METHADONE MAINTENANCE AND HARM REDUCTION IN NORTHERN THAILAND

Presented by Chawalit Natpratan, Ministry of Public Health, Chiang Mai, Thailand

Introduction

The north of Thailand, bordering Myanmar and Laos is a mountainous area where 10% of the population are ethnic minority hilltribe people. They have smoked opium for centuries in ritual, social and medicinal contexts. Changes in opioid production in the past decade has resulted in radically different patterns of opioid consumption. Opium smoking has rapidly been replaced by heroin smoking and injecting creating enormous social, economic and health problems for the community. AUSAID in conjunction with the Chiangrai Provincial Chief Medical Officer has funded a pilot among a group of hilltribe villages in Northern Thailand to limit the transmission of HIV among injecting drug users.

Objectives

· To study the feasibility of community-based harm reduction in selected hilltribe villages.

· To compare methadone detoxification with methadone maintenance and tincture of opium maintenance.

Methods

· Needle and syringe exchanges, together with AIDS education, were established in 3 Akha villages in November 1992 after discussion with village leaders, committees and drug users (project conducted by Dr. Jennifer Gray).

· In 1995, needle and syringe exchanges recommenced in 9 Akha villages, including 3 previous villages. 83.6% of IDUs in 9 villages participated.

· The project trained 10 Akha villagers to be PHC workers.

· Short term methadone detoxification (45-55 days) was commenced in 6 villages in 1995. 180 users in 6 villages participated. 6 achieved abstinence (3.3%)

· Methadone maintenance was provided in 8 villages and tincture of opium maintenance was provided in one village in 1996.

Results

Fig 1 Extent of Drug Users in 9 Akha villages

Fig 3 Methadone and Tincture of Opium maintenance in 9 villages, 1996 (period of 5-9 months) 326 users participated

Fig 4 HIV - 1 And HCV Seroprevalence

Specimens collected in June 1996 from 145 users

Fig 5 HIV - 1 Incidence among Drug Users

Fig 6 Incidence among Drug Users: Northern Drug Treatment Centre 1993-1995.

Source: Celentano, D.et all,1996: Incidence of HIV-1 Infection among Opiate Users in Northern Thailand

Conclusion

· It is feasible to do community-based HR in remote hilltribe villages.

· The retention rate among those following methadone maintenance was high and the abstinence rate was better in comparison to short-term detoxification.

· HIV prevalence and incidence were lower among IDU participated in the project.

This Project is supported by AUSAID.

Collaborating Researchers are:

Project Director Jennifer Gray, Rachanee Mikkitti and Sithijade Komsakorn, Chiangrai PCMO.

Pornpimon Saksoong, and Dampawan Pinitsuwan, Mae Chan Hospital.

This presentation was written by Jennifer Gray, Pornpimon Saksoong and Chawalit Natpratan.

WORKING WITH DRUG USERS IN KUALA LUMPUR

Presented by Palani Narayanan, IKHLAS Centre, Kualar Lumpur, Malaysia

Overview of AIDS in Malaysia

Statistics from Ministry of Health, Malaysia (1985 - 30.10.96).

Number of persons infected 18,161

Number of drug users who are positive 13,997 or 77.07%

Overview of Drugs in Malaysia

· 28 Rehabilitation Centres

· 12,657 Inmates

· Estimated 400,000 users

· 387,343 users not in treatment

· 13,846 new users detected from Jan-Dec 1996

(This figure makes up 45.3% of all users detected during this period i.e. the other half is 54.7% which is 15,719 previously detained users)

· Average new users detected per month 1,154

· Average new users detected per day 38

(Data from National Drug Agency)

· Type of drugs used - Heroin

· Street heroin purity ranges from 5% -25%

IKHLAS Centre c/o Pink Triangle

IKHLAS Community Centre was a street outreach project started by members of Pink Triangle Malaysia. Outreach Workers went to the streets where drug users gathered and gave them information on HIV and AIDS. The same was done for sex workers in the brothels close to the area where drug users were. This particular part of Kuala Lumpur is called Chow Kit and is known for it's notoriety.

The project has since developed into three substantial projects, namely the DU project, the SW project and the Trans-sexual support program. I must add that the developments of these project have taken place via responding to the needs of the communities we work with.

Drug users in this area are homeless, economically disadvantaged, live in very unhygienic conditions and were very often hungry. While we gave out information and bleach to clean their needles, we realised that it was something useless to the client who had an abscess on his leg which was infested with worms. So we started a medical program whereby, a volunteer nurse would dress and treat all sorts of wounds and illnesses. Currently , I am proud to say that we have an equipped clinic with facilities to treat 20 clients per day.

Harm Reduction information was also ineffective if given to a man who hasn't had a proper meal for 5 days. As they are the way to a man's heart is through his stomach - in this case be it man or woman their basic needs had to be met before something so invisible like HIV can take any importance. Currently we serve 3 meals a day at the drop in centre - breakfast, lunch and tea.

It is in this manner the IKHLAS Centre has grown to be able to serve 75-100 clients per day. Asking, listening, understanding and responding.

70% of our clients are under the age group of 21-39. Occasional we get clients who are as young as 12 years of age. Many of these clients have lived on the streets for more than 5 years. They have been to prisons and rehabilitation centres more than twice. Because drugs are criminalised and drug users viewed as the menace of society, these clients have very little self esteem and some have even resigned to the belief that their lives will continue and end of the street.

It is therefore especially important for IKHLAS to adopt a working method that is non-judgmental and non-moralistic, A method that is focused on ego building, not ego breaking. A method that is user friendly and aims to build clients self esteem. A method that is comforting, sensitive to client needs and definitely responsive.

I am sure many of you know that in Malaysia, the death penalty is in effect for those charged and proven to be trafficking or selling drugs. Malaysian government has also taken effective measures in reducing the supply of drugs. The problem of drugs in the country is now said to be worse than that posted by the communists during the 1950s. In a situation that is such, IKHLAS adapt a working method that is non confrontational. We believe in not antagonising the authorities but rather working with them to achieve what we want, bearing in mind the boundaries that have been set for us. This by no means that we are not challenging these boundaries, the very fact that IKHLAS was allowed to exist is proof of success to this working method. Although we are not allowed to distribute sterile needles (as this is said to be aiding and abetting drug use), we are still able to distribute bleach which strangely enough is for the same purpose!

Services of the IKHLAS Centre

At IKHLAS, Harm Reduction information is given at every opportunity that we get. Clients are given one on one counselling session. While HIV and AIDS is the main focus, clients are able to talk and seek advice on personal matters such as last night’s brawl, their guilt after having robbed someone, their fears of not being able to see their mother again. The issues are varied and sometimes extremely heavy and most times against the personal beliefs/principals of the counsellor or IKHLAS worker. Therefore all staff members are required to undergo a counselling training session.

There are also HIV and Drugs workshops every month at the centre. Apart from IKHLAS staff members, addiction specialist from universities also conduct group therapy and harm reduction information sessions with clients.

Harm reduction material that is given out is bleach, again both at the centre and on the streets through outreach. Due to their living condition and mobility, clients find the method inconvenience and time consuming. They may use it right after we given them but, it certainly is not a commodity that they come seeking for.

Carrying a needle with you will be seen as an incriminating evidence that you are a drug user. This has prevented many from having their own set of tools, especially clients who have regular jobs. These clients come around to the port (shooting area) and get a quick fix from a doctor (a person with needles and whose job is to inject others who do not have needles). This we identify as a very convenient and effective situation for HIV infection.

The harm reduction message we give out is as follows:

If you are taking drugs

· Stop, there are may ways and we can help you.

· If you don't want to or cannot stop, then just chase and don't inject

· If you must inject, then please don't share needles

· If you must share, then clean your needles with bleach and water

Outreach is done three times a week. Clients are given an outreach pack which contains:

· a bottle of water

· a bottle of bleach

· a leaflet

· a bottle of iodine

· gauze

· plasters

· vitamins

· panadol.

As an unofficial material we bring along cigarettes, drink packs and some biscuits.

Because of the recent clamp down on drugs in the country, users have moved further and further underground. When I say underground, I mean underground. Some of these clients avoid coming to the centre for fear of being caught. Although we receive information from clients as to where their friends are or gather, we face difficulties reaching out to them with limited manpower.

Other services in the centre include:

· Medical treatment and food, for reasons I have mentioned above.

· Shower and wash facilities - clients are able to wash and dry their laundry.

· Indoor games, television, video, newspapers and magazines contribute to the making of a daytime home for our clients.

· Resting area, for those who need to sleep.

Clients who wish to quite drugs will be given options for rehabilitation. They will then be referred to the service of their choice be it a private rehabilitation centre or a medical doctor. Referrals are also made to HIV/AIDS specialist, STD doctors and TB and other specialist hospitals.

As of last year, we have also started a regular prison and rehabilitation centre workshop program, with the financial assistance from the EU. These workshops for 50 participants per session uses slides and props to educate inmates on HIV and AIDS. We have found these workshops to be extremely interactive as participants who are confined seem to give HIV a bigger priority. So, there are usually more questions on personal health, who to deal with families and finally .. sex.

Here then we face another problem .. what HR materials can we give to prisoners and rehabilitation inmates who are having sex with each other and are themselves worried about HIV infection. We can demonstrate how to use a condom, but what is the point? They don't get any inside. And we are not allowed to give them as well.

· HR info - in centre, street, workshops

· HR materials - in centre and streets

· Outreach - bringing services to clients

· Medical treatment - for the discriminated, economically disadvantaged Food - taking care of basic need and attracting clients to the other services provided

· Shower, wash, games, sleeping area, newspapers, television and video - Creating a home

· Referrals - to rehab, detox, medical specialist, drug specialist, STD doctors. Prison and rehab program

· General awareness program - to education general public and specific groups like nurses, medical students.

Successes of the Project

1. HIV/AIDS Awareness Raised

When we first entered the scene, clients had very little knowledge on AIDS. They thought that if you took drugs you will get HIV. The level of knowledge among our clients currently is high and we hope and believe that knowledge is power.

2. General health awareness raised and therefore general health and hygiene of clients raised.

Our nurse acts as a hygiene counsellor and advisor on other harm caused by injecting drugs. Many of our clients have taken to injecting amphetamine pills together with heroin. This has caused severe health problems such as paralysis of limbs and major abscesses. clients are advised to swallow these pills and only inject heroin. This has proven successful as the number of people with such complications have reduced drastically.

3. Some aspects of case for HIV positive drug users taken care of

Clients who are HIV positive are taken to HIV specialist for medical treatment. An STD doctor also has volunteered o treat all our positive clients for free. Clients who are ill, are provided with temporary accommodation after their discharge from hospital and while waiting for other arrangements to be made. We also advise parents of these clients on how they can take cart of their sons or daughters who are HIV positive.

4. Client self esteem and ego elevated

This is very evident in clients behavioural change. Some clients have managed to reduce the number of times they inject in a day. Some clients have in fact changed from injecting to chasing. Some clients are in fact able to talk to students and guests about themselves, why they take drugs and what they think should b done about the situation.

5. More and more request for rehabilitation/detoxification

When clients feel better about themselves, they begin to see the light at the end of the tunnel. There then begins the will and desire to quite drugs. Currently we have about 10 clients whom we send for rehabilitation/detoxification services and about 10 others on the waiting list every month.

6. Successful referrals to rehabilitation/detoxification

Although not all clients have been successful in their rehabilitation, we find that clients who take responsibility for their rehabilitation are more successful than drug users who are forced into rehab.

7. Clients social menu increased with provision of services such as Narcotics Anonymous (NA).

NA meetings takes place at IKHLAS Centre every Tuesday nights and Thursday Lunch time. This meeting has enabled our clients to meet other users who have managed to give up drugs and this in turn makes them more ambitious. These meeting also allow clients to meet others outside of their own street community. Other such meeting also take place but more of a one off activity.

6. Are we making an impact?

The number of clients reached in a year is 1000 (0.25% of the community). Although this is a small figure we are optimistic that the word about HIV and AIDS will get around to at least another 0.25% of the community through the clients we have reached. IKHLAS hopes to bring about change in the country in relation to drug use and HIV through;

· advocacy;

· public awareness raised through media, workshops in School, Universities, factories etc.;

· respond to/halting punitive policies made by authorities;

· prison/rehabilitation program;

Future Needs

· Overall change in Drug & HIV related policies.

· Need for harm reduction to take priority in national strategy on AIDS Need for HIV/AIDS programs to be included in Treatment and Rehabilitation Need non-judmental, non moralistic drop in centres to be duplicated around the country.

· Need for needle exchange program to be studied and implemented.

· Accommodation services:

For clients coming out of hospitals;

For drug users coming out of prisons and rehab centres;

For drug user waiting for placements;

For women drug users.

Conclusion

· Need for Harm Reduction to take HIV positive drug users in consideration.

· Clear statistics on HIV positive drug users but clear omission of services for this community. Prevention that focuses on negative users alone is ineffective as it only tackles part of the union of infection.

HIV positive drug users must have incentives and must have knowledge of importance for not sharing needles.