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Guidelines on Primary Health Care Services for IDUs and their Sexual Partners


Injecting drug use is one of the major routes of HIV transmission, especially in the northeastern states of India. Injecting drug users (IDUs) and their regular sexual partners (including their spouses) are vulnerable to HIV infection due to multiple factors, including stigmatization and the adverse health impacts of drug use. The effective control and management of the health conditions of IDUs and their sexual partners, by ensuring provision of appropriate and quality primary health care services that are acceptable and accessible to them, is one of the essential strategies to reduce the spread of HIV infection.

foreword These Guidelines on Primary Health Care Services for IDUs and Their Sexual Partners have been developed by Family Health International (FHI) and Emmanuel Hospital Association (EHA), with the purpose of providing common approaches for injecting drug use-related health problems, and operating guidelines and standards for EHA Project ORCHID’s IDU interventions. Compiling this documentation involved detailed deliberations and consultations with national and international public health and harm reduction specialists and implementers to ensure that the recommendations are based on available evidence from India and international best practices, and in particular that they are feasible and realistic in field settings. Although this document has a northeast India focus, its application is expected to yield important lessons that could be adapted nationally and internationally. These guidelines have been developed with the intention of reaching a varied audience comprising implementing partner NGOs and other civil society partners, State AIDS Control Societies (SACS), the National AIDS Control Organisation (NACO), the Avahan India AIDS Initiative and other national and international partners. EHA Project ORCHID expresses its gratitude to FHI for its key role through the development process and the technical support provided by Dr Suresh Kumar. The provision of technical and financial resources by the Avahan India AIDS Initiative for the implementation of the strategies described in this document is gratefully acknowledged. Dr B Langkham Director HIV/AIDS & Partnership Projects Emmanuel Hospital Association


1. Introduction (pg 8 - pg 13) 1.1. Introduction 1.2. Major consequences of drug use 1.2.1. Major medical consequences 1.2.2. Major psychosocial consequences 1.2.3. Addressing barriers to services among IDUs 1.3. Drug use, dependence and risk behaviours 1.3.1. Drugs used in India 1.3.2. What are the levels of drug use? 1.3.3. Drug use patterns

table of contents

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Table of contents

1.4. Risk behaviours 1.4.1. Sexual risk behavior among IDUs 1.4.2. Injecting risk behavior 1.4.3. Use of multiple substances (overlapping substance use) 2. Comprehensive health care for IDUs and their sexual partners (pg 14 - pg 18) 2.1. Comprehensive package of services for IDUs using continuum of care 2.2. Harm reduction 2.3. Needle and Syringe Exchange Programme (NSP) 2.4. Preventive services for IDUs

Picture: Hornbill Festival, Nagaland

3. Health conditions associated with IDUs and their sexual partners (pg 19 - pg 44) 3.1. Common health problems associated with drug use/injecting drug use 3.2. Injection-related injuries and infections 3.2.1. Injection-related injuries 3.2.2. Injection-related infections 3.2.3. Management for serious complications of injectionrelated infections 3.3. Other injection-related issues 3.3.1. Contaminated injection or “dirty hit” (acute febrile reaction) 3.3.2. Tetanus 3.4. Drug use-related health problems 3.4.1. Overdose 3.4.1.1. Risk factors for opioid overdose 3.4.1.2. Signs and symptoms of opioid overdose 3.4.1.3. Management of overdose – educating the client 3.4.1.4. Opioid overdose management with naloxone 3.4.1.5. What not to do in case of overdose 3.4.2. Drug dependence 3.4.2.1. Opioid substitution therapy (OST) 3.4.3. Unplanned opioid withdrawal and its management 3.4.4. Other substance use-related withdrawals

Guidelines on Primary Health Care Services for IDUs and their Sexual Partners | Project ORCHID


3.5.

Infectious diseases 3.5.1. Sexually transmitted infections (STIs) 3.5.2. Viral hepatitis 3.5.3. Tuberculosis 3.5.4. Malaria 3.5.5. HIV/AIDS 3.6. Non-infectious disorders 3.6.1. Psychiatric disorders 3.7. Other common clinical conditions 3.7.1. Skin infections and infestations 3.7.2. Dental health 3.7.3. Constipation 3.7.4. Contraception and pregnancy 3.7.5. Pain 3.7.6. Nutrition 04

Table of contents

4. Models of primary health care delivery to IDUs and their sexual partners (pg 45 - pg 47) 4.1. Drop-in centre (DIC) 4.2. Community outreach and home-based care 4.3. Community or general practice (GP) clinic 4.4. Out-patient and hospital-based health services 4.5. Closed setting based health services for IDUs

9. Monitoring and Evaluation of Services (pg 64 - pg 65) 9.1. Programme data management 9.2. Recording and reporting 10. Appendices (pg 66 - pg 79) 1. Identifying and managing signs and symptoms of withdrawal from non-opioid substances 2. Patient education messages a. Hand-washing b. Safe injection practices c. Vein care d. Education on prevention of opioid overdose 3. Clinical features and management of abscesses and ulcers 4. Information on viral hepatitis 5. Frequently asked questions related to HCV infection among IDUs 6. Frequently asked questions related to opioid substitution therapy (OST) 7. Avahan–Project Orchid Monitoring and Evaluation tools 11. References and further reading (pg 80 - pg 82) Table of contents

5. Setting up services for IDUs: Staffing, out-reach and community mobilization (pg 48 - pg 51) 5.1. Desirable characteristics of health care providers (staff) 5.2. Responsibilities of peer educators and outreach workers 5.2.1. Responsibilities of peer educators (PEs) 5.2.2. Responsibilities of outreach workers (ORWs) 5.3. Outreach health care equipment 5.4. Community mobilization 6. Referral services for IDUs and their sexual partners (pg 52 - pg 54) 6.1. Networking and referrals 6.1.1. Networking 6.1.2. Referral linkages 7. Infection control and waste disposal (pg 55 - pg 59) 7.1. Hazards of not collecting and disposing of needles and syringes properly 7.2. Universal precautions and stages in waste disposal management 7.3. Needle-stick injury and post-exposure prophylaxis (PEP) 8. Special issues (pg 60 - pg 63) 8.1. Special issues of Female IDUs, spouses of IDUs and IDU sex workers 8.1.1. Female injecting drug users (FIDUs) 8.1.2. Spouses of male IDUs 8.1.3. FIDU sex workers 8.1.4. Barriers to accessing services by FIDUs/spouses of IDUs/FIDU sex workers 8.1.5. A comprehensive intervention strategy to address women’s issues 8.2. IDUs in prisons or detention centres 8.3. Adolescent and young IDUs 8.4. Co-existing alcohol use disorder

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Guidelines on Primary Health Care Services for IDUs and their Sexual Partners | Project ORCHID


AIDS ANM ART ATS ATT BBV BCC CCC CEF CMIS CPR COGS

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Acquired immune deficiency syndrome Auxiliary nurse midwife Antiretroviral therapy Amphetamine-type stimulant Anti-tuberculosis treatment Blood-borne virus Behaviour change communication Community care centre Client encounter form Computerized management information system Cardio-pulmonary resuscitation Clinic Operational Guidelines and Standards

PP QID RNTCP RPR RTI STI SSTI TB TI TID TT VDRL WHO

Preferred provider Four times daily Revised National Tuberculosis Control Programme Rapid plasma reagin Reproductive tract infection Sexually transmitted infection Skin, soft tissue infections Tuberculosis Targeted intervention Thrice daily Tetanus toxoid Venereal disease research laboratory World Health Organization

abbreviations

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Abbreviations

Abbreviations

DIC DOTS FHI FIDU GUD HAV HBV HCV HIV HRG IC ICTC ICST I&D IDU IEC IM M&E MMT NA NACO NGO NSP OI ORW OST PE PEP

Drop-in centre Directly Observed Treatment – Short course (TB) Family Health International Female injecting drug user Genital ulcer disease Hepatitis A virus Hepatitis B virus Hepatitis C virus Human immunodeficiency virus High-risk group Infection control Integrated counselling and testing centre Immuno-chromatographic strip test (for syphilis) Incision and drainage Injecting drug user Information, education and communication Intramuscular Monitoring and evaluation Methadone maintenance therapy Narcotics Anonymous National AIDS Control Organisation Non-governmental organization Needle syringe exchange programme Opportunistic infection Outreach worker Opioid substitution therapy Peer educator Post-exposure prophylaxis

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1.1. Introduction

1,2,3

The sharing of HIV-infected needles, syringes, and other injecting equipment by injecting drug users (IDUs) can spark and intensify HIV transmission, since HIV infection can be spread from IDUs to their sexual partners and from infected mothers to their infants. IDUs are therefore a key group for interventions for the prevention of HIV transmission. IDUs are a hard-to-reach population, often operating in hidden settings because they experience significant marginalisation, stigmatisation, harassment and fear of imprisonment in view of the illicit nature of drug use. Though many IDUs suffer from significant health and psychosocial problems, they face several barriers in accessing mainstream health services. Improving access to health services, offering services sensitive to the needs of the IDU community and providing relevant and useful information on health and preventive services could encourage users to seek help with trust and confidence. Greater access to primary health care and opioid substitution therapy (OST) has the potential to improve the health of IDUs, reduce HIV vulnerability and enhance their quality of life. Programmes offering a comprehensive package of services in an integrated setting are likely to effectively address the multiple health needs of IDUs. Hence establishing and delivering comprehensive services based on harm reduction principles in IDU-focused clinics is a sound approach to improve the health of IDUs and their partners.

chapter 1

With about 2% of the adult population in Manipur and Nagaland injecting drugs,4 this behaviour is the major route of HIV transmission in northeastern states of India. As per National AIDS Control Programme Phase III, there are 186,000 IDUs in India,5 of whom 62,000 are in Manipur and Nagaland. Despite the success of HIV interventions in reducing HIV prevalence in Manipur (from 24.5% in 2003 to 17.9% in 2007) and Nagaland (from 8.4% in 2003 to 1.9% in 2007), there are several places where prevalence is more than 15%.6,7

introduction

In addition to addressing IDUs, IDU programmes should ensure that they also address the regular sexual partners of IDUs, as many of them are likely to be infected with HIV/blood-borne viruses (BBV) or sexually transmitted infections (STIs), and some of them may be IDUs too.

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Chapter 1 Introduction


1.2. Major consequences of drug use

1,2

1.2.3. Addressing barriers to access to services among IDUs

1.2.1. Major medical consequences Drug dependence is a chronic, relapsing condition which is difficult to control due to compulsive drug use and craving, leading to drug-seeking and repetitive use, even in the face of negative physical and psychosocial consequences. These aspects of dependence need to be considered in designing and delivering intervention programmes for IDUs.

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Chapter 1 Introduction

Common health problems among people who inject drugs include those associated with the following: • Pharmacological effects of drugs: overdose, intoxication, withdrawal symptoms, dependence (and associated psychosocial consequences) • Practice of injecting (and sharing syringes/needles): - transmission of HIV and other blood-borne infections (e.g. hepatitis B or HBV, and hepatitis C or HCV) and its consequent morbidity and mortality (e.g. cirrhosis, hepatocellular carcinoma); - infection of skin, soft tissue, musculoskeletal system and systemic infections, e.g. skin abscess, osteomyelitis, septicaemia, bacterial endocarditis, tetanus; - endovascular complications: thrombophlebitis, endocarditis. • Sexual risk behaviour: transmission of STIs • Susceptibility to tuberculosis (TB) infection (predisposed by living conditions, HIV status, etc.) • Psychiatric co-morbidity including substance-induced psychosis, sleep disorders, anxiety, depression and suicide • Pain • Consequences of poly-substance dependence, including alcohol 1.2.2. Major psychosocial consequences Apart from medical problems, many active drug users struggle to cope with addressing life’s competing demands such as food, shelter and care of family, and face financial, legal and psychosocial consequences. Many drug users have significant economic limitations as they are jobless and spend a disproportionate amount of money to sustain their drug habits. The additional burden of seeking and utilizing health care services might be insurmountable or a lesser priority for many male and female drug users. The pervasive stigma, discrimination and judgemental attitudes related to drug use can also influence the attitudes of health care providers and the health care seeking behaviour of the client. Other psychosocial and legal consequences of drug use include social marginalization, homelessness (e.g. lack of safe shelter for female drug users doing sex work), crime (theft, corruption), violence, incarceration, rejection/neglect by their families and psychiatric morbidity. These factors could adversely impact treatment adherence and may in turn exacerbate drug use.

Barriers to accessing health services

Effectively addressing the barriers

IDUs are a hidden population and reluctant to access health care services

Involve ex-IDUs in services

Services located far away from the residence/hotspots of IDUs

Services should be close to the community or brought to the community through outreach

Stigma and discrimination at medical facilities - Lack of knowledge among health care providers on how to deal with DUs - Cultural differences between clients and service providers - Poor patient–physician communication - Lack of mutual trust, respect and confidentiality - Lack of knowledge in the community that drug dependence is a health problem

Ensure that the health care workers and facilities provide a friendly and supportive environment to the clients

Lack of comprehensive services catering to multiple needs of IDUs

Referral to appropriate services to deliver a range of comprehensive services to IDUs and their families

Poverty

Offering services free of cost or at subsidized rates; linkage to supportive services

Ensure that the human rights of clients are respected Ensure confidentiality Advocacy

Addressing these issues in user-friendly settings is critical to the success of IDU interventions, and the compassion and commitment exhibited by individual staff members can help the user seek and adhere to treatment. In addition, as all the above issues are interrelated and increase the risk of HIV infection among IDUs, severe and preventable issues can be prioritized in developing an intervention plan for an individual client. Linking with social welfare services that are available in the community will help drug users to mitigate some of the barriers impacting utilization of health care services (refer to Chapter 6).

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Chapter 1 Introduction


1.3. Drug use, dependence and risk behaviours 1,2,3 1.3.1. Drugs used in India

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Chapter 1 Introduction

Drug of use

Class

Heroin* Spasmoproxyvon*/Proxyvon*

Opioids Opioids

Codeine* Buprenorphine Pethidine, pentazocine, morphine Diazepam* Alprazolam,* nitrazepam* Promethazine* (Phenargan) Chlorpheneramine maleate (Avil)* Amphetamine-type stimulants – ATS (e.g. methamphetamine) Ecstasy Cannabis (Ganja, Hashish)* Glue LSD Ketamine Magic mushrooms (psilocybin)

Opioids Opioids Opioids Benzodiazepine Benzodiazepine Antihistamine Antihistamine Stimulants Stimulants Cannabis Inhalants Hallucinogens Hallucinogens Hallucinogens

Common modes of use Injecting, Chasing Injecting, Swallowing Swallowing Injecting Injecting Injecting Swallowing Injecting Injecting Chasing, Injecting Swallowing Smoking Sniffing Swallowing Injecting Swallowing

* Drugs commonly used in northeast India (Note: 1. Some IDUs inject raw opium, after processing and filtering, when they do not have access to heroin. 2. Spasmaproxyvan/proxyvon contains dextropropoxyphene, dicyclomine and acetaminophen).

1.3.2. What are the levels of drug use? • • • • •

Experimental: Single or short-term use that is motivated by curiosity or a desire to experience new feelings or moods Recreational: Controlled use in social settings Circumstantial: Use in situations where specific tasks are performed or freedom from pain is sought Intensive: Drug use (often high dose) on a regular basis Compulsive: Persistent, frequent use resulting in psychological and physical dependence

1.3.3. Drug use patterns •

In most cases, individuals start with non-injecting drug use (smoking, inhaling the vaporized form, snorting/sniffing, swallowing) and after a period shift to the injecting mode of administration. This could be due to various factors such as efficiency of injecting in delivering a substance directly into the bloodstream, lack of drug wastage, financial pressures (increasing cost of drug), impurity of substances and increased tolerance. However, this transition is not inevitable. Pooling of money to purchase drugs and sharing of needles is common in India.

• •

Professional injectors, who receive payment for injecting a client with an illicit drug (and who may also sell drugs), rarely employ hygienic practices. Shooting galleries, communal venues used by IDUs for injecting, are prevalent in India. Drug use patterns vary according to availability of drugs, trends and norms among peers in different drug-using communities. Sometimes people inject substances that are not made for injection. For example, some benzodiazepines, available in tablet form, are crushed, mixed with water and injected. Similarly, spasmoproxyvon capsules are emptied and the powder is injected. Because the particles do not break down well, the chance of developing vein damage, abscess and gangrene are high.

1.4. Risk behaviours 1.4.1. Sexual risk behaviour among IDUs • • • • • • •

Sex with multiple partners or with a partner who has multiple partners (e.g. sex worker) Some of the IDUs (male and female) may indulge in sex work or sell sex for drugs Increased sexual risk-taking Impaired skill in practising safer sex/negotiating for safer sex under the influence of drugs Sex in presence of STIs Low levels of condom use with partners, particularly, spouses and regular sexual partners (unprotected sex) Low sexual risk perception

Among IDUs, change in sexual risk behaviour is more difficult to achieve than change in injecting risk behaviour; therefore sexual transmission of HIV may often be overlooked by IDUs. (Also refer to Chapter 8). 1.4.2. Injecting risk behaviour • •

Sharing needles/syringe/paraphernalia – contributes to transmission of HIV/other BBV Unhygienic injecting practices – lead to injection-related infections, e.g. abscess

1.4.3. Use of multiple substances (overlapping substance use) • • •

Drug harm may substantially increase due to simultaneous use of other substances. Overdose is common when several substances are taken together (polysubstance use). In general, pharmaceutical drug use is characterized by a combination of several drugs. “Cocktailing” of diazepam, avil, promethazine (phenargan) with synthetic opioids such as buprenorphine or pentazocine is extremely prevalent in several parts of the country. A poly-substance user can use many different routes to administer various drugs (e,g. smoke tobacco, drink alcohol and inject heroin).

A brief account of alcohol use disorder is given in chapter 8.

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Chapter 1 Introduction


2.1. Comprehensive package of services for IDUs using continuum of care • • • • • •

chapter 2

• • • • • • • • • • • •

Management of common health problems among IDUs (primary health care) e.g. abscess management (discussed in chapter 3) Harm reduction/risk reduction services including access to safe injecting equipment through needle syringe exchange programme (NSP) and condoms (male and female condoms) Treatment of drug dependence/withdrawal: OST; detoxification and rehabilitation; overdose and withdrawal management Infection control measures, e.g. supply of bleach for disinfecting equipment Encouraging and ensuring access to health/psychosocial services for IDUs, e.g. integrated counselling and testing centres (ICTC) Behaviour change communication (BCC) on reducing drug- and sex-related risks Peer outreach and community-based and peer-driven BCC Care and support for HIV positive IDUs, e.g. provision of antiretroviral therapy (ART) and management of opportunistic infections (OIs) Provision of services for the prevention, diagnosis and treatment of STIs, TB (verbal screening and referral), HBV (vaccination in particular) and HCV Home-based care and treatment Supporting treatment adherence Crisis care Linkages to support groups such as Narcotics Anonymous (NA) Support for sexual partners Referrals to other services such as specialized health care services (e.g. family planning, malaria), psychosocial (e.g. employment training), nutritional support Advocacy and enabling environment, e.g. advocacy with law enforcement agencies, churches, women’s groups and other pressure groups Ownership-building, e.g. IDU community mobilization and engagement Research, surveillance and feedback for programme development and refinement

Harm reduction, including NSP, is addressed in this chapter. Management of infectious and non-infectious conditions associated with IDUs is addressed in chapter 3. 2.2. Harm reduction

1,2,8

Harm reduction in relation to drug use means reducing the harmful consequences of drug use without necessarily reducing drug consumption.

comprehensive health care for IDUs and their sexual partners

The harm reduction approach is used to: • Reduce negative health effects and social harm caused by extensive drug use, e.g. overdose prevention strategies/OST • Keep drug users healthy until they are ready for treatment or outgrow their drug use • Reduce HIV and other BBV among IDUs and their drug/sexual partners • Reduce unsafe sexual practices • Provide support to reduce the financial, legal and social problems associated with drug use

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Chapter 2 Comprehensive health care for IDUs and their sexual partners


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Harm reduction takes a non-judgemental and non-confrontational position and recognizes that drug-using behaviours result from complex social, environmental, economic, cultural and personal factors, and that complete elimination of injecting drug use is unlikely in regions where drugs are cheap and readily available. Harm reduction views injecting drug use primarily as a health issue, rather than a moral or legal issue.

4. Involving current and ex-drug users (drug-user organizations and drug user networks) in designing, promoting and delivering services as they can advocate and serve on their behalf

The basic beliefs underlying harm reduction include the following: • Drug dependence is a chronic, relapsing medical condition with periods of remission (due to stressful circumstances, personal crises, peer pressure, etc.). • Abstinence and harm minimization are not mutually exclusive. • Harm reduction is a pathway to abstinence for many people. • Dependence and harm are not the same. • Not all people are ready to stop using drugs, so this approach aims to reduce harm while they continue to use them.

2.3. Needle and Syringe Exchange Programme

The principles of harm reduction are pragmatic, humane, effective and holistic:

Chapter 2 Comprehensive health care for IDUs and their sexual partners

1. Harm reduction emphasizes short-term pragmatic goals (e.g. preventing transmission of HIV) over long-term idealistic goals (e.g. abstinence and vocational rehabilitation). The key is early contact and encouraging drug users to progress towards reduced harm and improved health at a speed which is acceptable to them and thus more realistic. 2. Establishing a hierarchy of risks for avoiding HIV infection from drug use: - Don’t use drugs - But if you do, don’t inject - But if you do inject, use new equipment: Don’t share – do not re-use - But if you re-use, use your own equipment every time - If you do, clean it thoroughly with bleach 3. Harm reduction involves multiple strategies that could be complementary, working at multiple levels - Provision of accurate and credible information on safe injecting practices through community outreach (with focus on peer approaches) and BCC - Establishment of evidence-based drug dependence treatments, including OST - Access to new sterile injecting equipment through NSP - Outreach programmes and peer education - Access to primary health care such as vein care, overdose management - Removing barriers to safer injecting (addressing laws and police practices) - Targeting special groups, e.g. prisoners, ethnic minorities and women - HIV testing and counselling (voluntary and confidential) and care and support - Prevention of sexual transmission of HIV (through condoms and STI management)

Project ORCHID | Guidelines on Primary Health Care Services for IDUs and their Sexual Partners

A combination of strategies and individualization of interventions are important aspects of the harm reduction approach. 1,2,8

The key objective of NSP is to facilitate safe injecting practices by providing new needles/syringes/other injecting paraphernalia, safe disposal mechanisms for used equipment, and education on safer practices. Services provided • Sterile injecting equipment – provide clean needles and syringes, spoons, filters, sterile water, tourniquets, alcohol swabs and cotton balls • Condoms – male and female condoms provided to reduce the sexual trans mission of HIV • Information and education aimed at reducing drug-related harm – e.g. prevention of HIV/other BBV/STIs, safer injecting, infection control and overdose prevention • Referrals to other health services e.g. to drug use treatment, ICTC • Bins for appropriate disposal of used injecting equipment (refer to Chapter 7) Operational models • Fixed site (hospitals, community health centres, drop-in centres [DICs]) • Mobile or outreach (outreach visit to hard-to-reach IDUs such as sex workers injecting drugs) • Pharmacies (useful to different group of IDUs, such as professionals or those who inject only occasionally) • Syringe vending machines (provide 24-hour access to sterile syringes). Effectiveness • Reduces needle sharing and HIV transmission (positive impact on HIV risk behaviours) • Provides an entry point for the IDU into the intervention programme (more likely to remain in a drug treatment programme and reduce drug use; may also stop drugs) • Cost-effective – prevents injection-related morbidity/mortality and saves treatment costs • Can provide outreach and also improve access to treatment (including for more marginalized users) • Provides scope for safer disposal of injection equipments (reducing the amount of inappropriately discarded needles and syringes)

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Chapter 2 Comprehensive health care for IDUs and their sexual partners


Implementation • Public security and concerns of community must be addressed (e.g. Do NSPs promote drug use? Will dirty syringes be left on the street?). • Establish relationships with relevant government officials, e.g. security officials (police) • Consult with drug users when planning service delivery • Locate in areas with high levels of injecting drug use • Drug users must be allowed to take as many needles and syringes as they need 2.4. Preventive services for IDUs

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Apart from NSP and condoms, the risk of transmission of HIV/other BBV can be reduced by: • Offering effective drug treatment such as OST (refer to Chapter 3) apart from harm reduction services • Linkage with preventive and screening services for infectious diseases including HIV/STI/BBV/TB and with psychosocial services (refer to Chapter 6) • Educating the patient on safer drug use (refer to Appendix 2)

chapter 3

Chapter 2 Comprehensive health care for IDUs and their sexual partners

health conditions associated with IDUs and their sexual partners

Project ORCHID | Guidelines on Primary Health Care Services for IDUs and their Sexual Partners


3.1. Common health problems associated with drug use/injecting drug use

1

Injection-related injuries and infections Injection-related injuries

Injection-related infections 20

Chapter 3 Health conditions associated with IDUs and their sexual partners

Complications of injectionrelated infections

Other injection-related issues Drug use-related health problems

Infectious diseases

• Bruising • Scarring • Swelling and inflammation including urticaria • Venous injury • Arterial injury • Ulcers • Cellulitis and abscess • Thrombophlebitis • Ulcers • Septic thrombophlebitis • Bacteraemia and septicaemia • Embolization Musculoskeletal infections Endovascular complications • Contaminated injection or “dirty hit” • Tetanus • • • •

Overdose Drug dependence Unplanned opioid withdrawal Other substance use-related withdrawals

• STIs • Viral hepatitis (HBV, HBC) • HIV/Acquired immune deficiency syndrome (AIDS) • Malaria • TB • Respiratory tract infections

Non-infectious disorders

• Psychiatric disorders

Other common health problems

• • • •

Skin infections and infestations Poor dental condition/hygiene Constipation Contraception and pregnancyrelated issues • Pain • Nutritional deficiency

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3.2. Injection-related injuries and infections

1

While injection-related injuries and infections are a common issue among IDUs, serious complications are rare. When complications do occur, they can be severe and result in lengthy hospitalization, chronic illness and death. In general, assessment should determine: • Wounds or infections requiring medical management, such as antibiotics, compresses or topical treatment • Wounds requiring incision and drainage (I&D) • Wounds or infections requiring referral to a hospital The high rate of complications common to injecting drug use is due to: • Injection of drugs into the fatty layer under the skin (“skin popping”) • Leakage of drugs out of veins during the injection (extravasations) • Tissue death (necrosis) due to toxic materials in drugs • Increased numbers of bacteria on the skin surface • Injecting substances that are not meant for injection (e.g. injecting tablet spasmoproxyvon) Prevention of injection-related injuries and infections: • Avoid injecting and opt for alternative modes of drug use, e.g. oral intake • Education on safe injecting practices and hand-washing • Cleaning skin with an alcohol swab or soapy water prior to injection • Use of a new needle for every injection • Rotation of injecting sites • OST: one of the most effective interventions reducing the likelihood of injection-related infections among opioid injectors by reducing or eliminating the number of injections ��� Clinical examination: this is critical as IDUs may not complain of pain (due to the effect of drugs) 3.2.1. Injection-related injuries Bruising: Bruising occurs when blood leaks out from the vein under the skin during the process of injecting the drug. Bruising at the injection site can reflect poor injection techniques. Prevention • Education on safe injecting practices such as applying adequate pressure for a sufficient amount of time after injecting. • Using a new needle for each injection and rotating the injecting sites. • Using a soft, flexible, easy-to-open tourniquet and removing it before injecting. Treatment • There is no specific treatment; ice applications may be useful.

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Chapter 3 Health conditions associated with IDUs and their sexual partners


Scarring (track marks): Track marks are scars along the veins caused by repeated injections at the same site. Prevention • Alternating and rotating, using a new needle for each injection. • Using a sharp, sterile needle for each injection. Treatment • There is no specific treatment; for keloids and heavy scarring, refer to a specialist.

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Chapter 3 Health conditions associated with IDUs and their sexual partners

Swelling and inflammation, including urticaria: Redness or swelling around the injection site may occur if the vein is missed and the drug is injected into the soft tissue. Urticaria (a “histamine reaction”, appearing as raised, wellcircumscribed areas of erythema and oedema involving the dermis and epidermis that are very pruritic) occurs as a direct result of the drug entering the soft tissues. Prevention • Making sure of venous access before injecting prevents leakage into the soft tissues. Treatment • There is no specific treatment; usually resolves without treatment in a few days. • Application of cold compresses initially and warm compresses later may be useful. • Urticaria is difficult to prevent but resolves without treatment. Venous injury: Venous collapse occurs when repeated injections are given at the same site. Repeated injections lead to: a. Frequent local infections b. Repeated trauma to the vein c. Inflammatory reaction to injected irritants d. Trauma associated with barbed or blunt needle which tears the vein

Prevention • Choosing a large vein for injecting, cleaning the site well with alcohol and putting pressure on the injection site for at least 30 seconds after the needle has been removed. • Alternating and rotating the injection site and injecting in the direction of the body’s blood flow. • Inserting the needle at an angle of 15-45 degrees with the bevel of needle facing upwards. Treatment • Normal saline or povidone solution may be used on the wound and the part should be kept dry. • If the wound is large, use dressings that encourage tissue growth and reduce infection. Arterial injury: Arterial injury can result from an inadvertent injection into the artery. This is more common when a vein is located close to an artery such as in the groin. Arterial injuries can result in haemorrhage. Besides, they can also lead to vascular spasm with loss of distal tissue due to lack of blood flow. This may be complicated by infection (gas gangrene or tetanus) and muscle swelling (compartment syndrome), which may lead to amputation and renal failure. Prevention • A pulsating blood vessel should not be used for injection. • Adequate pressure should be applied for at least 15 minutes if an artery is punctured or the drug is inadvertently injected intra-arterially. Treatment • If there is significant haemorrhage, refer the IDU to a hospital. Venous ulcer: Ulcer is associated with swelling of the affected area and is painful. Venous ulcers occur mostly at bony prominences. The skin is dry, flaky and discolored. Thick dilated veins can be found around the ulcer. Management • Clean the ulcer with normal saline, dress with dry gauge and bandage it. • Elevate the affected limb while lying down or sitting. • Apply elastic bandage while walking around. • Refer the patient to a hospital if there is bleeding from the ulcer site.

Damage to the vein including valves in the vein – scarring (fibrosis/sclerosis) of vein Blood cannot return to the heart as fast as it is pumped and leads to chronic venous insufficiency and venous (stasis) ulcer

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Chapter 3 Health conditions associated with IDUs and their sexual partners


3.2.2.

Injection-related infections

Abscess is a collection of pus under the skin. It occurs as a reaction to pathogens (e.g. bacteria) or foreign materials (e.g. injecting needles) and is characterized by inflammation (pain, warmth, redness, swelling, tenderness). IDUs who have been injecting for many years may develop chronic recurrent abscesses that may be related to colonization with an abscess-inducing subspecies of a skin bacterium (e.g. Staphylococcus aureus).

24

Chapter 3 Health conditions associated with IDUs and their sexual partners

Risk factors • Poor injection technique • Injecting tablets (particularly diverted* buprenorphine or spasmoproxyvon/proxyvon) • Injecting frequently • Injecting frequently at the same site • Using non-sterile injecting equipment • Not cleaning the skin adequately before injecting • Skin popping (subcutaneous or intramuscular [IM] injection) • Injecting “cocktails” (e.g. mixtures of benzodiazepines, antihistamines and heroin) • “Booting” (repeatedly flushing and pulling back during injection) • HIV infection • Poor nutritional status (* Drug diversion: use of prescription drug for recreational purposes: e.g. diverting buprenorphine from OST service for sale in the street as a substitute for heroin.)

Prevention • Maintain skin hygiene and hand-washing. • Use clean injecting equipment every time. • Reduce the frequency of injections. • Ensure early diagnosis and treatment. Management: The aims of abscess care are to: • Provide early treatment to prevent increase in its size and other complications. • Heal the abscess as quickly as possible. • Provide appropriate pain relief. • Refer complicated cases for appropriate medical treatment. General care • Encourage injecting into sites far away from the abscess area until it has healed. • Clean the area with soap and water. • May need to cover the area with a clean dressing. • If the abscess is discharging pus or other fluid it will require daily dressing. Clean the area with water or saline and apply a clean gauze dressing. • If the abscess is painful, ibuprofen 200-400 mg may be taken 8-hourly. • Encourage early reporting of complications such as increase in abscess size, black tissue around the area (necrosis) or increase in pain.

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Specific management Clinical manifestation

Management *

Early: Abscess begins as a firm subcutaneous swelling (with or without cellulitis). It is painful with warmth, tenderness and redness.

- For pain and inflammation, ibuprofen may be given - If the swelling is associated with cellulitis, give antibiotics – tablet cephalexin 500 mg four times daily (QID) for 7 days, or cap cloxacillin 500 mg QID for 7 days - Advise to come back to clinic if the condition does not improve

Later the swelling increases in size and becomes fluctuant (soft and moves a little when you touch the swelling)

- Wash the area with salt water or with soap and clean water - I&D or aspiration with needle and syringe by a trained health care worker or referral to a hospital; fix a drain if necessary - Daily dressing of wound; clean with alcohol wipes followed by application of povidone solution to cover the wound and at least a three-inch margin around the site - Analgesic for pain relief may be given - Antibiotics – usually unnecessary after I&D

* Please refer to Appendix 3 for additional information on grading (staging) of abscess and ulcers and their management under each grade. Grading is required for clinical follow-up of their response to treatment and for documentation in the Clinic Encounter Form and Abscess Management Register (refer to Appendix 7). Refer to Appendix 2 for information on patient education messages on safe injection practices to prevent abscess/soft tissue infections.

Cellulitis is a severe, diffuse inflammation of the skin (involving dermis and subcutaneous layers), resulting in the skin becoming painful, red, hot, swollen and tender. It may manifest with fever, chills, malaise, myalgia and pain at the lesion. Oozing and swelling of local lymph node(s) may be found. Cellulitis and abscess often occur together. Management - analgesics such as Ibuprofen - antibiotics: body weight <50 kg – Cloxacillin tab 250 mg orally 4 times daily for 5 days; if >50 kg – 500 mg x 4 times daily for 5 days or Cefixime tab 400 mg daily in two divided doses for 5-7 days

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Chapter 3 Health conditions associated with IDUs and their sexual partners


Thrombophlebitis is an inflammation of the vein wall. It can be due to an extension of cellulitis or to an infected clot within the vein. Ulcer refers to a breach in the skin or mucous membrane. If unattended, ulcer may expand, increase in size and extend to involve deeper layers and muscle, exposing bone. It may also lead to osteomyelitis, septic arthritis and septicaemia. Ulcers sometimes seem not to heal, and healing, if it does occur, tends to be slow. Ulcers that heal within 12 weeks are usually classified as acute, and longer-lasting ones as chronic. Clinical manifestation

26

Chapter 3

Initial stage: Superficial ulcer/deep ulcer involving tendons but no bone involvement The skin around the ulcer may be red, swollen and tender; may discharge serous, purulent or bloody material; and may be painful

Health conditions associated with IDUs and their sexual partners

Deep ulcer with bone involvement (osteomyelitis)

Advanced stage: Presence of localized gangrene (darkening of the affected tissue; foul odour; loss of sensation) Extreme pain be present due to ischaemia (inadequate blood supply to the area)

3.2.3.

Management for serious complications of injection-related infections

Complications of injection-related infections Injection-related skin infections

Bacteraemia

Management * - Wash the area with normal saline - Cover with clean gauze and bandage (to absorb the oozing discharge) - If the ulcer is deep, pack with gauze soaked in saline/betadine and cover with clean gauze - Provide analgesics if necessary - If sign of infection present, such as yellow discharge, give antibiotics such as Cephalexin or Cloxacillin - For non-healing persisting ulcers, there is no need for antibiotics - Encourage rest of the affected part - Manage as above at the clinic and refer to higher health care facility for management of bone infection - Ensure rest to the affected part - Refer immediately to a higher health care facility where surgical specialist is available as it can progress quickly and may even lead to amputation.

* Please refer to Appendix 3 for additional information on grading (staging) of abscess and ulcer and their management under each grade. Grading is required for clinical follow-up of their response to treatment and for documentation in the Clinic Encounter Form and Abscess Management Register (refer to Appendix 7).

Septicaemia Bacteria lodge in small vessels in any organ Embolization

27

Chapter 3

Organ

Brain

Heart Valves

Bones

Joints

Fingers & toes

Splenic/ Brain Endocarditis Osteomyelitis Septic liver abscess/ arthritis abscess, Meningitis etc.

Gangrene

Bacteraemia: Bacteraemia is the presence of bacteria in the bloodstream. It is a common complication of injecting drug use, mainly caused by the introduction of skin flora into the vascular system. Poverty, poor nutrition, poor dental hygiene/condition, leg ulcers may contribute to bacteraemia. The initial symptoms include fever (over 38.5°C), chills, vomiting and exhaustion. Loss of consciousness, confusion, delirium and fits may be late symptoms. Complications • Bacteraemia can lead to septicaemia which can result in endocarditis and septic embolism (with the formation of multiple new abscesses, i.e. “seeding of infection” in the joints, pleura or other areas musculoskeletal infections). • Gangrene (tissue death): darkening of the affected tissue; foul odour; loss of sensation Septicaemia: An established blood infection resulting from bacteraemia. Risk factors for septicaemia include untreated injection-related infections and other untreated infections such as dental abscess. Septic thrombophlebitis: an infected blood clot in a vein, which may be fatal. Symptoms include: • Redness, swelling and tenderness of the skin overlying a vein • Pus draining from the vein • Septic clots in the blood vessels of lungs (pulmonary emboli) • Bloodstream infections (septicaemia)

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Management of complications of injection-related infections Prevention: Hand-washing and ensuring clean injecting equipment and paraphernalia are important to prevent complications. Treatment: Initiate treatment with intravenous broad-spectrum antibiotics (like new generations of cephalosporins) until cultures confirm the causative organism(s) and susceptible antimicrobial agent(s). If possible, the affected vein should be tied off and removed surgically. All complications such as embolization, infective endocarditis, meningitis, brain abscess, osteomyelitis, septic arthritis should be referred to a hospital for better care and management. 3.3. Other injection-related issues

1,2

3.3.1. Contaminated injection or “dirty hit” (acute febrile reaction) 28

Chapter 3 Health conditions associated with IDUs and their sexual partners

Dirty hit is a term used when drugs that have been contaminated are injected intravenously. Substances such as chalk, milk powder or talcum powder may be added deliberately to the drug to increase the amount of product that can be sold. Other substances, such as fungus or bacteria may be present through the use of old syringes or dirty water, drugs being stored in unhygienic places or transferred from dirty hands. In addition, detergent or bleach used in the cleaning process may also cause a dirty hit. Signs and symptoms Key features include severe headache, trembling, sweating, fever and possibly dehydration from persistent vomiting and/or diarrhoea. The effects may be intense and immediate or may occur hours, possibly days later. It is difficult to distinguish between a dirty hit and sepsis, so it is important that medical staff consider sepsis as a differential diagnosis when an IDU presents with these symptoms. Prevention To prevent a dirty hit, it is essential that users wash their hand before preparing the injection and that all equipment be clean before use, preferably sterile. In addition, users need to be aware of the dangers of buying adulterated drugs. Information and education on safe infection practices should be provided to users (Refer to Appendix 2). Treatment • Treatment is symptomatic and may include treatment of headache and fever, drinking fluids and keeping warm. • Aspirin or paracetamol may be helpful in reducing fever. • If the reaction is particularly intense or persistent, further investigation is required to rule out more serious health issues, such as sepsis.

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3.3.2. Tetanus Tetanus is an infection caused by Clostridium tetani. The injection-related wound and the drug itself, its adulterants, injection equipment and unwashed skin could be potential sources of infection with C. tetani. Although recommendations to prevent transmission of HIV among IDUs may limit infection from contaminated injection equipment, these measures may not be effective against spores of C. tetani inoculated from the skin or found in the drug. Clinical features Muscle spasm, which can lead to death if the respiratory muscles are affected. Prevention Tetanus is almost entirely preventable through vaccination and appropriate wound care. Check the tetanus toxoid (TT) immunization status at routine clinic visits: • When was TT last given? • Which dose of TT was this?

If tetanus toxoid (TT) is due

Chapter 3

• Give 0.5 ml IM in the upper arm after cleaning the skin with an alcohol swab • Advise when the next dose is due • Keep a record (documentation) Tetanus toxoid (TT) schedule • • • • •

At At At At At

first contact least four weeks after TT1 least six months after TT2 least one year after TT3 least one year after TT4

TT1 TT2 TT3 TT4 TT5

3.4. Drug use-related health problems 3.4.1. Overdose

29

1, 2, 3

Overdose of opioid drugs is discussed here with relevance to the situation in northeast India. Overdose happens when one takes too much of a drug, too strong a drug, or a combination of drugs and the body becomes unable to cope with the drug. By affecting organs such as the brain, liver or lung it may prove fatal, but overdose can be prevented.

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Health conditions associated with IDUs and their sexual partners


3.4.1.3. Management of overdose – educating the client

3.4.1.1. Risk factors for opioid overdose

30

Some facts on opioid intoxication

Risk factors

• Mixing of drugs (heroin, alcohol and benzodiazepines) is the most common cause of overdose death • Overdose deaths often happen several hours after heroin has been taken • Overdose death is less common among new or inexperienced users • High purity of heroin by itself is seldom the cause of overdose death • In most cases overdose deaths are not instantaneous and hence interventions are possible, as many overdoses are witnessed

• • • • • • •

Chapter 3 Health conditions associated with IDUs and their sexual partners

Old age Male gender Long history of drug use Injecting alone Poly-substance use – mixing with alcohol, benzodiazepines Previous history of overdose Change in tolerance – After stopping opioids following treatment, the tolerance level comes down. When these people relapse, use of the same drug quantity as used earlier often results in overdose At different times, the strength/ quality/purity of heroin varies considerably and those using the drug without ”testing” are in greater danger of overdose Sometimes factors unrelated to drug use such as poor health (e.g. impaired liver function due to HCV) and depression contribute to overdose

3.4.1.2. Signs and symptoms of opioid overdose • • • • • • • • • •

Pinpoint pupils Slurred speech Unsteady gait Drowsiness Slowed movement Dry mouth, constipation Disorientation, coma Respiratory depression Hypoxia Bluish discoloration of tongue, nail

2. 3. 4. 5. • •

• •

A typical triad of opioid overdose is: Pinpoint pupils, respiratory depression and central nervous system depression.

6.

If unattended, it may be fatal.

7.

bed

When someone is “high” on opioids

When someone is beginning to overdose on opioids

• • • • •

• Muscles become floppy • Snoring or gurgling noises (on breathing) • Slow, shallow breathing (less than 12 times per min) • Pale, cold, clammy skin • Heavy nod, not responsive to external stimuli • Slow heartbeat/weak pulse

Muscles become relaxed Speech is slowed or slurred Sleepy-looking Light nod Responsive to external stimuli

1. • • •

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Assess the signs – The following are the warning signs: The person looks asleep and unconscious Face or lips appear pale or blue Has trouble in breathing Continue to monitor, especially the breathing and pulse and try to keep the person awake and alert. Call out for help from people around you if the person does not respond to stimulation and remains unconscious or their condition appears to get worse Immediately look for medical assistance or help from a non-governmental organization (NGO) that provides naloxone Place the person in the “recovery position”. Do not place a pillow under the head. Keep the person in recovery position, if you have to leave the person at all, even for a minute to phone. Check for “DR ABC” Danger – remove anything nearby that may injure you or the person, e.g. needles. Response – Check responsiveness by shaking and shouting at the person. If this doesn’t work, give pain stimulation and try to wake the person by causing mild pain like pinching or rubbing your knuckles into their sternum. If the person responds, try and walk them around, otherwise, check for breathing. Airway – Check that the airway is clear and whether any foreign object is stuck inside. If so, lay the person on their side, insert a finger into mouth and “sweep out” any foreign objects. If the tongue is obstructing the breathing process, the head should be tilted back, which will clear the airway. Thereafter deliver rescue breathing. Breathing – If the person is not breathing, lay the person on the back, tilt the head back, clamp the nostrils closed, and give mouth to mouth breathing 15 times per minute. Make sure the chest is rising with each breath. Circulation – if no pulse is present, begin cardio-pulmonary resuscitation (CPR). It is not advisable to perform CPR unless trained to do so. Severe injury can result if it is not performed properly. However, it is unlikely that CPR will be required unless mouth-to-mouth has not been instigated for some time after the overdose. If overdose is recognized quickly, breathing for the client until respiration is established is the main treatment option. If possible collect information from friends of the affected person. Ask questions about the type of drug or drugs injected, the quantity injected and for how long the affected person has been unconscious or unwell. Ensure the person gets treated with naloxone as soon as possible. This is one of the most important parts of overdose care. Without naloxone it is likely that the person will die. Naloxone is available at hospitals and at some NGO clinics.

3.4.1.4. Opioid overdose management with naloxone Naloxone is a pure opioid antagonist that is safe and effective in reversing opioid overdose. Being an antagonist, it has no opioid effects and cannot be used to get high. It is active for about 30-90 minutes in the body. • If naloxone is available and the health care facility has a trained health care worker to administer naloxone, prepare the injection quickly. • 1-2 cc/1-2 mg IM injection in any big muscle (upper arm, thigh, buttocks). The half-life of naloxone is significantly less than that of heroin. As such, the client is likely to show signs of overdose again as the effect of naloxone wears off. Continue rescue breathing and monitoring the person until the drug acts. • Naloxone starts acting in 1-3 minutes. If there is no response after three minutes, additional dosage of Naoxone may be administered. • Monitor till the client starts to breath spontaneously, an ambulance arrives, or someone else can take over from you. • Refer to a better equipped centre, if possible.

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Chapter 3 Health conditions associated with IDUs and their sexual partners


3.4.1.5. What not to do in case of overdose

3.4.2.1. Opioid substitution therapy (OST)

• • •

Opioid substitution therapy or OST (often called maintenance therapy) involves the oral administration of a prescribed medication with a similar action to the drug of dependence. The most widely used medications in OST are methadone and buprenorphine. These agents do not produce rapid intoxication in the same way that heroin does. Substitution medication is usually provided as a Directly Observed Treatment strategy, largely because of the risk of diversion of the medication. OST is not a “cure” for opiate dependence; however it is effective in reducing the harms associated with drug use and its impact upon HIV/AIDS.

• •

Do not leave the person alone Do not put the person in a bath or leave in water – the person could drown Do not inject the person with anything else besides naloxone, such as salt solution or salt water: it will not work and could worsen the condition Do not induce vomiting: the person could choke Do not give something to drink as the person could vomit

Identify and address the prevailing myths around overdose and its management among the local IDU community. Clients should be educated on risks of overdose and ways to prevent it (refer to Appendix 2). 3.4.2. Drug dependence 32

Chapter 3 Health conditions associated with IDUs and their sexual partners

Drug use can be considered as a continuum, with experimental and recreational use at one end, contrasted with dependent use at the more severe end. Excessive users and dependent drug users experience more drug-related harms. Some key features of drug dependence include: • Drug dependence has grades of severity. • The most important feature is the loss of control over the use of a drug, with persistent use despite significant harms. • Dependence can be physical or psychological. • Dependence has multiple origins, with a mix of pharmacological, psychological, social, and cultural determinants. • Drug dependence is a chronic, relapsing, remitting condition. Dependence refers to a maladaptive pattern of substance use leading to clinically significant impairment or distress. The diagnostic criteria for substance dependence as recommended by the World Health Organization (WHO) are based on three or more of the following if they have been present together at some time during the previous year: • Evidence of tolerance • A physiological withdrawal state when substance use has ceased or reduced • A strong desire or sense of compulsion to take the substance • Difficulties in controlling substance-taking behaviour in terms of its onset, termination or levels of use • Progressive neglect of alternative pleasures or interests • Persisting with substance use despite clear evidence of overtly harmful consequences Drug dependence is an enduring illness and the abstinence rates following conventional treatment are alarmingly low. Long-term treatment such as OST is the most effective intervention for opioid-dependent individuals and should be recommended.

1,9

Buprenorphine is a partial opioid agonist, only partially activating opioid receptors, thus producing a milder, less euphoric and less sedating effect than full opioid agonists such as heroin, morphine and methadone. Nevertheless, its activity is usually sufficient to diminish cravings for heroin and prevent or alleviate opioid withdrawal in dependent heroin users. By its dual effects of producing opioid responses while blocking the effects of additional heroin use, buprenorphine reduces self-administration of heroin. Property Produces opioid effects

Prevents or alleviates heroin withdrawal symptoms Diminishes the effects of additional opioid use (e.g. heroin) Long duration of action Ceiling on dose response effect

Sublingual preparation No severe withdrawal precipitated by opioid antagonists

Clinical Implication Reduces cravings for heroin and enhances treatment retention. Less sedating than full agonists (heroin or methadone) Can be used for maintenance or withdrawal treatment Diminishes psychological reinforcement of continued heroin use May complicate attempts at analgesia with other opioids Allows for once-a-day to three-times-a-week dosing schedules Higher doses (e.g. >16 mg) may not increase the opioid agonist effects, while prolonging the duration of action. Safer in overdose, as high doses in isolation rarely result in fatal respiratory depression Safer in accidental overdose as poorly absorbed orally More time involved in supervised dispensing Treatment with naltrexone can be commenced within days of buprenorphine May complicate management of heroin overdose requiring high naltrexone doses

Side effect profile similar to other opioids

Generally well tolerated, with most side effects transient A particular side effect of note is the phenomenon of precipitated withdrawal

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Chapter 3 Health conditions associated with IDUs and their sexual partners


Indications for buprenorphine treatment 1. Only indicated for those who are opioid-dependent (see WHO criteria above) 2. The client must be at least 18 years of age (The prescribing doctor should seek consent from a family member before treating anyone less than 18 years of age) 3. The patient must be capable of giving informed consent to treatment with buprenorphine Contraindications 1. Anyone with known hypersensitivity and/or severe side-effects to buprenorphine 2. Severe respiratory or hepatic diseases

34

Chapter 3 Health conditions associated with IDUs and their sexual partners

Precautions Caution should be exercised when assessing the suitability of buprenorphine (being an opioid medication) treatment for anyone with: 1. High-risk poly-drug use 2. Concomitant medical conditions including recent head injury or increased intracranial pressure, compromised respiratory function and hepatic disease 3. Concomitant psychiatric disorder 4. Chronic pain Steps of oral substitution programme: 1. Assessment – no different from any other clinical assessment. It involves history; examination; investigations; and formulation and development of a treatment plan 2. Initiating treatment: The following factors should be considered: • The degree of tolerance to opioids • Extent of withdrawal experienced by the client at the time of the first buprenorphine dose • Perceived likelihood of continued alcohol, sedative drug (particularly benzodiazepines), or illicit heroin use • Concurrent medical conditions 3. Stabilization: Changing the buprenorphine dose should be done based on the following factors: • Features of intoxication • Features of withdrawal and cravings • Additional drug use (e.g. heroin), if using to treat withdrawal or cravings • Side effects or other adverse events (intoxicated presentations, overdose) • Adherence to dosing regime (attendance for dosing, route of administration) • Patient satisfaction with buprenorphine dose 4. Maintenance: Internationally, most patients are stabilized using daily dosing regimes, however some patients can be maintained on alternate-day dosing, some even on three times-a-week dosing, without experiencing features of intoxication or withdrawal. Although in India buprenorphine has often been dispensed on a twice-daily basis, daily dosing is the preferred option given the long-acting nature of the drug. A brief account of detoxification and OST is given in Appendix 5 (as frequently asked questions). For additional information, please refer to the National AIDS Control Organisation (NACO) guidelines on OST.9

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3.4.3. Unplanned opioid withdrawal and its management

1

IDUs may present to the clinic with opiate withdrawal symptoms. Symptoms are similar to a severe bout of flu: Opioid Withdrawal: Signs and symptoms • • • • • • • • • • • •

Fever, sweats, gooseflesh Running nose, watery eyes Yawning Tremor (shakes) and hot and cold flushes Nausea, vomiting, diarrhoea and loss of appetite Increased bowel sounds Generalized aches, tiredness, cramps (head ache, abdominal cramp) Headaches Anxiety, restlessness Sleep disturbance Wide (dilated) pupils Rapid heart rate and elevated blood pressure

Management With sublingual buprenorphine: Day 1: 6 mg Day 2: 8 mg Day 3: 10 mg Day 4: 8 mg Day 5: 4 mg Detoxification using buprenorphine is safe, effective and fast and even better than methadone in the management of withdrawals. With clonidine: Day 1: 150 µg thrice daily Day 2: 150-300 µg thrice daily Day 3: 150-300 µg thrice daily Day 4: 75 µg thrice daily Day 5: 75 µg twice daily Clonidine is the non-opioid drug used in detoxification.

Withdrawal symptoms peak around 24-36 hrs, and withdrawal is complete in about 3-5 days for heroin. Other drugs and supportive measures: Consider prescribing symptomatic treatment, especially in the absence of treatment with a specific agent such as buprenorphine/clonidine. Insomnia (sleep disturbance) is one of the most distressing withdrawal symptoms (especially when opioid drugs are not prescribed for withdrawal management) and can be managed with sedating antidepressants (e.g. trazodone, amitryptaline), antihistamines (e.g. chlorpheneramine maleate) and benzodiazepines (e.g. diazepam). Pain can be managed by ibuprofen, 600-800 mg every 6-8 hours for no more than 5 days, or ketorolac tromethamine, 30 mg IM every 6 hours for no more than 5 days. Abdominal cramps may require dicyclomine, 10 mg every 6 hours. While vomiting can be treated with prochlorperazine, 10 mg IM three times a day, or ondansetron, 8 mg orally every 8 hours; diarrhoea can be managed with loperamide, first 4 mg then 2 mg after each stool. In addition, the client needs to be supported and encouraged while suffering from withdrawal symptoms. 3.4.4. Other substance use-related withdrawals Among other substances used by opioid users, withdrawal to alcohol, benzodiazepine (diazepam, alprazolam, nitrazepam) and tobacco are common. Please refer to Appendix 1 for clinical features and management of withdrawal of the above substances.

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Chapter 3 Health conditions associated with IDUs and their sexual partners


3.5. Infectious diseases 3.5.1. Sexually transmitted infections (STIs) Although HIV prevention programmes for IDUs in India have almost exclusively focused on NSP, safe injection practices and abscess management, the recent surveillance data indicate an increase in the sexual mode of transmission. The extent of the STI problem in northeast India and its likely contribution to the sexual route of transmission of HIV among IDUs underline the importance of STI interventions. There are high proportions of IDUs consulting for STI complaints in clinics. Studies have shown high prevalence of syphilis and chlamydia infections among IDUs in northeast India. Additionally they report low condom usage, especially with their spouses or regular sexual partners. Strategies to prevent STIs among IDUs 36

Chapter 3 Health conditions associated with IDUs and their sexual partners

1. Integrating BCC on safe sexual practices, condom use, health-seeking behaviour, syphilis screening and partner management into existing programmes for IDUs 2. Providing comprehensive clinical services for IDUs and their sexual partners: includes treatment of symptomatic and asymptomatic infections (based on national guidelines), risk reduction counselling, semi-annual syphilis screening with point-of-care immunochromatographic strip test (ICST) kits, informed choice for HIV testing and partner treatment, and BCC. Being a specific test for syphilis, the ICST, once positive, will remain positive for the lifetime of the client. Hence clients positive for ICST must be followed semi-annually with rapid plasma reagin (RPR) or venereal disease research laboratory (VDRL) tests for syphilis (through referral to appropriate laboratory/hospital). Clients with negative ICST should be followed up with further ICSTs. Partner treatment for the regular sexual partners of IDUs: Provide partner treatment based on the syndromes diagnosed in the index IDU client, and counselling on STIs and its prevention. Where necessary, patient-delivered partner treatment or provider-led partner notification will be done. 3. Increasing the accessibility of STI services to IDUs and sexual partners through STI outreach services: Access to static clinics in the northeast region is made challenging by geographic constraints, poor roads and transportation difficulties. Such hard-to-reach populations could be served through outreach clinics, organized at a fixed place and time in areas where services are most needed and where IDUs congregate, with the following key services:

c)

Enhanced syphilis management – Syphilis screening with ICST: - Treat ICST-reactive clients onsite with doxycycline 100mg BD for 28 days, after counselling on adherence, possible side effects and follow-up advice. - Prioritize the outreach visits to these clients to monitor adherence and follow-up. - Strongly encourage to visit main STI clinic for clinical and serological follow-up.

d) Counselling on STIs, syphilis and HIV prevention; condom promotion and distribution 4. Establishing referral linkages for relevant services such as Directly Observed Treatment – Short course (DOTS) centre for TB, ICTC for HIV, as detailed in the Clinic Operational Guidelines and Standards (COGS) and NACO STI guidelines. 5. Conducting ongoing monitoring of services and surveillance of STI syndromes among IDUs: The programme managers/supervisor and project officers from the state are involved. The NACO/Avahan Computerized Management Information System (CMIS) data will be used for surveillance. Levels of STI services proposed for IDUs and their sexual partners/ spouses

Services

Site or provision

Service provider

Symptomatic STIs for IDUs & their partners and syphilis screening (ICST) Asymptomatic syphilis Syphilis screening – RPR/VDRL

Outreach clinic/Main STI designated clinic

Clinic staff - Doctor/nurse

Main STI designated clinic Main STI clinic/other labs

Clinic staff - Doctor/nurse

Referrals

Main STI clinic/ICTC/ community care centre (CCC)/ Rehabilitation centre/OST/ other service delivery points

Clinic staff Doctor/nurse/outreach worker (ORW)/peer educator (PE)

Clinic staff - Doctor/nurse

Interpersonal communication with supporting information, education and communication (IEC) materials; integrating STI messages with harm reduction messages b) STI clinical services, delivered as in the static clinics. Follow-up and partner treatment can be done at the next camp or at main clinics. No injections will be given during the outreach clinic. a)

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Chapter 3 Health conditions associated with IDUs and their sexual partners


Syndromic case management: Drugs will be packaged and colour-coded to facilitate easy dispensing (NACO STI Operational Guidelines). PACK

MEDICINES / DRUGS

SYNDROMES Male IDUs

Pack 1

38

Chapter 3 Health conditions associated with IDUs and their sexual partners

Pack 2

Azithromycin 1 gm Cefixime 400 mg

Urethral discharge Scrotal swelling Ano-rectal discharge

Female IDUs & sexual partners of male IDUs - Vaginal discharge (cervicitis) - Ano-rectal discharge - Vaginal discharge - Vaginitis

Flucanazole 150mg Secnidazole 2 gm or Metronidazole 2 gm

- GUD Genital ulcer (Syphilis/chancroid) disease (GUD) (Syphilis/chancroid)

Azithromycin 1 gm Doxycycline 100 mg bd for 15 days

- GUD GUD (Syphilis/chancroid) (Syphilis/chancroid)

Pack 5

Acyclovir 400 mg tds for 5 days

GUD (Herpes simplex)

Pack 6

Cefixime 400 mg once Metronidazole 400 mg bd + Doxycycline 100 mg bd for 14 days

Pack 4

Pack 7

Doxycycline 100 mg bd for 21 days

Signs and symptoms of viral hepatitis include: jaundice, fatigue, abdominal pain, loss of appetite, nausea, vomiting, joint pain and dark urine. HBV and HCV infection can lead to severe liver disease (acute/chronic hepatitis, cirrhosis, HBVinduced hepatic malignancy) leading to morbidity and mortality. Prevention • •

Azithromycin 1 gm Benzathine Penicillin 2.4 MU vial

Pack 3

HCV: Worldwide, most HCV infections are related to injecting drug use. Hepatitis C is easily transmissible compared to HIV. It can live in a syringe for several days to weeks. High levels (>90%) of HCV infection were reported from Manipur even a decade ago. Among IDUs recruited from the northeastern states of Mizoram and Nagaland, 48% had HCV antibodies, and among HIV infected IDUs, 79% were co-infected with HCV.11 Alcohol and other factors such as HIV co-infection, chronic HBV infection, age > 40 years when infected and male sex facilitate the progression of HCV infection.12

- GUD (Herpes simplex) - Lower abdominal pain

• •

Treatment Treatment of HBV (includes adefovir, lamivudine and tenofovir) and HCV (includes ribavirin and pegylated interferon) is challenged by its cost, longer duration of treatment and potential drug toxicity. Consider treatment for alcohol use disorders in individuals with pathological drinking patterns. HIV–HBV and HIV–HCV co-infection •

Inguinal bubo

- Inguinal bubo

Female IDU sex workers should be managed as per COGS guidelines10 with “essential sex worker package” which also includes delivery of asymptomatic treatment for gonococcus/chlamydia. 3.5.2. Viral hepatitis Drug users are at high risk of infection with hepatitis viruses: hepatitis A (HAV), hepatitis B (HBV), and hepatitis C (HCV). HBV is endemic in India and hence most IDUs have been exposed to HBV even before the commencement of drug use (please refer to Appendices 4 and 5).

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Hepatitis B vaccine is the best protection for HBV infection. There is no vaccine for HCV. Cleaning syringes with bleach reduces the risk of HIV transmission, but it is less effective against HCV. Using clean needles and one’s own injecting equipment each time one injects, and practising safer sex with correct and consistent condom use minimizes the risk of HIV/STI/hepatitis. Avoiding unsafe tattooing. Those with previous or current hepatitis B infection should not donate blood.

• • • • •

All HIV positive IDUs should be screened for HBV (and HCV if resources permit). HIV can facilitate progression of HBV and HCV. Co-infected IDUs should be prioritized in outreach and referral to ART centres. ART can delay or halt the progression of HBV/HCV in clients co-infected with HIV. With co-infected IDUs on ART, exercise a high index of suspicion on drug toxicity (hepatotoxicity in particular), drug interactions and on adherence to medications. Look for drug interaction between ART and OST medications. Coordinate with ART centre for proper ART/OI management.

(Refer: Treatment and care for HIV-infected injecting drug users: module 9, ASEAN Secretariat, 2007.)13

3.5.3. Tuberculosis

14

In addition to high rates of HIV and HCV, IDUs also have high rates of TB. The risk of developing clinical TB increases if they are also infected with HIV. Other factors such as poverty, malnutrition, homelessness, unemployment, incarceration and poor hygiene also increase drug users’ vulnerability to TB disease and multi-drug-resistant TB.

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Chapter 3 Health conditions associated with IDUs and their sexual partners


Management Follow the Revised National Tuberculosis Control Programme’s (RNTCP) DOTS guidelines in managing TB. Collaboration with community groups is needed in order to increase case detection of TB and compliance with treatment. The clinic and outreach team play an important role in TB referral linkages: Verbal screening (cough that lasts from two to several weeks, weight loss, loss of appetite, fever, night sweats, and coughing up blood) for TB by outreach team [document in outreach record] Verbal and clinical screening by Medical Officer [document in client encounter form (CEF)] 40

Chapter 3 Health conditions associated with IDUs and their sexual partners

Refer to Designated Microscopy Centre for sputum test [document in referral register] Follow up IDUs and sexual partners diagnosed with sputum-positive/negative TB Follow up of IDUs and sexual partners for initiation of TB treatment

Follow up for completion of treatment

Note: IDUs are vulnerable and prone to upper and lower respiratory tract infections (e.g. community-acquired pneumonia and pneumonia due to Staphylococcus aureus) due to risk factors such as tobacco smoking, inhaling/snorting of drugs, increased risk of aspiration (during overdose in particular), risk of HIV induced immunosuppression, poor socioeconomic and living conditions and nutrition. Hence respiratory symptoms in IDUs should be evaluated carefully and managed appropriately. 3.5.4. Malaria

15

Blood transfusions and needle-sharing among drug addicts can readily transmit malaria, especially in areas where malaria is endemic (as the majority of the population in an endemic area may have malaria parasites in their blood). Diagnosis of malaria is often missed because of an inadequate medical history and clinical assessment. The clinical findings include fever, with or without rigor; history of visiting or residing in an endemic area; anaemia; and enlarged spleen. Malaria should be the first differential diagnosis in patients with unexplained fever who live, or have been, in endemic areas. Previous history of malaria or blood transfusion is also an indicator. The patient should be referred to the closest health centre or hospital. If this is not possible, treatment regimes should be based on the National Malarial Treatment Programme. IDUs should be educated on protective measures against malaria including mosquito nets, awareness of the symptoms of malaria and seeking medical help if infection is likely. The management of malaria in drug users is similar to that of other populations, though drug withdrawal, behaviour problems on wards and high rates of self-discharge from the hospital may complicate clinical management.

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3.5.5. HIV/AIDS

14

For HIV/AIDS-related issues such as HIV prevention, identification, treatment and support and linkages, please refer to the FHI Primary HIV Primary Care and Support Training Manual. In addition to the HIV prevention strategies of NSP and condom distribution, harm reduction services should be involved in: • Providing easy-to-enter or accessible entry points for both HIV/AIDS and drug dependence treatment • Facilitating access to, or referrals for, ICTC, ART and OI care including prophylaxis, TB, co-infections with HBV/HCV, malaria, and other medical care • Monitoring and supporting adherence to HIV/substance dependence medications • Monitoring interaction between HIV and substance use medications • Delivery of directly observed ART to those receiving methadone daily • Referrals to other harm reduction services, including drug dependence treatment programmes, community support services and other health care services • Linkages to community-based programmes such as home-based care, livelihood support, positive networks, positive living and positive prevention services • Providing information on safer drug use and HIV prevention, potential interactions from the non-medical use of psychoactive drugs • Family planning services • Local health care facilities including emergency medical services HIV/AIDS and drug dependence services can be integrated either in a drug dependence treatment facility or in HIV/AIDS treatment facility (or offered through general practitioners or mobile health units), which can facilitate the access, delivery and monitoring of both HIV and drug use related services. 3.6. Non-infectious disorders A wide range of psychosocial support services should be available and accessed according to the psychosocial needs of the patient, including: • Psychological support/counselling, group therapy for IDUs and family members • Peer support groups and supportive services on issues such as drug adherence • Psycho-educational programmes • Social welfare services to deal with problems related to housing, employment, finances, legal issues, discrimination and other issues • Psychological/mental health services: assessment and management of mental health disorders 3.6.1. Psychiatric disorders IDUs often have co-occurring mental health problems, and detecting these at an early stage is important for effective management. The DICs and clinics provide an opportunity for health workers to establish a good therapeutic relationship with IDUs and this can facilitate a comprehensive psychiatric assessment. Psychiatric history and mental status examination are the two essential components in assessment for psychiatric disorders.

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Chapter 3 Health conditions associated with IDUs and their sexual partners


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Chapter 3 Health conditions associated with IDUs and their sexual partners

Intimate partner violence is responsible for problems such as depression, post-traumatic stress disorder and chronic pain in different parts of the body among female drug users and sexual partners of IDUs. Spouses of IDUs, in particular widowed ones, often endure mental health problems such as depression. Some of the common mental health problems among IDUs are discussed below.

Psychosis: The chief complaints in psychosis are abnormal behaviour; hearing voices when no one is around, seeing visions (hallucinations); strange and false beliefs or ideas (delusions); confusion; and apprehension. Psychosis should be managed with anti-psychotics (e.g. haloperidol, chlorpromazine, risperidone, olanzapine). Severe disruptive behaviour requires hospitalization and treatment.

Depression: This is the most common co-morbid psychiatric disorder among IDUs and is also frequently seen among spouses of IDUs. The clinical features include depressed/sad mood; crying; irritability; low self-esteem, guilt, pessimism; suicidal ideation; difficulty with concentration, or forgetfulness; lack of interest in pleasurable activities (anhedonia); lack of energy (anergia); sleep disturbance; appetite disturbance (anorexia); agitation or retardation.

3.7. Other common clinical conditions

The most important aspect of depression is a suicidal tendency, and assessing suicide is important in all patients presenting with depressive symptoms. Depression can be effectively managed with antidepressants such as fluoxetine (20 mg/day), escitalopram (10-20 mg/day), sertraline (50-150 mg/day) and imipramine (25-150 mg/day). Furthermore, depressed clients may benefit from psychological therapies that aim at providing emotional and social support. Insomnia: Sleep disturbance is common among IDUs. Episodes of insomnia are extremely distressing and can trigger relapse (of drug use) following a period of abstinence. The common causes of insomnia are poor sleep hygiene, depression and substance use. Management includes advice on sleep hygiene and treatment of the underlying disorder such as depression. In patients already using psychotropics, one can avoid using hypnotics by choosing or changing to sedative types of psychotropic medications. If a hypnotic is required, administer for only a short period and avoid chronic hypnotic prescription.

Improving sleep hygiene: • Arise at the same time each day • Limit daily time-in-bed to “normal” amount (6-7 h) • Discontinue use of drugs such as caffeine, tobacco, alcohol, opioids and stimulants • Avoid daytime napping • Exercise in the morning and remain active throughout the day • Substitute television-watching in the night with light reading and listening to music • Eat on a regular schedule; avoid large meals in the night • Evening relaxation routine • Comfortable sleeping conditions • Spend no longer than 20 minutes awake in bed

3.7.1. Skin infections and infestations IDUs are prone to infections and infestations of skin, due to poor personal hygiene and predisposing factors (e.g. excessive sweating with opioid withdrawal). Scabies and fungal infection are common. Scabies: Treat with overnight application of gamma benzene hexachloride (Lindane) 1% lotion/cream or permethrin cream (5%), to all areas of the body from the neck down and wash off thoroughly next morning (after around 8-10hrs). Clothes and bed linen should be washed following treatment. Household contacts should be treated, if feasible. Fungal infections: Infection with dermatophytes (manifesting with itchy reddish lesions with clear raised margin at groin/other parts of body – Tinea cruris/corporis) and tinea versicolor (hypo- or hyperpigmented patches with fine scales over chest, back, neck, arm and other sebaceous areas) can be managed with topical antifungals (clotrimazole, miconazole) and advice on personal hygiene. 3.7.2. Dental health

1, 2

Many drug-dependent individuals neglect their dental health before, and at times even after, entering intervention programmes. Poor dental health is related to teeth grinding (particularly associated with ATS use), reduced saliva secretion (xerostomia, associated with opiates) and poor maintenance of dental hygiene (not brushing). Xerostomia can contribute to caries and gum disease. Poor dental health can increase the risk of bacteraemia and infective endocarditis. It is necessary to assess dental health, educate the client on dental hygiene (proper dental care and the advantages of regular dental check-up and treatment) and refer them for appropriate treatment. IDUs continuing to use opiates or on OST should be encouraged to chew sugar-free gum (stimulate salivation), brush teeth regularly after each meal, rinse their mouth and swish water around their mouth at various times throughout the day. Regular or excessive eating of betel nut can result in tooth decay, gingivitis and decay and erosion of bone which holds the tooth root in the jaw, leading to early loss of teeth. 3.7.3. Constipation

1, 2

Constipation is relatively common among opioid users (effect of opioid). • Primary prevention strategies include: - Increased dietary fibre and fluid intake - Adequate exercise - Adequate time and privacy for going to the toilet

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Chapter 3 Health conditions associated with IDUs and their sexual partners


Pharmacological agents – required if primary prevention alone is not sufficient. - Osmotic laxatives (e.g. lactulose, sorbitol, milk of magnesia) - Emollient or lubricant cathartics (e.g. glycerine suppositories) - Stool softeners (e.g. docusate) - Bulk laxatives (e.g. psyllium seed husk)

Counsel on the hazards associated with long-term use of laxatives. Enema may be required in case of fecal impaction. 3.7.4. Contraception and pregnancy Opiate use and methadone treatment may impair normal male and female hormone cycles for a period of time, making health advice and contraception provision an important service. Female IDUs should be aware that while menstruation may stop or be irregular, the potential for pregnancy still exists. 44

Chapter 3 Health conditions associated with IDUs and their sexual partners

chapter 4

Persistent use of drugs such as opioids during pregnancy may lead to complications to the fetus (e.g. spontaneous abortion, growth retardation, pre-term delivery), newborn (e.g. low birth weight, postnatal growth deficiency and drug withdrawal syndrome) and later to the child. For opioid dependence in pregnancy, maintenance therapy with buprenorphine may be advantageous over methadone maintenance therapy (MMT) with regard to lower intensity of the neonatal abstinence syndrome. Managing dependence of pregnant drug users by OST involves not only a stabilization of their health and social situation, but also offers an opportunity for regular contact with health services. Linkages between OST services and maternal health services could benefit pregnant drug users with standard pre-natal care (refer to Chapter 8.1). 3.7.5. Pain Given the high rates of injury and infections, drug users often complain of pain. In managing pain, the source needs to determined and addressed. Depending on severity, manage with paracetamol, NSAIDs (e.g. ibuprofen) and opioids. Clients using opioids develop tolerance and may require higher doses of opioids compared with other non-dependent persons, in case they require opioid analgesia (e.g. during surgery). Neuropathic pain requires appropriate treatment with anticonvulsants or antidepressants (e.g. carbamazepine 200-400 mg every 6 hours, amitriptyline 25 mg at bedtime). At times, uncontrolled pain could be due to an underlying psychiatric disorder. (Further reading: Treatment and care for HIV-infected injecting drug users: module 10, ASEAN Secretariat, 2007.)13 3.7.6. Nutrition

1, 2

There is a high prevalence of poor nutritional status in both HIV positive and HIV negative drug users. High levels of food insecurity and alcohol use are seen among IDUs. Persons with HIV infection often have inadequate dietary intake of calories, proteins, and micronutrients and have unintentional weight loss, which is a strong predictor of mortality. Interventions on nutrition include: • Education regarding balanced diet, especially with HIV positive IDUs • Linkages to service points offering nutritional support • Proper nutritional counselling according to the client’s need e.g. encouraging high-fibre diets for heroin and buprenorphine users (as opioids can cause constipation)

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models of primary health care delivery to IDUs and their sexual partners


The preferred model is where all the required services for physical and mental health and drug use are located together in the same setting. If this is not possible, it is important to have referral linkages to deliver comprehensive services. The choice of model adopted often depends on the local context.1,2 4.1. Drop-in centre (DIC)

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A DIC provides a range of services such as peer support, condoms, NSP, OST, sexual health services, referral services, nutritional support and social and recreational activities for IDUs and their sexual partners, in a less stigmatizing and more comfortable environment and hence is attractive to the clients. DICs have been demonstrated to have a positive effect on increasing knowledge among clients on HIV/AIDS prevention, overdose prevention and other health outcomes. Several DICs are functioning within Nagaland and Manipur, providing services with support of various health personnel (comprising doctors, nurses, health workers, PEs and ORWs). DICs can be established exclusively for female IDUs and female regular sexual partners of male IDUs and can address genderspecific concerns such as reproductive health, pregnancy and child care.

The health care personnel (irrespective of the setting) should be trained to provide services in a non-judgemental and empathetic manner, maintaining confidentiality. Primary- or emergency-care medical and paramedical personnel should be trained in the management and prevention of overdose and other acute conditions. Health care settings also offer an ideal opportunity for referral to other specialist services. 4.5. Closed setting based health services for IDUs Prison health services should provide prevention and treatment, as well as care services for IDUs in detention along with HIV related services including ICTC, OST, TB, OI treatment and ART. Continuity of care is essential during the transition from closed settings to the community (refer also to Chapter 8.2).

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4.2. Community outreach and home-based care Chapter 4 Models of primary health care delivery to IDUs and their sexual partners

Chapter 4

Basic health care (e.g. treatment for common ailments, wound care) can be delivered by trained local workers, community health workers or auxiliary nurse midwives (ANMs) through community outreach. They can be effective in accessing “hidden” drug users and in isolated rural areas, allowing early intervention among IDUs and their sexual partners. PEs/ORWs (and family members, if appropriate) can be trained to provide basic health care to IDUs and their sexual partners in their homes. For complex health needs, clients can be referred to relevant health care facilities.

Models of primary health care delivery to IDUs and their sexual partners

4.3. Community or general practice (GP) clinic The geographical proximity of the community/GP clinic may improve access to health care for clients. For DICs which do not or cannot have a medical officer, clients can be referred to the local GP clinic for medical advice. Identifying an “IDU-friendly” medical officer willing to visit the static/mobile/DIC-based clinic on a regular basis can also be attempted. 4.4. Out-patient and hospital-based health services In Manipur and Nagaland, users are registered with the NGOs running OST with buprenorphine. Establishing linkages between the OST setting and other health care facilities (e.g. TB, HIV) is the key to delivering comprehensive and effective services. OST, with its daily dosing requirement, also provides an excellent opportunity to deliver directly observed anti-tuberculosis treatment (ATT) and ART, ensuring adherence. People on OST may desire abstinence and can be appropriately referred for drug detoxification, treatment and rehabilitation centres.

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5.1. Desirable characteristics of health care providers (staff) • • • • • • • • •

chapter 5

• • • •

1, 2, 8

An empathetic, caring and non-judgemental attitude towards clients Establishing rapport and ability to make the IDU feel welcome in the facility Being open and allowing time and freedom to clients to reflect on their drug use and related health concerns Being comfortable working with clients who are often marginalized and stigmatized Maintaining confidentiality Good communication and facilitation skills Organizational and record-keeping skills Committed to the aims and objectives of the service Flexible in their role and expectations and able to cope with unfamiliar situations Ability to work as a team and willingness to exchange information and ideas/thoughts Ability to network Willingness to learn and enhance capacity to manage clients Potential and confidence for leadership and self-discipline

Apart from the above characteristics, it is desirable that the members of the outreach team have the following qualities: • Ideally be from drug-using community (e.g. ex-user/someone undergoing OST) • Good understanding of the local current drug use context (especially the ex-user) • Have the goodwill of peers and their partners • Strong commitment to work with and advocate for IDU community • Flexible in their approach to various lifestyles of IDUs • Local resident of the project area • Cultural and social understanding of the project area and context • Knowledge of the local language(s) and basic literacy skills (especially ORW) • Strength and ability to control drug use at work 5.2. Responsibilities of peer educators and outreach workers

1, 2, 8

5.2.1. Responsibilities of peer educators (PEs) •

setting up services for IDUs: staffing, outreach and community mobilization

• • • • • • • • • • •

Identifying and initiating contact with peer IDUs and their regular sexual partners/spouses, rapport-building and maintaining contact in a planned manner through one-to-one and group sessions Providing health education on HIV and STIs, sexual risk reduction Building capacity of peers to negotiate safer sex and practice safe injection Delivering harm reduction services Distributing/collecting injecting equipment (as part of NSP) Providing education on overdose prevention Adhering to infection control protocols Reminding peers about their appointments (clinic visits, ART centres, etc.) Assessing and addressing barriers to clients in accessing health services Facilitating linkages between peers and project staff and services Educating and supporting treatment adherence (e.g. adherence to OST, ART, ATT) Setting up referral linkages (e.g. ICTC, OST and other health care services such as mental health)

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Chapter 5 Setting up services for IDUs: staffing, outreach and community mobilization


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Chapter 5 Setting up services for IDUs: staffing, outreach and community mobilization

5.2.2. Responsibilities of outreach workers (ORWs)

5.4. Community mobilization

• • • • • • • • • • •

Involvement of the community in programme management has the potential to generate demand for services, increase service utilization, improve service quality and enable appropriate problem solving.

Development of outreach work plan Identification of PEs Capacity-building, supervision and monitoring of peers Education on safer injecting and sexual practices Engaging in BCC on HIV/BBV/STIs IEC on harm reduction measures Education on overdose/withdrawal/drug dependence management Facilitating referral linkages with relevant service delivery points Formation of IDU support group Organizing advocacy meetings Ensuring regular uninterrupted delivery of harm reduction and infection control materials

Active or ex-drug users often have unique success as PEs and ORWs in accessing the hard-to-reach sectors of the IDU community; educating and motivating them for accessing health care services; and referring them to effective prevention, care and treatment services. However, the peers need to be supported in addressing issues such as conflict between being a professional health care worker and maintaining peer status; occupational stress; and to keep their own drug use under control and avoid relapse. 5.3. Outreach health care equipment

1, 2

Outreach health care equipment includes: • New needles and syringes of sizes preferred by the clients in the area (1 ml, 2 ml, or 5 ml syringe and 24”, 26” needles). The quantity to be distributed will be based on the micro-plan estimates. • Puncture-proof box for carrying used needles and syringes • Abscess prevention materials – spirit, alcohol swabs • Dressing materials for wound management e.g. cotton swab, bandages, saline, betadine • Thick rubber gloves and long forceps/tongs (to pick up needles/syringes lying on the ground) • Other related materials: distilled water, filter, cooker, tourniquet (if budget permits) • Condom packs (male and female condoms) • IEC materials, e.g. on HIV prevention and safe injections • Outreach records/tools/registers (maintained by PE/ORW) • Referral forms (in triplicate) for ORWs • Thick puncture-proof bag to carry all the above materials in the field

Project ORCHID | Guidelines on Primary Health Care Services for IDUs and their Sexual Partners

In the high-IDU-prevalent districts of Manipur and Nagaland, involving the drug-using community in decision-making in harm reduction programmes is critical, but still is a challenge. Physical and mental constraints and stigmatization by the general community discourage IDUs from taking prominent roles in working to improve service delivery. This is further complicated by the presence of insurgent groups, opinion of some church leaders, and strong civil anti-drug movements, all of whom have mostly punitive and coercive approaches to the drug-using community. However, there is an emerging strong focus on community mobilization and developing programme ownership among the IDUs from the initial stages itself. The strategies include: • Supporting the formation and strengthening of IDU community groups • Enhancing mobilization process via community events and group learning activities • Skill-building on leadership, communication, conflict resolution, organizational development • Creating spaces for involvement through community-led programme committees that oversee programme functions

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Chapter 5 Setting up services for IDUs: staffing, outreach and community mobilization


6.1. Networking and referrals The key objectives of networking and referrals are to ensure that IDUs and their regular sexual partners have access to health care services over and above those offered by targeted interventions (TIs), including psychosocial support and legal services (i.e. comprehensive care). 6.1.1. Networking

1, 2, 8

Networking is a process of building relationships and sharing information as well as resources with another individual/organization/group of people. It builds and strengthens linkages among stakeholders.

chapter 6

53

IDU intervention

Establishing a system of referrals Documentation & follow-up (maturity) of referral Maintaining the established network (ongoing process)

Mapping health care providers, services or facilities and actors that affect the enabling environment

Steps in Networking

Chapter 6 Referral services for IDUs and their sexual partners

Interacting with identified services & informing them about TI activities Building partnership

Advocating for making the service available to IDUs and their spouses/regular partners

referral services for IDUs and their sexual partners

Guidelines on Primary Health Care Services for IDUs and their Sexual Partners | Project ORCHID


6.1.2. Referral linkages

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Chapter 6 Referral services for IDUs and their sexual partners

In order to deliver comprehensive care to clients, clinics should establish referral linkages with various partners, including: • ICTC/ART/CCC • STI/reproductive health services; maternal and child care services • TB treatment services (DOTS) under RNTCP • More advanced health services such as secondary- and tertiary-care hospitals • Drug use treatment facilities: OST programmes, detoxification, rehabilitation centres • General practitioners who could refer clients to the DIC for support and education regarding injecting drug use, or who can visit and serve at the DIC • Support groups like legal aid groups, positive network, self-help groups, women’s organizations, youth groups • Welfare agencies and charitable/government organizations organizations that provide welfare schemes, food, shelter, clothes, income generation programmes • Actors who can influence the enabling environment (police, narcotics control bureau); general community; religious groups; influential persons in the community; pressure groups; legal aid; and other forums (e-groups)

chapter 7

To make the referrals effective and to reduce stigma and discrimination against clients in accessing the services, it is preferred to establish formal linkages with various services and to assist the referral by accompanying the clients with an outreach worker (accompanied referral). Further reading: Chapter 6 of part I & II of the Avahan Primary HIV/AIDS care and support manual14 (on the comprehensive HIV care and support components and the referral services).

infection control and waste disposal

Project ORCHID | Guidelines on Primary Health Care Services for IDUs and their Sexual Partners


This section deals with infection control (IC) measures with special reference to the IDU population. For additional information on IC protocol and post-exposure prophylaxis (PEP), please refer to the NACO and Avahan–Family Health International (FHI) COGS guidelines. 10, 16, 17

Storage in the DIC • Store the safety box/puncture-proof box/container in a well-secured place. • Storage area should be well-lit, easy to clean and away from rain. • Maintain a stock of the safety boxes (by numbering the boxes).

7.1. Hazards of not collecting and disposing of needles and syringes properly

Disinfection of needles and syringes • Empty the contents of puncture-proof boxes into a large bin with sieve. • Immerse this bin into a larger plastic bin (without sieve) which contains 1% sodium hypochlorite as the disinfectant solution. • Keep the contents immersed in the solution for 30 minutes. • Store the disinfected needles and syringes in a translucent white- or bluecoloured bin till final disposal.

Improper handling (collection and disposal) of needles/syringes could pose a risk of transmitting HIV or other blood-borne infections through: • Accidental injury to the health care worker with contaminated sharps • Reuse of injection equipment by IDUs • Resale of used injection equipment • Children getting access to used equipment and getting accidentally injured

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Additionally, there could be objections/outrage from the local general community if the used injection equipments are thrown away indiscriminately (may be a threat to the NSP). 7.2. Universal precautions and stages in waste disposal management

Chapter 7 Infection control and waste disposal

16

Collection of used needles/syringes should be done in a puncture-proof tin or a plastic box with a small opening at the top with a lid for closure. Mark the box with biohazard sign or the word “Biohazard” prominently. A rough guideline on the size of the box is as follows: • 25-30 needles: 300 ml bottle • 35-40 needles: 500 ml bottle • 75-80 needles: 1 l bottle Do’s and Don’ts while collecting needles: • Take needles/syringes given by the client from the syringe end (not from needle end). • Do not attempt to recap the needles/syringes. • Do not attempt to bend/cut the needles before inserting into the box. • Use the opening of the box to separate the needle along with the hub from the syringe. Thus, only the needle with the hub will be deposited into the box. • The syringes which are dismantled from the injecting equipment can be collected into a thick plastic bag, marked with biohazard sign or the word “Biohazard”. • Never fill the container/bag beyond three-quarters of its capacity. Draw a line on the box to mark ¾ of the volume. • With insulin syringes, where the needles/syringes cannot be separated, the entire equipment should be dropped into the box. • Secure the lid of the container tightly. • Avoid manual (direct hand) transfer of needles/sharps from one container to another. • While collecting needles from the community (hotspot): - Wear thick veterinary or electrician gloves (not the thin ones used in clinics). - Use tongs/long forceps with a long handle to pick up the needle/syringe. - If there is more than one needle/syringe lying together, separate each of them with a stick and pick up each one separately.

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Final disposal from the DIC • Link up with waste management agencies wherever available or explore with the local existing system (medical college/large hospital/municipality, etc.) • When the above linkages are not possible/available, adopt local disposal mechanisms. - Needles: Construction of “sharp pits” or “encapsulation” - Syringes: Shredding, or mutilation and burial on site In case of non-separated insulin syringes, the entire equipment must be disinfected and disposed of, as is done for needles described above. 7.3. Needle-stick injury and post-exposure prophylaxis (PEP)

16,17

Needle-stick injuries can be largely avoided if IC guidelines are strictly adhered to. In • • • •

case of needle-stick injury Do not panic Do not put the pricked finger into the mouth Do not squeeze the wound to bleed it Do not use alcohol, chlorine, bleach, betadine, iodine or any other antiseptic over wound • Remove gloves if appropriate and wash the exposed site thoroughly with running water and soap. Irrigate with water or saline if exposure sites are eyes or mouth • Contact the designated physician immediately to evaluate for PEP Steps in managing occupational exposure • Manage exposure site (wash wound and surrounding skin with water and soap; irrigate exposed eye with water or normal saline; rinse mouth, if exposed, with water or normal saline and then with spirit) • Counsel and reassure the health care worker – crisis counselling • Assess the status of the source and the severity of exposure to determine eligibility for PEP and PEP regimen (refer to the table on the following page). • Prescribe PEP, if eligible, after counselling and obtaining consent – should be started as early as possible, ideally within 2 hours, and certainly within 72 hours.

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Chapter 7 Infection control and waste disposal


• •

Provide basic information on HIV; educate on the efficacy, regimen, sideeffects and follow-up plans of PEP Laboratory evaluation: Counselling on HIV testing and prevention of HIV transmission (recommended at baseline, 6 weeks, 3 month and 6 months after exposure); other laboratory tests such as HBV, HCV testing, pregnancy test [if appropriate]) Follow-up: ongoing support; monitor adherence; follow-up laboratory testing; referrals as appropriate; symptom review; occupational health and safety review

PEP regimens • Basic regimen (2 drugs): zidovudine 300 mg + lamivudine 150 mg bid for 4 weeks • Expanded regimen (3 drugs): basic regimen + lopinavir/ritonavir (LPV/r) or nelfinavir (NLF) 750 mg TID (or) IND 800 mg TID 58

Chapter 7

Note: Apart from the outreach team, the capacity of secondary distributors on infection control protocols should also be built. Secondary distributors should be oriented on safe storage and handling of injection equipment and proper disposal of used equipment, e.g. disposing used equipment in secure locations/not flushing them down the toilet, etc.

How to determine the regimen?

Exposure

Status of source HIV+ and asymptomatic

HIV+ and clinically symptomatic

Mild – mucous membrane/nonintact skin with small volumes

Consider 2-drug PEP

Start 2-drug PEP Usually no PEP or consider 2-drug PEP

Moderate – mucosa/nonintact skin with large volumes or percutaneous superficial exposure with a solid needle

Start 2-drug PEP

Start 3-drug PEP

Severe – percutaneous with large volume

Start 3-drug PEP

Start 3-drug PEP

Infection control and waste disposal

Information to be shared with health care providers on PEP • If eligible, should start PEP (after consent) as early as possible for maximum benefit (within 72 hours at the latest). • Though there is strong evidence that PEP may prevent infection with HIV, it is not 100% effective. • May cause minor side-effects (gastro-intestinal upset, headache, fatigue, malaise, muscle aches or joint aches). • Must be taken regularly in two doses per day for 4 weeks (28 days). Poor adherence will compromise the benefit of PEP. • Must be backed up by regular laboratory check-ups. • Requires the use of condoms during the period of PEP treatment and until the results of HIV testing at 3 months are known. • Requires the use of efficient contraception methods during the period of treatment and until the results of the HIV testing at 6 months are known.

HIV status unknown

Chapter 7 Infection control and waste disposal

Doses of PEP should be kept ready for dispensing if indicated, to cover the time till the drugs are procured from the pharmacy.

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This chapter highlights specific issues of a few subgroups of the IDU community and spouses of IDUs. 8.1. Special issues of female IDUs, spouses of IDUs and IDU sex workers

1,2

8.1.1. Female injecting drug users (FIDUs) Though FIDUs constitute a small proportion of the IDU population, studies suggest that they play a critical role in the spread of the HIV/STIs/BBV, both through unsafe injecting practices and through sexual risk-taking. FIDUs are more vulnerable to acquiring HIV due to multiple factors: • More likely to face discrimination and disgrace than their male counterparts, due to traditional and cultural expectations • More likely to have a male sexual partner who injects drugs • Tend to be introduced to drugs by boyfriends, husband or other male members of family • Access to injectable drugs usually occurs through a male sexual partner • More likely to share needles and to be injected by their partner or someone else • Experience difficulty in avoiding drug use and accessing drug use treatment if the male partner is an active drug user • May engage in sex work for drugs/livelihood needs and not perceive themselves at risk for HIV • Physical (anatomical) vulnerabilities: more vulnerable to acquire STIs/HIV through sexual intercourse • Pregnant FIDUs, infected with HIV, form an additional subgroup of FIDUs with specific needs

chapter 8

To summarize, FIDUs differ from their male counterparts in terms of their background, their reasons for using drugs and their psychosocial needs and hence require interventions addressing these issues. 8.1.2. Spouses of male IDUs As shown in Manipur, the regular sexual partners, and particularly the spouses, of IDUs are vulnerable to HIV/AIDS. The proportion of non-injecting wives with HIV infection increased from 6% in 1991 to 45% in 1997.18,19 This population needs education on HIV and STIs and requires assertiveness and negotiation skills to encourage and ensure consistent condom use by their male partners. Mobilizing the community of spouses of drug users may be a critical step to facilitate safer norms.

special issues

Vulnerabilities of spouses of male IDUs to acquire HIV infection: • Low and inconsistent condom use by IDUs with their spouses (and other regular partners) • Low STI/HIV risk perception by spouses (as well as by the IDU) • Not aware of husband’s drug-using behaviour • Face stigma and discrimination and hence reluctant to access services • May engage in sex work for looking after dependants (more vulnerable if widowed) • May face physical and psychological abuse from close male relatives

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Chapter 8 Special issues


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8.1.3. FIDU sex workers

8.2. IDUs in prisons or detention centres

In some parts of northeast India studies have shown an overlap between sex work and injecting drug use. Female IDUs may sell sex to pay for drugs. Brothel owners may introduce sex workers to drugs. Women, coerced or sold into sex work, may resort to drug use. Hence an FIDU sex worker is at higher risk of acquiring HIV/BBV/STI, through sharing of injecting equipment and unsafe sex (probably due to impaired skills on using condoms/condom negotiation under the influence of drugs and by giving way to the demands of their partner at times of drug-craving).

Key relationships between drug use and sex includes selling sex (including male IDUs) to buy drugs and buying of sex, most often by male IDUs.

8.1.4. Barriers to accessng services by FIDUs/spouses of IDUs/FIDU sex workers

• Chapter 8 Special issues

Lack of gender-sensitive “FIDU-friendly” services (interventions are often designed for male IDUs) Household responsibilities and lack of family support/social networks/financial resources/privacy and confidentiality and thus fear of being identified and stigmatized Combination of various roles and behaviours such as being a spouse of an IDU, engaging in sex work and HIV status increases their likelihood of facing stigma and discrimination from different communities (i.e. general society, non-drug using sex worker community, HIV uninfected FIDUs)

8.1.5. A comprehensive intervention strategy to address women’s issues • • • • • • • • • • •

Identify the magnitude of the problem and the needs of FIDUs, FIDU sex workers, spouses of male IDUs Community outreach and education through well-trained peers from similar communitys (FIDUs, spouse of IDUs, etc.) on STIs/HIV and on risk reduction/harm reduction Access to women-controlled safe sex devices such as female condoms Deliver comprehensive primary health care services (including STI/reproductive health/pregnancy care) and improve access to these services (delivering female-friendly services at locations accessible to women) Develop relevant IEC materials and ensure their availability and access to women Crisis response system linked to FIDUs (violence, sexual and psychological abuse, etc). Formation of community-based support groups (e.g. for spouses of IDUs, IDU sex workers) and organizing community events/joint events with sexual partners (a step towards empowerment) Linkages to other services (e.g. gynaecological care, mental health support, night shelters, income generation programmes, etc.) Telephone helpline – may assist those who wish to remain anonymous Joint meetings/events with spouses and partners Capacity-building of health care team to provide gender-sensitive and intensive interventions

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• • •

1,2

Injecting drug use can happen in prisons and is usually associated with sharing of injecting equipment (no/limited access to clean equipment), increasing the risk of transmission of HIV/STIs/BBV. Overcrowded, ill-ventilated environment of some prisons can enhance trans mission of TB. Limited access to health services (such as ART, TB and drug dependence treatment). May undergo screening for infections (e.g. HIV, hepatitis) without proper coun selling and consent. The prison authorities may face difficulties in acknowledging that drug use does occur in their prisons, presenting a challenge to setting up health-care services for drug users in prisons. Sensitization programmes on evidence- and human rights-based approaches to drug use and HIV need to be arranged for prison staff (and police). Efforts are needed to ensure continuity of ART and TB treatment as well as OST at all stages – upon arrest, pre-trial detention, transfer to prison/within the prison system, and upon release.

8.3. Adolescent and young IDUs Adolescents or young people who use drugs are particularly vulnerable to HIV due to: • Less access to information on safe injection and safe sex practices • Less skilled at negotiating safer injections and safer sex • Less access to condoms and new injecting equipment • Poverty and homelessness could intensify the problems of drug use and HIV • Legal requirements of consent from guardian/parent effectively exclude minors from accessing health care services (as they might have been cut off from their families, or their families do not know about their drug use) 8.4. Co-existing alcohol use disorder Alcohol can: • Cause disinhibition and intoxication, contributing significantly to drug as well as sexual risk-taking behaviour. It can affect skills of practising safer sex and condom negotiation. • Affect liver functions and hence is hazardous to IDUs infected with HBV or HCV. • Interfere with judgement and negatively affect adherence to medications (e.g. ART, OST, and ATT). • Contribute to the progression of HIV, HCV and TB. • Negatively influence the service provider as well as client attitudes towards treatment (and treatment adherence). • Trigger relapse to illicit drug use in people who have managed to abstain from illicit drugs. • Alcohol dependence is often associated with malnutrition and vitamin (thiamine) deficiency.

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Chapter 8 Special issues


9.1. Programme data management Data for development of client profiles is collected by PEs and supplemented, collated and maintained by ORWs. A registration system with unique client identifiers with systems for confidentiality is developed. The client profile including risk assessments (frequency of injection, sharing of injection equipment, injecting location, sexual behaviour and condom use with different partners, including spouses) is updated weekly by the outreach team. The ORWs monitor and supportively supervise the PEs. 9.2. Recording and reporting The recording formats to be maintained by Avahan-supported clinics include high-risk group (HRG) registration form and prescription sheet; CEF; STI register (data from CEF is transcribed to the register at the end of the day and is sent to the data entry operator at the NGO office); stock register; drug inventory register; STI monthly register; TB register; referral register; abscess management register; OST register and disinfection and waste disposal assessment form. In addition, syphilis register (capturing the ICST/RPR/VDRL test results, and the individual test results should also be entered in the CEF) is maintained.

chapter 9

Mechanism for recording at Preferred Provider (PP) clinics The ANM/nurse from the NGO attends the PP clinic/s on clinic days to facilitate the documentation process. The PP documents relevant portions in the CEF and the rest is completed by the ANM. Data of the clinic visits of clients, collected on the CEF, syphilis and referral registers, is taken back to the NGO office by the ANM. The documentation of CEFs and other registers is mandatory at health camps too. Please refer to Appendix 7 for the monitoring and evaluation (M&E) tools specific to IDU clients. Following transition to NACO (Ministry of Health, Government of India), clinics must report using the formats prescribed by NACO. Note: IDUs are not injectors at all times in their injecting lifespan. They may inject, then fall back into non-injecting (e.g. oral) drug use, or abstinence, and then return to injecting. Thus for M&E purposes, IDUs are defined as those who have used any drugs through injecting routes in the last three months.20

monitoring and evaluation of services

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Chapter 9 Monitoring and evaluation of services


Appendix 1: Identifying and managing signs and symptoms of withdrawal from non-opioid substances Signs and symptoms

Management

Alcohol withdrawal Tremor of the extended hands, tongue or eyelids Sweating Nausea and/or vomiting Tachycardia (rapid heart rate) Psychomotor agitation Insomnia (sleep disturbance) Anxiety (fear) Headache Fever Decreased attention, disorientation Clouding of consciousness Hallucinations (visual, tactile or auditory) Withdrawal seizures (withdrawal fits) Delirium

Whereas mild to moderate alcohol withdrawal symptoms can be managed on an outpatient basis in DICs, severe alcohol withdrawal symptoms (seizures, delirium) require hospitalization. Usually, a tapered regimen over 1-2 weeks with a long-acting benzodiazepine (e.g. chlordiazepoxide, diazepam, lorazepam) is employed. Give thiamine (100 mg BID orally) in addition. With chlordiazepoxide: Day 1: 20 mg QID Day 2: 15 mg QID Day 3: 10 mg QID Day 4: 5 mg QID Day 5: 5 mg BID Day 6: 5 mg at bedtime Day 7: Stop

Benzodiazepine withdrawal* Anxiety (fear) Tremors (shakes) Nightmares Anorexia (loss of appetite) Nausea Vomiting Postural hypotension (significant reduction in blood pressure due to postural changes) Seizures (fits) Hyperpyrexia (increased body temperature) Delirium

appendices

Gradually reduce the dose of benzodiazepines. Give appropriate equivalent dose of diazepam in tapered doses over time (Equivalent doses: diazepam 5 mg = nitrazepam 5 mg = alprazolam 0.5 mg). The dose reduction interval must be at least one week between the dose reductions to make the withdrawal safe and comfortable. Starting dose: 15 mg in 3 divided doses (i.e. 5 mg TID) First reduction: 12.5 mg in 3 divided doses (5 mg – 2.5 mg – 5 mg) Second reduction: 10 mg in 2 divided doses (5 mg – 5 mg) Third reduction: 7.5 mg in 2 divided doses (2.5 mg – 5 mg) Fourth reduction: 5 mg (once at night) Fifth reduction: 2.5 mg (once at night)

Tobacco (nicotine) withdrawal Depressed mood; insomnia; irritability, frustration, anger; anxiety; difficulty in concentration; restlessness; decreased heart rate; increased appetite or weight gain.

Medications to facilitate smoking cessation (under expert guidance) include nicotine replacement therapy; bupropion (an antidepressant) and varenicline.21

* Patients who become physically dependent on benzodiazepines are usually poly-drug users of heroin or patients who have been prescribed benzodiazepines without proper supervision and monitoring. Abrupt discontinuation of benzodiazepines in patients who are physically dependent on them can lead to serious adverse medical events such as seizures and death. Guidelines on Primary Health Care Services for IDUs and their Sexual Partners | Project ORCHID

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Appendices


Appendix 2: Patient education messages

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Appendices

a. Hand-washing: significantly prevents injection-related infections especially abscess. • Always wash hands before and after injecting. • Remove/avoid wearing jewellery while washing hands and avoid nail polish. • Trim the nails and keep the nails clean. • Before starting turn on the water from the tap. Avoid splashes. • If running water is not available, use a cup to pour water on the hands at the beginning and while rinsing. • Point hands down when rinsing them with running water. • Soap the hands thoroughly including dorsum, web spaces and nails. • Hold the soap with two fingers on the edges, and rinse it before placing it back in the soap dish • Avoid touching the sink or soap dish, as they are probably contaminated. • Wash hands and wrist for at least 10-15 seconds. • Air dry hands or dry them with an unused, dry portion of a clean cotton towel. • Avoid using towels used by other people. • Hold the towel or a paper towel over the faucet to protect your clean hands from touching the faucet. b. Safe injection practices: Preventing abscesses and other skin, soft tissue infections (SSTIs) • Use sterile injection equipment for every single injection. • Try to use a small-gauge needle. • Avoid injecting “cocktails” – combination of various substances (for example, mixtures of benzodiazepines, antihistamines and heroin or proxyvon). • Avoid injecting substances that are not for made for injection (proxyvon capsules). • Wash hands before every injection. • Clean the injection site with alcohol swab before injection. • Avoid injecting frequently at the same site and rotate the site of injecting. • Make sure that there is venous access before injecting. • Insert the needle at an angle of 15–45 degrees with the bevel of needle facing upwards. • Avoid skin popping. • OST may be the most effective intervention available to reduce the likelihood of developing abscesses and other SSTIs. • Reduce or eliminate the number of injections. • Targeted, early and respectful health services for treatment of abscesses and cellulitis may reduce morbidity and the need for hospital admissions.

c. Vein care: It is important for IDUs and they should be educated on good vein care. • Educate on safe injecting practices. • Choose a large vein for injecting. • Clean the site well with alcohol and put pressure on the injection site after injecting for at least 30 seconds. • Use a sharp, sterile needle for each injection. • Always alternate and rotate the injection site. Inject in the direction of the body’s blood flow. • Insert the needle at an angle of 15-45 degrees with the bevel of needle facing upwards. • Make sure that there is venous access before injecting. • Use a soft, flexible, easy-to-open tourniquet and remove it before injecting. • If there is difficulty finding a vein, warm compresses, running warm water, flexing or mild exercise will help to dilate the vein, making it easier to find and access. • Avoid injecting in the groin or neck. • Avoid injecting into small veins of the hands and feet as these veins are close to nerves and tendons and may be easily damaged, resulting in loss of function and/or blood supply. • Avoid injecting in the arteries: - Differentiate between veins and arteries. - If the needle is inserted into the artery, blood will gush back into the syringe. - Feel the pulse – a pulse indicates the blood vessel is an artery. - If artery is accidentally hit, remove the needle immediately. Apply pressure for 15 minutes to stop bleeding and avoid bruising. • Do not inject tablets. • Consider alternatives to injecting: smoking, snorting, swallowing or injecting intramuscularly or subcutaneously (skin popping) may also be attempted if veins are difficult to access (in the case of opioids). d. • • • • • • • • • • • • • •

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Education on prevention of opioid overdose Avoid mixing drugs. The person using drugs must have knowledge about the drugs being used. Test small amounts of unknown quality first (wise to test purity of drug). Use a smaller amount of drugs if reinitiating or not used them recently: be aware of decreased tolerance. Use less if sick or recovering from an illness. Try to use drugs with a friend rather than alone. Use with someone who knows what to do in case of overdose. Try not to take too much in a short period of time. Use the drug in a way that gets a slower “high” (e.g. snorting heroin instead of injecting). Wait to experience the effects of the drugs before using more. Buy from a regular source that can be trusted. Keep a track of how much you have used. Build knowledge on recognizing signs of possible overdose to help another user. In case of possible overdose of partner/client, seek help and access treatment.

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Appendices


Appendix 3: Clinical features and management of abscesses and ulcers GRADING

22, 23

SIGNS AND SYMPTOMS

TREATMENT/ MANAGEMENT

- Hard subcutaneous swelling with or without cellulitis, - Redness - Swelling - Tenderness - Heat/hot (local rise of temperature)

- Give analgesic like ibuprofen - If the swelling is associated with cellulitis, give antibiotics – tablet cephalexin 500 mg QID for 7 days or continue cap ampiclox 500 mg QID for 7 days - Educate on follow-up visit, return if the condition doesn’t improve

GRADING

SIGNS AND SYMPTOMS

- Antibiotics should not be provided to chronic ulcer patient. Chronic ulcers are those which show no sign of healing or reduction in size after several weeks of daily treatment with antibiotic and dressing. - Encourage rest for the affected part

ABSCESS Grade 1 (2-5 days)

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Appendices

Grade 2 (recommended I&D by a trained professional or refer to a hospital)

Grade 3 (recommended treatment I&D by a trained professional or refer to a hospital)

- Tender soft swelling less than - 3 cm in diameter - Fluctuant on palpitation (soft and moves a little when you touch the swelling) - Tender - Hot

- Wash the area with soap and clean water - I&D or aspirate with needle and syringe - Daily dressing of wound; clean with alcohol wipes followed by application of povidone solution to cover the wound and at least a three-inch margin around the site - Analgesic may be provided - Antibiotics – usually not necessary after I&D

- Tender soft swelling more than - 3 cm in diameter - Fluctuant on palpation - Tender - Hot

- Wash the area with soap and clean water - I&D or and fix a drain - Daily dressing with sterile gauze - Analgesic may be provided - Antibiotics – usually not necessary after I&D

Grade 2

Grade 3

ULCER Grade 1 (the wound should be covered with a bulky gauze dressing to absorb the continued discharge of serosanguineous fluid. The packing should be changed every other day and the wound inspected to ascertain whether the skin has broken down or erythema is progressing)

Superficial break/ ulcer in the skin/

- Wash the area with normal saline - Cover with clean gauze and bandage - Provide analgesic if necessary - If there are any signs of infection present such as yellow discharge, give antibiotics such as cephalexin or ampiclox

Project ORCHID | Guidelines on Primary Health Care Services for IDUs and their Sexual Partners

TREATMENT/ MANAGEMENT

Grade 4

Deep ulcer, may involve tendons, no bone involvement

- Wash the area with normal saline - Pack the wound with gauze soaked in saline or betadine - Cover with clean gauze and bandage - Provide analgesic if necessary - If there is any sign of infection such as yellow discharge, give antibiotics such as cephalexin or ampiclox - Encourage rest for the affected part

Deep ulcer with bone involvement (osteomyelitis)

- Wash the area with normal saline - daily packing of the wound with gauze soaked in saline or betadine - Cover with clean gauze and bandage - Provide analgesic if necessary - Provide antipyretic such as paracetamol if needed to control the fever - If there is any signs of infection such as yellow discharge, give antibiotics (e.g. cephalexin or ampiclox) - Refer for management of bone infection - Encourage rest for the affected part

- presence of localized gangrene( area blacken or brown due to lack of blood supply or infection and with loss of sensation) - Extreme pain be present due to ischemia (inadequate blood supply to the area)

- Refer immediately to a hospital where specialist is available as this condition can progress very quickly and may even lead to amputation.

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Appendices


Appendix 4: Information on viral hepatitis How do you get it?

HAV

Faecal-oral route (Contaminated food)

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HBV Appendices

Sexual contact, blood, breast milk, motherto-child transmission

HCV Blood-toblood contact; sexual transmission uncommon; mother-tochild possible

Appendix 5: Frequently asked questions related to HCV infection among IDUs

What are the symptoms of acute infection?

Is it a lifelong infection (chronic)?

Is there a vaccine?

Fever, loss of appetite, fatigue, dark urine, lightcoloured stool and jaundice; 1 week to 2 months

Never chronic

Vaccine preventable. 2 doses 6 months apart

Similar to HAV Yes, fewer but many have than 5% no symptoms become chronically infected

Similar to HAV but most (75%) Yes, for most; have no 15% - 25% symptoms clear the virus

Q: What are the functions of the liver? A: The liver performs several functions; it filters and purifies everything we eat and drink; stores vitamins and iron; and helps the blood to clot. Q: What are the symptoms of â&#x20AC;&#x153;liver diseaseâ&#x20AC;?? A: Often even if the liver is damaged, there may be no symptoms. Some common symptoms of a damaged liver are fatigue, headaches and pain in the stomach. Q: What is hepatitis C? What are the symptoms of hepatitis C? A: Hepatitis C (HCV) is a virus that can harm the liver and produce scarring of the liver. There may be no clinical symptoms. In many HCV infected individuals, if the disease progresses, this can cause significant problems. Many things can be done to keep the liver healthy if one is infected with HCV.

Vaccine preventable. 3 doses over a minimum of 6 months

Q: How is Hepatitis C transmitted? A: Injecting drug use currently accounts for most HCV transmission in the world; needle sharing is a great risk for HCV transmission. HCV can also be transmitted by sharing of injection paraphernalia such as cookers, spoon and swabs. After 5 years of injecting, most users become infected with HCV. Sexual transmission of HCV can occur, particularly in sex involving skin/mucosal injury and blood contact.

No vaccine No PEP

Q: What are the differences in the transmission of hepatitis B and C? A: Both hepatitis B and C are transmitted by sharing contaminated injecting equipment. In addition, tattooing is an independent risk factor for HCV. Sexual transmission of HBV from infected individuals through unsafe sex to their sexual partners is common. Q: Is there a vaccine to prevent hepatitis? A: There is no vaccination against HCV. Hepatitis A and B are vaccine preventable. IDUs who are uninfected should be vaccinated against HBV. Q: What are the precautions to be taken by people infected with hepatitis? A: Alcohol is significantly injurious to the liver. Certain drugs harm the liver, including commonly used drugs such as acetaminophen (paracetamol), a drug to treat fever and headaches. Consult a doctor to know which drugs affect the liver. Proper diet, regular exercise and a healthy lifestyle are helpful in persons with infected with hepatitis. Q: How to find out whether the liver is infected with hepatitis B or C? A: Liver function tests identify the type and severity of liver disease. Tests are available for detecting whether one is infected with hepatitis B or C. Q: Can opioid substitution therapy be given to people who are HCV infected? A: Persons on OST lead a stabilized life that helps them adopt a healthy lifestyle and hence it is beneficial for HCV infected opioid injectors to receive OST Q: Is there a treatment for HCV? A: Yes, there is treatment available for HCV. Drugs like interferon and ribavirin are used to treat HCV. Currently, the availability of HCV treatment is limited and it is not provided in public sector hospitals.

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Appendices


Q: What is co-infection with HIV and HCV? A: Some people are infected with both HIV and HCV. The ART doctor will guide you on how to manage your co-infection. Depending on the liver functions, the doctor will prescribe appropriate ART drugs in co-infected individuals. Drugs like nevirapine and efavirenz can cause disturbance of liver functions. Completely avoiding alcohol, other harmful substances and drugs is important.

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Appendices

Q: Is there any Do’s for the HCV infected individuals? A: • Stop alcohol • Regular health check-ups • Balanced diet • Regular exercise; stress reduction plan • Drink a lot of fluids • Protect against re-infection • Vaccinate against hepatitis B Q: Co-infection with HIV and HCV: What is required? A: • Physicians knowledgeable about HIV and HCV should see the patient • Provide information to maintain liver health • Counsel about the transmission of HIV and HCV • Consider HIV and/or HCV antiviral treatment as needed • Counsel on drug interactions and side effects of HCV and HIV treat ments • Advise OST for injecting drug use related harm reduction Appendix 6: Frequently asked questions related to opioid substitution therapy Q: What is detoxification? A: Detoxification refers to the withdrawal over a short period from an opioid or sedative/hypnotic by the use of the same drug or a similar drug in decreasing doses. The objective of detoxification is to assist the patient’s transition to a ‘drug free’ state. Q: What are the limitations of detoxification? A: Dependence on heroin and other opioids is a persisting condition and the ‘quit’ rates following detoxification are alarmingly low. The high relapse rates are nothing to do with being bad or having no will power. Long-term use of illicit opioids such as heroin changes the brain in such a way that the brain continues to need an opioid to function properly. For such people, short-term treatment does not work and long-term treatment with OST is necessary. Q: What is opioid substitution therapy (OST)? A: Opioid substitution is replacing the illicit drugs the drug user is taking with another drug or a similar drug (e.g. replacing heroin with sublingual buprenorphine). It may also mean using the same drug but taking it in a different way (e.g. sublingual buprenorphine to replace buprenorphine injection). Q: What drugs are used in OST? A: Two commonly used drugs worldwide for OST are methadone and buprenorphine. In India, sublingual buprenorphine is available for OST in the public domain.

Project ORCHID | Guidelines on Primary Health Care Services for IDUs and their Sexual Partners

Q: How is buprenorphine administered in OST? A: Buprenorphine is available in tablet form. It is crushed into powder and placed under the tongue of the user; it is allowed to dissolve by itself. This is the only way it will work very effectively and consuming the tablet orally is not effective. To prevent diversion of this substance, it is ideal to administer the drug under direct observation of the health worker in the clinic. Patients are advised to sit in the clinic till the drug that was placed under the tongue is fully absorbed (usually about 10-15 minutes). Injecting the tablet leads to a lot of adverse consequences and hence patients should be advised against injecting. Q: How to prevent injecting of buprenorphine tablets? A: Since buprenorphine tablets dissolve readily in water, these can be injected. The use of combination tablets of buprenorphine and naloxone (in doses of 2 mg of buprenorphine and 0.5 mg naloxone) will help reduce the potential diversion and abuse. This combination will permit sublingual use without precipitating withdrawal. This combination of buprenorphine and naloxone is available in India.

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Q: When should buprenorphine be taken? A: Ideally six to eight hours after the last illicit opioid intake. Q: What is the right dosage of buprenorphine? A: The dose can vary from person to person and the correct dose is determined by the health care provider (doctor) in consultation with the patient. The doctor will consider several factors before deciding on the correct dose. It takes a few days before the maintenance dose is finalized for the patient. Usually in Indian settings, the buprenorphine dose ranges from 4-16 mg. Q: What is the relationship between buprenorphine dose and its effect? A: Even a smaller dose of buprenorphine (e.g. 0.2/0.4 mg) helps to relieve opioid withdrawal symptoms. A moderate dose (usually around 4 mg) is required for controlling craving for opioids. A high dose (usually upwards of 4 mg) is needed to suppress the effect of further use of opioids. This means at higher doses of buprenorphine the brain is saturated and if one uses illicit opioids such as heroin, the effect is blocked and the user does not experience the high. Q: What happens if a person misses a dose of OST drug? A: If a person has missed taking the OST drug buprenorphine for five days in a row, he/she has to come back to the clinic for a medical examination to decide on the dose. Often they require low doses to begin with and the doctor will decide on this after consultation with the patient. Q: What are the side effects of buprenorphine? A: The medical effects of buprenorphine are similar to those of other opioids and include constipation, dizziness, drowsiness, headache, constriction of pupils, nausea, sweating and vomiting. Opioid-dependent individuals do not exhibit many of these side effects. Q: What are the symptoms of buprenorphine withdrawal? A: The withdrawal effects from drugs such as heroin, morphine or methadone are marked but only a low intensity of withdrawal effects are observed when buprenorphine is abruptly withdrawn. The withdrawal symptoms appear delayed for 72 hours and include cold- or flu-like symptoms, headaches, sweating, aches and pains, sleeping difficulties, nausea and loss of appetite.

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Appendices


Q: What are the benefits of buprenorphine substitution? A: Maintains a majority of patients in treatment Improves the patients’ physical well-being Decline in the new infections of HIV, hepatitis B and C Reduces criminality among the clients significantly Improves clients’ quality of life

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Q: Why does buprenorphine work as a better substitution drug? A: Reduces the use of other illicit opioids such as heroin or injecting of opioids Keeps clients in treatment for longer duration Causes few side effects Has mild withdrawal symptoms only Safe and unlikely to be overdosed Long-acting – hence does not have to be taken every day; thriceweekly dosing with buprenorphine is possible Good opioid substitution drug for people with mild to moderate opioid dependence Attractive treatment to opioid users Acceptable to families, other stakeholders such as religious groups, law enforcement agencies

Appendix 7: Avahan – Project Orchid monitoring and evaluation tools 1. Clinic Encounter Form (Patient Medical Record)

1. ID: ________________

2.Typology of HRG

3. Referred by 4. Reason for Visit (Based on the description given by the patient) 5. Type of clinic visit (Based on the diagnosis made by the nurse or physician; can tick more than one) 6. Visit data 7. Duration of symptoms (longest running symptom)

8. Condom use during last sex? 9. Examination findings

10. Syndrome diagnosis

11. Syndrome treatment (add color of packs)

12. Abscess / Ulcer management Project ORCHID | Guidelines on Primary Health Care Services for IDUs and their Sexual Partners

Name of Clinic:

Name of the NGO:

District:

Date: ____ / ______ / ______ (dd/mm/yyyy) Peer educator?  IDU  IDUSW  FSW  MSM

Yes

Sex: Female

     

STI symptoms visit STI check-up visit STI follow-up visit

Partner of IDU

 

Partner of FSW/IDUSW Partner of MSM

 

Partner Other

Notes: TB Screening (Also fill TB Record) Repeat STI visit (same syndrome within 14 days) General visit/Abscess and ulcer management (also fill Abscess Register if abscess)

  

F irst STI visit?

Yes

b) No. of clinic visits ______________

No

_______ days Yes

Age: __ __ years

Transgender

No

Peer educator/Outreach work er Self STI related reason Non STI related reason

Male

Describe:

No

Speculum / proctoscopic examination done If yes :  Vaginal discharge  Cervical discharge or very red cervix  Genital ulcer  Lower abdominal pain (female)  VCD (Vaginal -cervical discharge)  GUD -Herpetic  GUD- Non herpetic  LAP (Lower abdominal pain –females)  UD (Urethral discharge )  IB (Inguinal Bubo)  SS (Scrotal swelling)  ARD (Anorectal discharge)  Rx1 (Asympt., Cervicitis, UD, ARD,SS)  Rx2 (Vaginitis)  Rx3 (GUD -non herpetic)  Rx4 (GUD -herpetic)  Rx5 (LAP) nd  Rx6 (UD 2 line)  New abscess/ulcer  Follow up management of abscess

     

    

Yes

 No

Cervical motion tenderness Urethral discharge (male) Ano-rectal discharge None Other     

Genital scabies Genital molluscum Genital pediculosis Genital warts Other STI

Asymptomatic

Rx 7 (IB) Inj benzathine penicillin OR Tab doxycycline Rx for other STI None General

Duration of abscess/ulcer at the first visit_________

77


a. HIV status : +ve -ve b. If –ve whether the test was done in

18. Clinic laborato ry test

Stages of abscess

I

II

III

Stages of Ulcer

I

II

III

IV

No

No 79

No

RPR/VDRL ICTC HIV care and support RNTCP Diagnostic Unit ART Other Syphilis ICST

Appendices

3. Syphilis Screening Register

If done, +ve -ve  Others  HIV / STI counseling  Condom demonstrated  Pre /Post test HIV counseling  Partner treatment discuss  IDU harm reduction discussed  Prevention and Management of abscess

19.Education / Counseling

20. Commodities provided:

c. Ever tested for HIV : Yes

Duration of abscess (in days)

1.No. of condoms provided_______

I.D VDRL/RPR Code

Quantitative Result

ICST/TPHA

Treatment started

Confirmatory Result

No of doses given (Inj. B.Pclin)

1st

2nd

Started Treatment on completed Tab. Doxycycline

3rd

dose dose dose

2. No. of needles/syringes provided ________

Date of next visit ............................................................................................................................................................... Follow-up plan .................................................................................................................................................................. Any other comments/remarks Dated :

Name and Signature of the Nurse

Project ORCHID | Guidelines on Primary Health Care Services for IDUs and their Sexual Partners

Guidelines on Primary Health Care Services for IDUs and their Sexual Partners | Project ORCHID

Yes/No

     

No

Type of visit

Yes/No

Yes

Yes

Yes

negative

the last six months

Suspect TB

positive

16. Primary HIV / OI management 17. Referrals Select all that apply

No

Name Referred by

titre

78

Verbal TB screening Yes

non- reactive

14. TB Screening (All patients clinic should be screened for TB) 15. HIV

No

# Date ID no

ongoing

Abscess/Ulcer treated Yes

2. Abscess Management Register

Ulcer  Grade-I  Grade-II  Grade-III  Grade-IV

1st visit

Abscess  Grade–I  Grade–II  Grade–III

reactive

13. Grades of Abscess/ Ulcer


1. Kumar MS, Walsh N. WHO Clinical Manual on Managing Common Health Problems of Injecting Drug Users. New Delhi, WHO Regional Office for South-East Asia, 2009. http://203.90.70.117/PDS_DOCS/B3230.pdf 2. WHO. Guidelines for primary health care services for injecting drug users. Ministry of Health, Myanmar and WHO Yangon, 2005. 3. WHO. Operational guidelines for the management of opioid dependence in the South-East Asia Region. New Delhi: WHO Regional Office for South-East Asia, 2008. 4. Chandrasekaran P, Dallabetta G, Loo V et al. Containing HIV/AIDS in India: the unfinished agenda. Lancet Infectious Diseases 2006;6(8):508–21. 5. National AIDS Control Organisation. Annual Report 2009-2010. Department of AIDS Control, Ministry of Health & Family Welfare, Government of India, 2010.

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6. From Hills to Valleys: Avahan's HIV Prevention Program among Injecting Drug Users in Northeast India. New Delhi: Bill & Melinda Gates Foundation, 2009. 7. HIV Sentinel Surveillance and HIV Estimation in India 2007: A Technical Brief. National AIDS Control Organisation, Ministry of Health and Family Welfare, Government Of India, October 2008. 8. A Manual on Working with Injecting Drug Users – a Trainers Manual. National AIDS Control Organisation, Ministry of Health and Family Welfare, Government of India, 2009. 9. Substitution Therapy with Buprenorphine for Opioid Injecting Drug Users – Practical guidelines. National AIDS Control Organisation, Ministry of Health and Family Welfare, Government of India, 2008. http://www.nacoonline.org/upload/Publication/NGOs%20and%20targetted %20Intervations/Bupenorphine_%20Practice_Guidelines.pdf 10. Clinic Operational Guidelines and Standards (COGS), Comprehensive STI services for Sex Workers in Avahan-Supported Clinics in India, developed by Avahan India AIDS Initiative and Family Heath International. 11. Mahanta J, Borkakoty B, Das HK et al. The risk of HIV and HCV infections among injection drug users in northeast India. AIDS Care 2009 Nov;21(11):1420–24. 12. Mehta SH, Vogt SL, Srikrishnan AK et al. Epidemiology of hepatitis C virus infection and liver disease among injection drug users (IDUs) in Chennai, India. Indian Journal of Medical Research 2010;132: 706–14.

references and further reading

13. Treatment and Care for HIV-positive Injecting Drug Users. A 12 module training course for clinicians who provide—or expect to provide—care and treatment, including ART, for HIV-positive injecting drug users. Jakarta: ASEAN Secretariat, 2007. www.aseansec.org, www.fhi.org, www.searo.who.int/hiv-aids

Guidelines on Primary Health Care Services for IDUs and their Sexual Partners | Project ORCHID

References and further reading


14. Primary HIV/AIDS Care and Support Manual for Clinics Providing HIV prevention Services for High Risk Groups. Family Health International, 2009. 15. Chau TTH, Mai NTH, Phu NH et al. Malaria in Injection Drug Abusers in Vietnam. Clinical Infectious Diseases 2002;34:1317–22. 16. Guidelines on Safe Disposal of Used Needles and Syringes in the Context of Targeted Intervention for Injecting Drug Users. National AIDS Control Organisation, Ministry of Health and Family Welfare, Government of India, 2009. 17. Antiretroviral Therapy Guidelines for HIV-infected Adults and Adolescents Including Post-exposure Prophylaxis. National AIDS Control Organisation, Ministry of Health and Family Welfare, Government of India, May 2007. 82

References and further reading

18. Chakrabarti S, Panda S, Chatterjee A et al. HIV-I subtypes in injecting drug users and their non-injecting wives in Manipur, India. Indian Journal of Medical Research 2000;111:189–94. 19. Panda S, Chatterjee A, Bhattacharya SK et al. Transmission of HIV from injecting drug users to their wives in India. International Journal of STD & AIDS 2000;11(7):468–73. 20. Targeted Interventions Under NACP III, Operational Guidelines, Volume I, Core High Risk Groups. National AIDS Control Organisation, Ministry of Health and Family Welfare, Government of India, October 2007. 21. AHCPR Supported Guide and Guidelines [Internet]. Treating Tobacco Use and Dependence: 2008 Update: Chapter 3 Clinical Interventions for Tobacco Use and Dependence. Rockville (MD): Agency for Health Care Policy and Research (US); 1992-2008. http://www.ncbi.nlm.nih.gov/books/NBK17949/ 22. Warner RM, Srinivasan JR. Protean manifestations of intravenous drug use. Surgeon 2004 Jun;2(3):137-40. 23. Stanway A. Skin Infections in Intravenous drug users. Department of Dermatology, Health Waikato, Hamilton, New Zealand.

Project ORCHID | Guidelines on Primary Health Care Services for IDUs and their Sexual Partners


Compiled and created by EHA-Project ORCHID Clinical Coordination Team in close coordination with STI Capacity Raising Team of FHI 360. We also thank James Baer who assisted in the editing of this document. February 2012 Project ORCHID is a collaborative effort between the Emmanuel Hospital Association and the Australian International Health Institute, University of Melbourne, to prevent HIV in Nagaland and Manipur, India. Postal address: EHA–Project ORCHID, CBCNEI Mission Compound Pan Bazar, Guwahati, Assam – 781001, India Phone: +91 (361) 273 0911 Fax: +91 (361) 273 0912 Photos: Project ORCHID Design: heyheyitsmary@gmail.com


Guidelines on Primary Health Care Services