IDU interventions in Bangladesh: An example of a successful model from a resource-poor setting

1. IDU interventions in Bangladesh:An example of a successful model from a resource-poor setting Dr. Munir Ahmed MBBS, MPH, Dip in HE Team Leader-UNICEF-HAPP HIV Program, CARE Bangladesh

2. Bangladesh Country profile • Area: 148,000 Sq. Km (Census-2001) • Pop: 130 million(Census-2001), Growth rate = 1.48 • 88% Muslim • GDP:US$ 55.4 Billion (BBS,Bd. Bank, Finance ministry) • Per Capita Income: US$444 • EconomicGrowth rate: 5.52% (BBS,BB, Finance Ministry) • Agro-based country • RMG, jute and jute products, manpower export are major wage earners. • Source:Bangladesh Demographic and Health Survey(BDHS)

3. Bangladesh Health Indicators • MMR: 3.2/1000(2001) • IMR: 65(2004) • TFR: 3 (2004) • CPR:58.1% (2004) • Annual Health Budget per person: US$1.61 • Source:Bangladesh Demographic and Health Survey(BDHS) • Life Expectancy: Male=68, female=68.6 • Source: BBS-2001

4. GoB Policy on drug use • Existing Law: • Carrying of Heroin less than 25 gm is punishable with 2-10 yrs imprisonment. • More than 25 gm - death penalty or life imprisonment • Carrying of pathedine, morphine, methadone, cannabis all are punishable crime. • Possession of injecting paraphernalia is also a punishable crime. • Source: Narcotics Control law,1990, GoB. NSEP not legal as per narcotics law

5. National Strategic Plan for HIV/AIDS 2004-2010 • Five Objectives: • Provide support and services to the priority groups of people. • Prevent vulnerability to HIV infection in Bangladesh society • Promote safe practices in the health care system. • Provide care and support services for PHAs. • Minimize the impact of the HIV/AIDS epidemic.

6. Cont’d… Sub component of Objective one is to provide support and services to drug users • 5 strategies: • Strengthen research on drug use • Strengthen harm reduction programs • Learn how drug use influences sexual behaviour. • Slow entry into drug use • Political, bureaucratic and legal support for effective programming

7. Background of CARE Bangladesh IDU program • HIV/AIDS included as programming initiative for Health and Population Sector of CARE-B in its multi-year planning document for 1993-2000 • 1993-94: HIV/AIDS orientation for 1600 staff • July 16, 1995: SHAKTI project launched (IDU component from 1998)

8. Baseline Study-1998 • Objectives: • Determine nature and magnitude of drug injecting in Dhaka • Study HIV risk behaviors of IDUs • Study harmful health consequences of drug injecting or other HIV risk behaviors • Determine interventions needed for HIV prevention among IDUs and their sex partners • Identify factors that may facilitate or constrain interventions

9. Major findings • Estimated number of IDUs: 5000 • Drug of choice : Injection (Buprenorphine) • Sharing of Syringe/Needle: >90% • Homeless IDUs: 30% • No education: 46% • Income: Tk 3000/month ($50USD) • Ever arrested by police: 84% • Ever been to jail: 66% • Ever been assaulted in the street by Police/Public: 57% • Syphilis: 12.9%

10. HIV Prevalence of IDUs in 5th Rounds of National Sero-surveillance

11. Evolution of Bangladesh IDU program 1997: Explored preliminary information related to drug injecting in Bangladesh 1998: 1st ever RSA done in Dhaka. Started harm reduction intervention 2000: SHG-concept for current IDUs conceived/ materialized Community based detox arranged with fullest cooperation of DNC/CTC. 2002: Inclusion of HSs, COHORT Started 2003: Intervention for ILWHAs 2004: DRE started, focus on female & child DUs.

12. 2004 2004 2004 2004 2004 2004 2004 2001 1999 2004 2004 2001 2003 2004 2004 1998 2002 2004 2003 2004v 2004 2004 2004 Year wise expansion

13. CARE-B DUI at a glance (2005): Total fund available: US$1.5 Million in last FY Districts covered =23 DIC = 59 Under coverage: IDU = 6000 plus HS = 10000 plus • 47 staff • 355 OWs • 40 Counselors • OW:IDU - 1:50 • OW:HS - 1:80

14. Team Leader Technical Coordinator PM/PDO/ PO Field Trainer DIC in Charge Field Supervisor Medical Assistant Dresser Guard Outreach Worker Organogram

15. Core Activities 1. Drop in Centers • health services (incl. abscess and STI management) • peer and group education • referral to detox programs • client & family counseling • recreational space • toilet and bath facilities 2. Detoxification • symptomatic management (no drug substitution)

16. Cont’d… 3. Outreach Activities • NSE • condom distribution • one on one counseling • IEC 4. Creating Enabling Environment: • capacity Building of IDUs self-help groups on technical & negotiating skills • advocacy & lobbing

17. Laurels achieved by this intervention • Best Performance Award from honorable PM for organizing community-based detoxification camp

18. Our best practices adopted by others • Outreach Model of Dhaka has been selected/mentioned as a best practice in ‘Preventing HIV/AIDS among drug users Case studies from Asia’ published by UNODC • Many examples and experiences have been incorporated into the WHO guideline for HIV prevention among IDUs • UNODC selected this intervention as a resource/model project for NEP outreach to develop standardized NSEP protocol for South Asian countries.

19. Source: Presentation of Anna Foss, 14th International HR conference

20. Why it is a successful model • Cost effective • NEP outreach adopted as a best practice for South East Asia recommended by UNODC • Replicated by other organization • NEP launched despite having no relevant law. • Other restrictive factors like conservative Muslim society and frequent eviction/harassment by law enforces.

21. Future Plans • Country wide program expansion • Start continuum of care for DUs • Crisis care home for street-based marginalized DUs • Mobile clinic and harm reduction service for DUs • 40 more RSAs • Start service for middle-class DUs • Work more closely with GoB and DNC • Vocational training and social re-integration • Pilot oral substitution of drug for ILWHAs. • Pilot ARV for ILWHAs • To install VCTC centers in hot spots.