Opioid substitution therapy in manipur and nagaland, north-east india: operational research in action

<p>Abstract</p> <p>Background</p> <p>There is good evidence for the effectiveness of opioid substitution therapy (OST) for injecting drug users (IDUs) in middle and high-income countries but little evidence regarding the provision of OST by non-government organisations (NGOs) in resource-poor settings. This paper reports on outcomes of an NGO-based OST program providing sub-lingual buprenorphine to opiate dependent IDUs in two north-east Indian states (Manipur and Nagaland), a region where conflict, under-development and injecting of heroin and Spasmoproxyvon (SP) are ongoing problems. The objectives of the study were: 1) to calculate OST treatment retention, 2) to assess the impact on HIV risk behaviours and quality of life, and 3) to identify client characteristics associated with cessation of treatment due to relapse.</p> <p>Methods</p> <p>This study involves analysis of data that were routinely and prospectively collected from all clients enrolled in an OST program in Manipur and Nagaland between May 2006 and December 2007 (n = 2569, 1853 in Manipur and 716 in Nagaland) using standardised questionnaires, and is best classified as operational research. The data were recorded at intake into the program, after three months, and at cessation. Outcome measures included HIV risk behaviours and quality of life indicators. Predictors of relapse were modelled using binary logistic regression.</p> <p>Results</p> <p>Of all clients enrolled in OST during the month of May 2006 (n = 713), 72.8% remained on treatment after three months, and 63.3% after six months. Statistically significant (p = 0.05) improvements were observed in relation to needle sharing, unsafe sex, incidents of detention, and a range of quality of life measures. Greater spending on drugs at intake (OR 1.20), frequently missing doses (OR 8.82), and having heroin rather than SP as the most problematic drug (OR 1.95) were factors that increased the likelihood of relapse, and longer duration in treatment (OR 0.76) and regular family involvement in treatment (OR 0.20) reduced the likelihood of relapse.</p> <p>Conclusion</p> <p>The findings from this operational research indicate that the provision of OST by NGOs in the severely constrained context of Manipur and Nagaland achieved outcomes that are internationally comparable, and highlights strategies for strengthening similar programs in this and other resource-poor settings.</p

My first time: initiation into injecting drug use in Manipur and Nagaland, north-east India

<p>Abstract</p> <p>Background</p> <p>The north-east Indian states of Manipur and Nagaland are two of the six high HIV prevalence states in the country, and the main route of HIV transmission is injecting drug use. Understanding the pathways to injecting drug use can facilitate early intervention with HIV prevention programs. While several studies of initiation into injecting drug use have been conducted in developed countries, little is known about the situation in developing country settings. The aim of this study was to increase understanding of the contextual factors associated with initiation into injecting drug use in north-east India, and the influence of these factors on subsequent initiation of others.</p> <p>Method</p> <p>In mid 2006 a cross-sectional survey among 200 injecting drug users (IDUs) was undertaken in partnership with local NGOs that provide HIV prevention and care services and advocacy for IDUs in Imphal, Manipur and Dimapur, Nagaland. The questionnaire elicited detailed information about the circumstances of the first injection and the contexts of participants' lives. Demographic information, self-reported HIV status, and details about initiation of others were also recorded.</p> <p>Results</p> <p>Initiation into injecting drug use occurred at 20 years of age. The drugs most commonly injected were Spasmo-proxyvon (65.5%) and heroin (30.5%). In 53.5% cases, a needle belonging to someone else was used. Two-thirds (66.7%) had used the drug previously, and 91.0% had known other IDUs prior to initiation (mean = 7.5 others). The first injection was usually administered by another person (94.5%), mostly a friend (84.1%). Initiation is a social event; 98% had others present (mean = 2.7 others). Almost 70% of participants had initiated at least one other (mean = 5 others). Initiation of others was independently associated with being male and unemployed; having IDU friends and using alcohol around the time of initiation; and having been taught to inject and not paid for the drug at the time of initiation.</p> <p>Conclusion</p> <p>Targeting harm reduction messages to (non-injecting) drug users and capitalising on existing IDU social networks to promote safe injecting and deter initiation of others are possible strategies for reducing the impact of injecting drug use and the HIV epidemic in north-east India.</p

Compliance with universal/standard precautions among health care workers in rural north India

Background: Universal Precautions (UPs) and more recently Standard Precautions have been widely promoted in high-income countries to protect health care workers (HCWs) from occupational exposure to blood and the consequent risk of infection with bloodborne pathogens. In low-income countries, the situation is very different: UPs are often practiced partially, if at all, thereby exposing the HCWs to unnecessary risk of infection. The aim of this study is to describe rural north Indian HCWs knowledge and understanding of UPs and identify predictors of compliance to target intervention programs appropriately. Methods: A cross-sectional survey was undertaken, involving 266 HCWs (response rate, 87%) from 7 rural north Indian health care settings. Information was gathered regarding compliance with UPs and a range of other relevant variables that potentially influence compliance (eg, demographic information, perception of risk, knowledge of bloodborne pathogen transmission, perception of safety climate, and barriers to safe practice). Results: Knowledge and understanding of UPs were partial, and UPs compliance was suboptimal, eg, only 32% wore eye protection when indicated, and 40% recapped needles at least sometimes. After controlling for confounding, compliance with UPs was associated with being in the job for a longer period, knowledge of bloodborne pathogen transmission, perceiving fewer barriers to safe practice and a strong commitment to workplace safety climate. Conclusion: Interventions to improve UPs compliance among HCWs in rural north India need to address not only their knowledge and understanding but also the safety climate created by the organizations that employ them

HIV risk behaviors of male injecting drug users and associated non-condom use with regular female sexual partners in north-east India

Background: In the context of increasing HIV prevalence among women in regular sexual partnerships, this paper examines the relationship between male injecting drug users\u27 (IDUs) risky injecting practices and sexual risk behaviors with casual partners and inconsistent condom use with regular partners. Methods: Data were drawn from the behavioral tracking survey, conducted in 2009 with 1,712 male IDUs in two districts each of Manipur and Nagaland states, in north-east India. IDUs\u27 risky behaviors were determined using two measures: ever shared needles/syringes and engaged in unprotected sex with casual paid/unpaid female partners in the past 12 months. Inconsistent condom use with regular sexual partners (wife/girlfriend) in the past 12 months was assessed in terms of non-condom use in any sexual encounter. Results: More than one-quarter of IDUs had shared needles/syringes, and 40% had a casual sexual partner. Among those who had casual sexual partners, 65% reported inconsistent condom use with such partners. IDUs who shared needles/syringes were more likely to engage in unprotected sex with their regular partners (95% vs 87%; adjusted OR = 2.31, 95% CI = 1.30–4.09). Similarly, IDUs who reported inconsistent condom use with casual partners were more likely to report unprotected sex with their regular partners (97% vs 66%; adjusted OR = 18.14, 95% CI = 6.82–48.21). Conclusion: IDUs who engage in risky injecting and/or sexual behaviors with casual partners also report non-condom use with their regular sex partners, suggesting the high likelihood of HIV transmission from IDUs to their regular sexual partners. Risk reduction programs for IDUs need to include communication about condom use in all relationships in an effort to achieve the goal of zero new infections

Scale-up of a comprehensive harm reduction programme for people injecting opioids: lessons from north-eastern India

PROBLEM: Harm reduction packages for people who inject illicit drugs, including those infected with human immunodeficiency virus (HIV), are cost-effective but have not been scaled up globally. In the north-eastern Indian states of Manipur and Nagaland, the epidemic of HIV infection is driven by the injection of illicit drugs, especially opioids. These states needed to scale up harm reduction programmes but faced difficulty doing so. APPROACH: In 2004, the Bill & Melinda Gates Foundation funded Project ORCHID to scale up a harm reduction programme in Manipur and Nagaland. LOCAL SETTING: In 2003, an estimated 10 000 and 16 000 people were injecting drugs in Manipur and Nagaland, respectively. The prevalence of HIV infection among people injecting drugs was 24.5% in Manipur and 8.4% in Nagaland. RELEVANT CHANGES: By 2012, the harm reduction programme had been scaled up to an average of 9011 monthly contacts outside clinics (80% of target); an average of 1709 monthly clinic visits (15% of target, well above the 5% monthly goal) and an average monthly distribution of needles and syringes of 16 each per programme participant. Opioid agonist maintenance treatment coverage was 13.7% and retention 6 months after enrolment was 63%. Antiretroviral treatment coverage for HIV-positive participants was 81%. LESSONS LEARNT: A harm reduction model consisting of community-owned, locally relevant innovations and business approaches can result in good harm reduction programme scale-up and influence harm reduction policy. Project ORCHID has influenced national harm reduction policy in India and contributed to the development of harm reduction guidelines