社区药物维持治疗工作进展报告 Scaling-up the methadone maintenance treatment program in China

1. 社区药物维持治疗工作进展报告Scaling-up the methadone maintenance treatment program in China UNETG Meeting , 2009.2.25 阿片类物质成瘾者社区药物维持治疗国家级工作组/秘书处 National Working Group on Community–based Methadone Maintenance Treatment for Opium Dependents

2. 内容提要Outlines • 我国的艾滋病流行形势 Update of the HIV/AIDS epidemic in China • 社区药物维持治疗工作的进展 The progress of China’s MMT program • 社区药物维持治疗的效果评估 Evaluation of the MMT program • 社区药物维持治疗的挑战和应对 Lessons learned and challenges

3. 中国艾滋病流行形势 Update on the HIV/AIDS epidemic in China

4. 艾滋病流行状况HIV/AIDS epidemic 2007年HIV/AIDS 报告病例 Reported HIV/AIDS cases by end of 2007: • HIV/AIDS: 230,643 （276,335） • AIDS : 66,392 (82,322) • AIDS death : 23,963 (38,150) 2007年HIV/AIDS 估计病例数 HIV/AIDS Estimates by end of 2007 : • People with HIV/AIDS: 700,000 (550,000-850,000) • AIDS cases: 85,000 (80,000-90,000). • HIV infection rate: 0.05 % (0.04-0.07%) Resource: A Joint Assessment of HIV/AIDS Prevention and Care in China(2007) (State Council AIDS Working Committee Office, UN Theme Group on AIDS in China )

5. 报告HIV/AIDS传播途径构成(2007)Transmission mode (2007) Increased sex transmission New reported in 2007 (Jan-Aug,2007) Cumulative (Until Aug2007) Resource: A Joint Assessment of HIV/AIDS Prevention and Care in China(2007) (State Council AIDS Working Committee Office, UN Theme Group on AIDS in China )

6. 报告HIV/AIDS传播途径构成 (2008) Transmission mode (2008) 2008年新报告 累计报告 报告HIV/AIDS传播途径构成

7. Drug Use in 2007 • 动态管控系统吸毒人数 Current total drug users :957,000 • 海洛因成瘾者 Heroin users: 746,460 • 静脉吸毒人员 Injecting drug use: 72.5% • 共用针具 Needle Sharing : 40% Resource: Annual Report on Drug Control in China, 2008. (China National Narcotics Control Committee) A Joint Assessment of HIV/AIDS Prevention and Care in China(2007) (State Council AIDS Working Committee Office, UN Theme Group on AIDS in China )

8. 毒品使用类型（2008年）Types of Drugs Used in China,2008 Resource: Annual Report on Drug Control in China, 2008. (China National Narcotics Control Committee)

9. 社区药物维持治疗工作的进展 The Progress of China’s MMT program

10. 美沙酮维持治疗工作：从试点到全面推广Evolution of China’s MMT Program: Moving from pilot stage to national scale-up • 2001年之前，政策倡导与开发 Before 2001: Policy advocation and development • 2001-2003年，组织结构的建立，实施方案的制定 2001-2003：Institutional organization and beging protocol formulation • 2003年11月-2006年6月: 试点阶段 Dec 2003- Jun 2006: MMT pilot phase • 自2006年7月: 从试点到全面推广 Since 2006: From pilot program to national scale-up

11. 艾滋病防治条例中华人民共和国国务院令 第 457 号2006年3月1日起施行 第二十七条　 县级以上人民政府应当建立艾滋病防治工作与禁毒工作的协调机制，组织有关部门落实针对吸毒人群的艾滋病防治措施。省、自治区、直辖市人民政府卫生、公安和药品监督管理部门应当互相配合，根据本行政区域艾滋病流行和吸毒者的情况，积极稳妥地开展对吸毒成瘾者的药物维持治疗工作，并有计划地实施其他干预措施。

12. Law Enforcement HIV/AIDS Regulation (In effective since March 1, 2006) Article 27. The people’s governments at the county level or above shall coordinate the relevant government sectors in order to implement effective measures for controlling the epidemic of AIDS. The departments of Health, Public Security and Food and Drug Administration of the people’s governments in Provinces, Autonomous Regions, and Municipalities shall jointly, based on their local situation of drug use and HIV/AIDS epidemic, implement community-based drug-maintenance treatment as well as other effective intervention program for drug users.

13. 中国遏制与防治艾滋病行动计划(2006-2010年) （二）具体目标和工作指标。 到2007年底实现以下目标 • 有效干预措施覆盖当地70%以上的主要高危人群和流动人口。登记在册吸毒者500人以上的县（市)，建立药物维持治疗门诊，为40%以上符合条件的吸食阿片类毒品（主要指海洛因）成瘾者提供药物维持治疗。 到2010年底实现以下目标 • 有效干预措施覆盖当地90%以上的主要高危人群和流动人口。登记在册吸毒者500人以上的县（市)，建立药物维持治疗门诊，为70%以上符合条件的吸食阿片类毒品（主要指海洛因）成瘾者提供药物维持治疗。

14. China’s Action Plan for Controlling HIV/AIDS(2006-2010) Specific Tasks (6) County (city) > 500 registered drug users, By 2007: (in urban) MMT cover > 40% (in rural) NEP cover > 30% By 2010: (in urban) MMT cover > 70% (in rural) NEP cover > 50%

15. 组织管理结构 卫生部 公安部 国家药监局 国 家 工 作 组 秘 书 处 中国疾病预防控制中心性艾中心 卫生厅 公安厅 省级药监局 省级疾病预防控制中心 省 级 工 作 组 当地工作组 美沙酮口服液配制单位 美沙酮门诊 美沙酮门诊 美沙酮门诊 美沙酮门诊

16. Organizational Structure Ministry of Health Ministry of Public Security State FDA China CDC State MMT Working Group Secretariat Department of Health Department of Public Security Provincial FDA Provincial CDC Provincial MMT Working Group Methadone Formulation Unit MMT Clinics MMT Clinics MMT Clinics MMT Clinics

18. Evolution of Implementation Protocol 2003 • Inclusion of the MMT program: Clients need to have several failed attempts to quit using heroin; at least two terms in a detoxification centre; being a registered local resident of the area in which the clinic dislocated; etc. • The number of allowable missing treatment days: if an MMT client missed any cumulative 15 days in 90 days they were discharged from the programm. • Services provided: relatively limited to administering of methadone • July 2006 • Inclusion of the MMT program: Clients no longer need a history of detoxification for entry and no longer required to be registered as local residents and a transfer system has been set up to meet the needs of those who are relocating either permanently or temporarily. • The number of allowable missing treatment days:must miss seven consecutive days (a rarer event, to be disqualified). • Services provided :counseling , HCV testing, ARV referral treatment, condom promotion, peer education, psychosocial supports, etc.

19. 美沙酮维持持治疗门诊建设The establishment of MMT clinics

20. 美沙酮维持持治疗门诊建设The establishment of MMT clinics 2008 吉林 新疆 2 27 内蒙 北京 9 3 1 天津 山西 宁夏 3 青海 3 甘肃 2 河南 21 陕西 1 江苏 18 13 安徽 上海 湖北 四川 重庆 8 9 37 36 26 浙江 江西 27 湖南 12 48 贵州 福建 54 9 云南 23个省（自治区、直辖市）600个门诊 广东 67 广西 56 50 海南 23

21. 21美沙酮流动车和延伸服药点21 Mobile MMT Vans （云南-8辆、四川/贵州/湖南/广东/新疆-2辆、湖北/重庆/浙江-1辆） （8/Yunnan; 2 each/Sichuan/Guizhou/Hunan/Guangdong/Xinjiang; and 1 each/Hubei/Chongqing/Zejiang)

22. 美沙酮维持治疗门诊建设The growing number of MMT clinics

23. 维持治疗累计和在治人数Cumulative patients treated versus currently receiving treatment （2004-2008）

24. 2008年社区药物维持治疗工作进展概况 Overall progress in 2008

25. The MMT Program implementation at provincial –level in 2008 08年12月全国社区药物维持治疗工作进展情况

26. 培训和技术支持Training System and Technical Support • 门诊专业人员培训 Training of MMT treatment and management personnel • 门诊后期综合干预培训 Training of comprehensive intervention and care personnel • 门诊开诊现场技术指导 On-site support for clinic initiation

27. 数字化管理和网络化建设Establishment of MMT database system • 临床管理软件： • Clinical MMT management software • 实时和定时统计系统 Real-time and fixed-time reporting system • 定期随访和跟踪系统 Follow-up and monitoring system • 实验室检测管理系统 Lab-based management system • Transferring/ referral system 　异地服药和转诊系统 智能IC卡管理系统 Intelligent card-system (IC card)

28. 咨询 Council ling 小组活动 Group Activity 激励机制 Incentive 同伴教育 PeerEducation

29. 社区药物维持治疗效果评估 Evaluation of the MMT Program

30. 社区美沙酮维持治疗三年效果评估结果（1） Evaluation of MMT Program (1)

31. 500个门诊对禁毒防艾工作的影响The impact of 500 MMT clinics on drug control and HIV/AIDS intervention 测量依据　（Estimation） 　　截至2008年12月30 (By 30 Dec 2008), 累计治疗 (Those cumulative patients): 178684，目前在治人数( currently receiving treatment) 93773，平均每门诊治疗人数（average of currently receiving treatment /clinic）156，年保持率（Annual retention rate）69.5％。 参数：（Parameters）： 　　社区吸毒者艾滋病新发感染率 (The new infection among IDUs in community)5%、人均日使用海洛因 (The average use of heroin/day) 0.6g/d、海洛因价格（The price of Heroin） 370 RMB/g，MMT门诊(MMT clinics) 500，平均每门诊治疗人数(The average of those on-treatment/clinics )150 ，治疗(Totally treated )75000。

32. 500个门诊对禁毒防艾工作的影响The impact of 500 MMT clinics on drug control and HIV/AIDS prevention 保守估计 Conservative Estimation • 一年减少新发艾滋病感染3377人(未包括二代性传播) Reduced new infections by 3377 annually (Exclude secondary transmission ) • 一年可减少海洛因消耗16,425公斤，约16.5吨 Reduced heroin consumption by 16.425 kg, approx 16.5 ton annually. • 一年可减少毒资交易60.77亿元 Reduced drug trade 607.7 Billion RMB annually.

33. 地震中的门诊和服药人员MMT clinics and clients during the aftershocks 捐款Donation 奉献 Dedication 救援 Succor 依从性　Adherence

34. 针具交换项目The progress of the NEP in 2008 • 2008年共有897个针具交换点，分布在26省526个县,为月均36,000IDUs提供清洁针具 In 2008，897 NEP operate in 526 counties (district) in 26 provinces, serving average 36,000injecting drug users monthly. • 发放针具（Distributed Needles）：1,173,764 回收针具（Collected needles）: 1,060,497

35. 减低危害策略 Harm Reduction Strategy MMT: • 减少毒品滥用和毒品相关的犯罪 Reduce drug use, drug related crime and • 减少艾滋病新发感染率 Reduce transmission of HIV/AIDS • 改善家庭和社会功能 Improve quality of life of drug users – developing a harmonious society • 萎缩毒品交易市场 Shrink heroin markets • 减少新的毒品使用者 Reduce the number of new drug users • 充分利用MMT 项目 Services should be utilized as much as possible

36. 减低危害策略Harm Reduction Strategy NEPs: 仅降低与静脉注射相关的艾滋病等血源性传播，但 对减少毒品滥用和毒品相关的社会犯罪无明显作用 Only addresses injecting related AIDS epidemic, not targeted at reducing drug use or drug-related crime • 城市和IDUs相对集中的地方推广MMT Urban areas and the places where IDUs concentrated use MMT • 边远农村地区和吸毒人员相对分散的地方推广NEPs Remote and rural areas and the places where IDUs not concentrated use NEPs

37. 　社区药物维持治疗 　面临的挑战和应对策略 Challenges and Response

38. 目前存在的问题和挑战Challenges Ahead • 部分地区领导认识和重视不足 Lack of adequate political commitment at local level. • 多部门合作尚未形成有效的合力 Need to further enhance multi-sectoral cooperation at the local level.

39. 目前存在的问题和挑战Challenges Ahead (con’t) • 维持治疗覆盖面有待进一步扩大和合理化 Need to further rationally expand coverage of the MMT program • 部分门诊在治人数和保持率偏低，脱失率较高 Need to increase the retention rate and reduce patient drop-out • 美沙酮门诊应成为禁吸防艾和社会支持的综合服务平台 Need to make MMT clinics serve as platform for comprehensive intervention and social support.

40. 目前存在的问题和挑战Challenges Ahead (con’t) • 门诊工作人员能力有待加强 Need to strengthen capacity building for clinical staff • 各地区门诊后期综合干预工作开展不平衡 Reduce the inequality in the spread of comprehensive interventions and support provided to clinics • 美沙酮维持剂量偏低 Improve the dosing of Methadone

41. 目前存在的问题和挑战Challenges Ahead (con’t) • 社区美沙酮维持治疗与针具交换项目的未能有机地结合 Appropriate combination of NEPs and MMT program needs to be strengthened • 病人仍存在畏惧心理，交通不便、缴费困难和流动性大等现况 Fear of being arrested and the problems of transportation and fee-payment.

42. 深化部门合作Deepen and optimize the multi sectors cooperation • 配合国家新出台的禁毒法和戒毒条例（即将出台），以及“在控率”的工作要求，加强并优化部门合作。 The enforcement of the new National Drug Control Law and the related regulations • 保障药品供应和安全 Guarantee methadone supply and safe management

43. 提高入组人数 Increase enrollment in the MMT program 充分发挥同伴教育者的作用 Fully mobilize peer education 加强部门配合，做好出所和入组的“无缝连接”。 Build connections between incarceration centers and MMT clinics to enable drug users to access MMT upon their release. 开展社区和家庭帮教工作 Advocate the involvement of family members and the community to provide social support 针具交换点病人的转介工作 Enhance the referral system between the NEP and MMT programs. 提高门诊管理和服务质量Improve access to, and the quality of MMT services

44. 提高保持率 Improve adherence and the retention rate 推广后期综合干预工作 Enhance the practice of comprehensive intervention and care 提高美沙酮治疗剂量 Improve the overall dosage of methadone use 提高门诊人员的能力和卫生服务质量。 Improve the capacity and quality of health delivery 开展门诊激励机制 Provide incentives for adherence 推广IC卡，规范并简化诊疗工作，提高依从性和保持率。 Apply Intelligence-Card Management System to further standardize the program 提高门诊管理和服务质量Improve access to, and the quality of MMT services

45. 加强人员能力建设Strengthen the capacity building • 加强省级工作组的能力：督导计划和技术支持能力 Strengthen the capacity of planning and M&E of Provincial Working Group/Secretariat • 完善培训方案: 后期综合干预培训方式（现场） Focus more training emphasis on comprehensive intervention and social support.

46. 加强维持治疗督导力度和效果Reinforce monitoring and evaluation • 国家级工作组督导 M&E by National Working Group • 国家级工作组/秘书处督导计划/省级交叉督导 M&E by National Working Group/Secretariat • 省级工作组督导和自查 M&E by Provincial Working Group/Secretariat

47. 加强数据管理质量Enhance database management 提高数据整合和分析能力 Improve database management to guide daily operation 利用数据结果提供决策依据 To provide evidence-based experience to inform further policy development

49. 2009年工作重点The focus of 2009 • 门诊建设突破700个 Scaling-up to 700 MMT clinics • 进一步拓展覆盖面，使布局更为合理 Increase access to MMT and depth of coverage • 大幅度提升综合服务质量 Improve the quality of MMT service • 优化数据管理系统 Optimize the MMT database system

50. 谢谢！