit
services and when is their next follow-up visit to that
service provider.
Even if clients are referred to other agencies, clients
prefer to get the services available in the agency
Gaps
with whom they have good rapport. Key informants
reported that it could be because of the fear of
Referrals from government hospitals
discrimination from other service agencies if they
revealed their drug use or HIV-positive status.
Key informant service providers stated that while there
is relatively good networking and linkages among
NGOs, referrals from government hospitals to NGOs
(HIV/AIDS NGOs and DACs) are almost nil.
“Though the staff of (name of two NGOs) know that we
are drug users but we are reluctant to reveal our drug use
habit to other doctors. So we prefer to be treated here.”
(A female IDU in a FGD)
Inadequate follow-up after
referral
Participants complained that
though some NGOs do follow-up
Diagram 2: Existing linkages and referrals across various service
agencies in Imphal city (Note: Broken arrows represent weak
linkages or inadequate referrals)
their clients who are referred to
other NGOs, many do not have a
proper follow-up mechanism: after
referral, they do not check whether
Targeted Interventions
Needle Syringe
Programs/ Condoms
Treatment
for HCV/HBV
the referred client has accessed the
service.
Narcotic
Anonymous
“Regular follow-up of the client’s
case, whether he has improved
or what’s needed to be done
more for him etc. should be
taken up. They should ascertain
whether the referred client
goes to the place of referral and
follow up on them regularly.”
(Wife of a male IDU)
Opioid
Substitution Therapy
PLHIV Networks
& NGOs/CBOs
Detoxi cation
(Home/ Community)
Govt. Hospitals
VCTC/ART/
Treatment for OIs/
Lab Investigations
De-addiction
Centres
Private Labs/
Clinic
|
|
5 Pages 41-50 |
▲back to top |
|
|
5.1 Page 41 |
▲back to top |
40 4. Recommendations
This study identifies several gaps in existing drug
dependence treatment and infections-related services
for IDUs, including IDUs living with HIV, in Imphal,
Manipur, and captures the perspectives of IDUs on
their needs and improving existing services. Barriers
and facilitators in accessing and using the existing
services, and problematic areas in linkages among the
services have also been identified.
This section summarizes key recommendations based
on evidence from the study. It is crucial that relevant
authorities implement these recommendations to
ensure a continuum of care for IDUs, including IDUs
living with HIV, in Imphal city (and other areas).
We deliberately tried refraining from making a long
list of recommendations at the risk of its being seen
as “another wish list” by policymakers and national/
state program managers. But we failed in our efforts.
We took the risk of compiling a more extensive
recommendation list because of the overwhelming
evidence that compelled us to make recommendations
in all the service areas necessary for IDUs, including
those living with HIV. We also wanted to convey,
without censoring, what communities of drug users
and people living with HIV have expressed as their
needs and concerns. However, we have prioritized
these recommendations according to the plausibility
of implementation over a short-term, medium-term,
and long-term period. This does not mean that
‘medium-term’ and ‘long-term’ recommendations
can wait until ‘short-term’ recommendations are
first implemented. It means that while all these
recommendations are important, we need to start
somewhere and then quicken our pace to achieve a
continuum of care for IDUs, including IDUs living with
HIV.
A. Recommendations that can be
implemented over a short-term
period (A few months to a year)
1. Improve the quality of existing services
Ensure that harm reduction training is provided
to all service providers – service providers of
drug dependence treatment and HIV prevention
intervention services as well as health care
providers –, to promote better understanding
of drug use/dependence as a health (rather
than a criminal) issue and to treat drug users as
equal human beings who deserve appropriate,
competent and comprehensive care.
a. De-addiction services [Primarily directed to
MSJE]
• Strengthen the follow-up of discharged clients
and ensure a tailored (individualized) relapse
prevention plan.
• Develop guidelines for the enrolment of
clients in the various treatment modalities
(community-based detox, home-based
detox, residential rehabilitation program) and
ensure referral to the next level of care after
detoxification.
• Establish long-term vocational training
programs that are useful to and in-demand
from the clients – within the existing drug
rehabilitation programs as well as connecting
|
|
5.2 Page 42 |
▲back to top |
with vocational training programs of relevant
• Develop mechanisms to maintain
ministries such as Ministry of Labour and
confidentiality of clients when they pick-up
Employment.
syringes at DICs - by providing unique identity
b.OST [Directed to NACO and MSJE]
code/number (and not insisting on writing
their names).
• Develop pragmatic measures for providing
OST medicines to out-station clients or those
who need to move out of the locality for some
period.
• Provide quality condoms along with water-
based lubricants at hotspots. (Educate IDUs
that government condoms such as ‘Nirodh’
are of high quality).
• Ensure proper understanding of OST
• Intensify promotion of condom use among
program by clients prior to enrolment to
IDUs and their sexual partners (male/female)
minimize drop-out. i.e. prepare the patient
for committing to long-term OST (‘treatment
• Intensify efforts to improve partner screening
41
readiness or preparedness’ or pre-enrolment
and treatment for HIV and STIs.
counselling/education). And once enrolled,
provide adherence support and ensure proper
monitoring.
• Ensure proper implementation of NACO’s
enrolment criteria (e.g., not to enrol oral drug
users in OST program).
c.Targeted Interventions for IDUs
[Directed to NACO/SACS]
d.ART and Management of opportunistic
infections (OIs) [Directed to SACS/NACO]
• Train government doctors in ART centres on
proper clinical management of IDUs living with
HIV (especially ART management; screening
and treating co-infections such as HBV and
HCV; and OST) as well as sensitization about
drug users and drug dependence.
• In NSPs under RIAC projects, consider (re)
distributing syringes/needles through
shopkeepers or influential persons in
a locality who understand about harm
reduction programs (referred to as ‘secondary
distributors’ in ORCHID project) to reach more
IDUs.
• Ensure adequate supply of different sizes of
syringes and needles to meet the needs of
drug users who use different drugs (Heroin
and ‘SP’)
• In needle syringe programs, ensure supply
of packaged distilled water, alcohol-soaked
cotton swab, and cooker.
• Develop appropriate mechanisms to remove
used syringes from the hotspots.
• Impart correct and complete knowledge
about ART through NGOs (outreach workers,
NGO counsellors), counsellors at government
ART and HIV testing centres, and through
mass media.
• Ensure appropriate ART regimens are provided
for IDUs who are co-infected with HBV/HCV
and/or TB as well as who are current users
(and who may be on OST).
• Ensure adequate and uninterrupted supply of
necessary free OI medications (antibiotics, anti
fungal and antiviral drugs – such as Flucanozole,
Acyclovir, Ganciclovir, Amphotericin-B) at the
government hospitals.
• Ensure access to appropriate information
concerning ART/street drug/prescription
drug (OST) drug-drug interactions.
• Establish
centralized
procurement
mechanisms for buying detox medications in
• Intensify promotion of condom use among
IDUs on ART.
targeted interventions (because of frequent
shortages and inexperience in procurement
among some NGOs).
• Ensure proper matching of the location of
DICs and hotspots used by IDUs.
2. Improve access to existing services
[Directed to SACS, State Health
Department and MSJE]
• Ensure financial coverage for comprehensive
|
|
5.3 Page 43 |
▲back to top |
health care services and laboratory investigations • Ensure available social welfare schemes (income
for needy IDUs and IDUs living with HIV.
generation programs, vocational training, micro-
• Provide free or affordable residential drug
treatment and rehabilitation care for IDUs and
credits and small loans) in the State Department
of Social Welfare also cover IDUs and PLHIV.
IDUs living with HIV.
• Establish specific schemes catering to the needs
• Provide free or subsidized lab tests (e.g., liver and
kidney function tests) to be done before starting
ART and while on ART at government and private
of IDUs (male and female), and spouse/children
of IDUs/PLHIV including provision of legal aid,
housing assistance, and employment assistance.
hospitals/labs as well as lab tests for diagnosing
and monitoring OIs.
• Provide free medications for managing overdose
at NGOs and Government Hospitals and train
42
3. IEC materials / Communication
[Directed to SACS/NACO]
emergency room physicians and paramedical staff
on overdose management.
• Involve stakeholders including IDUs at all stages of
development of IEC materials.
• Field test IEC materials before dissemination
and post-dissemination evaluation to find out
effectiveness.
• Provide water-based lubricants along with high
quality condoms at all suitable places – ART
centres, DICs, outreach sites, etc.
• Provide female condoms for female IDUs –
especially those who engage in sex work.
• Impart proper and adequate knowledge on HCV/
HBV prevention, diagnosis and treatment.
• Quicken the process of providing free second-line
ART regimens in Manipur.
• Develop IEC materials on prevention, early
diagnosis and management of abscess
management and drug overdose.
• Develop guidelines for diagnosing and treatment
of psychiatric disorders among PLHIV and IDUs,
and train health care providers on the same.
• Publicize information about OST to IDUs and
general public.
B. Recommendations that can be
implemented over a medium-term
period (~ 2 years)
1. Initiate new services
[Directed to SACS/NACO, MSJE, and
Department of Social Welfare, Manipur]
• Ensure that specific needs of various subgroups of
drug users (oral drug users, adolescents/children
using drugs, Female IDUs) are met in de-addiction
centres (Example: Separate spaces for adolescents,
Recreation for children/youth, Childcare services
for female IDUs).
• Develop strategies for improving the self-efficacy
of IDUs in relation to drug treatment adherence
and ART adherence.
• Provide housing support and night shelter for
homeless/needy female and male IDUs
• Provide nutritional supplements for IDUs living
with HIV as well as for those IDUs who are
malnourished (especially women and homeless
IDUs).
• Initiate training on self-care and home-based care
for family members by caregivers/field workers
when they make home visits.
• In prisons, introduce harm reduction services and
ensure treatment, including ART, for people living
with HIV, including IDUs
HIV/HCV/HBV-related lab tests and treatment
• Install HIV-DNA PCR machine at the government
hospitals to diagnose HIV infection among
children born to PLHIV.
• Install adequate number of CD4 machines to
reduce the waiting period.
• Establish test facilities for HIV and HCV viral load,
antiretroviral drug resistance test, and free/
subsidized screening and confirmatory testing
|
|
5.4 Page 44 |
▲back to top |
facilities for HCV/HBV infections.
continuum of care – discharge/transition plan
• Provide subsidized or free treatment for IDUs
from one level of service to another.
and IDUs living with HIV who have HCV/HBV • Ensure to keep priority on delivery of services
infections.
based on clients’ needs rather than focusing on
• Provide free HBV vaccination for IDUs, including
achieving project targets.
those living with HIV.
• Develop a resource directory of service centres to
help users and service providers.
2. Improve coverage of the existing
services [Directed to MSJE, and SACS/
4. Capacity building and Training
NACO]
[Directed to SACS and Dept. of Social
• Scale-up the availability of residential detox/
Welfare/ MSJE]
rehabilitation centres (Increase the capacity of • Hands-on training for physicians and other service
43
existing DACs and increase the number of DACs).
providers managing OST programs. And training
• Establish long-term and replicable vocational
training programs.
• Rapidly scale-up OST program to ensure adequate
coverage.
on prevention of injection-related abscess and its
management.
• Provide training on overdose prevention and
management for doctors, IDUs and outreach
workers and peer educators of TI programs.
3. Strengthen linkages and referral
mechanisms [Directed to SACS/NACO,
and MSJE]
• Develop guidelines on when and how to refer IDUs
from one service to another service. For example,
from NSP to OST or DACs.
• Develop and strengthen linkages among NGOs,
DACs and NA groups.
• Strengthen referrals from NA groups to other
services like OST, de-addiction - depending
upon the need of NA group members. (Educate
NA members about the various drug treatment
options and harm reduction).
• Build linkages with Imphal Municipal Council or
institutions which have incinerators for proper
disposal of used syringes.
• Link to PLHIV networks for adequate treatment
education and adherence counselling support.
• Develop detailed mechanisms for proper
networking and coordination among the various
service providers.
• Strengthen the existing NA networks in Imphal.
• Support formation of more self-help groups for self-
employment and income-generation programs
and build the capacity of the communities to
accomplish these.
• Provide vocational training depending upon the
skills, enthusiasm and background of IDUs and
PLHIV.
• Create and strengthen monitoring and evaluation
mechanisms to ensure all services for drug users
are of high quality, and accessible and acceptable
to drug users community.
C. Recommendations that need to
be implemented over a long-term
period and on an ongoing basis
1. Create enabling environment
[Directed to SACS/NACO and MSJE]
• Clarify any misunderstandings about OST and
harm reduction programs among various
stakeholders at all levels (including those who run
DACs).
• Develop a standard referral slip (without
compromising confidentiality) that can be used
by any service agency.
• Sensitize police (at all levels) and anti-drug
agencies on drug dependence and need for NSP
and OST.
• Develop follow-up mechanisms and ensure • Take stigma reduction measures in the health care
|
|
5.5 Page 45 |
▲back to top |
settings and sensitize health care providers on
overemphasis on drug control rather than drug
the health and human rights issues of IDUs and
user health.
PLHIV.
2. Create evidence-base
• Support the formation and strengthening
[Directed to SACS/NACO and MSJE]
of community organizations of drug users –
empowering them to understand their human • Conduct evaluation of detox and rehabilitation
rights and advocate for themselves.
programs to find out what make them effective or
less effective.
• Involve drug users in the development and
implementation of all government HIV/drug • Commission sociobehavioral and epidemiological
programs.
studies among IDUs and PLHIV to develop an
evidence-base and design evidence-informed
44
• Harmonize public health and public security
interventions to meet their unmet and emerging
policies to ensure programs and services for
drug users are not undermined by the current
service needs.
|
|
5.6 Page 46 |
▲back to top |
5. References
45
Beyrer, S., Razak, M. H., et al. (2000). “Overland heroin
trafficking routes and HIV-1 spread in south and south-
east Asia.” AIDS, Vol. 14, No. 1, pp. 75-83.
Bryant, J., Hopwood, M. (2008). Secondary exchange
of sterile injecting equipment in a high distribution
environment: A mixed method analysis in south east
Sydney, Australia. Int J Drug Policy. doi:10.1016/j.
drugpo.2008.06.006
Chakrapani, V., Mehta, S., Buggineni, P., Barr, F. (2008a)
Sexual and Reproductive Health of Males-at-risk in
India: Service Needs, Gaps, and Barriers. India HIV/AIDS
Alliance. New Delhi, India. http://www.aidsallianceindia.
net/Main/ViewPublication.aspx?id=948
Chakrapani, V., Shunmugam, M., Michael, S.,
Velayudham, J., Newman, P. A. (2008b). Barriers to HIV
Antibody Testing among People at risk in Chennai,
India. Indian Network for People living with HIV (INP+)
and Asia Pacific Council of AIDS Service Organizations
(APCASO), Malaysia.
Chakrapani, V., Velayudham, J., Michael, S.,
Shunmugam, M. (2008c). Barriers to free antiretroviral
treatment access for injecting drug users in Chennai,
India. Report presented to the National AIDS Control
Organization, India.
Chakrapani,V., Kumar J. Kh. (2009). Drug Control Policies
and HIV Prevention and Care Among Injection Drug
Users in Imphal, India. In Wolfe, D. & Saucier, R (Eds.)
At What Cost? HIV and Human Rights Consequences
of the Global War on Drugs. New York: Open Society
Institute - International Harm Reduction Development.
Retrieved February 18, 2009, from http://www.soros.
org/initiatives/health/focus/ihrd/articles_publications/
publications/atwhatcost_20090302
Charmaz, K. (2006). Constructing grounded theory: A
practical guide through qualitative analysis. London:
Sage.
County Alcohol and Drug Program Administrators
of California (2005, June). Advancing California’s
Continuum of Care for Persons with Co-occurring
Substance Use and Mental Health Disorders.
Sacramento, CA.
Creswell, J. W., Plano Clark, V. L. (2007), Designing and
conducting mixed methods research. Thousand Oaks,
CA: Sage.
Eicher, A.D., N. Crofts, et al. (2000). “A certain fate:
spread of HIV among young injecting drug users in
Manipur, North-East India.” AIDS CARE, Vol. 12, No. 4,
pp. 497-504.
Family Health International (FHI). (2007). Scaling Up
the Continuum of Care for People Living with HIV in
Asia and the Pacific: A Tool kit for implementers. FHI.
Glaser, B. (1978). Theoretical sensitivity. Mill Valley, CA:
The Sociology Press.
Glaser, B. and Strauss, A. L. (1967). The Discovery of
Grounded Theory: Strategies for Qualitative Research.
Chicago: Aldine De Gruyter.
India HIV/AIDS Alliance (2008). Breaking New Ground,
Setting New Signposts: A Community-Based Care
and Support Model for Injecting Drug Users Living
with HIV. Retrieved September 10, 2008 from http://
|
|
5.7 Page 47 |
▲back to top |
www.aidsallianceindia.net/Publications/Breaking%20 in rural Manipur, India. Indian Journal of Public Health,
New%20Ground,%20Setting%20New%20Signposts.pdf 41(April–June), 116–118.
Lawyers Collective HIV/AIDS Unit. (2007) Legal and
policy concerns related to IDU harm reduction in
SAARC countries. A review commissioned by UNODC –
Regional Office for South Asia, New Delhi, India.
Sharma, M., Singh, R.R., Laishram, P., et al. (2007). Access,
adherence, quality and impact of ARV provision to
current and ex-injecting drug users in Manipur (India):
An initial assessment. International Journal of Drug
Lorvick, J., Bluthenthal, R. N., Scott, A., Gilbert, M. L., Policy.18; 319–325
Riehman, K. S., Anderson, R. L., Flynn, N. M., Kral, A. H. Simpson, D. D. (2004). A conceptual framework for
(2006). Secondary syringe exchange among users of drug treatment process and outcomes. J Subst Abuse
23 California syringe exchange programs. Subst Use Treat. Sep;27(2):99-121.
Misuse;41(6-7):865-82.
46
National AIDS Control Organisation (NACO). (2007). WorldHealthOrganization(WHO).(2004).NationalAIDS
Targeted Interventions under NACP-III: Operational programmes: a guide to monitoring and evaluating
Guidelines. Volume 1. Core high risk groups. Ministry HIV/AIDS care and support. Retrieved October 5, 2008
of Health and Family Welfare, Government of India.
from http://data.unaids.org/Publications/IRC-pub06/
jc1013-caresupport_en.pdf
National Treatment Agency for Substance Abuse
(NTASA). (2002). Models of Care for treatment of
adult drug misusers. Framework for developing local
systems of effective drug misuse treatment in England.
NHS, London.
Oinam, A. (2008). Exploring the Links between Drug
World Health Organization (WHO). (2005). Policy and
programming guide for HIV/AIDS prevention and care
among injecting drug users. Retrieved August 12,
2008 from http://www.unodc.org/documents/hiv-aids/
policy%20programming%20guide.pdf
use and Sexual Vulnerability among Young Female World Health Organization (WHO). (2006). Treatment of
Injecting Drug Users in Manipur.
injecting drug users with HIV/AIDS: promoting access
Osborne, C.M., van Praag, E., Jackson, H. (1997). Models
of care for patients with HIV/AIDS. AIDS (11B), 135-
141.
and optimizing service delivery. Retrieved September
3, 2008 from http://www.who.int/substance_abuse/
publications/treatment_idus_hiv_aids.pdf
Ohio State Department. (undated). Redesigning
Ohio’s Continuum of Care and Service Taxonomy
Phase I Report. Draft. Retrieved July 10, 2008 from
UNAIDS. (2001). Reaching out, scaling up. Eight case
studies of home and community care for and by people
with HIV/AIDS. Best Practice Collection. UNAIDS.
www.odadas.state.oh.us/GD/Document Management/
DocumentDownload.aspx?DocumentID=3279
United Nations Office on Drugs and Crime (UNODC).
(2007). Opium Poppy Cultivation in South East Asia:
Saha, M. K., Chakrabarti, S., Panda, S., et al. (2000).
Prevalence of HCV & HBV infection amongst HIV
seropositive intravenous drug users & their non-
Lao PDR, Myanmar, Thailand. Retrieved September 14,
2008 from http://www.unodc.org/pdf/research/icmp/
south_east_asia_report_2007_web.pdf
injecting wives in Manipur, India. Indian J Med Res.
Feb;111:37-9.
United Nations Office on Drugs and Crime (UNODC).
(Undated). UNODC’s Comprehensive Package
Sarkar,K.,Panda,S.,Das,N.,Sarkar,S.(1997).Relationship Approach. Retrieved July 4, 2008 from http://www.
of National Highway with injecting drug abuse and HIV unodc.org/india/comprehensive_package.html
|
|
5.8 Page 48 |
▲back to top |
6. Glossary
47
Buprenorphine: A medication used in opioid
substitution therapy programs. It is included in the
World Health Organization (WHO) Model List of
Essential Medicines.
CD4: An immunological marker for HIV infection, the
level of which in an individual indicate the immune
status. Use in initiating and monitoring the response
to ARV drugs.
Drop-in Centre (DIC): A facility for IDUs where
services are accessed. It also serves as a place for
IDUs for recreation, trainings and for sustaining drug
abstinence.
Detoxification: The process by which a person who
is dependent on a psychoactive substance ceases
use, in such a way that minimises the symptoms
of withdrawal and risk of harm. While the term
‘detoxification’ literally implies removal of toxic
effects from an episode of drug use, in fact it has
come to be used to refer to the management
of rebound symptoms of neuroadaptation, that
is, withdrawal and any associated physical and
mental health problems. As a clinical procedure,
detoxification is undertaken a degree of supervision.
Detoxification involves administration of medication,
which is usually a drug that shows cross-tolerance
and cross-dependence to the substance(s) taken
by the patient. The dose is calculated to relieve the
withdrawal syndrome without inducing intoxication,
and is gradually tapered off as the patient recovers.
(Adapted from: Demand Reduction: A Glossary of Terms.
UNODC. New York, 2000)
Heroin: A widely used opiate. It has the chemical names
diacetylmorphine or diamorphine. It comes in different
forms; brown, white and pink. Brown form is smoked
or chased by inhaling the vapour from the heated
substance but in this form it is unsuitable for injection.
White heroin is typically in the form of the water soluble
salt diamorphine hydrochloride and is suitable for
injection. The purity of white heroin is often graded, e.g.
‘number 4’. Pink heroin, heavily adulterated with caffeine
powder, is found in some South-east Asian countries.
(Adapted from: Demand Reduction: A Glossary of Terms.
UNODC. New York, 2000)
Integrated Counselling and testing Centre (ICTC): An
integrated counselling and testing centre is a place
where a person is counselled and tested for HIV, on his
own free will or as advised by a medical provider. The
main functions of an ICTC include: early detection of HIV;
provision of basic information on modes of transmission
and prevention of HIV/AIDS for promoting behavioural
change and reducing vulnerability; and link people
with other HIV prevention, care and treatment services.
(Adapted from: ‘Operational Guidelines for Integrated
Counselling and Testing Centres’. NACO, 2007)
Injecting Drug User (IDU): In this report, a broad
definition of ‘IDUs’ has been used to cover people who
have injected experimentally or continue to inject
occasionally up to and including heavily dependent
drug users who may inject several times each day.
IDUs may inject legal or illegal drugs, stimulants
(such as amphetamines and cocaine), depressants
(such as heroin and benzodiazepines) or other drugs
such as steroids. They may inject intramuscularly
|
|
5.9 Page 49 |
▲back to top |
(into the muscle) or intravenously (into the vein).
(Adapted from the definitions of the WHO and UNODC:
http://www.cdc.gov/outreach/who/Glossary.pdf; http://
www.unodc.org/pdf/report_2000-11-30_1.pdf )
Narcotic anonymous: A group in which participants
support each other in recovering or maintaining
recovery from drug dependence problems
without professional therapy or guidance.
(Adapted from: Demand Reduction: A Glossary of Terms.
UNODC. New York, 2000)
substance (For example, substituting sublingual
buprenorphine or methadone syrup for heroin).
Substitution therapy seeks to assist drug users in
switching from illicit drugs of unknown potency,
quality, and purity to legal drugs obtained from
health service providers or other legal channels, thus
reducing the risk of overdose and HIV risk behaviours,
as well as the need to commit crimes to obtain drugs.
Some prefer the term “medication-assisted treatment
for opiate dependence” instead of OST.
48
Overdose: Overdose is defined as the use of any
drug in such an amount that acute adverse physical
PLHIV support groups: These are self-led groups of
PLHIV that meet regularly to provide support to group
or mental effects are produced. In heroin overdose, members and other PLHIV. In addition to providing
death usually occurs as a consequence of central services and participating in the management of the
nervous system suppression of respiratory function. continuum of care, PLHIV support groups play an
(Adapted from: Demand Reduction: A Glossary of Terms. important activist role through their participation in
UNODC. New York, 2000)
activities such as determining who is eligible to start
ART or advocating for clients who do not receive the
Opioid Substitution Therapy or Treatment services they need.
(OST): Substitution or replacement therapy is (Source: Scaling Up the Continuum of Care for People
the administration of a psychoactive substance Living with HIV in Asia and the Pacific: A Tookit for
pharmacologically related to the one creating Implementers, FHI, 2007)
substance dependence to substitute for that
|
|
5.10 Page 50 |
▲back to top |
