Establishing new OST centers:

Injecting drug use (IDU) is recognized as one of the main modes of transmission of HIV. J&K State AIDS Control Society is planning to establish more OST Centers in the State so as to minimize the risk of getting HIV through the medium of Injecting drug use. Full support from the State Health department is sought in establishing 4 OST centers across the State.

OST Centers - 2
OST Centre Kashmir:
1. SMHS Hospital, Srinagar
Department of Psychiatry, GMC, Srinagar.

OST Centre Jammu:
2. Psychiatric Diseases Hospital, Resham Garh
Department of Psychiatry GMC, Jammu

OST Staff at each Centre:
1 Medical Officer, 1Staff Nurse,
1Data Entry Operator, 1 Counsellor.

OPIOID SUBSTITUTION THERAPY FOR INJECTING DRUG USERS
Injecting Drug Use in India.
Injecting drug use (IDU) is recognized as one of the main modes of transmission of HIV in India. India has an estimated 1.77 lakhs Injecting Drug Users (IDUs) of which about a third have been identified in the North-eastern region of the country (NACO, 2009). As per the latest round of HIV sentinel surveillance (HSS, 2010-11), the HIV prevalence among IDUs is 7.17% which one of the highest of any sub-group of the population. The already high HIV prevalence coupled with unsafe injecting practices and the high efficiency of transmission through needle sharing engenders the IDU community with risk of rapid transmission of infection among the drug using networks. However, as most IDUs are young and sexually active, injecting driven HIV epidemics do not remain limited to the drug using community but also spread to the low-risk population through the sexual route. The documentation of injecting drug use among women and the frequent interface of drug use with sex work further increases the risk of spread of an injecting-related HIV epidemic among general population through the sexual networks.
Opioid substances like heroin, buprenorphine, etc., either alone or in combination with sedative hypnotic medications, are the most commonly injected drugs in India. Though, Injecting opioids has is common to all regions of the country, nature of opioid use, patterns of injecting behaviours and associated injecting practices varies significantly across states and regions.
National Response: The Harm Reduction Strategy
Injecting Drug Users (IDUs) have been identified as one of the High Risk Groups (HRGs) in the National AIDS Control Programme (NACP) of the Ministry of Health, Government of India. The National AIDS Control Organization (NACO), through the various State AIDS Control Societies (SACS), implements the Targeted Interventions Programme for the prevention and control of HIV infection among various HRGs including the IDUs and their sex partners.

The Government of India adopted Harm Reduction as the strategy for controlling HIV epidemic among IDUs in the National AIDS Prevention and Control Policy, 2002. Under this strategy, a package of evidence-based preventive interventions has been designed for IDUs and their spouses. These interventions are delivered to the identified communities through the Targeted Intervention projects (TIs). The TIs, implemented by the Non-governmental agencies contracted by SACS, provide preventive services to the beneficiaries in the community settings using a peer-led approach. The key services offered to IDUs and their spouses as part of the Harm Reduction package include: Needle and Syringe Programmes (NSP), condom promotion and distribution, diagnosis and treatment of Sexually Transmitted Infections (STIs), behaviour change communication (BCC), targeted education and information (on HIV, STI, safe sex, safe injecting, drug treatment, etc.), management of abscesses and referrals for HIV counselling and testing (ICTC), anti-Retroviral treatment (ART), diagnosis and treatment for TB (DOTS), treatment of substance abuse and rehabilitation. The TIs, with the help of members of the targeted community, deliver these services to the IDUs using both a drop-in-centre (DIC) as well as outreach-based approaches.

Harm reduction services have been rapidly expanded and extensively strengthened across the country under the third phase of the National AIDS Control Programme (NACP III). During NACP III (2007 to 2012), a threefold increase in the number of IDU TIs resulted in achievement of 81% coverage of the estimated IDU population by March 2012. This was associated with an impressive increase in the distribution of needles and syringes per client and proportion of clients receiving HIV counselling and testing services from ICTCs.
Opioid Substitution Therapy for Injecting Drug Users

In 2008, Opioid Substitution Therapy (OST) was included as an additional component in the Harm Reduction package for IDUs. OST is an evidence-based treatment for dependence on opioids and is also well established intervention for reducing drug related harms among IDUs particularly prevention of transmission of HIV and other blood borne diseases.
OST, as envisaged under NACP III, is a medical treatment for opioid dependent IDUs, delivered under clinic settings along with psychosocial interventions. OST involves long-term maintenance of people who injecting opioid drugs on medications that effectively relieve craving and withdrawals associated with abstinence from injecting drugs. Thus, the treatment effectively eliminates the need for continued administration of injecting drugs and enables IDUs to stop injecting. WHO, UNODC & UNAIDS, in a joint position paper on harm reduction services, have listed OST as one of the essential components of the comprehensive packages of services to be provided for IDUs.
The benefits of OST are not limited to just HIV prevention and extend to reduction of other harms associated with drug use, especially when combined with psychosocial interventions. OST stabilizes clients physically and psychologically which improves their ability to think coherently and makes them amenable to other lifestyle modifications necessary to achieve complete recovery and reintegration into the society. Clients taking OST regularly are able to be gainfully employed and take care of their families.Scientific studies from various countries have established role of OST in reducing crime rates among drug users, improving quality of life and reducing socio-economic consequences of drug use. The stabilization of clients’ lifestyle has also been demonstrated to improve adherence of HIV positive IDUs to ART thus benefitting both the individual and the society.
Buprenorphine and methadone are the two major medications used in substitution treatment programmes across the globe and both are currently available in India for use in maintenance treatment of opioid dependence. Under NACP III, buprenorphine based OST centres were to be established in both NGO and government healthcare settings while methadone based OST programme was to be implemented only through licensed government healthcare facilities as per the provisions of the Narcotic Drugs and Psychotropic Substances (NDPS) Act of 1985. At present, sublingual buprenorphine is being used in the OST programme supported by NACO. A pilot of Methadone maintenance treatment (MMT) has recently been initiated at 5 sites with support from UNODC and NDDTC, AIIMS to generate experience and evidence for subsequent scale-up of MMT under the national HIV programme. NACO has been supporting OST implementation in NGO settings since 2008. In this model, OST services are offered by NGOs already implementing an IDU TI project and offering the package of harm reduction services mentioned above. Hence, in this model, most of the harm reduction services are available from the same facility and OST is seen as an additional service provided to some of the IDUs. The services are offered by the existing staff of the IDU TI including a part-time doctor who is trained on OST. For dispensing of medications under supervision, an additional nurse is provided to the TI. The medications are dispensed to the clients on a daily basis directly under supervision by a qualified and trained nurse (DOTS).

In 2010, NACO piloted a collaborated model of OST delivery based on a tie-up between the Government hospitals and the NGOs implementing Targeted Interventions for IDUs. In this model, the OST centre is located in a government health care setting (medical college hospital, district hospital, CHC, etc.) and is tasked with clinical assessment, diagnosis, prescription of substitution treatment and dispensing of the medications. Each of these OST centres is linked with nearby IDU TI(s) which facilitate the service uptake by motivatingIDU clients in the project area and refer them to the centre for treatment. In addition, the linked IDU TIs also follow-up with clients who drop-out from treatment and conduct regular advocacy with local stakeholders to generate support for the OST programme.

NACO plans to expand the coverage of OST programme to at least 20% of the estimated IDU population in a planned fashion. Based on the established model of NGO-run OST centres and the encouraging response received by the pilot of the collaborative model, a plan for nation-wideexpansion of OST has been drawn and is currently being implemented across 30 states / UTs of the country. As part of the plan, districts with significant estimated population of IDUs have been identified for OST scale-up. At present NACO supports 85 OST centres across 24 states/UTs of the country with a total OST coverage of more than 8000 IDUs.

Name of the OST Centres working under JKSACS.

S.No	Name of the centre	District
01	General Hospital Community Centre, Institute of Mental Health & Neutro-Science, S.M.H.S, Kashmir	Srinagar
02	Psychiatric Disease Hospital, Govt. Medical Collage, Jammu.)	Jammu

The staffs of the OST centre Srinagar is trained on OST implementation prior to roll-out of services. NACO has developed a standard training module for all OST trainings in partnership with All India Institute of Medical Sciences. The 5-day training module includes training on clinical, programmatic, operational and procedural aspects of OST service delivery and training of OST staff on this module has been provided to all staff.