Transcript Anil Jhugroo

Role of Naltrexone implants
in managing
the spread of HIV
caused by
injecting buprenorphine
in Mauritius
Dr Anil Jhugroo
Consultant Psychiatrist
Apollo Bramwell Hospital, Mauritius
1.2 million inhabitants
Indian/African/Chinese/European/Mixed race
Nearly one million Tourists/year
Textile and Sugar industry
Stable democracy
About 2 % of population are believed to be injecting drug users, World Drug report, 2010
About 2 % of the 14-49 year-old group is believed to be HIV positive.
23 % of prison inmates have tested HIV positive over the last year
OPIATE USE PER CAPITA, 2010
WORLD OPIATE USE PER CAPITA
OTHER COUNTRIES USE/CAPITA
1. Iran
2.8%
New Zealand
2. Costa Rica
2.7%
England & Wales
0.8%
3. Afghanistan
2.7%
Kenya
0.7%
4. Mauritius
2.0%
USA
0.6%
5. Russian Federation
1.6%
France
0.5%
6. Scotland
1.5%
Egypt
0.4%
7. Estonia
1.5%
Australia
0.4%
8. Malaysia
1.3%
South Africa
0.4%
9. Ukraine
1.2%
Greece
0.3%
10. Puerto Rico
1.2%
Jamaica
0.1%
11. Macao
1.1%
Singapore
0.01%
Source :United Nations Office on Drugs and Crime, 2010
1.1%
Report of the International
Narcotics Control Board for 2009
 “There is evidence of an increase in the smuggling of
heroin to the islands of the Indian Ocean, particularly
Mauritius.
 Opiates from India and Pakistan are smuggled into
Mozambique and then South Africa and from South
Africa into Europe, as well as into East African
countries, notably Mauritius and Seychelles.
 Mauritius now has one of the highest levels of opiate
abuse in Africa, a spillover effect of the heroin
trafficking in that country.”

From heroin to buprenorphine…
 Heroin

80’s & 90’s






purity getting lower (higher purity in the Seychelles)
has lesser desired effect
difficulty with chasing, usually injected.
is expensive
shorter lasting
More difficult to smuggle
 Buprenorphine





Drug dealers: easier in importing and concealing; more lucrative.
IVDU: cheaper & lasts longer (cheaper than marijuana)
Last decade, demand and supply in favour of buprenorphine
Currently accounts for about 80% of drug used by IVDU in Mauritius
IVDU buy one eighth of this 8-mg pill at about Rs 300 (7.50 euros)
• Buprenorphine seizures: about 80 000 tablets in 2007 and about 40 000 tablets in 2008.
• Price has fallen from Rs 3,000 (75 euros) a tablet to Rs 1,200 (30 euros) a tablet over past 2 yrs.
• Changing pattern of drug selling:
• extensive use of mobile phone;
• cleaner to handle
• coming from other countries
POLICE SEIZURES
Heroin
2007
5,7 kilos
2008
11,5 kilos
2009
9,5 kilos
Buprenorphine
2007
79 617 tablets
2008
38 770 tablets
IVDU & HIV/AIDS
 “Mauritius also has a high prevalence of injecting drug
use and a concentrated HIV epidemic among these
users.”
World drug report, 2010
 Number of injecting drug users in Mauritius estimated
at between 10,000 and 18,000 people.
 “Prevalence of HIV in Mauritius estimated at 1.8%
representing approximately 12,000 people”
UNAIDS in 2007
Harm reduction programmes

In recent years Mauritius has recognised the seriousness of its injecting drug
use problem and injection driven HIV, scaling up harm reduction programmes
in the form of

Needle & Syringe exchange programme
 First African country
 Started Nov 2006
 46 sites across the island
 About 5,400 registered users out of 10,000-18,000 IVDU

Methadone substitution programme
 Introduced in 2006
 About 3,000 on treatment

Information campaign
 TV and radio
 Posters
• Between 2007 and 2010,
• 24 opiate dependent patients travelled to Perth from Mauritius to have the
O’Neil double Naltrexone implant
• Went in batches of 4-6, accompanied by care workers
• 4 of them later had repeat Naltrexone implants
• Upon return to Mauritius, reviewed regularly by their care workers for general
follow up and to assess their level of opiate abstinence.
• Random urine drug screening tests were also performed
Duration of abstinence
Number of opiateabstinent patients
Total number of
patients in study
6 months
24
24
1 year
20
24
1½ years
11
24
2 years
10
24
2½ years
10
24
3 years
7
18
4 years
5
13
Never relapsed
10
24
Currently abstinent
13
24
Percentage of opiate free patients
after 1st implant at follow up
6 months
100 %
1 year
83 %
1½ years
46 %
2 years
42 %
2½ years
42 %
3 years
39 %
4 years
38 %
Abstinence over time after
first implant
Benefit of 2nd implant
 After 1st implant, 42 % remained fully abstinent (10 out of 24)
 Four patients had repeat implants
 In the period between 6 to 18 months after the 1st implant
 Three of them following relapses
 One was still abstinent but wanted prophylactic treatment
 More wanted to have repeat implant but had visa restrictions
 After 2nd implant,
 All 4 remained abstinent from opiates to date.
 54 % are currently abstinent (13 out of 24)
 Of those 11 patients who are currently in relapse,
 7 are on a methadone programme (29%)
 4 have gone back to injecting heroin or buprenorphine (17%)
After 2nd Naltrexone implant
Among those who relapsed
 Reasons for relapses
 An identifiable precipitating factor
 Relationship difficulties
 Work related problems
 Reasons for not repeating naltrexone implants
 Visa restrictions
• as not locally available
 Financial reasons
• Costs of travel and accomodation abroad
 If available locally and at appropriate pricing,
 would be considered by all those who have relapsed
•To minimise risk of relapses,
• Need to perform Naltrexone implant operation in Mauritius
•Less expensive
•Local support
•No visa restrictions
• Infrastructure facility and trained staff available
• Current discussions with Government officials to set up unit.