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Barriers to Methadone in Afghanistan

Barriers to Methadone in Afghanistan

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Barriers to Methadone in Afghanistan

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  1. Abstract no. Barriers to Methadone in Afghanistan Authors: Olivier Maguet, responsible of MdM Harm Reduction program in Afghanistan – olivier.maguet@medecinsdumonde.net Abdul Raheem Mohammad, Afghan Drug Users Group, Kabul – afghandun@yahoo.com Ernst Wisse, medical coordinator, Kabul – medco.afghanistan@medecinsdumonde.net Mélanie Quétier, general coordinator, Kabul – genco.afghanistan@medecinsdumonde.net www.afghan-harm-reduction.org

  2. Afghan setting • Production • First country producing opium in the world (UNODC, Afghanistan opium survey, 2011) • Opium/heroin (manufactured in Afghanistan) widely available + purity • Demand • Increasing number of people who use drugs (UNODC, 2009): • Any drugs: 8% of population aged 15-64 years • 230,000 opium users (+ 53% since last 2005 survey) • 120,000 heroin users (+140% since last 2005 survey) • Growing trend of injection practices • Blood Born Viruses • HIV: from 3% among IDUs (2005) to 7% (2009)

  3. The rise of HR in Afghanistan (1) • June 2005: Exploratory mission in Kabul MdM • No Harm Reduction interventions • Detoxification not based on good practices • 2006: program implementation in Kabul / 2 major components • Introducing and customizing HR services in Afghanistan (DIC & Care Centre + outreach) • disseminating through capacity building (National Training and Resource Centre) • Milestones for HR services • 2006: NSP and condoms provision, community-based IEC, primary health care interventions • 2007: testing and counselling (HIV, HBV, HCV, STI), opportunistic infections treatment and prevention • 2008: STIs treatment and TB referal • 2009: ART, peer-based naloxone distribution • 2010: methadone • Dissemination: • National TRC established in 2009 (on behalf of the model program) • 20 Afghan HR NGOs trained • 10 police sessions • Religious leaders • MPs (health commission) • Media campaigns and demonstrations World AIDS dayDec 2011 /Letter to MoPH

  4. The rise of HR in Afghanistan (2) • OST advocacyprocess: • April 2007: first workshop on OST • November 2007: National Consensus Conference on “Opioid Substitution Therapy: an Essential Service for Harm Reduction in Afghanistan” (MoPH lead) • Endorses OST (methadone, buprenorphine and opium tincture) • Refers to Afghan laws, regulations and international treaties to promote OST • 2008: OST protocol (approved by MoPH) / Choice of methadone for introducing OST • 2009: OST policy (approved by MoPH) • 2008-2009: design of methadone importation process • 2009: contract with MoPH to implement the first pilot methadone program • February 2010, 20: first methadone intake in Afghanistan • August 2010: national workshop on methadone first results More information on methadone results: Wednesday poster exhibition (WEPE232)

  5. Dream story? • September 2010: politicalblockagefromMinistry of Counter-Narcotics → request for a third part evaluation → Inclusion blockedat 70 patients instead of 200 patients scheduled per contract • November 2010: methadoneshortage due to “administrative” postpone in methadone importation certificate • Februarry 2011: methadoneshortage + break (3 days) due to second “administrative” postpone in methadone importation certificate → 6 patients dead → April 2011: meetings in IHRA Beirutconference to try to solve out the issue

  6. The challenge of Scale up • April-May 2011: emergency evaluationfrom WHO • strong effectiveness of methadone in Afghanistan: 1 year retention rate = 76%; 1 year opiate urine tests = 86% negative • Report also states that OST is appropriate for the country as it enjoys strong satisfaction of patients, family members and community. • Cost effectiveness: “among the lowest cost of methadone maintenance therapy worldwide”. • Conclusion; recommend to scale up methadone based treatment, mentioning that there is good Afghan capacity for expanding OST in large cities. • September 2012: OST awareness workshop (Pr Wodakkeypanelist) • July 2012: draft report fromthird part evaluation • Despite local evidence, impossible to disseminate and scale up (Afghan MoPH, PUD, NGOs and Healthprofesionals are requesting for) • 70 OST patients out of 120,000 heroinusers→ 0.0006% coverage rate • Political future Afghanistan uncertain > 2014 →Therefore critical to implement now

  7. Twoexamples Mortality HIV development Consider 20,000 heroin injectors (95% male-5% female) Average of 7% HIV prevalence in IDUs → Concrete numbers: Assumed 1,330 HIV+ male and 70 HIV+ female If each HIV+ DU has sexual relationship with one non DU/month → 16.800 acts of discordant sexual intercourse/year Assume 0.1% HIV transmission rate = 17 new HIV infections in general population/year • Conservative estimate of 20,000 injectors • Usualy 1% deaths per year among injectors → 200 deaths • Usually 0.2% deaths per year among patients on methadone treatment → 40 deaths per year = currently saving 160 deaths per year

  8. Barriers?? • Opponents: Ministry of Contra-Narcotics • Corruption / “Conflict of Interest” • Lack of knowledge and skill on OST + global lack of commitment • Business: the detoxification market → 50 millions USD versus 0.2 million USD) / $ 100 to 50 $/day versus 2$/ day • Policy: INL lead on drug policy in Aghanistan • “Friends” • MoPH = weak political body • MENAHRA: supporting Iran Knowlewdge Hub / No interaction (counteraction?) with the national program for capacity building in an Afghan setting + networking • MdM • Ethnicity: majority of beneficiaries are native from demographic and social minorities (Hazaras people) • Low literate/social level among MdM staffs (<community based) • Lack in establishing alliances with other human right and social justice CSOs in Afghanistan

  9. Way forward • Go on strenghteningMoPHversusMoCN • Advocacy toward INL (country level / HQ in US) • “Afghanization process” /MdM will leave the country by the end of 2012: OHRA (Organization for HR in Afghanistan) + ADUG (Afghan Drug Users Group) • Alliances with local CSOs • Global advocacy: Afghanistan as a core laboratory of war on drugs consequences

  10. Meet Médecins du Monde / Doctors of the World Everydayat Booth n°21 / Hall C