drug treatment in myanmar - mohs
TRANSCRIPT
DrugTreatmentinMyanmar
NandaMyo Aung WanDrugTreatmentandResearchUnit
MinistryofHealthandSports
5th June,2019Naypyitaw
outline• Background• Majorandminordrugtreatmentcenters• Currentmethadoneprogram• ResearchfindingsonMethadoneMaintenanceTherapy
• Challengesandwayforward
MyanmardoubleburdenofHeroinandAmphetamine
• LonghistoryofHeroinuseandemergingofamphetamineuse
• PoppycultivationandATSproduction• 1in3PeoplewhoInjectDrug(PWID)islivingwithHIV(48
timeshigherthantheprevalenceinthegeneralpopulation)• 10newHIVinfectionsinthecountry,nearly3occuramong
PeopleWhoInjectDrug• IntegratedBiologicalandBehavioralSurveillance(IBBS)
2017-18estimated93,000PWID
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SustainableDevelopmentGoals(SDGs)
• Druguse- globalproblem• SDG3 - "Ensurehealthylivesandpromotewell– beingfor
allatallages"• Goal3.5- "Strengthenthepreventionandtreatmentof
substanceabuse,includingnarcoticdrugabuseandharmfuluseofalcohol"
• Indicator3.5.1- "Coverageoftreatmentinterventionsforsubstanceusedisorders"
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5
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UNGASS2016ü Recognizedrugdependenceasacomplex,multifactorialhealth
disorder characterizedbyachronicandrelapsingnatureü Encouragethevoluntaryparticipationintreatmentwithinformed
consentü Preventsocialmarginalization andpromotenon-stigmatizing
attitudesü Encouragedruguserstoseektreatmentandcare andfacilitate
accesstotreatmentü Expandcapacityofdrugtreatment
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MajorandMinorDrugTreatmentCenters
OpeningYear #Major DTC #MinorDTC1975 6 222002 20 182014 72019 3 9Total 29 56
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မးယစေဆးစြေရာဂါကသေရးဌာနမား
တငးေဒသႀကး ဌာနႀကး ဌာနငယရနကန ရနကနမႏေလး မႏေလး၊ ေကာကဆည၊
မတလာျပငဥးလြင၊မးကတ၊ပဥးမနား၊ ျမငးျခ
စစကငး မရြာ၊ကေလး ဟမၼလငး၊ ခႏး၊အငးေတာ၊ကသာ၊ဝနးသ၊ပငလညဘး၊ဗနးေမာက၊ေကာလငး၊တမး၊ ေရြဘ၊ေမာလက၊ ထးခင၊ ကန႕ဘလ၊ ကြနးလ၊
ဧရာဝတ ပသမ၊ဟသၤာတပခး ပခး၊ျပည၊ေတာငင သာယာဝတမေကြး မေကြး၊ပခကတနသာရ ျမတ၊ထားဝယ ေကာေသာငး
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မးယစေဆးစြေရာဂါကသေရးဌာနမားျပညနယ ဌာနႀကး ဌာနငယ
ကခင ျမစႀကးနား၊ ဗနးေမာ ပတာအ၊မးညငး၊မးေကာငး၊ဖါးကန႔၊ ဝငးေမာ၊မးေမာက
ကယား လြ ငေကာကရင ဘားအ ျမဝတခငး ဟားခါးမြန ေမာလျမငရခင စစေတြရမး ေျမာက လားရႈး ေကာကမ၊ကြတခင၊မဆယ၊နမခမး၊မးမတ၊နမဆန၊
မနတ၊မးကး၊ကြနလ၊ပနဆငး၊ေလာကကငရမး ေတာင ေတာငႀကး၊ လြယလင ကေလာ၊ ကြနဟနး၊မငးရႈး၊နန႔ဆန
ရမး ေရ႕ ကငးတ တာခလတ၊ မငးဆတ၊မငးျဖတ၊မငးေယာငး၊မငးယမး10
မးယစေဆးစြေရာဂါကသေရးဌာန အသစမား ၂၀၁၉
တငးေဒသႀကး ဌာနႀကး ဌာနငယရနကန သဃနးကြနးေဆးရမႏေလး မႏေလး၊ ကတင၃၀၀
သငၾကားေရးေဆးရစစကငး ေဖါငးျပင
ဧရာဝတ မအပငကခင မနစ၊ ေရႊက၊ခေဖြရမး ေျမာက သေပါ၊ နမတ၊တန႔ယနး၊ေနာငခ၊သႏၷ
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• MajordrugtreatmentcentersareattachtotheMentalHealthHospitalsandGeneralHospitals– exceptMyitkyina
• Major– Specialist,inpatient(atleast10beds),methadonetreatmentin7majorDTCs
• Minor– outpatient,methadonetreatmentin34minorDTCs
(၁၉၇၄ - ၂၀၁၇) မတပတငလနာဥးေရ ႏင သးစြသညမးယစေဆးအမးအစား
စဥ သးစြသညမးယစေဆးအမးအစား လနာဥးေရ၁။ ဘနးျဖ ၆၀၇၁၆၂။ ဘနးမ ၄၀၃၉၉၃။ စတၾကြရးသြပေဆး ၃၂၀၅၄။ စတျငမေဆး ၃၀၆၅။ ေဆးေျခာက ၇၅၂၆။ အျခား ၅၄၆၂
၂၀၁၈ ခႏစ လနာ အသစ၊ အေဟာငး အေရအတြကàóåÑÉIÑ {=ïÇâáÑX~DçjìaX îäÉãíçéÑlaX~C îäÉãí~xãáÑXlaX~C éâéâ~óÖáÑX
ìÅëáÑ ၃၆၁၄ QTM QMUQ
ééÑìÇâáÑX ONMT OQ ONPN
êbü~îX TQV STP NQOO
CÉÑìâÉÑ QTV QQQ VOP
CpêÑX=E~àêãìÑF TSN NMQ USR
CpêÑX=Eí~CprF ONU O OOM
CpêÑX=E~ïãáÑF U Q NO
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ógÅäX NPN M NPN
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êdÉÑ OQR NUS QPN
éâéâ~óÖáÑX UTVV OMRM NMUQV
၂၀၁၈ လနာ အသစ အသကအပငးအျခား
10 362
16651810
2878
1492
514 68
>15 15-19 20-24 25-29 30-39 40-49 50-59 > 60
၂၀၁၈ လနာ အသစ သးစြသညမးယစေဆးအမးအစား
íêëÇhXíéãX CÉÑìâÉÑ êbü~îX ééÑìÇâáÑX ìÅëáÑCpêÑX
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éÇïÑàáÇêÑ~èX M M M M M M M M M M M M MKMM
éÇïÑjìd~èX NUP RN QN SV QR N N UO OMS PRM NU NMQT NNKVM
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éâéâ~óÖáÑX QTV TQV ONMT PSNQ ONU U TSN NPN OQR PRM NPT UTVV NMMKMM
၂၀၁၈ လနာ အသစ သးစြသညနညးလမးမား
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êëÇh={=éãX PN PN OP SO OR P NP R NT M RQ OSQ PKMM
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í~jìãñÇâX OMV QTR NSRP OTRQ UQ N RPQ PM Q M R RTQV SRKPQ
Cpier M M U VP M M NM M M M M NNN NKOS
íàÅãX M M M M M M M M M M M M MKMM
éâéâ~óÖáÑX QTV TQV ONMT PSNQ ONU U TSN NPN OQR PRM NPT UTVVNMMKM
M
METHADONEMAINTENANCETHERAPY
18
WHO2016RecommendationsforMMT
• AllindividualswhoaredependentonopioidsshouldbeofferedMMT– Policiesshouldencourageflexible
dosingschedules,includinglevelandduration
– HIV,TBandHBV/HCVtreatmentshouldbeadministeredsimultaneouslywithOST
– OSTfacilitiesshouldalsoinitiateandmaintainARTon-site
19WHOHIVConsolidatedGuidelinesforKP2016(http://apps.who.int/iris/bitstream/10665/246200/1/9789241511124-eng.pdf?ua=1)
WHO2016RecommendationsforMMT• Forpeopledependentonopioids,MMTishighlyeffectivein
improvinghealthoutcomesandreducingcriminalactivities– Reducesinjectingbehaviorsthatputopioid-dependentpeopleatrisk
forHIV– ImprovesretentioninHIVtreatment
• MMTshouldbeprovidedfreeofchargeorcoveredbypublichealth-careinsurance
• Shouldbeaccessibletoallthoseinneed,includingthoseinprisonandotherclosedsettings
• MMTshouldnotbecompulsory;patientsmustgiveinformedconsentfortreatment
20WHOHIVConsolidatedGuidelinesforKP2016
UNDP,WHOandUNAIDS2012:GuidanceforSettingOSTTargets
•HowmanyPWIDshouldbeplaceonOST?–ForeffectiveHIVprevention,400per1000PWID(40%)
–Programsshouldtargetabout40%
21WHO,UNODC,UNAIDS2012(https://www.who.int/iris/bitstream/10665/77969/1/9789241504379_eng.pdf?ua=1)
Evidence:MMTdecreasesinjectionbehavior
22Gowing etal2008OralsubstitutiontherapyofinjectionopioidusersforHIVprevention.CochraneReview
• ComparesinjectiondruguseamongcohortsinandoutofMMT• Riskofinjecting13-55%lessamongthoseinMMT
ForPWIDonARTtreatment,MMTincreasesHIVtreatmentadherence• Non-engagementinMMTisassociatedwithHIVtreatmentdiscontinuationamongHIV-positivedrugusers• ThoseonMMTareat0.58timestheriskofHIVtreatmentdiscontinuationasthosenotonMAT(p<0.001)
23
MethadoneMaintenanceTherapy• Startedat3MajorDrugTreatmentCentersin2006withtechnicalassistantbyWHO
• Currently55methadoneclinicsand16,348takingMMT
• TotalcumulativenumberwhoreceivedMMT–39,006
• Scalingup16methadoneclinicsin2019
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NSPIIITargetsonMMTprogram
2018 2019 2020
MMT(currentwholecountryMyanmar) 23316 27658 32000
MMTAchievement 15994
MethadoneclientsinStateandRegionYangonRegion
4%MandalayRegion14%
KachinState45%
ShanState13%
SagaingRegion24%
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ရနကန တငးေဒသႀကး မကသာဒးေဆးခနး - ၂ ခနး လနာ - ၅၉၈ ဦး
ကခငျပညနယ မကသာဒးေဆးခနး - ၁၈ ခနး လနာ - ၇၂၃၅ ဦး
စစကငးတငးေဒသႀကး မကသာဒးေဆးခနး - ၁၅ ခနး လနာ - ၃၈၂၃ ဦး
မႏေလးတငးေဒသႀကး မကသာဒးေဆးခနး - ၄ ခနး လနာ - ၂၁၉၄ ဦး
ရမးျပညနယ မကသာဒးေဆးခနး - ၁၆ ခနး လနာ - ၂၁၄၄ ဦး
PWIDonMethadoneMaintenanceTherapybyStatesandRegions(2015-2018)
- 1,0002,0003,0004,0005,0006,0007,0008,000
Kachin Sagaing Shan Mandalay Yangon
Num
bero
fPWIDonMMT
State/Region
2015
2016
2017
2018
Source:MMTProgrammeReport
MethadoneCoverageSubnational2018
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NumberofMethadone
Clinic
Numberofcurrent
methadoneclient
Numberofnew
methadoneclient
PWIDPopulation
sizeestimate
MMTcoverage
6monthretention
rateHIVpositive HIVtested
YangonRegion 2 598 145 2848 21% 63% 74 397
MandalayRegion 4 2194 422 10095 21.73% 72% 15 339
KachinState 18 7235 3129 21827 33.15% 67% 568 1858
ShanState 16 2144 919 30288 7.08% 59% 89 773
SagaingRegion 15 3823 1757 19064 20.05% 64% 277 1760
RESULT
TrendsofHIVprevalenceamongmostatriskpopulation,HSS2000-2018andClientsonMethadone2006-2018
02000400060008000100001200014000160001800020000220002400026000280003000032000
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2016 2018
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PWID
FSW
#MMT
MSM
ProcurementofMethadone(2011-2019)Year Numberof
bottleUnitprice
USDYearwisetotal
USDFunding
2011 5,718 32.00 182,976 GlobalFund
2012 5,816 30.20 175,643 GlobalFund
2013 10,575 30.20 319,365 GlobalFund
2014 21,811 30.20 658,692 GlobalFund
201525,585 23.60 603,806 GlobalFund
9,125 23.60 215,350 MOHS
2016 37,510 20.50 768,955 GlobalFund
22,400 20.50 459,200 MOHS
2017 54,200 17 921,400 MOHS
2018 32,200 16 515,200 GlobalFund
2019 41,349 16 661,584 GlobalFund
RESEARCH
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1.EFFECTIVENESSOFMETHADONEMAINTENANCETHERAPYINMYANMAR(2018)DDTRU&WHO
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MMTtreatmentoutcomes:Clientretentioninmethadonetreatment
0%
10%
20%
30%
40%
50%
60%
70%
80%
>=6months >=12months >=18months
KALE(n=363) MUSE(n=283) YANGON(n=641) MYITKINA(n=367)
MONYWA(n=37)
Note:Allclientswhohadcompleted6monthsonMMTormorewereincludedinthisanalysis.Thoseclientstransferredoutwereexcluded.Retentionfor>=18monthsormorenotshownforMonywa duetosmallsample. 35
PredictorsofretentioninMMT
ThesinglemostconsistentpredictorofretentioninMMTinallsiteswas“receivingamethadonemaintenancedoseequalorabove60mg/day”.• Dailymethadonemaintenancedose≥60mgwasapredictorof6
to12monthsandmorethan12monthsretentioninKale,Muse,YangonandMyitkyina;
• DemographicfactorspredictingMMTretentionwerebeing30yearsorolderinKaleandMyitkyina,andbeingmarriedinMuse;
• ThesampleinMonywa (n=37)didnotallowformultivariableanalyses.
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FactorsdeterminingMMTretention
Variables >=6MMT<12months(reference:MMTdiscontinued)
MMT>=12monthsorcomplete(reference:MMTdiscontinued)
30yearsorolder(ref:<30years)
Kale:OR=2.4 (95%CI:1.2-5.1)*Myitkina:OR=1.1 (95%CI:1.0-1.2)
Kale:OR=2.1(95%CI:1.1-3.9)*Myitkina:OR=1.1 (95%CI:1.0-1.2)
Beingmarried(ref:single)
Muse:OR=3.3(95%CI:1.2-9.1)*
Methadonedose≥60mg/day(ref.<60mg/day)
Kale:OR=3.9 (95%CI:1.8-8.4)*Muse:OR=2.8 (95%CI:1.1-7.8)*Yangon:OR=7.5 (95%CI:4.1-14)*Myitkina:OR=2.8(95%CI:1.1-7.2)
Kale:OR=5.6 (95%CI:2.8-11.2)*Muse:OR=4.3(95%CI:1.8-10.5)*Yangon:OR=9.0 (95%CI:5.3-15.0)*Myitkina:OR=6.0 (95%CI:1.9-18.5)
Heroin(ref.opium) Non-significant Non-significant
Injection(ref.non-injection) Non-significant Non-significant
Morethandailyuse(ref.lessthandaily)
Non-significant Non-significant
Note:CI=ConfidenceInterval.*Regressioncoefficientp-value≤0.05.Multivariablemultinomialregressionmodelsadjustedforvariablessignificantatp<0.200inunivariateanalysis.Variablesadjustedforwereage,drugtype,frequencyofuse,administrationroute,MMTdoseandHIVtestinginKale(n=363);age,maritalstatus,treatmentoptionandMMTdoseinMuse(n=283);age,methadonemaintenancedose,HIVtestandHBVvaccinationinYangon(n=641)andagemethadonemaintenancedose,sharedneedlesandsyringesanddurationofdruguseinMyitkina (n=367).UnivariateanalysesonlyweredoneforMonywa duetothesmallsample(n=37).ThereferencegroupisthosewhodiscontinuedMMT.
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DiscussionØ AdaptMMTservicestoclientcharacteristics ineachsite(eg.youngMMT
clients);roleoffunctionalsupport(forMMTclientswhoaresingle).Ø GoodretentioninMMTatmaintenancedose≥60mg/day;Explorereasonsfor
lowdosesandsolutionstodeliverthem.Ø MMTconstitutesagoodentrypointfordruguserstoaccesspreventionand
treatmentforHIVandhepatitisBandhepatitisC.Ø ExpandavailabilityofHIV,hepatitisBandCtestingservicesandtestkitsinMMT
sites;Ø Waysofreflectingreferralsinone-stopsitestotrackprogress?Ø Challengeofmeasuringchangeindruguseandriskbehavioursovertime;
follow-updatacouldbecollectedat3/6months.
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2.HARMREDUCTIONSERVICEAVAILABILITYANDLINKAGEFORPWIDSAMONGPUBLICANDPRIVATESERVICEPROVIDERS(2018)
39
• IRprojectID– 46• FundedbyMinistryofHealthandSports• Dateofreceivinggrant- 1September2017• Estimateddateforfinalreporting- 31March2018
40
Findings• usingdifferentidentificationclientcodes• lackoffulltimemedicalofficerinmethadoneclinic• takehomemethadonepracticeneedtofollowtheguideline
• clientassessment andurineanalysis– notregularbasic• dropout/defaultertracingcouldnotbedone• MisperceptionsofcommunitytowardMMT,harmreductionservices,particularlyneedlesyringeprogram
41
RECOMMENDATIONS• Patientuniqueidentifiersystemshouldbeestablishedfor
properandvalidrecordingofdrugusersandstrategicplanning
• MMTexpansionisrecommendedconsideringoperationalfactors
• HumanresourceproblematMMTclinics,posingbarrierforeffectiveserviceprovisionshouldbesolvedurgently
• CommunityawarenessraisingonMMTservicesshouldbeorganized
42
RECOMMENDATIONS(cont;)• Self-helpgroupsshouldbestrengthenedinvolvingallNGOs
andMMTprogramme forrecoveryfromsubstanceusedisorderandtoadvocatethecommunity
• FuturestudyoncommunityacceptanceandlookingatHRserviceaccessibilityandbarriersfromclientperspective
• RecommendedtodevelopthenationalguidelineofharmreductionforPWIDsforstandardizationofserviceprovisionandreferralamongserviceproviders
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3.HIV,HEPATITISBANDHEPATITISCANDRETENTIONINCAREAMONGSTPEOPLEWHOINJECTDRUGSANDAREPLACEDONMETHADONEMAINTENANCETHERAPY,YANGON,MYANMAR
0.2
.4.6
.81
Prop
ortion
retai
ned
0 .5 1 1.5 2 2.5 3Years
630 421 295 197 108 49 0 Number at risk
95% CI Survivor function
Kaplan-Meier survival estimate
Kaplan-Meier plot showing retention rates (and their 95% confidence intervals) amongst PWID enrolled for MMT in Yangon, Myanmar: 2015 to 2017
Retentionat3yrs46% (41-52%)
Retentionat6mnths76%(72-79%)
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CHALLENGESANDWAYFORWARD
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Challenges• TreatmentGap– somedrugtreatmentcentersarenotfullfunction,
emergingtrendofstimulantdruguse,LowCoverageofMMT<20%• Notenoughhumanresourcefordrugtreatmentworkforce• Relapse/Dropoutrelatedmainlytotransportationand
unemployment• Psycho-socialsupportcomplimentarytotheholisticcareand
treatment• M&Esystemformethadoneprogram• Stigmaanddiscrimination
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WayForward• DeveloptheNationalStrategicPlanforNationalDrugControlPolicy
• DevelopmentofMentalHealthPolicy• ReviseandpublishtheMethadoneGuideline3rdEdition
• ProcurementofMethadonefromDomesticmanufacturebyBPI,MinistryofIndustry
• DeveloptheguidelineandSOPfordrugtreatmentcenters
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WayForward(cont:)• OverdosepreventionandNaloxonedistribution• Telementoringprogramamongdrugtreatmentcenters• Operationalresearch– femalePWID,communityacceptance,clientperspective,changeindrugtypeofuse,riskbehavior andcosteffectivenessstudy
• Scalingupthemethadoneclinicsconsideringoperationalfactors
49
Conclusion• Substanceabuseinruralandurbanareasisamajorpublichealthconcern.
• Preventionisstillveryimportantandshouldbehighlighted.
• Addictionisadiseaseandshouldbefocusedonbiopsychosocialandbehaviorchangeaswell.
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THANKYOUVERYMUCH
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