HIV & AIDS and Drug Use in Bangladesh Dept. of Narcotics Control (DNC), Ministry of Home Affairs National AIDS/STD Program (NASP), Ministry of Health and Family Welfare Icddr,b UNODC ROSA

GENERAL INFORMATION 2  Numbers of PWID in Bangladesh – 20, ,000  Numbers of female PWID – not known  Estimated number of HIV infected PWID - 444

HIV PREVALENCE IN PEOPLE WHO USE DRUGS, 2011 (source: 9th round HIV serological surveillance, NASP) 7529 PWUD sampled from 30 cities HIV found in five cities only

SYPHILLIS PREVALENCE AMONG PWUD, 2011 (source: 9th round HIV serological surveillance, NASP) Note: Combined PWID/HS refers to the combined group of PWID and heroin smokers. Numbers in brackets refer to the total numbers of PWUD sampled in each city

5 PRESENT NUMBER OF SITESNUMBER OF BENEFICIARIES NSP70 (supported by the Global Fund through Save the Children) 14,000 PWID Including female PWUD OST1 (supported by UNODC and fhi360, implemented by icddr,b) 1 (supported by Global Fund through Save the Children, will be implemented by CARE, Bangladesh with technical support from icddr,b and UNODC ROSA) 163 PWID including 8 females 150 (planned) FUTURE (additional) SOURCE OF FUNDINGNUMBER OF BENEFICIARIES NSPNASP 6,000 PWID OSTNASP150 PWID GLOBAL FUND150 PWID HARM REDUCTION SERVICES AVAILABLE IN BANGLADESH, 2012

Phase II of Project RAS/H13 in Bangladesh: an Overview 1.Services for females who use drugs (FPWUD) and Female Regular Sex Partners (FRSPs) of male PWUD Implemented by four PNGOs: APON, CREA, DAM and Light House Mentor agency: icddr,b Duration: December 2007 to October Opioid Substitution Therapy (OST) Implementer and technical agency: icddr,b Duration: March ongoing. Focal Agencies: DNC and NASP

INTERVENTION AREAS OF PNGOs IN BANGLADESH INTERVENTION AREA FOR OST Central Drug Addiction Treatment Centre (CTC) under the DNC in Dhaka

CAPACITY BUILDING OF PNGOs  Training – 15 events a)Basic training on HIV and AIDS b)STI – Prevention, transmission and treatment c)Positive Living d)Drug counselling e)Detoxification and abscess management f)Rapid Situation and Response Assessment (RSRA)  Cross visits (exchanging experience and knowledge among PNGOs)-16  Monthly monitoring visit  Quarterly coordination meeting 8

HARM REDUCTION SERVICES FOR FEMALE PWUD AND FEMALE REGULAR SEX PARTNERS OF MALE PWUD Peer Led Intervention provided through Drop in Centres and outreach:  Condom promotion and distribution - 1,66,216  STI management through part time doctor and paramedics – 1,051 STI cases  Counseling - 2,202 sessions  Enhancing awareness on HIV for safer practices - ~350 sessions  Low-cost community detoxification services (15 days) – 93 Female PWUD from 6 detox-camps  Community sensitization/advocacy meetings- 73  Support group formation – 14  VCT (through referral to Jagori, icddr,b)

10 NUMBERS OF BENEFICIARIES Note: in 2009, 83 male PWUD also covered (optional) in Gazipur in 2011, services were provided up to October 2011

SOME SPECIAL SERVICES AND MATERIALS ( ) 11  In some of the sites in Gazipur (DAM) and Natore (Light House) satellite services were provided to those living far away from the DICs  3 female PWUD and FRSP of male PWUD focused BCC materials developed and printed  Reproductive health services – Pregnancy test, prophylactic therapy during ANC and referred for X-ray, ultra-sonogram and safe delivery

RSRAs Two RSRAs were conducted in Phase II: First RSRA - with females who use drugs (FPWUD) and female regular sex partners (FRSPs) of male PWUD at the beginning of Phase-II (in 2007) Second (Midline) RSRA – among the same groups in % * p<0.05, **p<0.01 Baseline (N=137) Midline (N=214)

WHAT HAS HAPPENED AFTER OCTOBER 2011  Female PWUD in Hajaribagh, Dhanmondi, Katashur and Mohmmadpur Beribad areas of Dhaka (CREA & Apon) are receiving services from Modhumita project of fhi360 and CARE Bangladesh’s DICs  Female PWUD who sell sex in Gazipur (DAM’s area) and who are close to World Vision’s STI clinic are receiving STI services from World Vision  Female PWUD of Mohammadpur, Agargaon (BNP slum) of Dhaka (part of Apon’s area) and Natore (Light House’s area) are not covered by any harm reduction programmes  No services are available for female regular sex partners of male PWUD 13

14 Opioid Substitution Therapy (OST) Pilot in Dhaka, Bangladesh

Approved by the National Narcotics Control Board in August 2008 as a pilot using methadone Focal Agencies of the Government of Bangladesh: Department of Narcotics Control (DNC) and National AIDS/STD Programme (NASP) Supported by: UNODC and fhi360 Implementing and technical agency: icddr,b Overall guidance provided by the National Steering Committee Technical guidance provided by the Coordination Committee 15 OVERVIEW OF THE OST PILOT STUDY

16 Establishment of one MMT centre at CTC Opened on 8 July 2010 OST USING METHADONE

METHODOLOGY 17 Inclusion criteria:  ≥18 years  opioid dependent for at least 5 years  currently injecting drugs (at least for the last one month)  two failed abstinence attempts  willing to participate  Enrolled PWID receive transport fare of Tk. 50 (~US$ 0.68) for each visit  Urine tests for opioids and Benzodiazepines are conducted routinely every quarter and when clinically suspected So far 163 clients enrolled Of these 6 are HIV positive and 4 are on ART 102 opted for VCT

18 Between July 2010 and April 2012 among 150 clients enrolled, 27 dropped out (retention rate 82% ) RETENTION RATE AMONG 150 CLIENTS AND REASONS FOR DROP OUT Number of cases

Initial phase: o Lowest dose - 10 mg o Highest dose - 30 mg o Average dose - 15 mg Maintenance phase: o Lowest dose - 20 mg o Highest dose – 165 mg o Average dose - 50 mg Discontinuation phase: 12 PWID 19 METHADONE DOSAGE “START LOW AND GO SLOW”

DATA COLLECTION  Every quarter  Data is collected using questionnaires  Risk behaviour  Depression, Anxiety and Stress Scale (DASS-21)  Leeds Dependence Questionnaire (LDQ)  WHO Quality of life (WHOQOL-BREF) scale  Clinical assessment 20

Analysis of data for the first two quarters (six months after enrollment) has been conducted on 129 clients Baseline : 8 July 2010 to 3 April st quarter: 28 October 2010 to 5 July nd quarter : 27 February 2011 to 5 October

DEMOGRAPHIC PROFILE AT BASELINE (N=129) % (n) Frequency of age 18 – 24 years 25 – 34 years 35 – 44 years 45 year & more 1.6 (2) 37.2 (48) 45.0 (58) 16.3 (21) Sex Male Female 96.9 (125) 3.1 (4) Marital status Unmarried Currently married Separated/divorced/widow/widower 24.8 (32) 52.7 (68) 22.5 (29) Education Never been to school/can sign Class I – V Class VI – SSC HSC/Graduate 24.0 (31) 36.1 (47) 32.6 (42) 7.0 (9) 22

Main sources of income in the last three months (Multiple Responses) Baseline % (n) 1 st quarter % (n) 2 nd quarter % (n) Rickshaw puller/Driver/Transport worker30.2 (39)22.5 (29)20.9 (27) Small trade (tea stall, fruit seller etc.)21.7 (28)16.3 (21)15.5 (20) Service (paid job)24.8 (32)25.6 (33)32.6 (40) Tokai/garbage collector/daily labour/beggar/cleaner 51.9 (67)6.2 (8)9.3 (12) * Drug selling/cheating/stealing/ snatching/ extortion † 40.3 (52)00 Family member/family property56.6 (73)38.8 (50)27.1 (35)* 23 MAJOR SOURCES OF INCOME (N=129) * p<0.001 NB: † p value is not calculated

LIVING STATUS AND MARITAL SATISFACTION Current living status % * p<0.01; **p<00.05 Marital satisfaction (among those who are married) 24 Baseline (N=67) 1 st Quarter (N=69) 2 nd Quarter (N=79)

25 EXPERIENCED DEPRESSION (N=129) Level of depression on DASS-21 ҂ scale in the last month % *p<0.01; **p<0.001 NB: ҂ Depression Anxiety and Stress Scale (DASS-21) in the last three months

26 QUALITY OF LIFE ON WHOQOL BREF SCALE (N=129) Mean Scores *p<0.001

METHADONE ANONYMOUS (MA) MEETING Three MA groups formed in three different areas of Dhaka Since June 2011, fortnightly MA meetings are being conducted 27

ACKNOWLEDGEMENT All beneficiaries and participants Self help groups of PWUD DNC NASP UNODC fhi THANK YOU