1. Bringing Opioid Substitution Treatment to scale Dr. M. Suresh Kumar Inter-country Consultation on Preventing HIV among IDUs Scaling Up: From Evidence to Action April 10 2007 Kolkata India

2. Essential Harm Reduction Package Outreach: Community outreach to reach out to hidden populations; peer education and support Preventive focus: IEC materials, legal access to sterile needles and syringes (NSP), condoms Clinical focus: Opioid substitution treatment, STI care

3. Need for effective opioid substitution treatment Opioid dependence a chronic, relapsing condition Opioid substitution treatment (most evidence is for methadone) an effective individual and public health tool

4. UN endorsement for Substitution treatment WHO/UNODC/UNAIDS position paper: Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention, 2004 WHO: Methadone and buprenorphine added to Essential Drugs List, 2005 UNAIDS policy on preventing HIV/AIDS among IDU, June 2005

5. Substitution treatment in the world No of countries reporting injecting drug use 130 No of countries reporting HIV among IDUs 78 No of countries offering substitution treatment 58 No of countries with methadone maintenance 48 No of countries offering buprenorphine 33 Source: IHRA

6. Substitution treatment in the world Global Dev/trans countries Number of countries with IDU (and HIV)130 (78) Number of countries providing ST58 Global Estimates of IDU13.2m10.3 Global Estimates of ST* (IDU + non-IDU) 874,00048,000 ST coverage (ST/IDU%)6.60.46 Source: IHRA, 2006

7. Injection related risk reduction at follow-up -Opioid substitution, Chennai India Kumar et al, 2002

8. Crime and Employment at follow-up - Opioid substitution, Chennai India Reduction in number of IDUs in lock-ups Reduction in number of IDUs in jail Increase in employment Kumar et al, 2002

9. Safe neighborhood Opioid substitution, Chennai India “ I have been living in this area for the past twenty five years.. You know, we had a bad reputation.. all because of the drug addicts.. They used to snatch chains.. Women cant walk in the street in the evening.. Thank God.. Things are changing now.. I believe the worst guys are going for treatment.. Can we hope that this will last?” Community key informant Kumar et al, 2002

10. Current state of Substitution in India Development of substitution protocols /modules UNODC supported by AusAID Establishment of substitution treatment in selected centres UNODC supported by DFID and assisted by AIIMS DFID PMO Projects (Emmanuel Hospital Association, Project Network) Governmental support for substitution program SACS support in West Bengal, Maharastra, Tamilnadu

11. Opioid substitution treatment with buprenorphine – Emmanuel Hospital Association, Northeast India Emmanuel Hospital Association, Jan 2007

12. Benefits of substitution treatment Attractive to drug users Acceptable to drug users, families, communities, religious leaders, militant groups No diversions reported Linkages with other services like VCCT Potential for behaviour change Emmanuel Hospital Association, 2007

13. Opioid substitution treatment – Project Network

14. Opioid substitution or extended detoxification? Many centres in India have used buprenorphine for shorter periods (1-6 months) Evidence based action or issue of convenience? Demonstrating the success through follow-up?

15. Obstacles for scale-up in the region National legal restriction Substitution treatment seen as issue of law enforcement rather than public health issue Regulatory requirements Bureaucratic blocks and delays

16. Obstacles for scale-up in the region Medical, political and societal prejudice – ST ‘condones drug use’, drug users undeserving Lack of priority or concern for target population Perpetual pilots and single demonstration projects Costs, training

17. Frederic Sorge, 2001 BuprenorphineMethadone Buprenorphine or Methadone?

18. Future directions Opioid substitution policy – consideration of methadone Integration of substitution treatment in the comprehensive treatment program for drug users Collaboration between Government, teaching institutions and NGOs for the delivery of services Training of medical doctors in Opioid Substitution Treatment Large scale programs – cost considerations

19. Acknowledgements International Harm Reduction Association DFID PMO Projects – SHARAN India – Emmanuel Hospital Association SAHAI Trust National Institute of Epidemiology (ICMR), Chennai