China shares harm reduction innovations with East African counterparts
29 August 2018
Methadone maintenance treatment for people who use drugs is an important intervention for HIV prevention, as it allows clients to manage their addiction without the need to inject heroin. Sharing of needles, syringes and injecting equipment due to lack of access to harm reduction services is a major driver of HIV in some communities.
In most countries, methadone, which is taken orally, is administered to clients in a clinic setting, under the supervision of clinical personnel, because it is a controlled substance. But the daily trip to a methadone clinic can be a barrier for many people trying to kick a heroin addiction and protect themselves from HIV infection, and it can therefore limit client’s adherence as well as the overall impact of methadone programmes.
Injecting drug use is on the rise in East Africa, and health systems are struggling to make methadone accessible in ways that meet clients’ needs, but which are also sensitive to legal and cultural realities in the region.
Challenges of methadone treatment
In 2015 Ms. Helgar Musyoki, the key populations programme manager for Kenya’s National AIDS and STI Control Programme, was getting frustrated by some of the limitations faced by methadone clients who, for various reasons, were not staying in one place. “We were having challenges with some clients. Some had gone back to work, or back to college. Others were getting married and sometimes they have to go to the village, where they don’t have methadone and they get withdrawals. So they have to carry a satchel of heroin to just fix their craving until they come back for methadone. Then they are mixing methadone and heroin.”
Ms. Musyoki found herself wishing there was a way for clients, many of whom were taking positive steps in their lives, to be able to take some methadone home with them, but knew it wouldn’t be a simple fix. “My biggest worry is about diversion. I don’t want people to start selling it to their friends because they have it out there.”
So when a colleague from the International HIV/AIDS Alliance described to her a new take-home methadone programme in China, which used an ‘intelligent box’ to enable patients to take away several doses at a time, Ms. Musyoki had just one thought: “How do I get it?”
Take-home methadone in China
The boxes Ms. Musyoki heard about had been developed and piloted in Yunnan province, in southwest China, by AIDS Care China (an Alliance Linking Organization) and the Yunnan Institute for Drug Abuse (YIDA), a government agency. In 2013 some clinics in Yunnan began giving some methadone clients secure, internet-connected boxes with up to four days’ supply of methadone to take home. The high-tech take-home boxes, which are locally referred to as “intelligent medicine chests” are constantly monitored by clinic staff and were initially tracked by GPS.* They allow patients to reduce their number of trips to the clinic, giving them more time to attend to other aspects of their lives. Because of this, take-home methadone can improve clients’ adherence and outcomes. Take-home methadone has been a long-sought approach for many clients and providers, in China, Africa, and elsewhere.
More than two years after hearing about the intelligent medicine chests, Ms. Musyoki and colleagues from Kenya, Uganda, and Tanzania travelled to China to see the technology first hand and learn from Chinese public health officials about how they developed and implement the take-home methadone programme. As part of an official delegation jointly spearheaded by the UN Office on Drugs and Crime (UNODC) East Africa Regional Office and Kenya-based KANCO, and co-sponsored by UNAIDS and the International HIV/AIDS Alliance, twenty-two representatives of East African governments, UN agencies, and non-governmental organizations travelled to Beijing, Kunming, and Yuxi in early July 2018 where they were warmly received by national, provincial, and local public health leaders.
Yunnan province is considered ground zero for China’s HIV epidemic; the first cases of HIV in the country were confirmed there in 1989. The province borders Myanmar, Vietnam, and Laos, and has direct access to Thailand and Cambodia via the Mekong River. The area where these countries all meet is sometimes referred to as the ‘Golden Triangle,’ because of its history as a major opium production centre. Yunnan’s direct proximity to the Golden Triangle makes it a primary entry point into China for heroin and people who use heroin from neighbouring countries.
'Intelligent medicine chest'
For this reason, Yunnan province has always been a centre of HIV treatment and prevention efforts in China. The province’s methadone maintenance therapy (MMT) programmes, which began in Kunming in 2004, have been lauded in China and abroad as a model for HIV control among people who use drugs. And perhaps the most notable local innovation is the take-home MMT programme, which relies on the “intelligent medicine chests” (IMCs) and their associated software.
The IMC is a hard-cased silver box which contains four doses of methadone; one dose per day, meaning four days’ supply for a patient. The doses are delivered orally by ingesting a pink liquid, as all methadone in China is. Each dose is enclosed in a locked section of the box. On each of the four days clients are able to open one dose. Doses are accessed either by receiving a key code on their mobile phone, or by applying their fingerprint to a sensor on the box (there are two models in use).
Clients can access a given dose as many times as they want between 6am and 10pm on the designated day, at which point it self-locks again. Once the patient has used all four days’ doses, they return to the clinic to get a refill. All the while, client compliance is monitored by software used by the methadone clinic staff. The IMCs, which are the centrepiece of the take-home MMT programme, cost roughly 800 Yuan (about US$120) each.
Community-based drug treatment
The take-home boxes were not the only innovative approaches to improving methadone access in Yunnan, however. The delegates also had a chance to visit a community-based drop-in centre for people who use drugs in Kunming and a satellite methadone clinic in a farming village outside of Yuxi.
The drop-in centre was one of the most impactful stops on the tour. The four-story building provided places for clients to rest, eat, socialise, play games, and even get a haircut or garden on the roof. The centre also had a room for dispensing methadone. The delegates met some of the clients who were there at the time, some of whom asked for photos with the visitors. It was a simple yet thoughtful facility that felt more like a home than a clinic, by design.
The satellite methadone clinic was also part of the province’s efforts to expand the reach of methadone programmes in more rural areas. In addition to these small clinics, officials from YIDA described programmes where a van will drive from village to village each day to distribute methadone to clients, eliminating the need for them to travel distances to clinics themselves.
The East African delegates have had much to contemplate following their exploration of the Chinese response to HIV among people who use drugs. They returned home to a context that has less infrastructure, less security, and is perhaps not quite ready for all of the approaches they encountered in China.
Dr. Cassian Nyandini, who heads up the methadone programme for Tanzania’s Drug Control and Enforcement Agency, said that he actually launched a take-home methadone programme just three weeks before coming to China, “but our model is a little bit different.” He reflected: “There are certain things we can adapt from here. But it’s going to be different between China and Tanzania.”
*) GPS trackers were used in the early version of the boxes, when the first pilot of take-home methadone started in 2013. Because methadone is considered a controlled substance in China, carrying it outside of the clinic is against the regulations. GPS trackers were used to reassure the police that there was a level of control over the take-home methadone, and was a necessary measure to get permission to start the pilot. The GPS tracking functions were removed from the boxes once the police and public health authorities were satisfied that methadone taken out of the clinic was safe, and are no longer used.
This post was adapted from an article by Charlie Baran for the Global Fund Observer, which can be found here: http://aidspan.org/gfo_article/global-fund-multi-country-program-east-africa-spearheads-trip-china-learn-about-harm