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The trajectory of methadone maintenance treatment in Nepal
International Journal of Drug Policy 24 (2013) e57–e60
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
The trajectory of methadone maintenance treatment in Nepal Atul Ambekar a,∗ , Ravindra Rao a , Anan Pun b , Suresh Kumar c , Kunal Kishore d a
National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi 110029, India Recovering Nepal, Kathmandu, Nepal c T Nagar, Chennai, India d United Nations Office on Drugs and Crime-Regional Office for South Asia, New Delhi, India b
a r t i c l e
i n f o
Article history: Received 15 October 2012 Received in revised form 19 February 2013 Accepted 3 June 2013 Keywords: Opioid substitution treatment People who inject drugs HIV prevention
a b s t r a c t There are about 28,500 people who inject drugs (PWID) in Nepal and HIV prevalence among this group is high. Nepal introduced harm reduction services for PWID much earlier than other countries in South Asia. Methadone maintenance treatment (MMT) was first introduced in Nepal in 1994. This initial small scale MMT programme was closed in 2002 but reopened in 2007 as an emergency HIV prevention response. It has since been scaled up to include three MMT clinics and continuation of MMT is supported by the Ministry of Home Affairs (MOHA; the nodal ministry for drug supply reduction activities) and has been endorsed in the recent National Narcotics policy. Pressure from drug user groups has also helped its reintroduction. Interestingly, these developments have taken place during a period of political instability in Nepal, with the help of strong advocacy from multiple stakeholders. The MMT programme has also had to face resistance from those who were running drug treatment centres. Despite overcoming such troubles, the MMT programme faces a number of challenges. Coverage of MMT is low and high-risk injecting and sexual behaviour among PWID continues. The finance for MMT is largely from external donors and these donations have become scarce with the current global economic problems. With a multitude of developmental challenges for Nepal, the position of MMT in the national priority list is uncertain. Ownership of the programme by government, a cost-effective national MMT scale up plan and rigorous monitoring of its implementation is needed. © 2013 Elsevier B.V. All rights reserved.
Introduction Nepal has concentrated HIV epidemic among certain population groups, including people who inject drugs (PWIDs). The policy environment in Nepal has not been unfavourable to a harm reduction response to preventing the spread of HIV and Nepal initiated harm reduction services for PWIDs, including needle exchange programmes (NEP) and methadone maintenance treatment (MMT) much earlier than in other countries in South Asia. In fact, Nepal was the first country in South Asia to introduce MMT for opioid dependent people who use drugs. The trajectory of the MMT programme serves as an interesting case study, with implications for other developing countries with emerging or established HIV epidemics among PWIDs. The paper discusses salient issues to support learning for other countries in the region. We have relied upon our
∗ Corresponding author at: National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi 110029, India. Tel.: +91 11 26593236/9811155682; fax: +91 11 26588641. E-mail addresses: [email protected] (A. Ambekar), [email protected] (R. Rao), [email protected] (A. Pun), [email protected] (S. Kumar), [email protected] (K. Kishore). 0955-3959/$ – see front matter © 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.drugpo.2013.06.001
own experience of working on MMT in Nepal and have conducted a desk review of relevant documents. While buprenorphine based substitution treatment is also available, it is much smaller in scale and scope and therefore we restrict our focus to MMT. Injecting drug use and related HIV prevention services in Nepal Nepal has a long history of drug use. Cannabis was sanctioned for use on certain religious occasions, and occasional use of alcohol was tolerated socially. Reports of heroin use started appearing by the 1960s, and by the 1980s the number of heroin chasers had increased considerably. The next decade saw a shift in the pattern of drug use from heroin chasing to injectable opioid preparations such as buprenorphine (Reid & Costigan, 2002). A rapid situation assessment carried out in 1996 showed that 40% of drug users had injected drugs at least once in their lifetime; 66% PWIDs had injected buprenorphine and 20% had injected heroin (Ray, 2000). A study by Central Bureau of Statistics (2007) estimated that 61% of the 46,309 current ‘hard drug’ users were PWIDs (i.e. 28,439 PWIDs in Nepal). A recent nation-wide mapping study estimated the number of PWIDs to be in the range of 30,155–33,742. Among the PWIDs surveyed, a high proportion noted sharing needles/syringes and few reported using condoms (HSCB and NCASC, 2011). In 2011
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HIV prevalence among PWIDs was estimated at 6.3% in Kathmandu and 4.6% in the Pokhara valley (National Centre for AIDS and STD Control, 2012). Nepal was the first country in South Asia region to introduce NEP in the 1980s. Though HIV prevention services for PWIDs have been scaled up in recent years, the coverage remains low. The IBBS Round V survey conducted in 2011 showed that in the preceding year, only about 47% of PWIDs in Kathmandu and 82% in the Pokhara valley interacted with a peer educator/outreach worker, 2.9% and 3.5% visited a sexually transmitted infection (STI) clinic, and 20% and 31.3% visited a HIV testing centre (NCASC, 2011). The size estimation exercise conducted in 2011 also shows that in terms of services available for PWIDs, only one-third had access to a NEP, condom outlet or voluntary counselling and testing service within one kilometre of drug use hotspots (HSCB and NCASC, 2011) implying that much needs to be done to achieve universal access to HIV prevention services for PWIDs.
Methadone maintenance therapy in Nepal The first MMT clinic was introduced in a psychiatric hospital in Kathmandu in 1994 with the objective of “preventing relapse, facilitating recovery and reducing overdose, risk of HIV, hepatitis and other infections among drug users” (Shreshta, 2000). The clinic had a medical doctor and a trained nurse working under the supervision of a psychiatrist. Methadone was dispensed as a tablet of 40 mg (unlike the current practice of dispensing liquid form), and most clients received a maintenance dose of 40 mg daily. Each client paid a subsidised amount, roughly 25 US cents for a full dose of 40 mg methadone. By 2001, about 270 clients had received methadone (Burrows, Panda, & Crofts, 2001). Guidance for implementing MMT was also prepared. Yet, despite such efforts, the clinic was closed in 2002. While the reasons and consequences of such a closure have not been documented systematically, anecdotal reports show that factors including political instability, unfavourable public opinion, concerns about the illegal diversion of methadone and financial constraints led to the closure of the MMT clinic (Jha & Plummer, 2012; Lawyers Collective, 2007; Max, 2010). Worryingly, this closure occurred when HIV prevalence among PWIDs was estimated to be as high as 68% in Kathmandu (NCASC, 2011). MMT was reintroduced in 2007 and while there is little information about what happened to the clients in these five years, reports have suggested some medical casualties among drug users (Sharma, 2011). Elsewhere, the negative consequences of the closure of MMT clinics on drug use, criminal behaviour and HIV risk of PWIDs have been well documented (Grella, Anglin, Rawson, Crowley, & Hasson, 1996; Rosenbaum, Washburn, Knight, Kelley, & Irwin, 1996). Pressure from drug user groups such as ‘Recovering Nepal’ forced government and other bilateral/multilateral agencies to restart MMT as an ‘emergency response’. With ‘emergency’ funding from United Nations Office on Drugs and Crime (UNODC), MMT services were reinstated in 2007 in a tertiary care medical teaching hospital in Kathmandu. By 2011, MMT services were available in three clinics, catering for a total of 946 clients; 409 clients were actually receiving MMT (Sharma, 2011). Data show that only 3% of PWIDs have ever been on MMT and 1.5% are currently receiving MMT, which is way below what is recommended by WHO/UNODC/UNAIDS for universal access to HIV prevention among PWIDs (World Health Organisation, 2009). By contrast, despite late initiation, other countries in Asia region such as China, Indonesia, Malaysia and Myanmar have been able to scale up at a much faster rate compared to Nepal (Global state of Harm reduction, 2012; Sullivan & Wu, 2007). For example, Malaysia has expanded its opioid substitution treatment (OST) services from 95
sites in 2010 to 674 sites in 2004, China has currently about 738 OST sites catering for about 140,000 PWIDs (Global state of harm reduction, 2012). Initially MMT services were not restricted to PWIDs; criteria for access included a long history of opioid dependence with failure in other treatment programmes (irrespective of whether a client was injecting or not). Thus the aim of MMT was not primarily the prevention of blood borne diseases, but rather it was considered to be a long term pharmacological treatment for those who were opioid dependent. Since its reinstatement in 2007 as a central component of HIV prevention strategy, it has been restricted to PWIDs. This emphasis makes it likely that MMT will be seen only in terms of HIV prevention and not as a long term pharmacological treatment option for opioid dependence. Once rooted, such beliefs become difficult to change among policy makers, service providers and consumers alike. There is also an ethical dilemma, as it inadvertently gives the message that injecting is the only way to get access to methadone treatment, and in Nepal, where many opioid users are non-injectors, this is concerning. Restricting access to MMT/OST services to PWIDs also occurs in other South Asian countries (Rao, Agrawal, Kishore, & Ambekar, 2013; Rao, 2008). The current model of MMT operation differs from the earlier approach in a number of ways. There is now greater involvement of NGOs in the running of MMT clinics. The ‘clinical care unit’, run by the psychiatry department of tertiary care hospitals, is in charge of the daily dispensing of methadone to the clients, while the NGO runs a ‘Social Support Unit’ (SSU) and is responsible for identifying PWIDs, motivating them to seek MMT services, outreach based follow-up and referral of PWIDs to other services. There is no longer any fee for MMT (Rao et al., 2013). The reinstatement of MMT in Nepal occurred at a time when the country was undergoing major political upheaval. The royal family of Nepal had been massacred in 2002 and the country was moving from a monarchy to a democratic form of governance in 2007. This period also witnessed Maoist insurgency (or a ‘people’s war’) and their eventual entry into mainstream electoral politics. Since then, there has been major unrest in the country over the drafting of the constitution. In the midst of this political turbulence, MMT has been expanded in other sites, which should be seen as a major achievement. This sequence of events is interesting in light of the observations of some researchers on priorities accorded to HIV by democratic versus autocratic and authoritarian regimes. Pisani (2010) cites examples of Iran and China (seen as autocratic regimes) where policies and programmes are much more conducive for providing harm reduction services as opposed to many democratic countries (like USA and India). In Nepal, the transition from a monarchy to a democracy coincided with the relaunch of MMT. More importantly, on this occasion, the ownership of the methadone programme rested primarily with the Ministry of Home Affairs (MOHA), which was also busy handling on-going internal security issues. The Ministry of Home Affairs is in charge of matters related to the control of illicit drugs in Nepal, including the formulation of policies and programmes and it has administrative oversight of the implementation of activities approved in policy. Apart from control of the supply of illicit drugs through a ‘drug enforcement’ section, the ministry has a separate project office to implement plans for treatment, rehabilitation and other demand reduction activities (MOHA, 2012). This is a happy departure from the division of labour followed in other countries in South Asia, where there are different ministries overseeing various aspects of drug use. For example, India has at least four different ministries/departments in charge of different aspects of the drug problem. This includes the Ministry of Social Justice and Empowerment (for demand reduction), Ministry of Home (for supply control), Ministry of Finance (for revenue
A. Ambekar et al. / International Journal of Drug Policy 24 (2013) e57–e60
associated with opium), and Ministry of health (for treatment of people who use drugs (PWUDs) and for prevention and treatment for HIV/AIDS). In such a scenario there is often an ideological clash between ministries overseeing law enforcement/supply control activities and those mandated to provide treatment and care for PWUDs (Rao and Ambekar, 2009). In Nepal so far, such an ideological clash has been avoided for MMT, even though here too different arms of the government are involved. The hospitals where MMT is provided are part of the health sector; the Ministry of education is in charge of medical college hospitals where MMT is located. Coordination between these various arms of government is ensured by MOHA, which also works with NGOs and other service providers on drug demand reduction. The National drug control strategy (2010) outlines specific programmes for OST and other harm reduction measures for minimising infections by blood borne viruses, as well as sexually transmitted diseases among drug users and their families (Ministry of Home Affairs, 2010). In Nepal, interestingly, one section of society that resisted the reintroduction of MMT were ‘ex-drug users’. The opposition for these ‘abstinence-only’ loyalists was both ideological and financial. Ideologically, they saw MMT and other OST programmes as an encouragement for the continuation of drug use. Many of these lobbyists also ran ‘Rehabilitation Centres’, and saw MMT as a threat to their ‘businesses. They wrote to Government officials asking them not to re-open MMT and allegedly spread false rumours such as “MMT causes brain damage” or “MMT causes impotency” (Kingdom of Nepal, undated). To counter this, various community groups such as ‘Recovering Nepal’ conducted advocacy programmes and helped to negate these rumours among beneficiaries and the general community (USAID, 2005). The fact that these community based organizations were part of the implementation process (by running ‘SSUs’ of MMT) also helped. Nepal boasts of a strong civil society movement as well as a socially active group of people who use drugs. Together, these various networks have been able to keep HIV prevention and MMT on the radar of policy makers, planners, national programme managers as well as funding agencies. Unfortunately, the major source of funding for the MMT programme is from external donors, who to date have funded almost all components of MMT, including procurement of methadone, staffing (for the clinical unit and for SSU), office support, and rent. This dependence on external donors is not limited to MMT; of the overall spending on HIV/AIDS in 2009, the Nepalese government contributed 1.3%, while the rest was financed by the Global Fund, bilateral agencies, multilateral agencies, and international not-for-profit agencies (HSCB, 2010). With funding from bilateral and multilateral agencies shrinking following the global economic meltdown, there is now a big question mark on the sustainability of MMT. Recently, there was a threat of closure of many drug rehabilitation centres following withdrawal of funding by Department of International Development (Nefport, 2011). With a small number of clients and a limited number of centres, the fear of closure of MMT for staff, clients and various stakeholders is not unfounded. Indeed, concerns over the absence of a concrete plan to ensure its sustainability are being voiced by many, including the government, civil society as well as other stakeholders (Pathak, 2007). It is well known that for a country such as Nepal, there are a number of developmental issues and challenges; drug use problems have to compete with other development priorities. This makes ensuring the continuity of MMT difficult. The availability of funds to scale up MMT through Global Fund Round 10 project provides some hope that MMT will be continued in Nepal (The Global Fund, 2012). Conclusion A systematic evaluation of the outcome of MMT in Nepal is still needed. However, programme reviews and many small reports
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on MMT give encouraging signals (Ojha, 2011; Ambekar, Pun, & Kumar, 2010; Sapkota, 2010). While there is much to celebrate in the country’s attempt to overcome various barriers in implementing MMT, there are many areas of concern as well as lessons that can be learnt from this experience. According to the target setting guidelines, the scale of MMT has to be increased to cater for at least 12,000 PWIDs. Small funds from donors and other agencies would not be adequate to financially support such expansion. A costed national OST scale-up plan to achieve the target is urgently required. Such a plan should be drawn up by all the key stakeholders and its implementation should be regularly monitored through a coordination committee involving government, civil society, drug user groups and funding agencies. Getting enough human resource and capacity to deliver a scaled up target, while maintaining quality in service delivery, would also be challenging. The current practice of engaging only specialists such as psychiatrists could be changed to involve non-specialists medical staff in methadone delivery. Finally, practice guidelines and operating procedures are needed to ensure uniformity in MMT services (Ambekar et al., 2010). For other governments as well as for donors, Nepal’s story provides an example of how token ‘pilot’ projects are not enough. These can close even after running for a long period of time. Unfortunately, Nepal’s neighbouring countries are still in the pilot mode of OST implementation. Bangladesh and the Maldives have on going pilot projects, while a pilot of OST in Pakistan has recently been introduced (Qasim, 2012). India has been able to initiate scale-up of the OST programme after a long period of ‘pilot’ projects (Rao et al., 2013). An important factor in scaling up of pilots is government’s own willingness to assume ownership of this process. Unfortunately, drug use problems and drug users are often neglected in government’s health and social development programmes. The Nepal MMT story also provides an example of how civil society and drug user groups can effectively engage with the government to reinitiate closed down programmes and help promote client friendly services. Thus, civil society and drug user groups can not only act as an effective advocacy force, but also assist in actual implementation of MMT programmes. A sustained effort in this direction can help ensure universal access to evidence based programmes such as MMT in Nepal. Funding source None. Acknowledgement None. Conflicts of interest statement We declare no conflict of agency/organization whatsoever.
interest
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References Ambekar, A., Pun, A., & Kumar, S. (2010). A Review of Opioid Substitution Therapy in Nepal. Regional Office for South Asia: United Nations Office on Drugs and Crime. Burrows, D., Panda, S., & Crofts, N. (2001). HIV/AIDS Prevention among Injecting Drug Users in Kathmandu Valley – Report for The Centre for Harm reduction. Melbourne: The Centre for Harm Reduction. Central Bureau of Statistics. (2007). Summary report of the survey on Hard Drug User in Nepal – 2063. Government of Nepal. Global Fund. (2012). Grant performance report (February 2012). Retrieved from. http://portfolio.theglobalfund.org/en/Grant/Performance/NEP-H-NCASC Grella, C. E., Anglin, M. D., Rawson, R., Crowley, R., & Hasson, A. (1996). What happens when a demonstration project ends: Consequences for a clinic and its clients. Journal of Substance Abuse Treatment, 13, 249–256.
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HIV/AIDS and STI Control Board. (2010). Resource inflow for the HIV and AIDS Programme in Nepal-2010. Nepal: HIV/AIDS and STI Control Board, Government of Nepal. HIV/AIDS and STI control Board (HSCB) and National centre for AIDS and STD Control (NCASC). (2011). Mapping and size estimation of Most-at-risk-Population in Nepal, 2011, Vol. 2: Injecting Drug Users. Nepal: Authors. Jha, C. K., & Plummer, D. (2012). Unpacking drug detoxification in Nepal: In-depth interviews with participants to identify reasons for success and failure. International Journal of Psychosocial Rehabilitation, 16(2), 50–61. Kingdom of Nepal (undated). Retrieved from http://www.methadonesupport. org/World.html Lawyers Collective HIV/AIDS Unit. (2007). Legal and policy concerns related to IDU harm reduction in SAARC countries. Regional Office for South Asia: United Nations Office on Drugs and Crime. Max. (2010). Hammer in the Himalayas. Retrieved from. http://www.nuaa.org. au/index.php?option=com content&view=article&id=552:users-storyhammer-in-the-himalayas&catid=31:users-news-no-61-winter-2010&Itemid= 83 Ministry of Home Affairs. (2010). Drug Control Strategy. Nepal: Author. MOHA. (2012). Controlling Narcotics. Retrieved from. http://www.moha.gov. np/en/major-activities-22.html#5 Controlling National Centre for AIDS and STD Control. (2011). NCASC and ASHA Project 2011 Integrated Biological and Behavioral Surveillance (IBBS) Survey among Injecting Drug Users in Kathmandu and Pokhara Valley, Nepal, Round V-2011. Nepal: Author. National Centre for AIDS and STD Control. (2012). Nepal Country Progress Report 2012. Retrieved from. http://www.unaids.org/en/dataanalysis/ knowyourresponse/countryprogressreports/2012countries/ce NP Narrative Report.pdf Nefport. (2011). Docking Nepal’s economic analysis. Retrieved from. http://asiafoundation.org/resources/pdfs/nefport4.pdf Ojha, S. P. (2011). The context of methadone maintenance treatment in Nepal. In Paper presented at the Annual National conference of Indian Psychiatric Society New Delhi, India. Pathak, P. K. (2007). Drug dependence treatment in preventing HIV among IDUs in Nepal: A Policy Maker’s Perspective. Retrieved from. http://asci.researchhub. ssrc.org/drug-dependence-treatment-in-preventing-hiv-among-idus-in-nepala-policy-makers-perspective/resource view Pisani, E. (2010). Tilting at windmills and the evidence base on injecting drug use. The Lancet, 376, 226–227. Qasim, M. (2012). Training in Opioid Substitution Therapy for drug addicts concludes. In The News (October 20, 2012). Retrieved from. http://www.thenews.
com.pk/Todays-News-6-138465-Training-in-Opioid-Substitution-Therapy-fordrug-addicts-concludes Rao, R. (2008). Substitution Therapy with Buprenorphine for opioid injecting drug users: Practice guidelines. New Delhi: National AIDS Control Organisation, Ministry of Health and Family Welfare, Government of India. Rao, R., Agrawal, A., Kishore, K., & Ambekar, A. (2013). Delivery models of opioid agonist maintenance treatment in South Asia: A good beginning. Bulletin of the World Health Organisation, 91, 150–153. Rao, R., & Ambekar, A. (2009). Need of coordinated response to drug problems in India: Is ‘three ones’ the answer? [powerpoint slides]. Retrieved from. http://www.ihra.net/files/2010/05/../Presentation 21st C16 Rao.pdf Ray, R. (2000). Current extent and pattern of drug abuse. In R. Ray (Ed.), South Asia Drug Demand Reduction Report (pp. 6–33). New Delhi: UNDCP Regional Office for South Asia. Reid, G., & Costigan, G. (2002). Revisiting the hidden epidemic: A situation assessment of Drug Use in Asia in the context of HIV/AIDS. Melbourne, Australia: The Centre for Harm Reduction/The Burnet Institute. Rosenbaum, M., Washburn, A., Knight, K., Kelley, M., & Irwin, J. (1996). Treatment as harm reduction, defunding as harm maximization: The case of methadone maintenance. Journal of Psychoactive Drugs, 28, 241–249. Sapkota R. (2010). Socio-economic changes brought by the Drug Substitution Treatment (Methadone) Kathmandu, Nepal. Retrieved from. http://www. brugerforeningen.dk/bf.nsf/pagesuk/A809DE4CDE51057FC12578AE0073A14E? OpenDocument&K=Treatment&S=UK Sharma, V. D. (2011). MMT implementation: Lessons from Nepal. Retrieved from. http://siteresources.worldbank.org/SOUTHASIAEXT/Resources/2235461296680097256/7707437-1318366151525/VDSharmaMMTPNepalExperience. pdf Shreshta, N. M. (2000). Methadone maintenance programme. In R. Ray (Ed.), South Asia Drug Demand Reduction Report (pp. 133–135). New Delhi: UNDCP Regional Office for South Asia. Sullivan, S. G., & Wu, Z. (2007). Rapid Scale-up of Harm reduction in China. International Journal of Drug Policy, 18, 118–128. The Global State of Harm Reduction. (2012). Towards an integrated response. In C. Stoicescu (Ed.), Harm Reduction International (p. 2012). US agency for International Development (USAID). (2005). Core Package Final Report: A Pathway to Stopping the Rapid Spread of HIV/AIDS in Nepal: Increasing the Participation of Affected Groups in Designing Effective Policies and Programs, Policy project. Retrieved from. http://www.policyproject.com/byCountry.cfm/NE World Health Organisation. (2009). WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention treatment and care for injecting drug users. Geneva: Author.
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
The trajectory of methadone maintenance treatment in Nepal Atul Ambekar a,∗ , Ravindra Rao a , Anan Pun b , Suresh Kumar c , Kunal Kishore d a
National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi 110029, India Recovering Nepal, Kathmandu, Nepal c T Nagar, Chennai, India d United Nations Office on Drugs and Crime-Regional Office for South Asia, New Delhi, India b
a r t i c l e
i n f o
Article history: Received 15 October 2012 Received in revised form 19 February 2013 Accepted 3 June 2013 Keywords: Opioid substitution treatment People who inject drugs HIV prevention
a b s t r a c t There are about 28,500 people who inject drugs (PWID) in Nepal and HIV prevalence among this group is high. Nepal introduced harm reduction services for PWID much earlier than other countries in South Asia. Methadone maintenance treatment (MMT) was first introduced in Nepal in 1994. This initial small scale MMT programme was closed in 2002 but reopened in 2007 as an emergency HIV prevention response. It has since been scaled up to include three MMT clinics and continuation of MMT is supported by the Ministry of Home Affairs (MOHA; the nodal ministry for drug supply reduction activities) and has been endorsed in the recent National Narcotics policy. Pressure from drug user groups has also helped its reintroduction. Interestingly, these developments have taken place during a period of political instability in Nepal, with the help of strong advocacy from multiple stakeholders. The MMT programme has also had to face resistance from those who were running drug treatment centres. Despite overcoming such troubles, the MMT programme faces a number of challenges. Coverage of MMT is low and high-risk injecting and sexual behaviour among PWID continues. The finance for MMT is largely from external donors and these donations have become scarce with the current global economic problems. With a multitude of developmental challenges for Nepal, the position of MMT in the national priority list is uncertain. Ownership of the programme by government, a cost-effective national MMT scale up plan and rigorous monitoring of its implementation is needed. © 2013 Elsevier B.V. All rights reserved.
Introduction Nepal has concentrated HIV epidemic among certain population groups, including people who inject drugs (PWIDs). The policy environment in Nepal has not been unfavourable to a harm reduction response to preventing the spread of HIV and Nepal initiated harm reduction services for PWIDs, including needle exchange programmes (NEP) and methadone maintenance treatment (MMT) much earlier than in other countries in South Asia. In fact, Nepal was the first country in South Asia to introduce MMT for opioid dependent people who use drugs. The trajectory of the MMT programme serves as an interesting case study, with implications for other developing countries with emerging or established HIV epidemics among PWIDs. The paper discusses salient issues to support learning for other countries in the region. We have relied upon our
∗ Corresponding author at: National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi 110029, India. Tel.: +91 11 26593236/9811155682; fax: +91 11 26588641. E-mail addresses: [email protected] (A. Ambekar), [email protected] (R. Rao), [email protected] (A. Pun), [email protected] (S. Kumar), [email protected] (K. Kishore). 0955-3959/$ – see front matter © 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.drugpo.2013.06.001
own experience of working on MMT in Nepal and have conducted a desk review of relevant documents. While buprenorphine based substitution treatment is also available, it is much smaller in scale and scope and therefore we restrict our focus to MMT. Injecting drug use and related HIV prevention services in Nepal Nepal has a long history of drug use. Cannabis was sanctioned for use on certain religious occasions, and occasional use of alcohol was tolerated socially. Reports of heroin use started appearing by the 1960s, and by the 1980s the number of heroin chasers had increased considerably. The next decade saw a shift in the pattern of drug use from heroin chasing to injectable opioid preparations such as buprenorphine (Reid & Costigan, 2002). A rapid situation assessment carried out in 1996 showed that 40% of drug users had injected drugs at least once in their lifetime; 66% PWIDs had injected buprenorphine and 20% had injected heroin (Ray, 2000). A study by Central Bureau of Statistics (2007) estimated that 61% of the 46,309 current ‘hard drug’ users were PWIDs (i.e. 28,439 PWIDs in Nepal). A recent nation-wide mapping study estimated the number of PWIDs to be in the range of 30,155–33,742. Among the PWIDs surveyed, a high proportion noted sharing needles/syringes and few reported using condoms (HSCB and NCASC, 2011). In 2011
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HIV prevalence among PWIDs was estimated at 6.3% in Kathmandu and 4.6% in the Pokhara valley (National Centre for AIDS and STD Control, 2012). Nepal was the first country in South Asia region to introduce NEP in the 1980s. Though HIV prevention services for PWIDs have been scaled up in recent years, the coverage remains low. The IBBS Round V survey conducted in 2011 showed that in the preceding year, only about 47% of PWIDs in Kathmandu and 82% in the Pokhara valley interacted with a peer educator/outreach worker, 2.9% and 3.5% visited a sexually transmitted infection (STI) clinic, and 20% and 31.3% visited a HIV testing centre (NCASC, 2011). The size estimation exercise conducted in 2011 also shows that in terms of services available for PWIDs, only one-third had access to a NEP, condom outlet or voluntary counselling and testing service within one kilometre of drug use hotspots (HSCB and NCASC, 2011) implying that much needs to be done to achieve universal access to HIV prevention services for PWIDs.
Methadone maintenance therapy in Nepal The first MMT clinic was introduced in a psychiatric hospital in Kathmandu in 1994 with the objective of “preventing relapse, facilitating recovery and reducing overdose, risk of HIV, hepatitis and other infections among drug users” (Shreshta, 2000). The clinic had a medical doctor and a trained nurse working under the supervision of a psychiatrist. Methadone was dispensed as a tablet of 40 mg (unlike the current practice of dispensing liquid form), and most clients received a maintenance dose of 40 mg daily. Each client paid a subsidised amount, roughly 25 US cents for a full dose of 40 mg methadone. By 2001, about 270 clients had received methadone (Burrows, Panda, & Crofts, 2001). Guidance for implementing MMT was also prepared. Yet, despite such efforts, the clinic was closed in 2002. While the reasons and consequences of such a closure have not been documented systematically, anecdotal reports show that factors including political instability, unfavourable public opinion, concerns about the illegal diversion of methadone and financial constraints led to the closure of the MMT clinic (Jha & Plummer, 2012; Lawyers Collective, 2007; Max, 2010). Worryingly, this closure occurred when HIV prevalence among PWIDs was estimated to be as high as 68% in Kathmandu (NCASC, 2011). MMT was reintroduced in 2007 and while there is little information about what happened to the clients in these five years, reports have suggested some medical casualties among drug users (Sharma, 2011). Elsewhere, the negative consequences of the closure of MMT clinics on drug use, criminal behaviour and HIV risk of PWIDs have been well documented (Grella, Anglin, Rawson, Crowley, & Hasson, 1996; Rosenbaum, Washburn, Knight, Kelley, & Irwin, 1996). Pressure from drug user groups such as ‘Recovering Nepal’ forced government and other bilateral/multilateral agencies to restart MMT as an ‘emergency response’. With ‘emergency’ funding from United Nations Office on Drugs and Crime (UNODC), MMT services were reinstated in 2007 in a tertiary care medical teaching hospital in Kathmandu. By 2011, MMT services were available in three clinics, catering for a total of 946 clients; 409 clients were actually receiving MMT (Sharma, 2011). Data show that only 3% of PWIDs have ever been on MMT and 1.5% are currently receiving MMT, which is way below what is recommended by WHO/UNODC/UNAIDS for universal access to HIV prevention among PWIDs (World Health Organisation, 2009). By contrast, despite late initiation, other countries in Asia region such as China, Indonesia, Malaysia and Myanmar have been able to scale up at a much faster rate compared to Nepal (Global state of Harm reduction, 2012; Sullivan & Wu, 2007). For example, Malaysia has expanded its opioid substitution treatment (OST) services from 95
sites in 2010 to 674 sites in 2004, China has currently about 738 OST sites catering for about 140,000 PWIDs (Global state of harm reduction, 2012). Initially MMT services were not restricted to PWIDs; criteria for access included a long history of opioid dependence with failure in other treatment programmes (irrespective of whether a client was injecting or not). Thus the aim of MMT was not primarily the prevention of blood borne diseases, but rather it was considered to be a long term pharmacological treatment for those who were opioid dependent. Since its reinstatement in 2007 as a central component of HIV prevention strategy, it has been restricted to PWIDs. This emphasis makes it likely that MMT will be seen only in terms of HIV prevention and not as a long term pharmacological treatment option for opioid dependence. Once rooted, such beliefs become difficult to change among policy makers, service providers and consumers alike. There is also an ethical dilemma, as it inadvertently gives the message that injecting is the only way to get access to methadone treatment, and in Nepal, where many opioid users are non-injectors, this is concerning. Restricting access to MMT/OST services to PWIDs also occurs in other South Asian countries (Rao, Agrawal, Kishore, & Ambekar, 2013; Rao, 2008). The current model of MMT operation differs from the earlier approach in a number of ways. There is now greater involvement of NGOs in the running of MMT clinics. The ‘clinical care unit’, run by the psychiatry department of tertiary care hospitals, is in charge of the daily dispensing of methadone to the clients, while the NGO runs a ‘Social Support Unit’ (SSU) and is responsible for identifying PWIDs, motivating them to seek MMT services, outreach based follow-up and referral of PWIDs to other services. There is no longer any fee for MMT (Rao et al., 2013). The reinstatement of MMT in Nepal occurred at a time when the country was undergoing major political upheaval. The royal family of Nepal had been massacred in 2002 and the country was moving from a monarchy to a democratic form of governance in 2007. This period also witnessed Maoist insurgency (or a ‘people’s war’) and their eventual entry into mainstream electoral politics. Since then, there has been major unrest in the country over the drafting of the constitution. In the midst of this political turbulence, MMT has been expanded in other sites, which should be seen as a major achievement. This sequence of events is interesting in light of the observations of some researchers on priorities accorded to HIV by democratic versus autocratic and authoritarian regimes. Pisani (2010) cites examples of Iran and China (seen as autocratic regimes) where policies and programmes are much more conducive for providing harm reduction services as opposed to many democratic countries (like USA and India). In Nepal, the transition from a monarchy to a democracy coincided with the relaunch of MMT. More importantly, on this occasion, the ownership of the methadone programme rested primarily with the Ministry of Home Affairs (MOHA), which was also busy handling on-going internal security issues. The Ministry of Home Affairs is in charge of matters related to the control of illicit drugs in Nepal, including the formulation of policies and programmes and it has administrative oversight of the implementation of activities approved in policy. Apart from control of the supply of illicit drugs through a ‘drug enforcement’ section, the ministry has a separate project office to implement plans for treatment, rehabilitation and other demand reduction activities (MOHA, 2012). This is a happy departure from the division of labour followed in other countries in South Asia, where there are different ministries overseeing various aspects of drug use. For example, India has at least four different ministries/departments in charge of different aspects of the drug problem. This includes the Ministry of Social Justice and Empowerment (for demand reduction), Ministry of Home (for supply control), Ministry of Finance (for revenue
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associated with opium), and Ministry of health (for treatment of people who use drugs (PWUDs) and for prevention and treatment for HIV/AIDS). In such a scenario there is often an ideological clash between ministries overseeing law enforcement/supply control activities and those mandated to provide treatment and care for PWUDs (Rao and Ambekar, 2009). In Nepal so far, such an ideological clash has been avoided for MMT, even though here too different arms of the government are involved. The hospitals where MMT is provided are part of the health sector; the Ministry of education is in charge of medical college hospitals where MMT is located. Coordination between these various arms of government is ensured by MOHA, which also works with NGOs and other service providers on drug demand reduction. The National drug control strategy (2010) outlines specific programmes for OST and other harm reduction measures for minimising infections by blood borne viruses, as well as sexually transmitted diseases among drug users and their families (Ministry of Home Affairs, 2010). In Nepal, interestingly, one section of society that resisted the reintroduction of MMT were ‘ex-drug users’. The opposition for these ‘abstinence-only’ loyalists was both ideological and financial. Ideologically, they saw MMT and other OST programmes as an encouragement for the continuation of drug use. Many of these lobbyists also ran ‘Rehabilitation Centres’, and saw MMT as a threat to their ‘businesses. They wrote to Government officials asking them not to re-open MMT and allegedly spread false rumours such as “MMT causes brain damage” or “MMT causes impotency” (Kingdom of Nepal, undated). To counter this, various community groups such as ‘Recovering Nepal’ conducted advocacy programmes and helped to negate these rumours among beneficiaries and the general community (USAID, 2005). The fact that these community based organizations were part of the implementation process (by running ‘SSUs’ of MMT) also helped. Nepal boasts of a strong civil society movement as well as a socially active group of people who use drugs. Together, these various networks have been able to keep HIV prevention and MMT on the radar of policy makers, planners, national programme managers as well as funding agencies. Unfortunately, the major source of funding for the MMT programme is from external donors, who to date have funded almost all components of MMT, including procurement of methadone, staffing (for the clinical unit and for SSU), office support, and rent. This dependence on external donors is not limited to MMT; of the overall spending on HIV/AIDS in 2009, the Nepalese government contributed 1.3%, while the rest was financed by the Global Fund, bilateral agencies, multilateral agencies, and international not-for-profit agencies (HSCB, 2010). With funding from bilateral and multilateral agencies shrinking following the global economic meltdown, there is now a big question mark on the sustainability of MMT. Recently, there was a threat of closure of many drug rehabilitation centres following withdrawal of funding by Department of International Development (Nefport, 2011). With a small number of clients and a limited number of centres, the fear of closure of MMT for staff, clients and various stakeholders is not unfounded. Indeed, concerns over the absence of a concrete plan to ensure its sustainability are being voiced by many, including the government, civil society as well as other stakeholders (Pathak, 2007). It is well known that for a country such as Nepal, there are a number of developmental issues and challenges; drug use problems have to compete with other development priorities. This makes ensuring the continuity of MMT difficult. The availability of funds to scale up MMT through Global Fund Round 10 project provides some hope that MMT will be continued in Nepal (The Global Fund, 2012). Conclusion A systematic evaluation of the outcome of MMT in Nepal is still needed. However, programme reviews and many small reports
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on MMT give encouraging signals (Ojha, 2011; Ambekar, Pun, & Kumar, 2010; Sapkota, 2010). While there is much to celebrate in the country’s attempt to overcome various barriers in implementing MMT, there are many areas of concern as well as lessons that can be learnt from this experience. According to the target setting guidelines, the scale of MMT has to be increased to cater for at least 12,000 PWIDs. Small funds from donors and other agencies would not be adequate to financially support such expansion. A costed national OST scale-up plan to achieve the target is urgently required. Such a plan should be drawn up by all the key stakeholders and its implementation should be regularly monitored through a coordination committee involving government, civil society, drug user groups and funding agencies. Getting enough human resource and capacity to deliver a scaled up target, while maintaining quality in service delivery, would also be challenging. The current practice of engaging only specialists such as psychiatrists could be changed to involve non-specialists medical staff in methadone delivery. Finally, practice guidelines and operating procedures are needed to ensure uniformity in MMT services (Ambekar et al., 2010). For other governments as well as for donors, Nepal’s story provides an example of how token ‘pilot’ projects are not enough. These can close even after running for a long period of time. Unfortunately, Nepal’s neighbouring countries are still in the pilot mode of OST implementation. Bangladesh and the Maldives have on going pilot projects, while a pilot of OST in Pakistan has recently been introduced (Qasim, 2012). India has been able to initiate scale-up of the OST programme after a long period of ‘pilot’ projects (Rao et al., 2013). An important factor in scaling up of pilots is government’s own willingness to assume ownership of this process. Unfortunately, drug use problems and drug users are often neglected in government’s health and social development programmes. The Nepal MMT story also provides an example of how civil society and drug user groups can effectively engage with the government to reinitiate closed down programmes and help promote client friendly services. Thus, civil society and drug user groups can not only act as an effective advocacy force, but also assist in actual implementation of MMT programmes. A sustained effort in this direction can help ensure universal access to evidence based programmes such as MMT in Nepal. Funding source None. Acknowledgement None. Conflicts of interest statement We declare no conflict of agency/organization whatsoever.
interest
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any
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