1. + Opioid Substitution Therapy for Injecting Drug Users: Scale versus Quality WORKSHOP “OST in Developing Countries: A Primer” Atul Ambekar, Alok Agrawal (India)

2. + We already know that… Most effective treatment for opioid dependence - reduces illicit drug use and stabilizing life styles Works in variety of settings – hospitals, community, prison, etc. Both available medicines (Methadone and Buprenorphine) work well Known to reduce injecting and associated risky behaviours among PWID Reduction in high risk sexual behaviours One of the 9 components of the comprehensive package of harm reduction services

3. + Intended scale of OST services UN Target Setting Guide (2013) Low coverage – up to 20% Medium coverage – 20-40% High coverage – more than 40% Current worldwide coverage – about 8% (UN ref group on IDU and HIV, 2010) OST needs to be implemented at a large scale to accrue the benefits at a community level

4. + Implications for India Estimated number of PWID – about 200,000 HIV prevalence among PWID – 7.14% Minimum OST Coverage Medium – 40,000 High – 80,000 In 2010 Number of PWID on OST – 3800 Number of OST centres - 52 Need for massive scale- up of OST coverage across all regions and settings

5. + What we did…

6. + How quality is linked with scale-up… Large proportion of OST slots unutilized – despite huge numbers recruited Poor retention in treatment – most clients drop-out and go back to injecting Low adherence to treatment – few clients benefit completely Any expansion of OST must take into consideration issues relating quality of services offered

7. + OST implementation: learning from Indian Experience Scale-up should be planned and phased with priority areas and populations well-defined Necessary to build sufficient local experience and expertize with the intervention while attempting expansion Critical to focus on quality of service delivery in parallel Multiple mechanisms for quality assurance should be incorporated into the system

8. + Thank You

9. + How quality is linked with scale-up

10. + Quality of services Quality assurance mechanism s SOPs and operation al guideline s Standardize d training tools Monitorin g and hand- holding by field staff Regular reports contributing as inputs for improvement Accreditati on for quality Independen t evaluation