Chapter three: no-threshold program or field OST clinic.
We‘re now at an outreach OST centre. Sure enough, it is a field OST clinic!
And this is a small share of the wide range of services for addicted people. These programs aren‘t limited to intravenous users, because they receive funding not only from HIV prevention programs but other public resources as well. They accept drug users who inhale, smoke or otherwise use opiates.
The outreach clinic is located in the area of Delhi where the government once rehoused people from the densely populated central areas. The people from the health ministry arrived in the area in 2006-2007, saw that there was need for narcological assistance, found an abandoned state building nearby and decided to open a clinic offering both buprenorphine and methadone.
The clinic rents the building. It was decided to start the treatment first, and then, if possible, refurbish the rooms. We were sitting in an unrefurbished room, equipped with with squirrels running round the window frames. The doctor said that he saw and understood the premises were shabby, but the upside was that the government could see that it was possible to quickly set up help to those in need with even small resources.
The first floor of the building now accomodates a registry office. The second - a library. The third – the OST and drop-in-center (syringe exchange, referrals, social assistance). The services are funded by the state, the program is called „deaddiction“. The clinic provides services to all PUD, injecting or not. That‘s because it‘s financed from a non-HIV program.
Since the clinic opened it's served about 3,000 registered OST patients. Now 120 people get methadone and 60 to 80 – buprenorphine with about 180 visiting the center every day.
The clinic is open seven days a week from 8am till 3.30pm; doctors and social workers come twice a week.
Listen to how the doctor talks about his clients! Most patients are 18-35 years old, Muslims, Hindi, two or three women. Practically all of them have families, they are not homeless (although we wouldn‘t call the hovels many of them live in "homes“). Clients of the field clinic use brown heroin, some use opioid-based medications. Many patients don‘t even have primary education, most don‘t work. Those who do work are self-employed: they sell fruit, work as drivers, resale something.
The doctor openly admits that many of his clients lead a criminal way of life: they are drug dealers, pickpockets. He tells us how they form gangs and operate in markets. They use the money to buy drugs.
When a person comes too the center for the first time they‘ll be registered, but such information can‘t be passed on to the police without an official request. In most cases the client is free to chose their own medication because they have expectations based on the methadone or buprenorphine they bought on the street. The average dose of buprenorphine is 12-18 mg, methadone - 40-50 mg, so the patients decide and choose the dosage. The dosage is higher in other centers in the north of the country. One of the reasons for that is that here they use brown heroin which is much weaker than the white heroin they use in the north.
In other clinics, they take a urine sample to test for drugs, here the evaluation is based on communication and trust. In 90% of cases, the treatment starts on the day the person applied. There are no waiting lists. Conditions are discussed, the patient comes every day, they can undergo group therapy with friends or family. Working with the family is mandatory. Overdose education, care for abscesses, safe injections, ways to contact site managers in case a person can‘t come to the center. In some cases they can pass the medicine to a family member. Of course, there is discussion about treatment of HIV and tuberculosis.
It is clear that many participants in this program take illegal drugs, 1 in 3 use street drugs, of which 50% use cannabis. The medical staff don't pay much attention to the use of cannabis. And it‘s a fact. When the doctor and our group were leaving the clinic, the people who had just received OST were sitting on their motorcycles and mopeds giving off the pleasant smell of marijuana. They did not hide the joints, they did not try to hide. And the doctor just carried on talking to us.
If a person comes regularly, has a job, things are normal with the family, then he gets take-home OST medication and comes in only twice a week. After four months he can take home a weekly dosage of medication. This only works with buprenorphine, there‘s no take-home methadone available.
"It doesn’t matter to us whether a person seeks to just get by when he’s run out of money or he’s just curious to try. Our task is to use every opportunity to help. If a cancer patient is not cured, it’s the doctors' fault for the most part. We treat people with addiction in the same way: if something doesn’t work out, first we ask ourselves what we did wrong”. These words of the field clinic doctor touched me deeply. Again, I am crying because I’m happy for the addicted people of India, and because I’m sad for the shortage of such doctors in our countries.
There is an AIDS center nearby for testing and treatment. Naloxone is used only for the center‘s needs. Patients can buy it at a pharmacy for one dollar. At an HIV-oriented syringe exchange points naloxone is given to patients for free. A mobile OST site is set to open soon. Even a foreigner can easily get help at the field clinic. I'm in awe. When in the bus, Pulod, Natasha and me look at each other wide-eyed, saing "Wow! That's the approach! " We talk about what surprised or impressed us the most. Just like band members after a successful gig, we hug and share our impressions with each other.
Chapter four: only a fingerprint is needed to receive OST
And the definitive moment of our internship, which wrapped up everything we’ve seen and brought us to a deep understanding of India’s culture of relationships and respect for the identity of every person is the drop-in-centre in Delhi.
When we were approaching the drop-in-centre, I felt a disgusting taste in my mouth and there was a stench which almost made me throw up. "This is a good place for a drop-in-centre. It’s where Indians burn corpses, according to ritual, so the police don’t want to come here“- the centre’s coordinator explained. So, the urge to vomit was explained, what wasn’t explained was how to deal with it. In three minutes time though we delved into the work of the centre and I tried to switch off my taste buds and my sense of smell so as not to be distracted.
"This centre was established in 1998," says the representative of the mayor's office who came to meet our delegation. “Here one can spend the night, sit quietly during the day, make injections. Doctors and social workers are nearby, we introduced OST in 2003. The patients can receive medicine every day from morning to evening. All services are paid for by the government.
You‘ll see up to 150 customers within one hour who come and go; The daily coverage is about a thousand customers. We know there are 200 women who need help but they hide. There are women among the outreach workers to visit female clients. We invite them to the center, but they don‘t come. Therefore, we‘ve opened a separate center for women and now 50 to 60 women come to us there.
Things are made difficult by the fact that people speak different languages, we have a multy-national clientele. These people came to Delhi from different states, they tried to open their own businesses to make a better living. But it didn‘t work out.
There are another 200 people who only come for OST. Most of them come and then leave immediately.
How do our clients live? They get up in the morning, collect empty bottles, buy a dose and come here to use. It’s mainly homeless and jobless people. Once every three months they undergo a medical examination for STIs and abscesses.
80% of drop-in centre employees are former drug users, some still use. Outreach workers earn 7500 Rupees ($120) + travel expenses. The cost of commute to work and back is $30 a month. If a client is taken to hospital, they take a rickshaw. The average salary level is $240 which is the level of a project manager. Interestingly, if there is a pay rise, as happened over the past few years, it means an across-the-board pay rise for all employees of all drop-in-centers throughout India. There are 200 such centers in Delhi alone.
Talking to people, taking notes and photographs, I enter the OST room. And there‘s a shock. There are fingerprints instead of signatures in the patient registration journal. "There are many clients who are uneducated, it's their signature." A fingerprint is enough to get buprenorphine in the state addiction treatment program!
And here I just froze, I take pictures and I can’t believe my eyes: government funding, proper drug distribution records, and fingerprints. It's obvious for them: a person needs help, so it has to be made available.
Yes, the room isn’t very pretty. But I feel mush cosier and warmer here than in the snow-white walls of our drug-treatment centres.
I know you might think "What, they coundn‘t take the rubbish out for 20 years? Or hang a washbasin?“ At first I also thought like that too. Then I saw one guy taking a brush and going to decorate the temple for the gods. A stone's throw from us is a temple which is perfectly clean and fragrant with incense.
Finishing this blog, I realised: they will take the rubbish out first, long before state-run harm reduction programs in our “clean” countries start treating people with such calmness, understanding and respect.
Chapter five: the nature of the HIV epidemic and how to obtain a state procurement order in India
When we talk about India, we talk about a continent with different languages, social and cultural norms where the HIV epidemic and its nature change every year. Each individual state is like a separate country. The economic situation forces men to migrate from industrially-underdeveloped regions to Delhi, Mumbai and other cities. Migration affects 300 - 400 million people. The HIV rate is high among sex workers in Mumbai, often a man returns home and transmits it to his wife.
HIV is now concentrated in key populations and bridge populations such as migrants and long-distance truck drivers.
All HIV programs in India are financed as follows: 8% by international means and 92% by the state, that’s according to the National AIDS Control Organization (NACO). Programs work with their own target groups. That means there are no testing programs for schoolchildren, students and elderly women. They work with those who are at risk today. The cost of the package of services, including eight interventions recommended by the World Health Organization (WHO), for 400 people who use drugs is $39,000 per year. This includes rent, syringes and personnel, all but drugs - naloxone and buprenorphine are bought by the state and then transferred to NGOs. The diagnostics and treatment of hepatitis C is just beginning in India. Funding and all HIV programs are implemented nationally through one organization - NACO. They also announce open calls for state procurement of social services and shape the HIV-related policies in the country. To date, NACO covers 170,000 injecting drug users. The total number of people who use drugs in India has yet to be accurately estimated, because the community believes that the current figures are lower than the real number of people who need help. It took India eight years to start implementing substitution therapy at the expense of the state budget. First OST sites funded by the European Union appeared in 1999. In 2010, NACO began financing the program.
State procurement and implementation through NGOs.
Being responsible for the activities aimed at reducing the spread of HIV, NACO draws up a national work plan - what services are needed and in what amount - and then posts the information on its website. The announcement is available for 40 to 60 days, during which time tenders open in every state.
NGOs meeting the criteria specified in advance submit letters of interest. After that a commission evaluates the organisations and awards points (for availability of skilled staff, premises, experience in implementing grants, etc.). The NGO with the most points get the job and then has five years to implement the project. There is one (!) person in each state who controls the implementation of NACO programs.
You can invite people to training sessions and seminars hundreds of times, but still not become truly and deeply familiar with them. It may be possible though if the training is like a rope ladder. However, such an option is rare in our programs. It’s a trip together that helps reveal each other’s character faster and more effectively.
Natasha Podogova is the organizer and head coach of our team. Everything is under control, the organization is at the highest level. At the same time she’s cheerful, friendly, stylish and wise. The Queen of working with governments.
Pulod Djamolov is calm and wise. When Pulod asks questions, I often want to ask: how did you see this side? Why didn’t I notice? I ask him and I listen to him. This is the value of our friendship.
I had a heart-to-heart with the representatives of Tajikistan’s public services only on the day of the departure. That’s how it should be. We only just met, I needed time and so did they.
And, my long-time acquaintance and new friend - Charen Sharma - bold and calm, confident, dignified. He asks questions beautifully and answers openly and wisely. Charen was with us almost around the clock. Thanks to him, India bared its programs to us, without embarrassment and fear of being misunderstood.
I’m thinking “How can they manage harm reduction programs with so many people when there’s so many people in the country, where the language, people's habits, religion and food change every 100 kilometres. When I was in Ukraine I often heard that Georgia was able to reform its drug policy because the population is smaller. And here in India, there’s lots and lots of people. And they managed to set up harm reduction programs so that they are worth admiring and learning from.
Thank you for this experience.
From May 27 to June 2, 2017, delegation of officials and representatives of NGO's from Tajikistan visited India with a study tour. The aim of the tour is to learn the experience of the implementation of harm reduction programs within the framework of government programs and policies, as well as public financing of harm reduction programs and financial mechanisms non-profit organizations for the implementation of non-medical services within the framework of such programs. HIV/AIDS Alliance in India, as a receiving partу provided Eurasian Harm Reduction Network with a comprehensive support. This study tour is organized under the regional program “Harm Reduction Works—Fund It!” implemented with support from the Global Fund to Fight AIDS, Tuberculosis and Malaria.