towards a public health response for preventing the spread of hiv amongst injecting drug users...

International Journal of Drug Policy 10 (1999) 375–383

Towards a public health response for preventing the spreadof HIV amongst injecting drug users within Nepal and thedevelopment of a treatment, rehabilitation and prevention

programme in Pokhara

Peter Dixon *Drug Education Programme Manager, 35 Woodlands Dri6e, Hoole, Cheshire CH2 3QQ, UK

Abstract

Within Nepal there remains an urgent need to develop strategies and policies aimed at reducing the spread of HIVinfection amongst injecting drug users. Programmes currently operating within the country need to be evaluated andthese programmes need to be expanded and strengthened and encouraged to work together in a more cohesive way.A programme for drug users in Pokhara, Nepal which was initiated in 1994 is attempting to provide an integratedand co-ordinated approach, and to give a comprehensive range of services to Nepali people which includes education,prevention, treatment, support, care and rehabilitation in a way which is both culturally appropriate and sensitive tothe local scene. © 1999 Elsevier Science B.V. All rights reserved.

Keywords: Public health responce; Preventing the spread of HIV; Injecting drug users

www.elsevier.com/locate/drugpo

1. Introduction

Nepal is one of the world’s poorest coun-tries. As a result, the health status is deficientdue to major factors such as poor nutrition,inadequately protected water supplies andovercrowded, poor housing. Although thegovernment is making many efforts to meetthe health needs of the population, there arestill many areas that need to be addressed

including substance abuse. In the urban cen-tres the combination of poverty and wealth,increased educational opportunities plus ris-ing unemployment have created an environ-ment within which wealthy, educated youthand others less fortunate, who have little or noprospects for the future, are increasingly beingdrawn into substance use.

2. Initial assessment of the drug problem andintervention strategies

Although the misuse of drugs within Nepal* Tel.: +44-1244-319-477.E-mail address: [email protected] (P. Dixon)

0955-3959/99/$ - see front matter © 1999 Elsevier Science B.V. All rights reserved.

PII: S 0955 -3959 (99 )00018 -3

P. Dixon / International Journal of Drug Policy 10 (1999) 375–383376

is not a new phenomenon patterns of alcoholand drug use are changing rapidly. Sub-stances such as ganja (cannabis) have beentraditionally used for many centuries. How-ever, in the last decade there has been a veryclear shift away from the use of such tradi-tional drugs towards patterns of polydruguse. Polydrug use includes the use of coughmedicines, opiates such as heroin andbuprenorphine, cannabis, as well as benzodi-azepines mainly Diazepam and Nitrazepamwhich were often used in conjunction withalcohol. It is now widely accepted in Nepalthat drug use is a major problem affectingboth rural and urban youth but very few‘hard facts’ detailing the extent of the prob-lem existed at that time. Following a generalrecognition amongst Government officials,NGO’s and INGO’s of the increasing trendof drug use by Nepali youth the need forsome investigation into the extent and natureof drug problems in Western Nepal becameapparent.

Between 1994 and 1995 the InternationalNepal Fellowship’s (INF) Drug Programmecarried out a survey into the prevalence ofdrug misuse among young people in Pokhara(precise population size is unknown but isestimated at 200 000), west of Kathmandu.The survey was the first of its kind under-taken in the country at that time and subse-quent evidence suggests that the resultsaccurately reflected patterns of drug misusein other urban centres of Nepal such asKathmandu, Biratnager and Butwal. For thepurposes of this study a ‘key informant’ ap-proach was used, conducted by Peter Dixon,an English language speaker and ShantaMaya Shrestha whose first language isNepali. Key informants were drawn from avariety of backgrounds, including ward (geo-graphical areas within the city) chairpersons,youth club leaders, teachers, doctors, reli-gious leaders, and medical hall shop owners.

In total 144 people were given in depth inter-views usually lasting 1 h or longer. Only onestructured questionnaire was used and mostof the interviews were conducted in Nepali.Whenever possible, respondents were‘probed’ to give greater clarification and wereencouraged to give as much information aspossible. Because there is no established wayin Nepal of contacting drug misusers, re-sourcefulness and initiative was required inorder to do this. However, by adopting the‘snowballing’ method we were able to makecontact with a considerable number of drugusers and subsequently over half of thoseinterviewed were either drug users or ex-drugusers.

During the course of our investigation webecame aware of a number of differentgroups of drug users of whom a significantpercentage were injecting. In Pokhara, as inKathmandu, significant increases in the num-ber of people using Tidigesic (otherwiseknown as buprenorphine and is available inliquid form) with a rapid transition fromnon-injecting to injecting drug use have beenobserved. Most drug users in Pokhara buybuprenorphine in India and patterns of druguse in Nepal are rapidly influenced by theprevailing patterns in India. This is evidencedby the rapid spread of injecting and tablet useamong drug users in Nepal. There has been arapid spread of illicit buprenorphine injectingin many communities in Indian states. Dis-cussions with users suggests that the cost ofbuprenorphine in Nepal is much less thanheroin. The transition, therefore, from herointo buprenorphine appears to have been madefor mainly economic reasons. Heroin suppliesbeing mainly reserved for affluent Nepalipeople and the tourist market. Buprenorphine has become most people’s drug ofchoice.

Of the 2700 clients contacted since theprogramme began subsequent to the survey,

P. Dixon / International Journal of Drug Policy 10 (1999) 375–383 377

44% are IDU’s. At the time of the surveymost IDU’s reported needle sharing betweenfriends. Although most realised the need forneedle hygiene their knowledge of effectivecleaning methods was inadequate. Thesecleaning methods were categorized into fivedifferent groups: those using distilled water,those using tap water, those who were shak-ing out their equipment, those who usedsaliva and those who used savlon (obtainablein liquid form).

The survey clearly showed high levels ofdrug misuse together with significant levels ofhigh-risk behavior, including inadequateknowledge in relation to ways of preventingthe spread of HIV. The survey work laid thefoundation for the future strategy and direc-tion of the programme. There was an obviousneed for harm reduction activities including aneedle exchange programme to be imple-mented as soon as possible as well the needfor a rehabilitative component to the pro-gramme. Many of the drug users met wererequesting help as at that time but few ser-vices, with the exception of Fr Gavney’s‘Freedom Centre’ and the ‘Life Giving andLife Saving Society’ (LALS), both based inKathmandu, were available to them withinNepal. LALS began work in 1991 with twopart-time volunteers and now has eight out-reach workers. It is a street based outreachservice which provides a needle exchange,primary health care and HIV prevention edu-cation and is presently in the process of es-tablishing a drop-in centre.

2.1. A proposed strategy for using acommunity based approach for alcoholconsumption in Nepal

An important factor, which emerged fromthe survey, was the extensive use of alcoholand in particular of the home brewed spirit,‘raksi’. There have been no attempts, that

this author is aware of, to quantify theamount of raksi consumed in Nepal but itwould seem to be high relative to that ofother countries. If this is the case then theconsumption of alcohol is likely to be a ma-jor factor in the health problems of the coun-try. This is increasingly the case when therelationship between alcohol and nutrition isconsidered. The grain used for distilling isvery often the same supply which would oth-erwise have been used for feeding the family.As Nepal remains one of the poorest coun-tries in the world, and it is certainly thepoorest within Asia, most families are livingby subsistence farming and cannot in healthterms afford to waste grain brewing raksi.

Our survey sample reported alcohol use ingreat detail. Users stated that the effects ofbuprenorphine were enhanced by alcohol. Al-cohol and tablets were very often used to-gether. Other research work needs to becarried out into the nature and extent ofalcohol abuse in the country and interven-tions established that are directed at thewider community. Many myths surround theuse of alcohol in Nepal and there is a need todevelop culturally appropriate Health Pro-motion and Drug/Alcohol materials. Mythsvary but include ideas such as drinking raksiand eating meat or eggs as a snack to go withit, is good and healthy. Resources are limited.Health problems associated with alcohol con-sumption need to be identified and imple-mented as early as possible and integratedinto the existing health systems. There maybe advantages in resisting classifying alco-holism as a special disorder as has happenedin the West. Potentials for treating peoplewith such problems already exist in Nepal.Traditional faith healers, rural health clinicsand other resources need to be utilised andresourced with information and training thusenabling the early detection and response to


alcohol use. Prevention work in this particu-lar field needs to be further developed andexpanded as well as resourced.

It has already been mentioned that anywork initiated within Nepal in the area ofsubstance abuse needs to be integrated intoexisting community health structures and ser-vices and adapted so as to make them cultur-ally appropriate and applicable. For examplecentral to a programme of prevention shouldbe the development of a vocabulary and be-haviours, which enables people to either ac-ceptably refuse alcohol or stop after drinkinga safe amount. The original survey workhaving indicated that culturally there is littleor no concept of ‘sensible drinking’. Thedefinitions of what are ‘safe amounts’ wouldneed to be taught. Certain phrases alreadyexist within the English language in collo-quial expressions such as ‘say when’. Withinthe Nepali language and culture there doesnot appear to be any such readily availablephrases with which a person can use to indi-cate when they have consumed enough. How-ever, there are words and expressions inrelation to food that could readily be adaptedfor the use of alcohol. These include wordssuch as ‘pugio’ (enough), ‘deri buyo’ (com-pleted) and ‘ectdum laagyo’ (more thanenough). Within certain ethnic groups it isacceptable to consume considerable amountsof alcohol, especially on specific occasionsand festivals, of which there are many in theHindu and Buddhist calendars. Culturallyappropriate materials and strategies need tobe developed aimed at changing the socialnorms of these groups and thereby integrat-ing the idea of sensible drinking thereby en-couraging people to exercise control overtheir consumption habits.

Central to the notion of a communityhealth programme being established is theeducation of women who are the producers

of alcohol in rural Nepal and to a lesserextent in urban environments. Althoughthere is considerable sexual inequality withinNepal, women among certain ethnic groupsdo play a key part in the decision makingprocesses within the family unit. Men alsoneed to be targeted but the task of changingattitudes towards alcohol consumption willnot be an easy one.

Regulations governing the sale of drugsneeds clarification. In particular there are noregulations governing the sale and produc-tion of alcohol although tighter legislation onthe sale of pharmaceuticals has been intro-duced in the last few years. Opiates are con-trolled and it is an offence to sell or be inpossession of these kinds of drugs. However,over the last few years there has been amarked increase in the production of andadvertising of different types of alcohol, duein part to the arrival of multi-nationals in thecountry. This can only lead to further healthrelated problems in relation to alcohol in thefuture.

There is an urgency for further research tobe carried out into the consumption of alco-hol and health related costs to the country aswell as into the extent to which pharmaceuti-cal drugs are being used both legitimatelyand illegitimately. Greater understanding ofcurrent trends and facts in relation to alcoholconsumption need publicising, raising publicawareness and hopefully stimulating publicdebate.

3. Service provisions

Following the initial survey work, a pro-gramme for drug misusers was initiated at thebeginning of 1995. More than 4 years havepassed by since the programme began work-ing.. It has been an incredibly eventful and


encouraging 3 years; many young peoplehave been treated and helped in differingways during this time. The main aim hasbeen to provide a comprehensive range ofservices for drug users and their familieswhich includes a ‘treatment and counsellingcentre’ (Naulo Gumty), a residential facility(Naulo Awas), outreach work as well as drugprevention work within the community. Theharm reduction activities have largely con-centrated upon targeting IVDU’s. The pro-gramme serves not only people who are livingwithin Pokhara but also treats others fromelsewhere within Nepal.

3.1. The ‘counselling and treatment centre’(Naulo Gumty)

Since opening, we have established a‘counselling and treatment centre’. The centreis now proving to be well attended by drugmisusers. Mention has already been made ofthe fact that since the programme openednearly 2700 drug users have been contactedwithin Pokhara and that almost 44% of theseare injecting drug users. Not only are theyinjecting but it is a fairly common practice toshare needles and syringes between friends.Although many drug users are aware of HIV/AIDS and most realize the need for needlehygiene their cleaning methods are still inade-quate. However, through health educationand outreach work, awareness amongst drugusers about HIV/AIDS and drug related dis-eases are being raised. One of the aims of theprogramme is to reduce the numbers whoreport sharing injecting equipment. The pro-gramme runs a needle exchange schemethrough the local hospital and through it’soutreach workers. However, in the next yearthere is an urgent need to extend the accessi-bility of needles and syringes to IVDU’s aswell as to begin a drug substitution pro-gramme, possibly using buprenorphine. For

both initiatives, it would be helpful if thegovernment gives a clear policy and guideli-nes relating to harm reduction issues thusallowing us and other NGO’s to initiate ac-tivities without fear of reprisals. The need forthe further implementation of harm reductionactivities nationwide is urgently being high-lighted by the fact that we are repeatedlyseeing more and more people coming to the‘counselling and treatment centre’ who areHIV positive.

People are not only injecting drugs such asheroin and buprenorphine but tranquillisersalso, are increasingly being used. Since theprogramme began patterns of drug misuseappear to be constantly changing. Recordsshow that there has been a marked increasein the use of tablets, mainly benzodiazepinesi.e. Nitrazepam, Librium and Valium, whichare often consumed in conjunction with alco-hol. Young people continue to experimentwith drugs and often begin with tablets. Theprogramme’s outreach workers report thatthe age at which people are beginning to usedrugs is dropping and that they are increas-ingly coming into contact with 12 and 13 yearold children who are using benzodiazepines.

3.2. Accommodation patterns and thein6ol6ement of families in the treatmentprocess

The programme provides help, detoxifica-tion, counselling and many other services fordrug users and their families, who want to dosomething about their problem. One of themost surprising indications of the originalsurvey was in relation to the accommodationpattern of drug users. Only a very smallpercentage actually lived away from home.Most drug users whether married or unmar-ried are living with their parents. A total of98% of single people were still living with


their parents and 96% of married people werealso living with their parents. This presents avery different picture to that which is nor-mally seen in many developed countries inthe West. The accommodation patterns ofdrug users clearly had implications for thenature of any treatment and prevention strat-egy devised by the programme which wouldneed to educate the parents as well as theuser and utilise the family as a support net-work. The family, the drug user as well asother people affected by his or her drug use,would also need to make appropriate changesif any interventions were to be successful. Asfar as possible, therefore, the family was inte-grated into the treatment process and familiesspecifically targeted in prevention work car-ried out within the community.

One of the main principles underlying ourphilosophy is that the family must share inthe responsibility of the work done with theirsons. Relatives are asked to come with theirsons to the ‘treatment and counselling centre’every day and then to collect them at the endof each day; they must also be involved inweekly family meetings. The drug users workon the land in the morning, cook and eatlunch together and then during the after-noons are involved with therapeutic activitiessuch as seminars, counselling, family andgroup work etc. They will normally attendthe centre on a daily basis for about 6 weeksbefore going on to the residential facility fora further 4 months.

3.3. Further areas for future research

It has been good to see the programmedevelop and expand over the last few yearsbut a lot more work remains. As well asincreasing the programmes harm reductionactivities we also intend to carry out HIVprevalence monitoring of five different clientgroups every 6 months. In this particular

study, consent to having a blood sampletaken may vary between different types ofIDU’s. For this study it will be important toinclude in the survey the following groups ofIDU’s:1. Those who are attending programme for

treatment;2. Those who are known to the drug educa-

tion programme’s outreach workers;3. Those who are new contacts for the out-

reach workers;4. Drug users (tablets users only);5. Young men aged 18–25 years who are

non-drug users. To avoid bias theseyoung men should not be users of thesame tea shops or otherwise be known tomix socially with drug users.

This should not only give an indication oftrends over a period of time but also give theprogramme a tool for monitoring the effec-tiveness of harm reduction activities withinPokhara as well as indicating what kinds ofAIDS care facilities may be required in thefuture. It is essential that programmes haveaccurate knowledge about the prevalence ofHIV among drug users. To date, backgroundprevalence of HIV is unknown within Nepal.Accurate information may well increase levelsof awareness among drug users and of itselfpromote less risky behaviour.

3.4. Detoxification and abstinence

While at the centre the majority of clientswill embark on a programme of detoxifica-tion. The opiate users, i.e. buprenorphine andheroin users, are treated with a combinationof librium and low dose sub-lingualbuprenorphine over a 9 day period. Thisproved to be a very successful interventionfor these types of opiate users, with very fewsevere symptoms having been experienced.Central to the programmes strategy has been


the underplaying of the importance of detox-ification as part of the treatment process.Many drug users during the initial assessmentperiod maintain that detoxification is all thatis required. The staff have always emphasisedthat this is actually the easiest phase of recov-ery from drug use and that the real ‘work’begins after detoxification. Discussions withmany drug users have highlighted a mythprevalent among them that detoxificationalone is usually enough. However, most re-lapse quickly and this only serves to heightentheir sense of low esteem and in some casesleads to even more chaotic drug use. Thosegenuinely wishing to pursue abstinence notonly require detoxification but also need tolearn how to maintain abstinence. The ‘coun-selling and treatment centre’ effectively offerspeople a time of preparation before embark-ing on a detoxification programme. Alterna-tively, it enables those who do not wish tobecome drug free a chance to stabilise theirlifestyles and lead less risky life styles as aresult.

For those wishing to pursue abstinence asa goal a residential facility (Naulo Awas) wasopened and already we are encouraged to seesome ex-clients who have managed to remaindrug free. The facility has 20 beds and a staffteam of eight. Residents normally stay for aperiod of 4 months and during that time livetogether within an intensive therapeutic com-munity, learning about themselves, how theyrelate to each other, their strengths andweaknesses and how they can avoid futuredrug misuse. The facility, therefore, aims toprovide a caring, supportive environment inwhich the ex-drug user can feel secure enoughto allow real change to take place so that hecan develop his real potential. For this tohappen he also needs other people who arestrong enough in themselves to confront hisbad habits and wrong attitudes whilst clearlycontinuing to care about him during thisprocess.

3.5. Implementing community action

In recent years, developed countries haveseen intervention strategies move from theuser of a drug to the general community ofpotential users. In other words from treat-ment to prevention. One of the reasons forthis may be the perception that treatmentprogrammes have failed and not producedsignificant enough results with those who arealready addicted as well a general shift inthinking in health towards preventing drugmisuse before treatment becomes necessary.

A new aspect of the programme was begunin 1996 called the drug prevention initiative(DPI). This is a community based initiativeseeking to prevent the spread of drug misuseamongst young people, as well as to raisepublic awareness about the problems associ-ated with drug abuse, alcohol abuse andHIV. It aims to help break down the stigmaof drug use within society by strengtheningthe capacity of local groups to do somethingabout the problem in their own community.In any culture there will be established normsdealing with the consumption of drugs. Thesewill govern, to varying degrees, what thatculture will accept or tolerate and whether ornot it will take action against it. It is, there-fore, important that any community educa-tion begins with an understanding of whatthese norms are in the community beingtargeted and if possible strengthen them orwork to develop new ones that are existentwithin the culture.

For Nepal there are many complicatingfactors influencing community work, one be-ing the large amount of different ethnicgroups. After some initial survey work withinone ward of Pokhara (there are 19 wardsaltogether) the two new members of staff inthis team decided to concentrate work on aparticular area of Pokhara to begin with,rather than targeting a large area with many


diverse communities within it all at the time.Work began by community leaders forming aworking committee who then decided to se-lect and train volunteers form their ward. Adoor to door programme was initiated withthe aim of teaching parents new skills indealing with the drug problem in their owncommunities. Much of the work accom-plished so far has been in one to one meet-ings as well as meeting people in smallgroups. In Nepal these meetings are usuallyheld under a ‘Pipal tree’. Alternative activitiesare being established which will give youngpeople something constructive to do withtheir free time. It is an exciting developmentand the ward members are enthusiastic aboutthe work which has been accomplished sofar. Community members need to become ‘apart of the solution’ and the DPI team ishelping them to achieve that.

3.6. The role of the go6ernment

Since Nepal became a democracy in 1990the country has struggled to find a stronggovernment. No one party has remained inpower for longer than a year. There does,however, appear to be a change in attitude ofsuccessive governments which has been stim-ulated by its growing concern in relation toinjecting drug use within the country. Policiesare currently being drawn up but in certainareas a greater clarification is required espe-cially in relation to harm reduction policies.NGO’s, for example, are uncertain as towhether or not it is acceptable to establishneedle exchange schemes in their areas.Presently, establishing a scheme would ap-pear to be acceptable as long as it does notraise objections from within the local com-munity. This is not always easy to achieve.Our own programme established a needleexchange scheme from a drop-in centre,which resulted in a backlash from the local

community. Several meetings were held withcommunity members with a view to influenc-ing their attitude towards drug users andhopefully encouraging their acceptance of theaims of the drop-in centre. Our attemptsfailed to change opinion and the scheme waseventually moved to the Western RegionalHospital. Often it seems to be the case thatdrug programmes are welcomed everywherein the world as long as they are not onpeople’s own doorsteps. Without communityeducation, government policies will not beable to facilitate lasting change but to achievethis a considerable amount is required at thelocal level to really change public attitudes.

4. Conclusion

Substance misuse use has spread rapidlyover the last 10 years in Nepal. Increasingnumbers of people are becoming infectedwith HIV and there is, therefore, a need toconsiderably expand the effectiveness of ex-isting programmes within the country so thatthe threat to public health can be reduced.Although, there are over 70 NGO’s registeredwith the government to work in this area,only a few are able to work effectively. Inpart, this is due to a lack of resources butmore importantly to a lack of expertise. Theoverriding philosophy of some NGO’s is theunrealistic goal of total eradication of drugmisuse within the country and there is a lackof trust in the effectiveness of harm reductiontechniques. Much needs to be done in chang-ing these attitudes as a matter of some ur-gency. Programmes currently operatingwithin the country need to be evaluated andexpanded with more co-ordinated activity be-tween them. These activities must include anincrease in the availability of clean needlesand syringes as well as the distribution ofbleach and cleaning equipment. Dr D.


Shrestha, the Superintendent of Patan’s Psy-chiatric Hospital, Kathmandu is the only per-son currently running a substitutionprogramme in Nepal using methadone. Fur-ther substitution programmes need to be es-tablished in all urban centres andconsideration needs to be given as to whetheror not buprenorphine should be used as adrug of substitution. Since this is most IDU’sdrug of choice at the moment, provision ofbuprenorphine may well serve to attract morepeople into treatment. However, such initia-tives can only be freely implemented if thereis a supportive policy from HMG/N.

The drug programme in Pokhara has at-tempted over the last 5 years to provide acomprehensive range of services to the Nepalipeople, whilst beginning to collate clearstatistical data in relation to patterns of drug

use in Nepal. Data between NGO’s needs tobe pooled and evaluated on a regular basis.Outreach has been an important and neces-sary component of the work in order toprevent the epidemic spread of HIV into thecommunity. However, a key aspect has beenits provision of a treatment service for drugusers and their families. Attempts have beenmade to make these services as accessible aspossible. In view of the importance of thefamily within Nepal, the programme has en-couraged family members to be involvedwithin the treatment process. In both devel-oping and developed countries considerationmust be given to making programmes asappropriate as possible to their cultural con-texts, otherwise these programmes will not beaccessed by nationals.

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towards a public health response for preventing the spread of hiv amongst injecting drug users...

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