IDU interventions in IDU interventions in Bangladesh:Bangladesh:

An example of a successful model An example of a successful model from a resource-poor settingfrom a resource-poor setting

Dr. Munir AhmedMBBS, MPH, Dip in HE

Team Leader-UNICEF-HAPPHIV Program, CARE Bangladesh

• 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 • Economic Growth 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)

Bangladesh Country profile

• 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

Bangladesh Health Indicators

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

Five Objectives:1. Provide support and services to the priority groups of

people.

2. Prevent vulnerability to HIV infection in Bangladesh society

3. Promote safe practices in the health care system.

4. Provide care and support services for PHAs.

5. Minimize the impact of the HIV/AIDS epidemic.

National Strategic Plan for HIV/AIDS 2004-2010

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

Cont’d…

Sub component of Objective one is to provide support and services to drug users

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)

Baseline Study-1998Baseline Study-1998Baseline Study-1998Baseline 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

Major findingsMajor findingsMajor findingsMajor 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%

HIV Prevalence of IDUs in 5th

Rounds of National Sero-surveillance

H I V a m o n g i n j e c t i o n d r u g u s e r s i n B a n g l a d e s h

1 . 51 . 7

44

00 . 5

11 . 5

22 . 5

33 . 5

4

R o u n d I I R o u n d I I I R o u n d I V R o u n d V

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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.

19981998

19991999

20012001

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20022002

20032003

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20042004

20042004

2004200420042004

20042004

2004v2004v

20042004

20042004

20042004

20042004

2004200420042004

20042004

20042004

2004200420042004

Year wise expansion

• 47 staff• 355 OWs• 40 Counselors• OW:IDU - 1:50• OW:HS - 1:80

CARE-B DUI at a glance (2005):

Districts covered =23DIC = 59 Under coverage:IDU = 6000 plusHS = 10000 plus

Total fund available: US$1.5 Million in last FY

Organogram

Team Leader

Technical Coordinator

PM/PDO/ PO

Field Trainer

DIC in Charge Field Supervisor Medical Assistant

Outreach WorkerGuardDresser

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)

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

• Best Performance Award from honorable PM for organizing community-based detoxification camp

Laurels achieved by this intervention

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.

Our best practices adopted by others

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

Why it is a successful model

1. Cost effective

2. NEP outreach adopted as a best practice for South East Asia recommended by UNODC

3. Replicated by other organization

4. NEP launched despite having no relevant law.

5. Other restrictive factors like conservative Muslim society and frequent eviction/harassment by law enforces.

• 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.

Future Plans