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
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
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- EMMANUEL HOSPITAL ASSOCIATION
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.
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
Bishnupur240
Ukhrul120
Chandel
Churachandpur320
Imphal W.400
Imphal E.
280
Thoubal
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
Wokha
Phek80
Zunheboto
Tuensang
KiphireDimapur100
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
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
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
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
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
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
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
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
Armstrong et al, 2010
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
Long term outcome in Dec 10 for patients enrolled in May 06-Dec 07, Project Orchid
Armstrong et al, 2010
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
Predictors of cessation due to relapse
Armstrong et al, 2010
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
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
• 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
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
FIDU – an emerging challenge
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
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 %
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
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
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
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.
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
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.
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
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
PROJECT ORCHID- EMMANUEL HOSPITAL ASSOCIATION
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