CA SE ST U D Y : HAR M R E D U CT I ON & M E T H A D ON E P R OG R A M S

Mauritius

Table of Contents

1

introduction

1

background: country and programmatic context

20

harm reduction strategy: development and detail

22

costing of mmt in mauritius

22

costs of needle and syringe exchange program (NEP)

23

benefits of harm reduction in mauritius

27

challenges to mauritius’ harm reduction approaches

27

conclusionS and KEY MESSAGES

36

tanzania: the rch platform approach

Methadone day care centre

introduction Mauritius, a small island nation in the Indian Ocean, is home to a concentrated HIV epidemic affecting primarily people who inject drugs, sex workers and men who have sex with men (MSM). The country’s government and its partners have sought to address the epidemic in several different ways. For example, people who test positive for HIV have access to free antiretroviral therapy (ART) and other health services. Moreover, in response to a growing epidemic among people who inject drugs, a partnership of civil society and the government initiated harm reduction practices in 2006 that include access to free opioid substitution therapy (OST)—primarily through methadone maintenance—and needle and syringe exchange in conjunction with scale up of HIV testing and ART access. Following the introduction of the harm reduction strategies, a total of some 7,000 individuals have initiated methadone maintenance therapy (MMT) since 2006. This has contributed to a reduction in HIV incidence among people who inject drugs from 68.1% in 2011 to 47.2% in 2012; 38.1% in 2013; and 31.1% in 2014. The HIV response in Mauritius provides an evidence-informed best practice that should be considered by other countries that face persistent and disproportionate HIV transmission attributed primarily to injecting drug use.

BACKGROUND Country Context and Situation Analysis AS OF MARCH 2015, MAURITIUS HAD A POPULATION OF 1,261,208 COVERING A TOTAL AREA OF 2,040 SQUARE KM (788 SQUARE MILES)² WITH A DENSE POPULATION OF 647 PERSONS PER SQUARE KM (250 PERSONS PER SQUARE MILE)². Mauritians are a multi-ethnic society including people of Indian, African, Chinese and European origin. Mauritians are multilingual, with English as the official language; however, Creole is the most commonly used language, spoken by a vast majority of the population at home. Mauritius is religiously diverse, with 49% of the population identifying as Hindu, followed by Christian (32%), Muslim (17%), and Buddhist (0.4%). (Population and Vital Statistics Jan-June 2014).

The Mauritius economic success story has been widely noted, with some referring to it as the ‘African Tiger’ with sugar. Other pillars of the economy are associated with an export processing zone, tourism and financial services. The government is giving top priority to the development of information and communications technology to make it a fifth pillar of the economy. The World Bank classifies Mauritius as an upper middle-income economy that ranks particularly strongly in indicators on starting a business, protecting investors and paying taxes. As a result, Mauritius has acquired a reputation for good governance, a business-friendly environment and solid social indicators.1

Mauritius’ Health System Mauritius has a regionalized system of public health services through a network of accessible and free health care delivery institutions. Nearly 100% of the population has reasonable access to the first point of contact with the health system—a community health center (CHC) or area health center (AHC) within a radius of three miles. Mauritius has a reasonably decent doctor-topatient ratio (one doctor per 519 inhabitants) and a national plan to guide the sector’s future development. The Mauritius health system consists of primary health care, district and regional health care, hi-tech/quaternary care and the private sector. Services are offered at the primary level through community health centers, area health centers and medi-clinics. At the secondary level, services are provided through district hospitals, community hospitals, regional general hospitals and specialized hospitals (eye; ear, nose and throat;

chest diseases; psychiatry as well as diabetes and vascular diseases) and an oncology department. The tertiary level, which is the highest referral level, comprises four specialized hospitals. These health services are backed by several support services that include: • regional laboratory services, • national blood bank and transfusion services, • national pathological services at the Central Laboratory, and • the National Reference Laboratory. Private health care has evolved in two forms: (i) private practice of medical and dental care practitioners, and (ii) private clinics with in-patient beds and facilities for examination, consultation and diagnostic procedures, mainly in radiology and clinical pathology,

P R I VAT E S E CTO R / H I - T E C H / Q U AT E R N A R Y C A R E D I S T R I CT A N D R E G I O N A L C A R E

P R I M A R Y H E A LT H C A R E

10%

OF GENERAL GOVERNMENT EXPENDITURES ARE A L LO C AT E D FO R H E A LT H

1 2

1

operating rooms and deliveries. There are at present 17 clinics with in-patient services operating in the private sector; in addition to renal dialysis, these also provide cardiac surgery among other services. The total number of beds available in the private sector amounts to 656, representing more than 15% of all hospital beds in the country.2 Slightly less than 10% of general government expenditures in Mauritius are allocated for health. Overall, per capita total expenditure on health is only about $222. The main sources of funding for health in the country are taxes; out-ofpocket payments by individuals and families; voluntary health insurance; and external partners, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. Public health care services are free and are tax funded.

S P E C I A L I Z E D H O S P I TA L S C O M M U N I T Y & R E G O I O N A L H O S P I TA L S C O M M U N I T Y H E A LT H C E N T E R S & M E D I - C L I N I C S

$222

P E R C A P ITA EXPENDITURE ON H E A LT H

African Economic Outlook 2014: see www.africaneconomicoutlook.org/fileadmin/uploads/aeo/2014/PDF/CN_Long_EN/Maurice_EN.pdf. African Health Observatory and the World Health Organization. See www.aho.afro.who.int/profiles_information/index.php/Mauritius:The_Health_System.

Mauritius: Methadone Maintenance Therapy

15%

O F A L L H O S P I TA L BEDS IN THE COUNTRY ARE IN THE P R I VAT E S E CTO R

HIV Epidemic and Vulnerable Populations in Mauritius Mauritius has a concentrated HIV epidemic that is primarily driven by injecting drug use. HIV incidence reached a plateau between 2004 and 2010, with an average of 545 people diagnosed annually as HIV-positive. Of the total prison population, at any one time around 30% of inmates are estimated to be HIV-positive. In 2014, HIV prevelance among adults 15 years and above in Mauritius was 0.9% with an estimated 8,100 people living with HIV. (UNAIDS) Other estimates and data regarding HIV in Mauritius in recent years include the following: • Based on a population size estimation exercise in 2011, the estimated number of people living with HIV in Mauritius was about 10,000, which was about 0.7% of the island’s population of 1.3 million.3 • Although the population of those who inject drugs remains the most affected by HIV, the yearly number of newly diagnosed cases in the population has decreased from 401 in 2011 to 320 in 2012 and 260 in 2013. This trend that has brought the

HIV Prevalence Among Populations at High Risk of Infection Source: Global AIDS Response Progress Report (2014)

number of monthly detected cases from 46 in the year 2006 to 33 in 2011, 27 in 2012, and 20 in 2013. The average number of newly diagnosed HIV cases per month among people who inject drugs was 26 in 2014. • Among other specific populations in Mauritius, HIV prevalence is estimated to be relatively high among sex workers and MSM. HIV counseling and testing (VCT) began in 1988. In 2000, decentralization of HIV testing started with the establishment of a VCT unit in each of the island’s five regional hospitals. To further accelerate uptake of HIV testing, a hotline service was initiated in 2000 to provide information and VCT referrals. HIV testing was also integrated into antenatal care and outreach program among people who inject drugs, MSM, sex workers and prison inmates to allow for more people to be tested, as well as to provide data on overall HIV prevalence. Given that VCT accounts for very few of the HIV tests performed at the rate of 1,000 per

24%

[20–28%] (IBBS 2012)

SEX WORKERS

year, the Ministry of Health and Quality of Life (MoH) has shifted towards increased provider-initiated HIV counseling and testing (HCT) as one of the measures to reach members of the community, especially key populations. In 2013, there were 88,151 HIV tests performed with 271 positive test results.4 The MoH then proceeded to set up treatment and day care centers in all five health regions to provide doorstep services to people living with HIV. There are approximately 4,000 clients who have been registered, and day care centers are operational at four out of five regional hospitals (Dr A.G. Jeetoo Hospital, SSRN Hospital, Victoria Hospital and Jawaharlal Nehru Hospital) whereby clients can access ART and adherence support services. Transportation costs in terms of bus fares to the centers are reimbursed to all clients who attend appointments at the day care centers irrespective of their financial status.

17%

44%

[ 12.8–20.7% ] (IB B S 2012)

MEN WHO HAVE SEX WITH MEN

[40.5–47.8%] (IBBS 2012)

PEOPLE WHO INJECT DRUGS

Policy and Programmatic Response for HIV and People Who Inject Drugs The HIV response in Mauritius is built upon advocacy from civil society and the motivation of the government to utilize innovative approaches and form partnerships with community groups. In the late 1990s, civil society groups started raising the alarm about the potential of HIV transmission among people who inject drugs. The first community-based HIV organization, PILS (Prevention information et Lutte contre le Sida), was created by a group of volunteers in 1996 to specifically address HIV issues on a national scale. It is now the largest HIV organization in Mauritius, providing care and support services, undertaking advocacy, and administering a Global Fund grant. 3 4 5

The National AIDS Committee (NAC), a multisectoral body, was officially established in 1987; operating within the MoH with its main function to provide policy guidance. A key component of the NAC is the National AIDS Control Program (NACP), also established in 1987. In its initial year, the NACP implemented a program with an initial focus on primary prevention of HIV transmission through blood transfusion safety awareness and condom promotion campaigns, education and communication activities for the population at large and for the most vulnerable groups, including sex workers, MSM, prison inmates and people who inject drugs.5

The first Multi-sectoral HIV/AIDS Strategic Framework was developed in 2001 and its implementation ended in 2005. In 2005, a situational analysis was carried out and validated in July 2006, paving the way for the formulation of an Action Plan for People Living with HIV, which was integrated into the National HIV and AIDS Strategic Framework (NSF) 2007-2011 developed by the Mauritian government in collaboration with the civil society partners and United Nations agencies. The most recent NSF runs from the years 2013 to 2016.

Mauritius, Integrated Behavioral and Biological Surveillance Survey (IBBSS) 2011. National HIV statistics, government of Mauritius; see http://health.govmu.org/English/Statistics/Documents/HIVWEBJun14.pdf. National Multisectoral HIV and AIDS Strategic Framework (NSF) 2013-2016, National AIDS Secretariat, Prime Minister’s office, Mauritius.

Mauritius: Methadone Maintenance Therapy 2

1987 2001 2005-6 2007-11 T H E N AT I O N A L A I D S COMMITTEE (NAC) E S TA B L I S H E D

F I R S T M U LT I - S E CTO R A L H I V / A I D S S T R AT E G I C F R A M E W O R K D E V E LO P E D

The HIV/AIDS Act, passed in December 2006 and enacted in August 2007, provides a legal and institutional framework to eliminate all forms of discrimination and protect the human rights of people living with HIV. It also offers an effective legal framework for voluntary counseling and testing, confidentiality of test results, and the implementation of the needle and syringe exchange program (NEP). The HIV Act created the basis for a wider consensus and stronger unity of action among national government and other stakeholders.6 In 2006, the Government of Mauritius, in collaboration with civil society partners, started implementing various harm reduction strategies. Eventually (in 2010), they became formally established under the Harm Reduction Unit (HRU) within the MoH, with the aim to control HIV infection among people who inject drugs.

S I T U AT I O N A L A N A LY S I S CA R R I E D O U T A N D VA L I D AT E D

FO R M U L AT I O N O F A N A CT I O N P L A N FO R P E O P L E L I V I N G W I T H H I V I N T E G R AT E D I N TO T H E N AT I O N A L H I V A N D A I D S S T R AT E G I C F R A M E W O R K ( N S F )

The Mauritian government has endorsed the following resolutions and commitments as part of its efforts to address the country’s HIV and AIDS challenges:

ment to improve treatment, care and support for people living with HIV. Economic and psychosocial support include:

• Abuja Declaration on HIV and AIDS, Tuberculosis and Other Related Infectious Diseases (April 2001)

• economic aid for people living with HIV who are not able to work;

• United Nations General Assembly Special Session on HIV/AIDS (UNGASS) Declaration of Commitment on HIV/AIDS (June 2001) • United Nations Millennium Declaration, including Millennium Development Goal (MDG) 6, which called for halting and reversing the HIV and AIDS epidemic by 2015 • World Health Assemblies’ Resolutions on HIV and AIDS (2000). • Resolution of the World Health Organization Regional Committee for Africa in 2005. The government has a high level of commit-

HIV Treatment in Mauritius ART monotherapy became available in December 1999 and initially was only available as prophylaxis for the prevention of mother-to-child transmission (PMTCT), for occupational accidental injuries and for use by victims of rape (as of 2003). Eligibility and access expanded more broadly over time to include anyone diagnosed as HIV-positive who met World Health Organization (WHO) recommended guidelines. As of early 2015, the eligibility criteria for ART initiation was based on the 2010 WHO guidelines, which called for all with CD4 counts below 350 cells/ml to be offered ART. (At the time this publication was finalized, Mauritius was considering whether to raise the threshold to 500 cells/ml, as per the 2013 revised WHO guidelines.) As of December 2014, 2283 HIV + patients had been enrolled on ART, and 1900 of these were reported adherent (MOHQL). A subset of 1500 adherent clients underwent viral load testing, of which 1000 were found to be virally suppressed. Since 2002, health care services, including VCT, ART, and other HIV-related services, have been provided at no cost to all clients. Of note is that there was a 19% decrease between 2012 and 2013 in the number of new HIV cases registered (from 320 to 260).7 The MoH sees the decline in new cases as a positive development and as an indication that the overall incidence rate is declining. 6 7

3

• transportation stipends for those who attend the National Day Centers for Immunosuppressed. • milk substitution for babies born to HIV-positive mothers; • psychological support provided in collaboration with non-governmental organizations (NGOs); • treatment literacy to improve adherence; and • provision of antiretroviral drugs free of cost to users.

HIV Treatment Cascade (as of December 2014) 10000

E S T I M AT E D PLHIV

9200

8000 D E T E CT ED CASES OF HIV

6000

6090

D E T E CT ED CASES E X C LU D I N G D E AT H S

5137

C U R R E N T LY ENROLLED IN CARE

4000

4085

I N I T I AT E D ON ART 2 2 8 3 A D H E R E N T TO A R T

1900

2000

1000 0

* Of the 1500 clients tested for viral supression

National Multisectoral HIV and AIDS Strategic Framework (NSF) 2013-2016, National AIDS Secretariat, Prime Minister’s office, Mauritius. ART Register, NDCCI, MoH, 2013

Mauritius: Methadone Maintenance Therapy

V I R A L LOA D S U P R E SS E D *

Funding for HIV and AIDS in Mauritius As documented in the pie chart below, in 2012 nearly three quarters (72%) of funding for HIV came directly from the Mauritius government. That figure underscores the fact that Mauritius is less dependent on donor resources for health than the average country in the sub-Saharan Africa region. The second largest source of HIV funding that year and in other recent years has been the Global Fund, which awarded a multi-year grant to Mauritius in 2010.8

Snapshot of Information About All Clients Initiated on ART from January Through December 2012 TOTAL NU M B ER O F CLIENTS I NI TI ATED O N ART JAN-D EC 2012

CLIE NTS WHO D I ED WITHI N 12 M O NTHS AFTER STARTI NG ART

C L I ENTS LO ST TO FO L LOW-U P

324

66 390

89.4%

77.5%

11 3 14 62

4

79.5%

66

CLIENTS STI L L O N ART 12 M O NTHS AFTER STARTI NG

251

59

P E R C E N TAG E O F A D U LT S A N D C H IL D R E N W IT H H IV K N O W N TO BE O N T R E AT M E N T 1 2 M O NT H S A F T E R IN IT IAT IO N O F A R T

310

MAL E

FEMALE

TOTA L

Source: (MOHQL)

Financing Source

1% 1%

2% 2% 1% P U B L I C F U N D - N AT I ON A L F U N D I N G R E SOURCE

21%

E U R OP E A N U N I ON & I OC WOR L D H E A LT H OR GA N I Z AT I ON ( WH O ) GLOB A L F U N D

72%

UNAIDS & UNDP P R IVAT E SECTOR C ON T R I B U T I ON S I N T E R N AT I ON A L N GOs

8

National AIDS Spending Assessment Report, NAS, 2012

Mauritius: Methadone Maintenance Therapy 4

Medical consultation of methadone beneficiary

PROGRAM DESCRIPTION Harm Reduction Strategy Strategy initiation summary Recognizing that Mauritius’ HIV epidemic is largely concentrated among people who inject drugs, the Mauritian government began implementing various harm reduction strategies aimed at this population in 2006. These activities were formally established under the Harm Reduction Unit (HRU) within the MoH in 2010. The HRU aims to prevent the spread of HIV through implementation of two interventions: needle and syringe exchange and methadone maintenance therapy (MMT). In 2001, clinicians working with people who inject drugs teamed up with people living with HIV to advocate for development of harm reduction programs by carrying out mass media activities that targeted both the general population and political leaders. In 2004, a harm reduction coalition was created by civil society; that coalition eventually became the Collectif Urgence Toxida (CUT), the organization that provides needle and syringe exchange services in the country. Other key initial steps included a comprehensive outreach program endorsed by the government in the 2001-2005 National HIV and AIDS Strategic Framework and a rapid assessment report of substance use in Mauritius in 2004 that further strengthened the need to urgently tackle the issue of injecting drug use. In 2005, the United Nations Office on Drugs and Crime (UNODC) held deliberations with the government of Mauritius to prompt the operationalization of the MMT program.9 With the ratification of the 2006 HIV Act, the MoH introduced harm reduction approaches through the development of the MMT initiative and needle and syringe exchange in collaboration with the National Agency for the Treatment and Rehabilitation of Substance Abusers (NATReSA), Collectif Urgence Toxida, and several other NGOs. Although the NEP was started in a restrictive legal environment—the program 9

5

National Multisectoral HIV and AIDS Strategic Framework (NSF) 2013-2016, National AIDS Secretariat, Prime Minister’s office, Mauritius

Mauritius: Methadone Maintenance Therapy

conflicts with the Dangerous Drug Act of 2000, which prohibits individuals from carrying used injecting equipment—there was a consensus among civil society and government stakeholders for the need for harm reduction services. Through consistent advocacy and community, government, and police consultations, the implementation of the NEP program has gone smoothly with the near elimination of arrests and prosecutions for illegal possession of syringes and needles. The aims of the harm reduction program are as follows: • reduce the HIV transmission rate among people who inject drugs while improving their quality of life as a human right; • help ensure that all people who inject drugs and their families are connected with health care and social support; • minimize the co-morbidity rates of hepatitis B and hepatitis C; and • prevent complications associated with injecting practices.

The comprehensive package of harm reductions services include: • • • • • • • • • •

Needle and syringe exchange Opioid substitution therapy (primarily through MMT) and other drug dependence treatment Generalized health care services HIV testing and counseling Antiretroviral therapy (ART) Prevention and treatment of sexually transmitted infections (STIs) Vaccination for viral hepatitis Prevention, diagnosis and treatment of tuberculosis and other opportunistic infections Condom distribution Targeted information, education, and communication (IEC) materials for people who inject drugs and their sexual partners

Figure 1

National harm reduction strategy goals related to MMT and the NEP Methadone maintenance therapy (MMT) program

Needle and syringe exchange program (NEP)

HARM REDUCTION STRATEGY GOAL

Prevent transmission of HIV, hepatitis B &and C, and other blood-borne viruses among people who inject drugs, their sexual partners and children, and from them to the non-injecting commununity

Mauritius: Methadone Maintenance Therapy 6

table 1

MMT and NEP package of services and clientele

Component of national harm reduction approach Methadone maintenance therapy (MMT)

Target groups People who inject opiates

Service provision sites • MMT drop-in-centers (MMT DICs) • Residential and day care induction sites (4 in number in 2014, reduced to 3 in 2015) • Distribution points at community level (18 in 2014, increased to 42 in 2015) • Prisons

Needle and syringe exchange (NEP)

People who inject drugs

• Fixed-site exchange in designated areas in community • Mobile vans/ outreach services, which can vary as per requests/ requirements of people who inject drugs

Services

• Comprehensive package of services, which in addition to MMT includes outpatient (OPD) services, psychosocial, nutritional and occupational counseling • Referral to other health care services, including HIV care and treatment services

• Comprehensive package of services which, in addition to needle and syringe exchange, includes counseling, condom distribution

MMT and NEP clients voluntarily receive HIV counseling and testing. Those who test positive are referred to HIV clinics for ART and treatment of co-infections, and to other service providers for support.

7

Mauritius: Methadone Maintenance Therapy

table 2

Methadone maintenance therapy (MMT) and HIV data, Mauritius

Key data points

2010

2011

2012

2013

2014

No. of people who inject drugs reached under the NEP

—

—

2,649

2,540

3,078

No. of people who inject drugs on methadone

3,279

4,728

5,442

5,692

5,571

646

1,349

1,527

1,830

1,900

81%

96%

96%

96%

97%

Dec 13

Dec 14

HIV detected cases (total)

5,768

6,090

HIV detected cases (male)

4,526

4,716

HIV detected cases (female)

1,242

1,374

788

953

2012

2013

0.97%

1.02%

No. of adults and children adherent to ART % of HIV-positive pregnant women receiving PMTCT services Other data

Total Number of Deaths due to AIDS HIV prevalence General population Key population epi data

Year

Pop size

prevalance

People who inject drugs

2013

10,000

44%

Sex workers

2012

9125

24%

MSM

2012

9000

17%

Prisoners

2012

2675

28%

Fishermen

2008

N/A

7%

ART uptake Number of people who inject drugs on ART

2012 (Modes of Transmission Study) 1,050

Source: Ministry of Health and Quality of Life (MoH) 2015

MMT program description: a three-pronged approach Methadone is a form of synthetic opioid (opium derivative). A powerful painkiller, it has been successfully used for decades in the treatment of opioid dependence (heroin, etc.). For many people who are addicted to

Mauritius: Methadone Maintenance Therapy 8

opioids, methadone reduces and/or eliminates the use of injectable opiates, reduces the cravings for opiate use, and allows them to improve their health and social productivity. In addition, enrollment in a methadone maintenance therapy has the potential to reduce transmission of HIV and hepatitis C, as well improve adherence to HIV medications. While methadone can be used for long periods of time, some users may complain of increasing side effects and may seek ways to stop their use of the drug and become drug-free; such users are referred to the drug treatment clinics run by various NGOs in Mauritius. Currently there is no concerted methadone detoxification component in the MMT program; however, the MoH is in the process of designing such a component. The MMT program is based on a three-pronged approach as described in Figure 2 below.

figure 2

MMT program’s three-pronged approach SELECTION OF BENEFICIARIES NGOs identify people who inject drugs who are interested in the MMT program and then register them

NGOs' social workers pyschologically prepare potential clients for MMT; preparatory counseling Refer to the induction centers

INDUCTION Clients inducted on methadone under medical supervision (doctors, nursing officers and healthcare assitants) for 14 days Residential or day care center induction

Initiated on specific methadone doses; closely monitored amd stabilized; screened for other medical problems; provided psychosocial, occupational and nutritional counselling

METHADONE DISPENSING AND PSYCHOSOCIAL FOLLOW-UP NGOs staff/social workers provide psychosocial follow-up of methadone patients Upon completion of induction phase, MMT clients are administered their daily dose.

Daily dose administered at community distribution points, health care settings, police stations, prisons, and via mobile vans

Selection of beneficiaries Although the MMT program was initially launched exclusively for male clients (in November 2006), it was extended to female clients in March 2008 and to prison inmates in 2011. The selection of beneficiaries for the program is carried out by five NGOs which conduct outreach and provide potential clients with information about the MMT program. The five NGOs are Dr. Idrice Goomany Center, Help De-Addiction, Sangram Seva Sadan (SSS), Lacaz A, and Groupe Renaissance de Mahebourg.

9

Mauritius: Methadone Maintenance Therapy

Clients meet with social workers who assess their readiness and provide pre-enrolment counseling. The selection phase can range from 1-2 days to a couple of weeks, depending on when the next induction program is scheduled. The NGOs then link potential clients with the MMT program sites for registration.

Induction phase Induction is a two-week phase during which a client is started on MMT and supported in the transition to methadone from active drug use. Through a process of continued assessment and gradual increase in medication, the program determines an appropriate daily methadone dose for each client. In addition to the daily calibrated methadone dose, clients in this phase receive additional health services, including daily psychosocial and occupational counseling and consultations with a dentist and a nutritionist. Clients are also provided with education around HIV and HIV testing services. This phase, which was an inpatient treatment in the early years of the program implementation, is gradually evolving to become a day care process (8am to 5pm every day). In 2014, only 138 (40%) of a total of 345 clients inducted underwent the inpatient induction.

table 3

Trends in MMT uptake

Year

People who inject drugs on methadone

2008

1,169

2009

1,994

2010

3,561

2011

5,068

2012

5,874

2013

6,353

Methadone dispensing and psychosocial follow-up Maintenance/Distribution is the process of dispensing specific daily methadone dose to each client who has successfully undergone the two week induction. Clients in this phase also have access to clinical consultation through daily outpatient (OPD) clinics staffed by HRU doctors, as well as follow up visits by NGO counselors. Program managers believe that these services play a very important role in promoting treatment adherence. The OPD clinics are important for management of methadonerelated side effects that could lead to non-adherence, while the NGO visits are aimed at early detection and referral of clients who might be at risk of relapsing. In its present stage (as of early 2015), Mauritius’ MMT program does not have a methadone detoxification program. Thus the maintenance therapy is expected to last for an undefined duration, and can be life-long in some cases.

Needle and syringe exchange program (NEP) Needle and syringe exchange is an integral element of Mauritius’ harm reduction strategy. The main aim of the NEP is to reduce transmission of HIV and other blood-borne viruses via sharing of injecting equipment as well as to minimize other harms linked to injecting drug use. The NEP was first initiated in 2006 in two sites run by two NGOs: Collectif Urgence Toxida (CUT) and Prevention information et Lutte contre le Sida (PILS). The MoH launched its mobile van in 2008 as part of scal-

Mauritius: Methadone Maintenance Therapy 10

Methadone maintenance: a proven way to reduce HIV transmission

ing up efforts of NGOs and complementing their limited capacity in meeting the demand of needle and syringe exchange. As of February 2015, CUT was providing needle and syringe exchange at 11 sites, with the MoH offering the service at 36 sites. (PILS no longer operates any needle and syringe exchange services.)

“Strong and consistent evidence from a number of well-designed, randomized controlled trials shows that opioid agonist maintenance treatment—including methadone and buprenorphine—is effective in reducing illicit opioid use and increasing retention of opioid-dependent patients in drug abuse treatment (Mattick et al., 2003a,b; Gowing et al., 2004, 2005). There is also strong evidence that this treatment reduces drug-related HIV risk behavior, including frequency of injecting and sharing of equipment (Gowing et al., 2004, 2005). Given the strong evidence of its effectiveness, opioid agonist maintenance treatment should be made widely available, where feasible. The medication should be provided in sufficiently high doses and for a sufficient duration for therapeutic effects to occur (Sees et al., 2000; Vanichseni et al., 1991; Strain et al., 1993; Faggiano et al., 2003). Programs should be scaled up enough to exert a public health impact, provide adequate public health infrastructure, include a plan for sustainability, and balance strategies to decrease potential diversion of treatment drugs with strategies to disseminate them.”

Needle and syringe exchange is delivered through fixed sites, mobile vans, backpack outreach workers, and peer educators; a total of 3,078 individuals were served in 2014. The MoH provides all the required injection equipment and funding for field workers’ allowances. At fixed NEP sites, people who inject drugs freely access needles and syringes as well as additional services such as rapid HIV testing, pre- and post-counseling, and referrals to other welfare and health services.

—Preventing HIV Infection among Injecting Drug Users in High-Risk Countries: An Assessment of the Evidence (Institute of Medicine, 2006)

The mobile vans provide similar services but enable the NEP to reach other areas without fixed sites, thus enabling mobility of services. Mobile vans essentially take services to existing and potential new clients where hard-to-reach and ‘hidden’ populations (e.g., sex workers, MSM and women who inject drugs) need services. Each mobile van conducts at least two visits on each NEP site every week. Out of the two visits one is during daytime while the 2nd visit is in the evening. The clients figure 3 are offered registration cards with a unique code number, which is used to track the provision of consumables and services such as 3500 syringes, extra needles of different 3000 sizes, condoms, HIV counseling and testing, referral services, alco2500 NGOS hol swabs and IEC materials.

Number of clients reached under the NEP, by sector type

MOH

2000

In addition, backpack outreach workers are hired to go into communities to facilitate access to services to people who inject drugs who may not easily access fixed sites or mobile vans. As such, these individuals serve as ‘foot sol-

1500

1771

1638

2092

878

902

986

2012

2013

2014

1000 500

11 Mauritius: Methadone Maintenance Therapy

0

diers’ in delivering services to clients. Many of these outreach workers are part of the same communities as the clients and are well known and recognized. They therefore play a critical role as peer educators to encourage clients to utilize NEP services and MMT.

NEP data: number of syringes distributed per client per year table 4

Numerator:

719,427

Denominator:

2,540

Number of needles and syringes distributed months across the overall NEP in 2013

Number of clients accessing NEP services in 2013

The NEP is a vital health-promotion initia283 tive because it has had a positive impact on Number of needles and syringes distributed per client per year throughout the NEP clients’ injecting practices, with the use of sterile injecting equipment greatly reducSource: MoH/Global AIDS Response Report 2014, National AIDS ing the risk of HIV infection. In addition to Secretariat/Prime Minister’s Office, Government of Mauritius providing a platform for assisting people who inject drugs to adopt safer injecting practices, the NEP serves as a bridge to all other services that people who inject drugs might want and need across the broader health, social welfare and psychosocial areas. For example, many now have an easier and more consistent way to obtain access to HIV testing, referrals for HIV treatment and care services, and linkages to MMT centers. Through the mobile vans, peer educators, and backpack outreach workers, more than four-fifths (83%) of NEP clients are registered and continue to receive services more than a year after first being identified and offered support.

Current State & Future Goals for Coordination & Collaboration Between Ministries The focus of this case study is to profile and cost the Harm Reduction Strategy in Mauritius; however, given the historically high HIV transmission rates among people who inject drugs, it is important to highlight how the HRU, MoH, and HIV units coordinate their respective programs with the objective of integration where possible. Effectively addressing the ‘twin epidemics’ of injection drug use and HIV requires a cohesive and concerted partnership involving all key stakeholders (people who inject drugs, civil society, government, community members and leaders, etc.). The government of Mauritius’ strategy to engage civil society, promote coordination among ministries, and provide adequate health services to anyone susceptible to HIV infection is seeing success. This coordination and integration process began with HIV testing becoming fully integrated in the methadone maintenance program with HIV testing offered to all clients who are inducted on methadone. Voluntary HIV testing is also performed by NEP mobile van staff who, in addition, refer interested clients to HIV clinics and methadone treatment services.

the daily methadone distribution program are HIV-positive. MMT clients found to be HIV-positive during the induction phase are referred to the HIV clinic. The number of people who inject drugs on ART is, according to estimates, around 2,200 out of the 3,000 who have been initiated on ART as of December 2014. Physicians at the methadone clinics have been trained and are qualified to treat HIV-positive clients and these clients are counseled to attend their HIV clinic and stay on treatment. ART is available in the same premises—i.e., at regional hospitals, which are one of the types of dispensaries for methadone. The MoH and HIV Units are currently further exploring how to fully integrate HIV clinical care within methadone clinics. Moving forward, this integration will consist of the provision of methadonerelated services and provision of HIV-related services within a single location. The services will include: methadone prescribing, methadone dispensing, follow-up of methadone beneficiaries, HIV testing, ART prescribing, ART dispensing, HIV diagnostic tests, referral services, counseling, adherence and treatment literacy services, among others.

Although the HRU does not currently track the HIV status of its MMT clients, HRU staff estimate that 50% of the 6,700 clients enrolled in

Mauritius: Methadone Maintenance Therapy 12

COSTING OVERVIEW Costing of MMT in Mauritius Overview and major findings The MMT program is an innovative public-sector led approach to harm reduction and HIV prevention, and this analysis aimed to determine the costs of implementing the program on a per-client basis. In a concentrated epidemic like that in Mauritius, these costs are critical to prevent further spread of HIV and to ensure that all people who inject drugs, including those who are HIV-positive, have access to the necessary support and healthcare services that can help them transition from active drug use if they wish to stop using. However, these costs have to be contextualized within the broader HIV response, and are supplementary to costs related to ART service delivery. From a costing perspective, the MMT program consists of two main phases10 – a resource-intensive induction phase, and a lower-cost distribution phase. The team collected and analyzed the costs associated with the above-mentioned two phases of Mauritius’ national MMT program for a 12-month period (January through December 2014), which showed a cost per patient per year (PPPY) of $267. This is a weighted average of the costs of the two programmatic phases: in 2014, it cost an average of $1,031 to induct a client and $199 PPPY year to maintain a client on daily methadone. Given the high cost of induction on a per-client basis, it is apparent that the larger the proportion of induction clients (relative to distribution clients), the higher the overall cost of the MMT program is likely to be. For HIV-positive MMT clients, these costs are supplemental to the cost of ART or pre-ART care. Although this analysis did not cost HIV service delivery in Mauritius, the National AIDS Secretariat (NAS) estimates that antiretroviral drug costs alone are about $300 PPPY, without accounting for personnel time, lab tests and other figure 4 costs.

MMT program costs in 2014

$1 2 0 0

$1,031.20

$1 0 0 0

OTHER COSTS DEMAND GENERATION

$8 0 0

LAB TESTS $6 0 0 $4 0 0

METHADONE PERSONNEL

$267.05

$199.43

$2 0 0 $0

AVERAGE COST PPPY (WEIGHTED AVERAGE)

COST PER CLIENT INDUCTED

DISTRIBUTION COST PPPY

Program decentralization in 2015 This case study comes at an interesting time with the HRU and MoH working together to decentralize the distribution component of the MMT program. The number of sites at which MMT clients can access their daily dose of methadone is being scaled up from 18 sites in 2014 to 42 sites11 in 2015. The decentralization, which was started in

10 The program originally had an additional six-week stage called the ‘assessment’ or the ‘selection and recruitment’ phase, which preceded the induction phase. This phase, which is performed by NGO partners, has come to acquire a variable duration which can range from 2-3 weeks to 2-3 days. Because these NGOs work with clients through the entire cascade of services—assessment, referral to induction centers, continued counselling through the course of maintenance therapy—costs related to this phase were included in the ‘demand generation and outreach’ cost component. 11 The 42 sites in 2015 include three sites in prisons. Similar to the 2014 costing, the 2015 costing does not include prison sites.

13 Mauritius: Methadone Maintenance Therapy

early 2015 and was completed by March 2015, is aimed at decongesting the distribution sites, some of which provided services to over 500 clients every day in 2014. In this analysis, members of the research team have costed the MMT program both in its 2014 structure as well as in the decentralized model (projected 2015 costs) to provide insight into the resource implications of the decentralization. Under decentralization, the increased number of distribution sites has been accompanied by resource optimization in other areas. The key structural changes resulting from the program decentralization are noted in the table ahead:

table 5

Structural changes in the MMT program post decentralization key program structural changes CHANGES THAT DRIVE COSTS UP

CHANGES THAT DRIVE COSTS DOWN (RESOURCE OPTIMIZATION)

BUILDINGS: Increased number of mobile distribution sites (6 to 29)

BUILDINGS: Decreased number of induction centers (4 to 3); decreased # of fixed distribution sites (12 to 10)

PERSONNEL: Increased number of parttime staff engaged in distribution (30 to 60)

PERSONNEL: Decreased number of staff at induction centers (22 FTEs to 15)

FTE = Full time equivalent

The research team’s analysis concludes that decentralization will increase the overall cost of the program from the $267 in 2014 to $282 in 2015. This is a weighted average of the costs of the two programmatic phases: in 2015, it is estimated that it will cost $737 to induct a client and $233 PPPY year to maintain a client on daily methadone. The increase in distribution costs PPPY— driven mainly by costs of new equipment and higher running costs—are offset to an extent by a reduction in induction costs (which is driven by resource optimization in personnel costs).

figure 5

MMT program costs post-decentralization $737.02

$800 $700

OT H E R C OS T S

$600

D E M AN D G E N E RAT ION

$500

L AB T E S T S $400 $300

M E T H AD ON E

$281.71

$233.38

$200

PE RS ON N E L

$100 $0

AVERAGE COST PPPY (WEIGHTED AVERAGE)

COST PER CLIENT INDUCTED

DISTRIBUTION COST PPPY

Patient numbers Through the costing analysis, the study team looked at the costs of service delivery for the national MMT program, including both induction and distribution services.

Mauritius: Methadone Maintenance Therapy 14

In 2014, a total of 345 clients were inducted on methadone therapy at the country’s four induction sites. Of these, 138 were inducted at an in-patient facility and the remaining 207 were inducted at one of the HRU’s three day care centers. In general, each two-week induction session in 2014 included 7-10 clients each.

figure 6

Number of IDUs receiving MMT services in 2014 6000 5000 4000

INPATIENT INDUCTIONS

3000

OUTPATIENT INDUCTIONS

2000

In the same timeframe, a total of 5,456 clients received daily metha1000 done distribution from 17 metha0 done distribution points12 across CLIENTS CLIENTS ON INDUCTED DISTRIBUTION the island. Of these 17 distribution IN 2014 IN 2014 points, six are mobile sites, serviced through vans. (The community of people who inject drugs is primarily concentrated in or near Mauritius’ capital, Port Louis, so some of the biggest distribution sites are located in the city.) The total number of distribution clients includes the 345 ‘new clients’ who were enrolled into the distribution program after completing induction in 2014 in addition to 5,111 ‘established clients’. The National AIDS Secretariat estimates that the total number of people who inject drugs in Mauritius is around 11,000, which indicates that the MMT program currently reaches about 50% of them.

Costing Methodology Costs breakdown by programmatic phase (induction vs. distribution) To determine the cost of Mauritius’ MMT program, researchers collected data around all aspects of service delivery, including methadone, laboratory commodities, personnel, demand generation and other running costs (buildings, utilities, etc.). A top-down costing approach was primarily used for this analysis; it consisted of comprehensively collecting all the resources used for the MMT program in 2014 and then allocating them to induction or distribution. (Shared resources—staff responsible for methadone preparation, HRU staff responsible for overall program coordination, etc.—were allocated to induction or distribution as per interviews with program officers.) Through site visits and interviews, cost data were collected at two (of the four) induction centers, three (of the 17) distribution points, and two (of the eight) methadone preparation sites. Data were then extrapolated as appropriate for those sites that the study team was not able to directly observe. The total dollar spent on the process of induction was divided by the total number of people inducted (also referred to as ‘induction clients’) to arrive at a unit cost per person inducted. Similarly, the total spent on the

12 The 18th distribution point was in a prison; it is not included in the costing analysis, as explained in the section on costing methodology. In 2014, a total of 34 prison inmates were inducted on MMT, and about 400 inmates were on methadone distribution.

15 Mauritius: Methadone Maintenance Therapy

process of distribution was divided by the total number of client years on maintenance/distribution therapy (also called ‘distribution clients’) to arrive at a unit cost per distribution client per year. As in ART costing, a client year unit combines the number of clients with time receiving the service. One client year may be formed of one client who received continuous care from January through December—or for example, by four clients who each received the service for only one quarter in the same costing year. Hence, the total of 5,456 clients who received services in 2014 get rolled up into 5,261 client years.

client breakdown between induction and distribution

figure 7

6% CLIENTS INDUCTED IN 2014 CLIENTS ON DISTRIBUTION IN 2014

94%

Calculating weighted averages The overall programmatic cost PPPY calculated through this analysis represents the weighted average of costs for the two program phases (induction and distribution). Thus, for each cost value represented in this report, the induction cost PPPY was multiplied by 6%, and distribution costs multiplied by 94% (these percentages/ weights are based on the current client breakdown between the two phases). Both were summed to arrive at a final programmatic cost to reflect the proportion of clients actually receiving each service.

Costing methodology for 2015 decentralization The research team for this analysis worked with HRU to understand the cost implications of the structural changes that would accompany the 2015 program decentralization. Of note too is that it followed the same methodology as 2014 to estimate costs PPPY. For the purpose of this analysis, the team assumed that the number of new inductions in 2015 as well as the number of clients on distribution will remain within the same range as 2014.

Non-inclusion of prisons in costing At the start of the MMT program, the MoH was criticized for not providing access to one of the most vulnerable key populations: people who inject drugs who are in prisons. In response, distribution was started for prisoners in 2007, and induction in 2011. Since then, a total of 267 prison inmates have been inducted and around 400 inmates received their daily methadone within the prisons at any point of time throughout the year. However, because the infrastructure for supporting the MMT to prisoners is largely separate from the overall program, prisons were not included in the costing analysis.

Mauritius: Methadone Maintenance Therapy 16

Training costs Because the MMT program has not conducted any new or refresher trainings in the past two years, this cost analysis does not include any training costs. However, it is important to mention that program supervisory staff attribute a large part of the program’s success to the trainings on formal skill development and behavior sensitization that were conducted in the early years of the program (in 2006 and 2008) and to refresher trainings in 2009 and 2010. In interviews during the data collection process, staff members noted that the trainings were an intensive all-staff process, conducted over a period of one week, and had the participation of international MMT experts and national leaders. The sessions were aimed at increasing understanding of needle and syringe exchange, MMT and public health concerns specific to the community of people who inject drugs. The trainings encouraged participants to understand drug use through a public health perspective rather than a criminal justice system one and emphasized the need to eliminate stigma in the service delivery context. Given staff turnover, only about half of the personnel currently engaged with the program were participants in the original trainings. Nevertheless, it seems evident that the trainings have served the purpose of infusing the entire program with a non-judgmental viewpoint, and thus have been useful. Given these observations, such trainings would be a critical start-up cost at the outset of any harm reduction or MMT project.

cost categories The costs associated with the MMT program have been analyzed under five major categories: methadone, personnel, laboratory monitoring, demand generation and other costs (which include investment costs and costs of running the program).

figure 8

program costs by category 0.3% 5%

PE RSON N EL

22% 22%

17 Mauritius: Methadone Maintenance Therapy

ME TH A D ON E

51%

LAB T ES TS DE MAN D GEN ER ATI ON OTHE R C OS TS

Methadone costs The weighted average cost of methadone PPPY is $57.46. (That number represents the weighted cost of the expenditure in the induction and distribution phases.) Methadone accounts for the largest commodity-related cost of the MMT program, even though the MoH is able to procure the drug at very competitive prices.13

figure 9

methadone costs (2014)

$ 60 $ 50

$57

$57

$ 40 $ 30

The cost of methadone is only $1.30 per patient over the two weeks of induction. Costs remain low during the induction period mainly because of the fine titrations in doses carried out to determine the most appropriate dose for each client; a client’s starting dose during induction can be as low as 5mg (1ml) and will be gradually increased over the induction period. In contrast, the average daily dose of methadone for a client in the distribution phase in 2014 was 50mg (10ml), amounting to an average methadone cost of $57.38 PPPY for the distribution phase.

$ 20 $ 10 $0

$1 AVERAGE COST PPPY (WEIGHTED AVERAGE)

COST PER CLIENT INDUCTED

DISTRIBUTION COSTS PPPY

personnel With a weighted total cost of $136 PPPY, staff costs are the biggest overall cost driver of the MMT program. These costs are the largest cost component in both phases of treatment. In the induction phase, these costs are $793 per patient, and make up 74% of total costs. This is primarily due to the large number of direct clinical staff dedicated to the day care and inpatient induction sites. To support the clinical and psychosocial needs of clients under induction, the program had dedicated seven doctors, eight nursing officers and 10 healthcare assistants on a full-time basis at the four induction centers in operation across the country in 2014. Additionally, a number of personnel are dedicated figure 10 part-time to induction services, including a dentist and a $800 nutritionist—both of whom provide consultations to cli$793 $700 ents once in the two-week period—and a pharmacist, who performs daily dose titrations and adjustments. $600

personnel costs (2014)

$500 $400 $300 $200 $100 $0

$136 AVERAGE COST PPPY (WEIGHTED AVERAGE)

$84 COST PER CLIENT INDUCTED

DISTRIBUTION COSTS PPPY

In the distribution phase, personnel costs are comparatively lower, at $84 PPPY, and account for 43% of total distribution costs. Although the distribution program reaches far more clients than those reached during induction, the intensity of service delivery is much lower and primarily involves daily methadone distribution. Distribution only occurs in the morning, with most sites open for methadone distribution between 6am and 9am—though sites serving a disproportionately high number of clients

13 Perhaps owing to the program’s long history, and the large size of the national MMT cohort, the procurement price of methadone per liter declined from $22 in 2008 to $13 in 2014.

Mauritius: Methadone Maintenance Therapy 18

were open until noon. Distribution is conducted by nurses and pharmacy technicians (also known as ‘dispensers’) that are only dedicated to the program during morning distribution hours. However, distribution costs also include the OPD (outpatient) hours that HRU doctors dedicate to distribution clients on a regular basis.

High staff-to-client ratio in induction phase

Total FTEs engaged in induction and distribution figure 11 50

DOCTOR N U R S I N G OF FICER

40

30

HE ALT HC AR E AS S I S TAN T

TOTAL FTEs

22

20

PART-TIME STAFF

I N DI R E CT S TAF F

30

TOTAL FTEs

10

0

OT HE R DI R E CT STAFF

The relatively high personnel costs in the induction phase are due to the high staff-to-client ratio: 63 FTEs (full-time employees)/1,000 induction clients versus 2.3 FTEs/1,000 distribution clients. Given the intensity of service provision during induction, a total of 22 FTE personnel were allocated to the induction phase of the program in 2014. Those individuals are primarily direct staff; indirect staff comprise less than 1 FTE and consist only of the supervisory staff in the MoH and HRU.

13

The high staff-to-client ratio is the main reason why the induction phase is the most resourceINDUCTION DISTRIBUTION intensive phase of treatment. It is also perhaps one of the main reasons why the HRU has moved from a residential to a day care model and, in 2015, scaled down the induction centers from four to three. With decentralization, the staff-to-client ratio is expected to decrease by 30%, which will lead to overall efficiency of service delivery. In contrast, in the distribution phase the service providers consist of 13 FTEs, supplemented by 30 part-time staff who are paid a stipend for the 4-5 hours of work performed daily.

Laboratory costs Laboratory costs, at $0.87 PPPY, are the smallest cost component of the MMT program. Lab requirements of MMT clients are limited to two kinds of tests, HIV testing and urine drug monitoring.

figure 12

laboratory costs (2014)

$8

$7.54

$7 $6 $5

All clients undergoing induction are offered an HIV rapid test; even though the test is voluntary, over 80% of clients choose to get tested. Clients who test positive undergo three confirmatory tests—one Western Blot and two Elisa tests, which are run at one of Mauritius’ central labs. In addition, all induction clients undergo one urine test for drug level analysis and methadone dose calculation.

19 Mauritius: Methadone Maintenance Therapy

$4 $3 $2 $1 0

$0.38

$0.87 AVERAGE COST PPPY (WEIGHTED AVERAGE)

COST PER CLIENT INDUCTED

DISTRIBUTION COSTS PPPY

In 2014, average laboratory costs totaled $7.54 per inducted client.14 Lab costs for distribution clients are minimal ($0.38 PPPY) because only about one in four clients in the distribution phase are required to undergo random urine testing to monitor adherence and to adjust methadone dosing.

Demand generation/outreach costs The HRU primarily relies on five NGOs 15 to perform demand generation and outreach activities for its program. These NGOs carry out various community-focused services and get reimbursed by NATReSA16 for their support to the MMT program. NGO support includes assessment and enrolment of clients into induction, counseling services during induction as well as afterwards, and referral services in case of relapse, etc. The total weighted outreach costs of the program are $13.21 PPPY. In general, the NGOs allocate a larger proportion of their time/resources in providing services to clients on maintenance than on induction. Accordingly, the team allocated the 70% of the demand generation costs to distribution clients and 30% to induction clients. As expected, the costs allocated to distribution clients, being spread over a larger patient base, are only $9 PPPY. These costs cover follow-up visits, counseling, referral services and other services that the NGO staff carries out to ensure long-term adherence to the program. In contrast, the demand generation costs allocated to the two-week induction period are $60 per client, and include the costs incurred by the NGOs in carrying out a range of activities such as generating awareness about the MMT program, assessing and enrolling potential clients for induction, counseling services to prepare clients for induction, visiting them during induction, etc.

‘Other’ costs This category consists of three sub-categories: costs associated with running the program (utilities, fuel, etc.) and costs of equipment and buildings.

Running Costs

figure 13

“other” costs (2014)

$ 200

$169 $16

$ 150

$8

EQUIP M ENT BUIL DINGS RUNNING COST S

$ 100 $146

Running costs of the program include various $59 different costs, some of which are common to $48 $18 $ 50 $1 $17 the induction and distribution phases while $40 $31 others are unique to each phase. The category $0 includes expenditures incurred through utilities AVERAGE COST COST PER DISTRIBUTION PPPY CLIENT COSTS PPPY like water, electricity and phone bills; costs of (WEIGHTED INDUCTED AVERAGE) fuel; and costs of support services such as meals and transport reimbursements. The overall weighted costs to run the program are $40 PPPY. For clients undergoing induction, the costs of running the program are high: $146 per client over the twoweek induction period. The bulk of the cost is composed of nutritional support in addition to the utilities 14 In countries with an HIV testing algorithm that relies more on rapid tests, laboratory costs would likely decrease on a per-client basis. 15 As noted elsewhere in this report, the five NGOs are the Dr Idrice Goomany Center, Help De-Addiction, Sangam Seva Sadan (SSS), Lacaz A, and Groupe Renaissance de Mahebourg. 16 The National Agency for the Treatment and Rehabilitation of Substance Abusers (NATReSA) is a body under the MoH and is responsible for liaising with and funding the NGOs that work in harm reduction.

Mauritius: Methadone Maintenance Therapy 20

used at the induction centers. (Nutritional support is provided to all clients throughout the course of induction as part of an effort to enhance adherence.) The costs also include utility costs at all four induction centers. For clients undergoing distribution, two additional costs are incurred over and above the utility bills at distribution sites. The first is the cost of fuel for the four vans that serve the mobile sites17, and the second is the reimbursement of transport expenses incurred for those traveling to distribution sites. This reimbursement is provided only to a small section of the clients (about 5% of the total distribution clients)18 who meet the criteria necessary to receive government financial assistance. The running costs attributed to the distribution phase are $31 PPPY.

Equipment Costs The equipment cost of the program was determined to be $18 PPPY for the 2014 costing year. Equipment utilized for the induction phase includes furniture and fixtures at the induction clinics and amounted to a cost per inducted client of $16. For distribution clients, the cost of vans was the major driver of the equipment cost of $17 PPPY.

Buildings costs Buildings are the smallest component of the MMT program costs. In 2014, the overall building costs were only $0.92. This was composed of induction phase building costs of $6.24 PPPY and distribution phase building costs of $0.51 PPPY. The cost of buildings for induction is higher because dedicated spaces are required to monitor clients and to provide services all day over the two-week induction period. Conversely, distribution, which is a 3-6 hour process every day, is mainly carried out of small rooms in clinics or from vans.

17 Two vans serve two sites each in 3-hour shifts, while the remaining two serve one site each. Post the decentralization, 15 vans will serve 33 sites (14 vans which will serve the 29 non-prison sites have been included in the costing) 18 Only about 300 clients received this reimbursement during the costing year reviewed by the research team.

21 Mauritius: Methadone Maintenance Therapy

personnel costs before and after decentralization figure 14

table 6

cost category

$793

$800 $700

$540

$600

$400 $300

$100 $0

2015

AVERAGE COST PPPY (WEIGHTED AVERAGE)

$84 $95 2014

2015

COST PER CLIENT INDUCTED

2014

2015

DISTRIBUTION COSTS PPPY

costs post decentralization (2015)

METHADONE

$57.46

$57.46

PERSONNEL

$136.09

$129.91

$0.87

$0.87

“OTHER” COSTS

$59.41

$80.25

Equipment

$18.01

$30.75

$0.92

$0.65

Other Running Costs

$40.48

$48.84

DEMAND GENERATION

$13.21

$13.21

TOTAL PROGRAMMATIC COST PPPY*

$267.05

$281.71

Buildings

$136 $130 2014

cost in 2014

LAB TESTS

$500

$200

cost details

*Weighted average of cost per client inducted and cost per client on distribution. NO CHANGE DECREASED

INCREASED

Projected MMT costs with decentralization and resource optimization As mentioned previously in this report, the HRU and MoH designed a decentralized model of the MMT program in response to growing concerns about congestion at distribution points. The new model was fully implemented by March 2015. Although the study team did not collect costs during 2015, it modelled expected costs under decentralization to estimate how costs will change. The changes in program structure have resource implications for two of the five cost categories described above: personnel and other running costs. The decentralization did not have a direct impact on the costs of methadone, lab monitoring and demand generation because all of those costs are driven solely by client numbers.

Decentralized personnel costs Overall weighted personnel costs are expected to drop with the decentralization from $136 to $130. As mentioned previously, under the decentralized model, the HRU is reducing the number of induction centers from four to three and is expanding the number of distribution sites from 18 to 39.19 The drop in personnel costs in the decentralized model is due to the systemic efficiencies created by reducing the number of induction centers and scaling down the underutilized staff at these centers. Because of these changes, the personnel cost for induction clients is projected to decrease from $793 to $540 per inducted client. To support the increased number of distribution points, the number of part-time distribution staff has increased from 30 to 60. However, the increase in personnel costs (from $84 PPPY to $95) is more than offset by resource optimization within the induction phase as described above. 19

Of the 42 current sites, three are in prison and hence not included in the costing.

Mauritius: Methadone Maintenance Therapy 22

Decentralized ‘other’ costs As expected, the ‘other” costs of the program are estimated to increase by about 35% (from $59 PPPY to $80 PPPY) in 2015. Decentralization has an impact on all three subcategories in this category: running costs, equipment costs and building costs. Decentralization is expected to reduce induction costs in each (because of the closure of one induction center) and increase distribution costs in two of the three (all except building costs).

“other” COSTS BEFORE AND AFTER DECENTRALIZATION

figure 15 $200

$169 $16

$150

$8

E Q U IP ME N T

$128

B U IL D IN G S

$9 $5

$100

$59 $50

$18 $1 $40

$80

$146

$31 $114 $49

R U N N IN G C O S T S

$48

$72 $30

$17 $31

$41

2014 2015 2014 2015 2014 2015 • Running Costs: The most signifi$0 AVERAGE COST COST PER DISTRIBUTION cant structural change in the MMT PPPY CLIENT COSTS PPPY (WEIGHTED INDUCTED model under decentralization has AVERAGE) been the increase in the number of distribution points from 18 to 39, mainly supported by mobile vans. In response, a three-fold increase in fuel costs is estimated. The costs to run the program are expected to increase from $40 to $49 in 2015.

• Equipment: The cost of equipment is expected to increase to $31 PPPY, primarily because of the 10 additional vans20 that the program will need to purchase to support the increased number of distribution points. • Buildings: Overall building costs are projected to decrease (from $0.92 PPPY in 2014 to $0.65 PPPY in 2015) as a result of decentralization. This is because mobile vans, which are being used more heavily for distribution, have no building costs.

20

The MoH is using existing vehicles from other programs to support the distribution points until the 10 additional vehicles are purchased.

23 Mauritius: Methadone Maintenance Therapy

Hypothetical scenario with increased efficiency One of the key observations of the study team during its site visits in Mauritius was that the induction centers were underutilized in 2014. Based on HRU reports, the demand for induction peaked in 2010, but the total number of induction clients has since been decreasing. In 2014, for example, an average of seven clients was inducted at each of the four induction centers per session, even though an average induction center can provide services to 14-18 clients. The HRU and MoH have recognized this trend of underutilization, and hence have closed one of the four centers as part of the decentralization process. In the wake of that step, the average number of clients at induction session is expected to increase to about 10 and the study team estimates that this will reduce the costs of induction by 29%—from $1031 per inducted client in 2014 to $737 in 2015. Beyond decentralization, the study team also looked at a hypothetical scenario of maximized utilization, in which the number of induction centers would be scaled down even further to two centers. In this scenario, each induction center would work at full capacity (i.e., the number of participants per session would be about 14). Below is a comparison of the structural and staff changes in the 2015 decentralization and the hypothetical scenario of maximum utilization.

Structural elements of the 2015 decentralization and the high-efficiency scenario

table 7

2014

2015 (MoH-led decentralization)

Hypothetical scenario

4

3

2

Average no. of participants per induction session

7.2

9.6

14.4

No. of FTEs engaged in induction

22

15

10

No. of distribution points*

17

39

39

No. part-time staff engaged in distribution*

30

60

60

Number of induction centers

*The hypothetical scenario involves no changes in the distribution side of the program.

Analysis indicates that this scenario would decrease costs in two key cost categories within the induction phase— staff costs and ‘other’ costs. Distribution costs would be unaffected; however, since induction is the most resourceintensive part of the MMT program, increased efficiency in this phase of service delivery is an important consideration. Maximum utilization at induction sites is projected to further reduce the costs of induction to $585 per inducted client, which would represent a 20% cost saving per inducted client over the 2015 induction costs.

Mauritius: Methadone Maintenance Therapy 24

table 8

Impact of increased efficiency on induction costs

cost category

cost per inducted (2014)

cost per client post decentralization (2015)

cost per client inducted in hypothetical scenario

METHADONE

$1.30

$1.30

$1.30

PERSONNEL

$793.30

$540.00

$399.80

$7.50

$7.50

$7.50

$168.60

$127.70

$115.70

$16.10

$9.20

$6.90

$6.20

$4.20

$2.10

Harare-Based CATS Costs Other Running

$146.20

$114.40

$106.70

DEMAND GENERATION

$60.50

$60.50

$60.50

$1,031.20

$737.00

$584.80

LAB TESTS “OTHER” COSTS Equipment Buildings

Total cost of induction per patient

NO CHANGE Costs in hypothetical scenario lower than post-decentralization costs

Given that induction clients represent only 6% of overall programmatic costs, the additional efficiency may not seem to have any significant impact on the big picture. As shown in the table below, the overall post-decentralization programmatic costs would only exhibit a small decrease of about 3.5% (from $282 PPPY to $272 PPPY).

table 9

Impact of increased efficiency on overall costs

cost category

PROGRAM COSTS IN 2014

PROGRAM COSTS POST DECENTRALIZATION (2015)

METHADONE

$57.50

$57.50

$57.50

PERSONNEL

$136.10

$129.90

$120.70

$0.90

$0.90

$0.90

“OTHER” COSTS

$59.40

$80.20

$79.50

Equipment

$18.00

$30.80

$30.60

$0.90

$0.60

$0.50

Other Running Costs

$40.50

$48.80

$48.30

DEMAND GENERATION

$13.20

$13.20

$13.20

$267.10

$281.70

$271.70

LAB TESTS

Buildings

Total programmatic cost PPPY*

PROGRAM COSTS IN A HYPOTHETICAL SCENARIO

NO CHANGE Costs in hypothetical scenario lower than post-decentralization costs

*Weighted average of cost per client inducted and cost per client on distribution

25 Mauritius: Methadone Maintenance Therapy

However, in spite of this seemingly small impact on the overall program costs PPPY, the hypothetical scenario represents a savings of over $50,000 in the year-on-year cost of the decentralized program.

table 10

Cost savings in hypothetical scenario of increased efficiency

cost category INDUCTION

2014

2015

HYPOTHETICAL

$355,765

$254,273

$201,759

DISTRIBUTION

$1.05M

$1.24M

$1.24M

OVERALL PROGRAM COST

$1.40M

$1.50M

$1.45M

Mauritius: Methadone Maintenance Therapy 26

Costs of Needle and Syringe Exchange Program (NEP) The needle and syringe exchange program (NEP), while separate from the MMT, is the other harm reduction strategy implemented by the Mauritian government. Similar to the MMT, the program is housed under the Harm Reduction Unit. As noted previously in this report: • The implementation of the program is currently undertaken by a group of NGOs, Collectif Urgence Toxida (CUT), in addition to the MoH. • In 2014, needle and syringe exchange was carried out from 47 sites across the island; of those, 11 were run by CUT, while the remaining were managed under the MoH.

Client numbers A total of 3,078 people who inject drugs received needle and syringe services in 2014, which was an increase over client numbers of 2,649 and 2,540 in 2012 and 2013, respectively. Even though there are fewer NGO sites than MoH ones, the NGO-run sites serve far more people overall because those sites operate in areas with higher densities of people who inject drugs.

Costing methodology Similar to the costing approach used for the MMT program (Section 4 of this report), the research team collected data around the key resource requirements of service delivery for the NEP, including commodities, personnel and running costs (buildings, utilities, etc.). Also similar to the MMT costing, a top-down costing

figure 16

Cost of the needle and syringe exchange program

clients reached under the NEP

table 11

3 5 00 3 0 00

cost category

2 5 00

NGOS

$37.87

MOH

2 0 00 1 5 00

PERSONNEL

COST IN 2014

1771

1638

2092

COMMODITIES

$4.33

EQUIPMENT

$2.53

RUNNING COSTS

$4.77

1 0 00 5 00 0

878

902

986

2012

2013

2014

27 Mauritius: Methadone Maintenance Therapy

TOTAL COST PER PATIENT

$49.49

approach was used for the analysis; it consisted of collecting all the resources used for the NEP program in 2014 through interviews with NGOs engaged in the program as well as with staff at the MoH responsible for the centralized procurement. The total dollar amount spent on the program was divided by the total number of clients who received services to arrive at a unit cost per person. The analysis shows that the cost of providing needle and syringe exchange is slightly less than $50 per client served through the program per year. However, there may be some additional program expenses not covered in the analysis. For instance, field workers providing some services receive some per diem costs to top up their salaries. These top-ups are paid by other NGO partners as well as some private-sector companies (as part of their corporate social responsibility, or CSR, initiatives).

Cost categories (2014) The costs of the NEP consist of four major categories: commodities, equipment, staff and running costs. • Personnel Costs: As might be expected, the cost of personnel is the biggest cost driver in the NEP. Two staff categories are relevant: the NGO staff which performs awareness generation as well as NEP service delivery in the community and the MoH staff which manages the needle and syringe exchange points. The personnel cost per client served per year in 2014 was $38. • Commodities: Commodities are a relatively small cost component of the program and consist mainly of paraphernalia related to drug injection (e.g., needles, syringes and swabs). The cost of commodities per client was about $4 in 2014. • Equipment: The main component in this cost category is transport—i.e., the mobile vans used in providing needle and syringe exchange services. Of the 47 exchange sites in operation in 2014, four were mobile sites served by two caravans, very figure 17 similar to the four vans that were used by Harm Reduction Unit (HRU) for its MMT program. The remaining 43 sites (36 MOH-managed and 7-NGO PERSONNEL managed were fixed sites and had minor equipCOMMODITIES ment costs for the basic furniture items. The EQUIPMENT cost of equipment per client served per year was RUNNING COSTS slightly less than $3.

COST CATEGORIES IN the NEP

5% 10% 9%

76%

• Running Costs: This category includes the expenses related to ‘program management and administration’—e.g., utility bills, fuel for the vans, and other expenses related to logistic requirements. The cost of running the program was about $5 per client served in the program per year.

Mauritius: Methadone Maintenance Therapy 28

Benefits of Harm Reduction Interventions in Mauritius overview In Mauritius, community advocates were the first to realize the potential value of utilizing harm reduction approaches to counteract a rapidly growing HIV epidemic concentrated among people who inject drugs. Effective advocacy by civil society and political will by the government led to a partnership that has implemented interventions that have helped reduce HIV transmission. Mauritius therefore offers a notable example of how to approach a serious health problem collaboratively, involving civil society and ministries, with a reliance on scientific evidence and a respect for human rights. The process and impact may be of particular interest to countries in which HIV transmission associated with injecting drug use continues to increase. The success of the partnerships in Mauritius stems from having clearly defined roles for agencies that serve to engage the target populations and address the full spectrum of their needs. Overall, the program has been and continues to be successful in reducing HIV transmission and reducing the number “We have been using drugs for many years, but now of people who regularly inject drugs.

for seven years I have been on the methadone program. We have sessions with the NGO, [and] receive information and communication materials and HIV testing at the drop in center.”

Mauritius is committed to providing free health care to its citizens and views harm reduction as one component of its health services program. The MMT program has been — MMT program client who participated in a focus group discussion during a site visit in used as an entry point to other services such February 2015 as HIV testing and, ultimately, ART initiation. All clients undergoing MMT induction are offered an HIV rapid test; even though the testing is voluntary, over 80% of clients choose to get tested. The NEP has both government and civil society arms that overlap and thus successfully provide clean injecting equipment across the island. The unique and targeted outreach strategies help to ensure that different sections of the population are offered services they want and need in ways that protect them from harassment or criminal prosecution. The attention to detail is exemplified in the government agreeing to provide transport reimbursement to anyone on the ART program in need of such support, thereby removing a potential deterrent for clients and removing a common reason for poor treatment adherence. The Mauritian government has set a bold target of reducing the annual number of new infections by 50% in 2015. More ambitiously, it hopes to reduce that number by up to 80% by strengthening existing programs and embarking on new initiatives. 21

21

The Global AIDS Response Report 2014, National AIDS Secretariat/Prime Minister’s Office, government of Mauritius.

29 Mauritius: Methadone Maintenance Therapy

Among those new initiatives are the following: • improving national coordination and response regarding drug use, • re-establishing the harm reduction committee within NAS, • decriminalizing the distribution and utilization of syringes by working closely with the ADSU (Anti-Drug and Smuggling Unit) within the Mauritius Police Force, • implementing extensive harm reduction services in prison, and • conducting frequent harm reduction awareness programs in the community so as to mitigate stigma and discrimination.

clients To date, more than 6,000 clients have been inducted into the MMT program. MMT clients have access to a broad array of health services, including referrals for HIV treatment. While statistics showing the number of MMT clients who have initiated ART are not available, the number of people who have started on HIV treatment has risen substantially in alignment with the scale up of the MMT program.

“The program has helped us and allowed some to go to work, lead normal lives and look after their families.” — MMT program client who participated in a focus group discussion during a site visit in February 2015

The satisfaction of the majority of MMT clients can be seen in the program’s high adherence rates; for example, data showed that over 80% of clients were adherent over a one-year period in 2012. In a 2011 independent evaluation of the MMT program, clients consistently stated that it had benefited them in a variety of areas such as employment; improvement in family and social relationships; and improved sense of self and stability in day-to-day life by reducing the need for drug seeking and injecting behavior. Many have noted as well that MMT had allowed them to stop using any illicit drugs.22 There is anecdotal evidence that the availability of methadone may have led to an overall reduction of injecting drug use in Mauritius. However, there needs to be further study to link the MMT programme to the decline in injecting drug use. The NEP has been structured to meet a diverse group of clients, providing them with a variety of ways and locations to obtain clean needles and syringes. Thousands of people have benefitted from this program, which has significantly reduced HIV transmission caused by unsafe sharing of equipment by people who use drugs. According to the integrated biological and behavioral surveillance (IBBS) survey in 2011, the percentage of people who injected drugs who reported using sterile injecting equipment the last time they injected was 84%.23 This figure rose to 98.9% 2013 as reported in Mauritius Global AIDS Progress Report 2014. The NEP has also provided clients with HIV testing, condoms, information, referrals to drug treatment and HIV treatment programs, and wound treatment. These services not only provide benefits to clients, but provides opportunities to keep HIV transmission from bridging to the general population. The consistent engagement with clients presents a number of opportunities to provide access to these and other relevant healthcare services and information. It is this consistency that can compel clients to access services from organizations they can trust. 22 The Right Service, At the Right Place, at the Right Time: An Evaluation of the National Harm Reduction Program in Mauritius; prepared for the National AIDS Secretariat by AIDS Project Management Group. May 2011. 23 The Global AIDS Response Report 2014, National AIDS Secretariat/Prime Minister’s Office, government of Mauritius.

Mauritius: Methadone Maintenance Therapy 30

Overall, the MoH has estimated that the implementation of the harm reduction programs has coincided with a significant decrease in the overall number of people who inject drugs, with numbers cut by almost 50%.

Communities Communities have benefitted more broadly in a number of ways. The MoH has reported that since the introduction of the harm reduction program, crime has decreased—with one likely reason being that increased uptake of methadone has meant there are fewer street-based drug sales. Moreover, the increased presence of local NGOs and government agencies working in communities to provide access to harm reduction programs and HIV services is encouraging dialogue within communities around social issues facing key populations. Many of the MMT program clients after completing the detoxification and began on Methadone treatment have returned to regular employment and are living more stable lives with their families and within their communities. As a growing number of clients are integrated back into communities, it is easier to devise and implement successful awareness-raising programs aimed at mitigating the stigma and discrimination that many current and former people who inject drugs face.

Providers The stabilization that MMT provides to clients offers providers with multiple opportunities to engage clients in health services, including drug treatment, HIV testing and treatment, wound treatment and treatment for non-communicable conditions such as heart disease and diabetes. Methadone use also significantly lowers the risk of overdose and development of abscesses. The need for clients to come to methadone distribution sites every day provides opportunities to offer psychosocial services and track adherence. The NEP also provides clients with opportunities for referral and information dissemination to increase their overall engagement in health care.

“The needle exchange program [run by] CUT has been successful because it is flexible in catering for different community and individual needs—for example, providing needles outside working hours and the backpack and peer program.”

With 80% of the funding for harm reduction coming from the government, there is a level of sustainability in Mauritius that many other countries implementing a harm reduction program do not have. This support is contributing to a level of confidence and assurance by providers that they will be able to continue the level of care and services to those who are ready and willing to access services.

— NGO REPRESENTATIVE

Providers and the overall health system are also benefitting from policies and processes that are allowing clients to access services with less fear of being harassed or stopped and charged with criminal behavior. One result has been an increase of clients, most of whom are members of populations that are hard to reach, coming forward for care and services. This positive development underscores the fact that harm reduction-related collaboration among NGOs, service providers and the government agencies is increasing demand for services and providing a bridge into health care services for a population that is traditionally wary of government services.

31 Mauritius: Methadone Maintenance Therapy

Challenges to Mauritius’ harm reduction approaches Challenges overview Despite the successes of harm reduction programming in Mauritius, many challenges remain. Improved integration of the MMT program with other health services, in particular HIV treatment services, would increase effectiveness and provide a more in-depth understanding about how people who inject drugs are accessing and using treatment. Currently there is limited data on the number of MMT clients who have initiated ART, nor how many are adherent to ARV treatment.  An estimated 4,000 out of 10,000 people in Mauritius do not know that they are infected with HIV and, overall, the number of people on treatment is low. The MoH is committed to more targeted testing approaches. Progress is clearly needed in that and other key areas (e.g., reliable and updated surveillance data) if HIV prevention and treatment targets are to be met. Other notable overarching challenges include the following: • Despite the commitment of and funding for civil society organizations to provide psychosocial services, they are often lacking for methadone maintenance clients once the induction period has ended. • Integration of methadone and ART distribution could further strengthen adherence to both. However, concerns have been raised about the implementation of the decentralization efforts that aim to streamline services. For example, some methadone distribution is being moved into inappropriate settings such as police stations. That is an unwise and ineffective step given the continued stigmatization and criminalization of drug use in Mauritian society; as such, it undermines the potential further success of harm reduction and HIV services because people who inject drugs are not likely to seek out and utilize harm reduction and other health services if they have to go anywhere near a police station. • While the harm reduction program has reduced HIV rates and increased participation in HIV treatment programs, hepatitis C infection remains largely untreated. The need to boost access to treatment for this debilitating infection is crucial given that an estimated 97% of people who inject drugs are living with the hepatitis C virus.

Clients In establishing the harm reduction program, the government’s primary objective was to reduce the rates of HIV infection and prevent HIV from moving into the general population. While the MMT and needle and syringe exchange programs provide many benefits for clients, including access to free methadone, health care, and HIV treatment, there are aspects of the program that could be structured more appropriately to meet client needs. These include the following:

Mauritius: Methadone Maintenance Therapy 32

“There is one place [from] where we collect our treatment and that causes stigma. They should just put it in all hospitals so that we do not stand out. Even [in] prison there is a special wing for ART; hence the stigma among inmates and visiting family members.”

• The decentralization of methadone distribution sites can make it easier for clients to pick up their daily dose. However, the cutback in hours at the distribution sites has made it much harder for clients to pick up their methadone on their way to work, thus affecting some clients’ ability to remain employed.

— MMT program client who participated in a focus group discussion during a site visit in February 2015

• The continued criminalization of drug use and incarceration of drug users, coupled with documentation of such incarceration, has severely limited the employment options for many clients in the methadone program. Many of these clients want full-time employment but are unable to obtain it because government documents identify them as “immoral” former prisoners. As a result, those clients often have little to do during the day after picking up their methadone dose in the morning. They tend to congregate together outside distribution sites because they have nowhere else to go. This leads to complaints from community members and harassment by the police. Increasing the employment opportunities for MMT clients would probably go far to further stabilize clients and improve their standing in their communities.

• The government provides all syringes and needles for the NEP, including those run by community organizations under CUT. The organizations have complained about the quality of this injecting equipment, but there has yet to be an adequate response from the government. Clients will stop utilizing these needles and syringes and share with others if they cannot get products that meet their needs. • Women remain underrepresented in the MMT program because services during the induction phase do not often meet their needs. Without the provision of child care services, most women cannot participate in the induction phase. • Women have a low uptake in the NEP due to especially high levels of fear associated with stigma. As a result, only about 11% of females who inject drugs are estimated to be NEP clients. • Interviews with clients revealed that their HIV care was adequate and provided satisfactorily. However, many reported high rates of stigma and discrimination from health care providers in other areas. The integration of HIV services into methadone distribution sites would help limit such stigma and also make it easier for clients to pick up medication, have diagnostics performed, and engage in adherence support services. • Many clients have now been on methadone for many years and worry about long-term effects of methadone use. Clients need increased opportunities to either use alternative substitution drugs and/or detoxify so that they can stop using any such substances altogether.

33 Mauritius: Methadone Maintenance Therapy

• The NEP and MMT program have contributed to lower HIV infection rates and likely have helped prevent more extensive transmission of viral hepatitis. However, although HIV treatment is now widely available, little action has been taken towards meeting hepatitis C treatment needs.

Communities Of the estimated 10,000 people living with HIV in Mauritius, an estimated 4,000 do not know their status. This threatens their health and increases their likelihood of transmitting the virus to others. Currently around 83,000 HIV tests are performed annually in Mauritius, but testing is not well targeting those most in need (e.g., people who inject drugs, MSM and sex workers). Increased efforts to target HIV testing are in development. Expanding the ability of community workers to conduct HIV testing would go far to achieving improved results as these workers may be better placed to engage hard-to-reach populations. Communities in which methadone distribution sites are placed face problems with clients loitering outside of the distribution site after picking up their methadone. The program was decentralized in response to increasing congestion, but challenges remain around the perception that it is not safe to bring dispensing points closer to the community. In general, it has been observed that clients find it easier to admit that that they are enrolled into the MMT program as compared to the ART program because stigma associated with HIV is higher at all three levels—health care providers, family and community. And finally, it is important to reiterate that many females who inject drugs are especially stigmatized with rising rates of HIV infection. This makes it harder to reach them and convince them to enroll into the different arms of the harm reduction program and the associated services that come with it.

Government and service providers When the harm reduction program started, policy makers did not anticipate the demand for the services and thus it was scaled up quickly with quality not being a priority. There is a need for the government to continue to work on improving the quality of service delivery such as how to dispense both methadone and ART in an integrated and non-stigmatizing manner. Based on interviews with staff and clients, the following challenges were noted: • The integration of the MMT and HIV treatment programs is still in the process of being implemented and will take time to complete because doing so is operationally complex. Currently the MoH is trying to establish follow-up clinics within the same buildings that are being used to treat HIV. However, this is still at a pilot stage. The personnel working for both programs are different and client databases are also kept separately, so there is no way to determine which MMT clients are enrolled in ART programs. Adherence support across the two programs is not in place at the moment. As a way of strengthening both programs and making it easier for clients to obtain services, ART distribution and HIV diagnostics could be offered out of MMT distribution sites. • HIV testing needs to be scaled up and targeted towards those at risk. Despite free access to ART, uptake is low. Improved testing, improved integration between MMT and ART programs, and increased treatment literacy services could go far towards increasing the numbers of people on treatment.

Mauritius: Methadone Maintenance Therapy 34

“There is a need to strengthen civil society within the program as the bringing in of clients and initiation of methadone or ART is not necessarily a reflection of good work but an indication of high demand for the services….”

• Health care providers working outside of HIVspecific health services need additional training and supervision regarding discrimination and stigma towards people who use drugs and people living with HIV.

— Representative from the National AIDS Secretariat

• The manual preparation of 5,000 methadone doses daily presents a challenge for staff.

35 Mauritius: Methadone Maintenance Therapy

Conclusions and Key Messages The Harm Reduction Program in Mauritius provides an evidence-based best practice that should be considered by other countries experiencing increased HIV transmission associated with injecting drug use. As of February 2015, a total of 6,739 individuals had initiated MMT since 2008, thereby contributing to a reduction in HIV transmission among people who inject drugs from 68.1% in 2011 to 31.4% in 2014. Mauritius also provides an example of both effective advocacy by civil society and political will by the government leading to a partnership that has helped curb HIV transmission. The Mauritius program is a best practice because it is: • Demonstrating Political Will: The government’s political will to design and institute, in collaboration with civil society, a harm reduction strategy and services linked to HIV services is an excellent example of partnership between the two key stakeholders. • Creating Demand: Using the harm reduction services as a gateway to people who inject drugs, the government has linked the methadone maintenance and needles and syringe exchange programs to its HIV testing and linkage to care programs. • Innovative: There is no other African government that has taken such a decisive step to engage this population (people who inject drugs). The government of Mauritius took a close and clear-eyed view of the cost of inaction and the increase in new HIV infections within the country and decided to engage stakeholders (civil society, the general public, and government ministries) to develop and implement a plan of action for people who inject drugs. The design and implementation of the harm reduction strategy and its linkage to HIV services was done in collaboration with the civil society and is an excellent example of partnership among key stakeholders. • Showing a Decrease in HIV Infections: The yearly number of newly diagnosed cases among people who inject drugs has shown a downward trend since the introduction of the harm reduction program—from 401 in 2011, to 320 in 2012, and to 260 in 2013.

Mauritius: Methadone Maintenance Therapy 36

Best Practices Project Pangaea Global AIDS, in partnership with the Clinton Health Access Initiative (CHAI), received funding from the Bill and Melinda Gates Foundation to develop and cost a series of single descriptive case studies documenting effective approaches to HIV service delivery in Sub-Saharan Africa. The selection of programs for the case studies will seek to present information and costs about a diverse set of programs, looking at both community- and facility-based services and at programs addressing urban and rural populations, key affected populations, and programs that are well integrated with other areas of health services including primary care, sexual, reproductive, and maternal health, and TB services. The case studies will provide information on both health systems level programs as well as specific implementation models that program managers and others can consider and adapt for their constituencies. Through this process, Pangaea seeks to improve uptake and scale of HIV services and fill the gaps in the HIV treatment cascade.

Pangaea Global AIDS Pangaea Global AIDS is an international public health technical cooperation agency, based in Oakland, California USA, and Harare, Zimbabwe. We convene experts from science, health services, affected communities and the private sector, helping countries design the best quality, affordable and sustainable strategies for HIV and related health issues. We work at the global level, and with national partners to promote rights- based, evidence driven public health strategies.

CHAI – Clinton Health Access Initiative In 2002, the Clinton Health Access Initiative (CHAI) began as the Clinton HIV/AIDS Initiative to address the HIV/AIDS crisis in the developing world and strengthen health systems there. Taking the lead from governments and working with partners, CHAI works to improve markets for lifesaving medicines and diagnostics, lower the costs of treatments, and expand access to life-saving technologies — creating a sustainable model that can be owned and maintained by governments.

Acknowledgements The Project Team would like to acknowledge the support of the following people, without who the site visit and case study work would not be possible: Mr. Corceal Sewraz and colleagues at the Mauritius Ministry of Health and Quality of Life (MOHQL), Ministry of Health (MOH), and the Harm Reduction Unit (HRU).  Case Study Graphic Desig ner: Trevor Messersmith of 80East Design  Editor: Jeff Hoover

Pangaea & CHAI Project Team (Alphabetical Order) David Barr, Pangaea Katie Callahan, CHAI Ben Cheng, Pangaea Manjot Kaur, CHAI Brian Maguranyanga, Pangaea Imelda Mahaka, Pangaea Obrian F. Nyamucherera, Pangaea Salinda Phanitsiri, CHAI  Mikaela Rejbrand, Pangaea

ACRONYMS A R T

Antiretroviral therapy

HRU

Harm Reduction Unit (of the MoH)



M o H

Ministry of Health and Quality of Life

M M T

Methadone maintenance therapy

M S M

Men who have sex with men

NAS

National AIDS Secretariat

NE P

Needle and syringe exchange program

NG O

Non-governmental organization

P M TCT

Prevention of mother-to-child transmission

P P P Y

Per patient, per year

VCT

Voluntary counseling and testing

W H O

World Health Organization

Note on text: All $ figures are U.S. dollar amounts.

PANGAEAGLOBAL.ORG PA N G A E A G LOBA L A ID S 436 FOU RTE E N TH S TREET, SU ITE 920 OAKLAND, CA 94612 P : 510- 379- 4003 F: 5 10-836-7325 C ON [email protected]