Transcript Successful IDU intervention model in a resource poor

IDU interventions in
Bangladesh:
An example of a successful model
from a resource-poor setting
Dr. Munir Ahmed
MBBS, MPH, Dip in HE
Team Leader-UNICEF-HAPP
HIV Program, CARE Bangladesh
Bangladesh Country profile
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Area: 148,000 Sq. Km (Census-2001)
Pop: 130 million(Census-2001), Growth rate = 1.48
88% Muslim
GDP:US$ 55.4 Billion (BBS,Bd. Bank, Finance
ministry)
Per Capita Income: US$444
Economic Growth rate: 5.52% (BBS,BB, Finance
Ministry)
Agro-based country
RMG, jute and jute products, manpower export are
major wage earners.
Source:Bangladesh Demographic and Health Survey(BDHS)
Bangladesh Health Indicators
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MMR: 3.2/1000(2001)
IMR: 65(2004)
TFR: 3 (2004)
CPR:58.1% (2004)
Annual Health Budget per person: US$1.61
Source:Bangladesh Demographic and Health Survey(BDHS)
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Life Expectancy: Male=68, female=68.6
Source: BBS-2001
GoB Policy on drug use
Existing Law:
• Carrying of Heroin less than 25 gm is punishable
with 2-10 yrs imprisonment.
• More than 25 gm - death penalty or life
imprisonment
• Carrying of pathedine, morphine, methadone,
cannabis all are punishable crime.
• Possession of injecting paraphernalia is also a
punishable crime.
Source: Narcotics Control law,1990, GoB.
NSEP not legal as per narcotics law
National Strategic Plan for HIV/AIDS
2004-2010
Five Objectives:
1. Provide support and services to the priority groups of
people.
2. Prevent vulnerability to HIV infection in Bangladesh
society
3. Promote safe practices in the health care system.
4. Provide care and support services for PHAs.
5. Minimize the impact of the HIV/AIDS epidemic.
Cont’d…
Sub component of Objective one is to
provide support and services to drug users
5 strategies:
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Strengthen research on drug use
Strengthen harm reduction programs
Learn how drug use influences sexual behaviour.
Slow entry into drug use
Political, bureaucratic and legal support for effective
programming
Background of CARE Bangladesh IDU
program
• HIV/AIDS included as programming initiative
for Health and Population Sector of CARE-B in
its multi-year planning document for 1993-2000
• 1993-94: HIV/AIDS orientation for 1600 staff
• July 16, 1995: SHAKTI project launched (IDU
component from 1998)
Baseline Study-1998
Objectives:
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Determine nature and magnitude of drug injecting in
Dhaka
Study HIV risk behaviors of IDUs
Study harmful health consequences of drug injecting or
other HIV risk behaviors
Determine interventions needed for HIV prevention
among IDUs and their sex partners
Identify factors that may facilitate or constrain
interventions
Major findings
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Estimated number of IDUs: 5000
Drug of choice : Injection (Buprenorphine)
Sharing of Syringe/Needle: >90%
Homeless IDUs: 30%
No education: 46%
Income: Tk 3000/month ($50USD)
Ever arrested by police: 84%
Ever been to jail: 66%
Ever been assaulted in the street by Police/Public: 57%
Syphilis: 12.9%
HIV Prevalence of IDUs in 5th
Rounds of National Sero-surveillance
Percentage
HIV among injection drug users in
Bangladesh
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3.5
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2.5
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1.5
1
0.5
0
4
1.5
4
1.7
Round II Round III Round IV Round V
Evolution of Bangladesh IDU program
1997: Explored preliminary information related to drug
injecting in Bangladesh
1998: 1st ever RSA done in Dhaka.
Started harm reduction intervention
2000: SHG-concept for current IDUs conceived/
materialized
Community based detox arranged with fullest
cooperation of DNC/CTC.
2002: Inclusion of HSs, COHORT Started
2003: Intervention for ILWHAs
2004: DRE started, focus on female & child DUs.
Year wise expansion
2004
2004
2004
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1999
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1998
2004
2002
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2004v
2004
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2004
CARE-B DUI at a glance (2005):
Total fund available: US$1.5 Million in last FY
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47 staff
355 OWs
40 Counselors
OW:IDU - 1:50
OW:HS - 1:80
Districts covered =23
DIC = 59
Under coverage:
IDU = 6000 plus
HS = 10000 plus
Organogram
Team Leader
Technical Coordinator
PM/PDO/ PO
Field Trainer
DIC in Charge
Dresser
Field Supervisor
Guard
Medical Assistant
Outreach Worker
Core Activities
1. Drop in Centers
• health services (incl. abscess and STI management)
• peer and group education
• referral to detox programs
• client & family counseling
• recreational space
• toilet and bath facilities
2. Detoxification
• symptomatic management (no drug substitution)
Cont’d…
3. Outreach Activities
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NSE
condom distribution
one on one counseling
IEC
4. Creating Enabling Environment:
• capacity Building of IDUs self-help groups on
technical & negotiating skills
• advocacy & lobbing
Laurels achieved by this intervention
• Best Performance Award from honorable PM for
organizing community-based detoxification camp
Our best practices adopted by others
 Outreach Model of Dhaka has been selected/mentioned
as a best practice in ‘Preventing HIV/AIDS among drug
users Case studies from Asia’ published by UNODC
 Many examples and experiences have been incorporated
into the WHO guideline for HIV prevention among
IDUs
 UNODC selected this intervention as a resource/model
project for NEP outreach to develop standardized NSEP
protocol for South Asian countries.
Source: Presentation of Anna Foss, 14th International HR conference
Why it is a successful model
1. Cost effective
2. NEP outreach adopted as a best practice for South
East Asia recommended by UNODC
3. Replicated by other organization
4. NEP launched despite having no relevant law.
5. Other restrictive factors like conservative Muslim
society and frequent eviction/harassment by law
enforces.
Future Plans
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Country wide program expansion
Start continuum of care for DUs
Crisis care home for street-based marginalized DUs
Mobile clinic and harm reduction service for DUs
40 more RSAs
Start service for middle-class DUs
Work more closely with GoB and DNC
Vocational training and social re-integration
Pilot oral substitution of drug for ILWHAs.
Pilot ARV for ILWHAs
To install VCTC centers in hot spots.