The trajectory of methadone maintenance treatment in Nepal

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Abstract

There are about 28,500 people who inject drugs (PWID) in Nepal and HIV prevalence among this group is high. Nepal introduced harm reduction services for PWID much earlier than other countries in South Asia. Methadone maintenance treatment (MMT) was first introduced in Nepal in 1994. This initial small scale MMT programme was closed in 2002 but reopened in 2007 as an emergency HIV prevention response. It has since been scaled up to include three MMT clinics and continuation of MMT is supported by the Ministry of Home Affairs (MOHA; the nodal ministry for drug supply reduction activities) and has been endorsed in the recent National Narcotics policy. Pressure from drug user groups has also helped its reintroduction. Interestingly, these developments have taken place during a period of political instability in Nepal, with the help of strong advocacy from multiple stakeholders. The MMT programme has also had to face resistance from those who were running drug treatment centres. Despite overcoming such troubles, the MMT programme faces a number of challenges. Coverage of MMT is low and high-risk injecting and sexual behaviour among PWID continues. The finance for MMT is largely from external donors and these donations have become scarce with the current global economic problems. With a multitude of developmental challenges for Nepal, the position of MMT in the national priority list is uncertain. Ownership of the programme by government, a cost-effective national MMT scale up plan and rigorous monitoring of its implementation is needed.

Introduction

Nepal has concentrated HIV epidemic among certain population groups, including people who inject drugs (PWIDs). The policy environment in Nepal has not been unfavourable to a harm reduction response to preventing the spread of HIV and Nepal initiated harm reduction services for PWIDs, including needle exchange programmes (NEP) and methadone maintenance treatment (MMT) much earlier than in other countries in South Asia. In fact, Nepal was the first country in South Asia to introduce MMT for opioid dependent people who use drugs. The trajectory of the MMT programme serves as an interesting case study, with implications for other developing countries with emerging or established HIV epidemics among PWIDs. The paper discusses salient issues to support learning for other countries in the region. We have relied upon our own experience of working on MMT in Nepal and have conducted a desk review of relevant documents. While buprenorphine based substitution treatment is also available, it is much smaller in scale and scope and therefore we restrict our focus to MMT.

Nepal has a long history of drug use. Cannabis was sanctioned for use on certain religious occasions, and occasional use of alcohol was tolerated socially. Reports of heroin use started appearing by the 1960s, and by the 1980s the number of heroin chasers had increased considerably. The next decade saw a shift in the pattern of drug use from heroin chasing to injectable opioid preparations such as buprenorphine (Reid & Costigan, 2002). A rapid situation assessment carried out in 1996 showed that 40% of drug users had injected drugs at least once in their lifetime; 66% PWIDs had injected buprenorphine and 20% had injected heroin (Ray, 2000). A study by Central Bureau of Statistics (2007) estimated that 61% of the 46,309 current ‘hard drug’ users were PWIDs (i.e. 28,439 PWIDs in Nepal). A recent nation-wide mapping study estimated the number of PWIDs to be in the range of 30,155–33,742. Among the PWIDs surveyed, a high proportion noted sharing needles/syringes and few reported using condoms (HSCB and NCASC, 2011). In 2011 HIV prevalence among PWIDs was estimated at 6.3% in Kathmandu and 4.6% in the Pokhara valley (National Centre for AIDS and STD Control, 2012).

Nepal was the first country in South Asia region to introduce NEP in the 1980s. Though HIV prevention services for PWIDs have been scaled up in recent years, the coverage remains low. The IBBS Round V survey conducted in 2011 showed that in the preceding year, only about 47% of PWIDs in Kathmandu and 82% in the Pokhara valley interacted with a peer educator/outreach worker, 2.9% and 3.5% visited a sexually transmitted infection (STI) clinic, and 20% and 31.3% visited a HIV testing centre (NCASC, 2011). The size estimation exercise conducted in 2011 also shows that in terms of services available for PWIDs, only one-third had access to a NEP, condom outlet or voluntary counselling and testing service within one kilometre of drug use hotspots (HSCB and NCASC, 2011) implying that much needs to be done to achieve universal access to HIV prevention services for PWIDs.

Section snippets

Methadone maintenance therapy in Nepal

The first MMT clinic was introduced in a psychiatric hospital in Kathmandu in 1994 with the objective of “preventing relapse, facilitating recovery and reducing overdose, risk of HIV, hepatitis and other infections among drug users” (Shreshta, 2000). The clinic had a medical doctor and a trained nurse working under the supervision of a psychiatrist. Methadone was dispensed as a tablet of 40 mg (unlike the current practice of dispensing liquid form), and most clients received a maintenance dose

Conclusion

A systematic evaluation of the outcome of MMT in Nepal is still needed. However, programme reviews and many small reports on MMT give encouraging signals (Ojha, 2011, Ambekar et al., 2010, Sapkota, 2010). While there is much to celebrate in the country's attempt to overcome various barriers in implementing MMT, there are many areas of concern as well as lessons that can be learnt from this experience. According to the target setting guidelines, the scale of MMT has to be increased to cater for

Funding source

None.

Acknowledgement

None.
Conflicts of interest statement

We declare no conflict of interest with any other agency/organization whatsoever.

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