Experience on OST Implementation in Manipur and Nagaland in NE

FIVE YEARS OF EXPERIENCES ON OST IMPLEMENTATION IN

MANIPUR AND NAGALAND,NE INDIA

PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION

PRESENTATION OUTLINE

•BACKGROUND

•OST SITES

•DESIGN OF THE PROGRAM

•RESULTS

•IMPLEMENTATION CHALLENGES

•LESSONS LEARNED



BACKGROUND• Project ORCHID funded by BMGF targeting 18000 IDU with harm

reduction in select districts of Manipur and Nagaland in NE India since 2004

• Feasibility Study for OST conducted with Avahan funding in 2005

• Buprenorphine based drug substitution therapy initiated in February 2006, in 13 sites at Nagaland and Manipur with DFID Challenge Fund.

• Increased to 1800 slots from the initial slot of 1200 due to high demands from the community.

• After DFID funding, NACO through EHA (an Agency) continued funding the OST for 6 months (January to June’08) and since then OST is integrated with other IDU Targeted Intervention by NACO


Project ORCHID OST PROGRAM STATUS - 2011

•9 implementing partners and 11 sites.

• 9 sites in Manipur & 2 in Nagaland.

• 1360 in Manipur.

• 180 in Nagaland.

• Total Target -1540.


Bishnupur240

Ukhrul120

Chandel

Churachandpur320

Imphal W.400

Imphal E.

280

Thoubal


Wokha

Phek80

Zunheboto

Tuensang

KiphireDimapur100


DSTP (2006-2009) OST/TI integration (2009-10) OST/TI integration (ORCHID model) - 2010 onwards

Staffing:One full or part time doctorOne nurseOne counselorOne ORW for every 5 PEsOne PE for every 40 clients

Staffing:1 nursePart time doctorNo separate outreach staff

Staffing:1 nursePart time doctorSeparate outreach team for OST ( ORW- 1:200; PE 1:50)

Outreach / follow up:Outreach by PE with support from ORW

Outreach / follow up:Outreach integrated with TI, normally with active IDUs

Outreach / follow up:Separate teams to address specific needs of OST clients

Space/ Infrastructure:Adequate and not shared Space and Infrastructure as independent unit

Space/ Infrastructure:DIC integrated with TI DIC, no increase in the number of clients taken into consideration

Space/ Infrastructure:Additional space for OST DIC

Inbuilt design for coordination mechanism with TIs and Capacity building of staff

Designated staff at ORCHID level for monitoring and technical support


OST program outcomesSignificant improvements when baseline is compared with 3 months•HIV risk behaviours

–Shared needle past month 26% → 2%, p<0.001–Unsafe sex past month 15% → 8%, p<0.001–Jailed/detained past month 12% → 1%, p<0.001

•Quality of life indicators–Self report good QoL 14% → 63%, p<0.001–Employed 53% → 52%, NS–Days of family conflict past month4.5 → 0.6 days, p<0.001

Armstrong et al, 2010


Following a cohort for one yearAll clients enrolled in May 2006 (n=713) were followed for one year

•At 3 months 73% retained

•At 6 months 63% retained

•At 12 months–13% completed the program–51% remained in OST–27% relapsed–9% unknown outcome Armstrong et al, 2010


OST program outcomes

Retention in OST treatment only slightly less than that reported by a WHO collaborative study* that included sites from low, middle and high-income countries

After six months, retention in treatment was63% in Manipur and NagalandApprox 70% across the countries in the WHO collaborative studyOnly 55% in Australia



Long term outcome in Dec 10 for patients enrolled in May 06-Dec 07, Project Orchid



Predictors of cessation due to relapse


Type of drug use: Those who reported heroin as most problematic drug were almost twice as likely to relapse compared to those reporting SP

Missing doses: Clients who frequently missed more than two doses a week were almost nine times more likely to cease treatment due to relapse

Duration of treatment: Every additional month spent in treatment reduced the risk of cessation due to relapse by 24%

Family involvement: Clients whose families were not regularly involved in their OST treatment were five times more likely to cease treatment due to relapse

Spending on drugs at intake: Greater spending associated with cessation due to relapse

• Retention can be enhanced by:– Increasing family involvement in the

program

– Facilitating active follow-up for clients regularly missing doses

– Enhancing support for clients during first month on OST and for those who identify heroin as most problematic drug


• The OST program in Manipur and Nagaland, implemented by NGOs in a severely constrained context managed to achieve outcomes that are internationally comparable

• This program has arguably made an important contribution to HIV prevention in the region, as well as improving the quality of life for a large group of people with opiate dependence, their families and communities



FIDU – an emerging challenge


151

53 50

94.4

35.1

94.3

0

20

40

60

80

100

120

140

160

Tested atleast once Total positive On ART (pre+on)

% and number of FIDU/SW tested and positive

Numbers %


CHALLENGES• Current staff structuring and implementation design- what

will happen after Project ORCHID phase out in 2013?

• Challenges in integrating to TI under NACO guidelines

( staffing, counseling, follow up of clients etc.)

• Female specific OST provision and inclusion of women specific needs in the OST guidelines

• Need to rapidly scale up OST as coverage is still low – and high prevalence of HCV, HIV


CHALLENGES• Currently there is inequity in distribution of OST- rural Vs

urban areas.

• High unemployment rate among the OST clients (72%) and is one of the indicators that have not improved post OST intervention.


LESSONS LEARNED• Strong and stable medicine supply chain is important

especially in a politically unstable environment

• Adequate dosing is important

• Client ‘s involvement in designing friendly services are to the success of OST program (involvement in dosage decision, opening hours, flexibility to clients’ needs)

• Good OST program enhances general public buy in and greater involvement in harm reduction programs.


LESSONS LEARNED• Enhanced capacity to mobilise the drug using

community for HIV prevention

• Stabilisation of clients lives so that they are able to re-engage with employment, family and community.

• Adequate infrastructure and staffing is a must for OST treatment

• In a resource constraint settings, it is possible to have OST treatment outcomes comparable to global findings except for employment


Some published papers - for further readings

• Kumar MS, Natale RD, Langkham B, Sharma C, Kabi R, Mortimore G: Opioid substitution treatment with sublingual buprenorphine in Manipur and Nagaland in Northeast India: what has been established needs to be continued and expanded. Harm Reduct J 2009, 6:4. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text

• Opioid substitution therapy in manipur and nagaland, north-east India: operational research in action. Gregory Armstrong1*, Michelle Kermode1, Charan Sharma2, Biangtung Langkham3 and Nick Crofts1

Harm Reduction Journal 2010, 7:29 doi:10.1186/1477-7517-7-29The electronic version of this article is the complete one and can be found online at: http://www.harmreductionjournal.com/content/7/1/29

http://www.harmreductionjournal.com/pubmed/19243636

http://dx.doi.org/10.1186/1477-7517-6-4

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=19243636

http://www.harmreductionjournal.com/content/7/1/29/





http://www.harmreductionjournal.com/content/7/1/29

Documents

Experience on OST Implementation in Manipur and Nagaland in NE