Country Report Nepal

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Community BasedQuality Monitoringstudy of key HarmReduction Servicesfor People WhoInject Drugs inNepalCOUNTRY REPORTNEPALDecember 2019

Community Based Quality Monitoring study of key Harm Reduction and otherhealthcare services for People Who Inject drugs in Nepal.This report presents a detailed description, methodology, and findings of the Community BasedQuality Monitoring study. This study is the first of its kind in the region, designed, implemented,and analyzed in a peer-to-peer approach and model. The study presents information on the quality of Needle Exchange Services, Opioid Substitution Therapy Services, HIV testing, ARTservices, and the treatment of Hepatitis C, B, and TB infection. This study has also looked atthe current linkage to essential HIV and other healthcare services for people who inject drugs inNepal.The study has been designed and conceived by ANPUD with the active participation and thesupport from our partners in Nepal. ANPUD appreciates the support from the data collectorsand the community groups who directly and indirectly supported the implementation of this study.This study is funded by The Global Fund To Fight AIDS, Tuberculosis, and Malaria under theprogram title: Key Population Research & Advocacy project and managed by Save the ChildrenInternational, Nepal as the Principal Recipient.For questions, clarification, and suggestions please get in touch with:Asian Network of People who Use Drugs (ANPUD)Regional Secretariat10/96 Trendy Building, 6th Floor,Soi 13, Sukhumvit Road, Klong Toey,Bangkok 10110,

ACKNOWLEDGEMENTOur sincere thanks to all those who supported, were involved andparticipated at all stages of the study. From the pre-research stage tofinalization of study sites and from data collection to the analysis stage forsuccessfully completing the study report.Thanks to the entire NCASC team who supported and ensured that thestudy was carried out proficiently and scientifically especially Mr. BirBahadur Rawal, Statistical Officer, who played a coordinating andmonitoring of the study. We also appreciate the inputs by the NepalHealth Research Council (NHRC) through a professional review played apivotal role in the improvement of study protocols.ANPUD team along with Mr. Francis Joseph Project Coordinator andMr. Sushil Koirala, Regional Consultant, at Bangkok who deservespecial appreciation for the technical backstops they provided for theaccomplishment of this study. I wish to compliment the untiring effortsof our team Mr. Ujjwal Karmacharya National Focal Person andMr. Prabhu Raj Poudyal National Consultant for their efforts, teamwork andcoordination.Lastly, our heartfelt appreciations to Dr. Zakir Kadirov, Chief of Party,Mr. Bhawani Prasad Dahal, Senior Knowledge and Advocacy Managerand the entire Regional Project Implementation Unit of the Global fundKey Population Research and Advocacy Project in Save the ChildrenInternational based in Nepal for their oversight during the entire studyperiod.This study would not have been completed without support from teams atRecovering Nepal, SPARSHA, Dristi Nepal, Sathi Samuha and CommunitySupport Group.In solidarity,Bishnu Fueal SharmaExecutive DirectorRecovering NepalCountry Report NepalI

ABSTRACTCommunity Based Quality Monitoring (CBQM) Study of key Harm Reduction services forpeople who use drugs in Cambodia, Indonesia, Nepal and Vietnam.Country Report: NepalKEY WORDSHarm Reduction, People Who inject drugs, Needle Syringe Exchange Program (NSP), OpioidSubstitution Therapy (OST), HIVCONTEXTThis study comes in the context of a multi-country grant from the Global Fund to ANPUD and otherthree regional networks. One of the components of the grant is to conduct a study to monitor thequality of services related to Needle Syringe Exchange Programming (NSP), Opioid SubstitutionTherapy (OST) and linkage to health care for people who inject drugs (PWID) in Cambodia, Indonesia,Nepal and Vietnam. In this backdrop, the report comes as the country report of Nepal, as a part andpartial of the regional study, conducted by ANPUD along with Recovering Nepal, the national networkof People who Use Drugs (PUD) in Nepal, with the financial support of a regional grant from the GlobalFund, namely: Key Population Research Advocacy Project.OBJECTIVEKey specific objective of this study is to improve understanding of the perceived quality of harmreduction services among PWID in Cambodia, Indonesia, Nepal and Vietnam. The broader objectiveof this study is to build evidence for advocacy for improved quality of Harm Reduction, HIV, HBC, HCVprevention and care services to PWID in Cambodia, Indonesia, Nepal and Vietnam.RESEARCH DESIGNA mixed methods research entailing of community survey (CS) using structured interview and focusgroup discussion (FGD) among service users of NSEP and OST and key informant interview (KII) amongservice providers in Kathmandu and Pokhara cities of Nepal.RESULTSIt was found that 92% of service users of NSEP were either very satisfied or satisfied with the overallquality of survey while around 7% were neutral to the overall quality. Less than one percent were founddissatisfied with the overall quality of NSEP. In the context of OST, more than a half of service users(64.10%) agreed — among which a quarter of respondents (25.60%) strongly agreed and more thantwo-third (38.50%) agreed; that OST services they had been receiving was perfect. In contrast only17.10 % either strongly disagreed or disagreed that OST services they had been receiving was perfect.IICountry Report Nepal

ABBREVIATIONAIDSANPUDARTBCCCDOCOW uired Immuno-Deficiency SyndromeAsian Network of People who Use DrugsAnti-Retroviral TherapyBehavior Change CommunicationChief District OfficerClinical Opiate Withdrawal ScaleCommunity SurveyDrug Control StrategyFocus Group DiscussionFacility AssessmentFemale Injecting Drug UserFacility ObservationGlobal AIDS MonitoringGlobal FundViral Hepatitis BViral Hepatitis CHuman Immunodeficiency VirusInformation Education CommunicationImplementing Non-Governmental OrganizationIdentify, Reach, Recommend, Test, Treat and RetainKey Information InterviewKey PopulationLiterature ReviewMen who have Sex with MenMedical UnitNational Center for AIDS and STD ControlNon-Government OrganizationNational HIV Strategic PlanNeedle Syringe Exchange ProgramNeedle and Syringe ProgrammingOpioid Substitution TherapyPeople who Use DrugsPeople Who Inject DrugsRecovering NepalStandard Operating ProcedureSocial Support UnitTB TuberculosisTGTransgender PeopleWHOWorld Health OrganizationCountry Report NepalIII

TABLE OF CHAPTER 1 : INTRODUCTION.11.1 Backround.11.2 The Study rationale.11.3 Objective of the study.21.4 Expected outcome of the study.3CHAPTER 2: HARM REDUCTION PROGRAM IN NEPAL.42.1 Legal Context.42.2 Strategic Framework.42.3 Poppulation size.42.4 Harm reduction program for PWID.4CHAPTER 3: METHODOLOGY.63.1 Study Design.63.2 Research Location.63.3 Sampling.63.4 Eligibility criteria for research participants.73.5 Instruments and participants of qualitative methods.73.6 Ehical consideration.83.7 Limitations of the study.8CHAPTER 4: RESULTS.94.1 Socio-demographic Characters.94.2. NSEP services.94.3. OST services.28CHAPTER 5: DISCUSSION.445.1 NSEP services.445.2 OST services.50CHAPTER 6: CONCLUSION .576.1 NSEP services.576.2 OST services.60CHAPTER 7: RECOMMENDATIONS.637.1 NSEP services.637.2 OST services.63BIBLIOGRAPHY.65TABLES.66ETHICAL APPROVAL.69IVCountry Report Nepal

LIST OF TABLESTable 1:Satisfaction on the issue of the quality of needles and syringes. 10Table 2:Perceived Sufficiency of injecting equipment received. 10Table 3:No. of needles and syringes received by person in a week. 11Table 4:Satisfaction among NSP clients on information provided on saferdrug use and safer sex. 13Table 5:Proportion of respondents who received information on HIV throughan NSP site or outreach. 13Table 6:Proportion of respondents who received information on HepatitisB & C at an NSP site or by an outreach worker/peer educator. 13Table 7:HIV Testing service utilized in NSP. 17Table 8:Proportion of PWID who experienced overdose on any drugsto the point of losing consciousness. 20Table 9:Knowledge about Naloxone and its availability among PWID. 20Table 10:Refusal of clean needles/syringes because of a shortage ofneedles/syringes by experienced service users at the NSP site. 22Table 11:Experience of ever insulted by the health workers while visiting NSP site. 23Table 12:Perception among PWID on behavior of service providers at NSP site. 23Table 13:Money spent buying new needles/syringes from a pharmacy in aday by a PWID. 26Table 14:Satisfaction Level of overall quality of NSP services. 28Table 15:Waiting time to first treatment admission (in days) experienced byOST service receivers. 29Table 16:Satisfaction with Methadone/Buprenorphine dosage received during OST. 30Table 17:Proportion of OST clients who paid out-of-pocket expenses whilereceiving OST. 32Table 18:Source of payment of out-of-pocket expenditures for receivingOST services. 32Country Report NepalV

Table 19:Perceptions of OST clients on the assessment of substance usebefore the enrollment into OST Program. 33Table 20:Preference of take-home dosage among OST users. 34Table 21:Proportion of OST clients who received adherence counsellingon OST program. 36Table 22:Transportation Cost to and from the OST site. 38Table 23:Proportions of OST clients who missed of dose because of a stockout/ shortage of the OST medicine. 39Table 24:Perceptions of OST clients on maintenance of confidentiality at OST site. 40Table 25:Perception on OST services that respondents had been receiving. 43Table 26:Gender of respondents of quantitative survey. 66Table 27:Current marital status of respondents of quantitative survey. 66Table 28:Education level of respondents of quantitative survey. 66Table 29:Age group of respondents of quantitative survey. 67Table 30:Reponses of those respondents who were either neutral ordissatisfied on the quality of needle and syringe . 67Table 31:Out of pocket expenditures for receiving OST services by cost category. 67VICountry Report Nepal

CHAPTER 1INTRODUCTION1.1 BackgroundDue to social and biomedical advances, the responses to HIV have yielded remarkable results.There are better, improved tools for screening, diagnostics, and treatment of HIV. Communityresponses to HIV are also established as the cornerstone of effective, equitable and sustainableprogrammes. They play a critical role in demanding and delivering services, supporting healthsystems and reach those most vulnerable to HIV where state facilities cannot.Communities are increasingly involved in monitoring access and quality of HIV treatment, care,and support services. They can act as barometers in their watchdog role, tracking what worksand what does not, from a local, contextualized perspective. Communities give a voice to thosewho need services, provide feedback as to whether policies and programmes are working andsuggest how they can be improved. As service recipients, they are best positioned to evaluate theprograms and provide critical feedback to HIV and health programs.Asian Network of People who Use Drugs (ANPUD) is a regional network of people who use drugsestablished to address the obstacles faced by the people who use drugs and their families in Asia.The core belief behind the formation of ANPUD is that, people who use drugs living in countriesof the region coming together with a unified voice can have a greater impact in ensuring thatthe community enjoy equal human rights and opportunities for a better quality of life. ANPUDbelieves drug use as a health issue (and not a law and order issue) and can work more effectivelytowards creating a better environment for people who use drugs and their communities, buildingfrom within the community.In 2014, ANPUD along with other three (03) regional networks applied for a multi-countrygrant to the Global Fund and was subsequently approved. One of the components of the grantis to conduct a study to monitor the quality of services related to Needle Syringe Programming(NSP), Opioid Substitution Therapy (OST), and linkage to care for people who inject drugs inCambodia, Indonesia, Nepal and Vietnam. With the objective of conducting the study, ANPUDhas entered into collaboration with the national networks of People who Use Drugs (PUD) of theabovementioned six countries.In this backdrop, the report comes as the country report of Nepal, as a part and partial of theregional study, conducted by ANPUD along with Recovering Nepal, the national network ofPeople who Use Drugs (PUD) in Nepal, with the financial support of a regional grant from theGlobal Fund, namely: Key Population Research Advocacy Project.1.2 The study rationaleIn 2014, ANPUD reached out to its country constituents in the region for meeting in BangkokThailand to discuss key gaps in HIV and Drug User program in the countries. Among a few areasidentified, during the consultation, the following are the key observations:Country Report Nepal1

1. The community of current and former drug users are required to play more central roles inadvocating for the quality of programs being provided to the drug users2. There is a tendency among service providers to count the number of people reached throughthe programs and lack of interest in improving comprehensiveness and effectiveness of theservices provided3. The Community of people who use drugs are more capable than ever in designing andimplementing simple and grounded studies that will bring about information on the quality ofcare, as often it is in the best interest of the community to advocate improvement of servicesbeing provided for them.The following are the rationale of the community quality monitoring of key HIV PreventionServices for people who use drugs in Cambodia, Indonesia, Nepal, and Vietnam study:1. There is a need to better understand the quality of the key HIV prevention services provided topeople who use drugs in the study countries. There is an opportunity to encourage programsin the study countries to focus on monitoring and improving the quality of services providedand not limit themselves in only reporting coverage.2. Communities of people who use drugs feel that services are partially provided and there is aroom for improvement in the quality of services provided. They believe that there is too muchfocus on coverage while often times comprehensiveness and quality of those services are notprioritized.3. Donors, specifically the Global Fund is increasingly interested in the community-centricmonitoring of the quality of programs they fund. The people that are the recipients of theservices will be extra eyes and ears on the ground to help ensure that the programs aredelivered according to expected standards.These avenues are new to this region, that is why ANPUD has taken leadership in designing anddelivering a quality monitoring study, which will pave a way towards a national and regional leveldialogue particularly on the quality of the services provided alongside the improving access1.3 Objective of the studyThe broader objective of this study is to build evidence for advocacy for improved quality of HarmReduction, HIV, HBC, HCV prevention and care services to PWID in Cambodia, Indonesia, Nepaland Vietnam. The study also aims to expand community-based monitoring in South and SouthEast Asia, moving it out of that which is just related to donor programs and starting to monitornational programs and local services. The evidence generated from the study is expected to helpto reshape policy, address bottlenecks and provide an important feedback mechanism for theimprovement of the quality of HIV prevention, care, and support programs for the people whoinject drugs.The following are the specific objectives of the study: To improve understanding of policy position, program strategies, legal barriers and the stageof implementation of harm reduction services for PWID in Cambodia, Indonesia, Nepal andVietnam. To improve understanding of the perceived quality of harm reduction services among PWID inCambodia, Indonesia, Nepal and Vietnam. To explore the status and the function of referral services, lifesaving care such as provision ofART, management of TB and Treatment of Hepatitis C and B.2Country Report Nepal

The information gathered from this study will be used to advocate for improved quality of harmreduction programs.1.4 Expected outcome of the studyThe approach used for quality monitoring under this study broadly relates to (with limitationspecified in the following section) with the model 1: Downward accountability: Services incorporatemechanisms to allow service users to provide feedback and for feedback to be acted upon (e.g.complaint-handling systems) among the four models of community-based monitoring reported ina review commissioned by the Global Fund. The study which is a significant part of this grant aimsfor the following outcomes.The following outcomes are expected from the study:Outcome 1: Consolidated report on HIV prevention and care program, legal environment andtypes of services provided to PWID in Cambodia, Indonesia, Nepal and Vietnam along withcountry-specific profile and a regional consolidation on HIV prevention and care program,legal environment and types of services provided to PWID in Cambodia, Indonesia, Nepal andVietnam. The report will include the perceived quality of harm reduction services among serviceusers (PWID).Outcome 2: A study report each from each study country which will incorporate the policyposition, program strategies, legal barriers and implementation of harm reduction services andperceived quality of harm reduction services among service users (PWID) in Cambodia, Indonesia,Nepal and Vietnam.Country Report Nepal3

CHAPTER 2HARM REDUCTION PROGRAM IN NEPALThis chapter deals with the findings of literature reviews that has been done basically to brieflydescribe the legal, strategic and programmatic backdrops for the harm reduction program inNepal. .2.1 Legal ContextNepal came up with its latest version of Drugs Control Policy in 2006 with one of its objectivesto minimize the risk of transmission of HIV, Hepatitis and STI among People Who Use Drugs andtheir families. Further to this, building upon the plinth of Drugs Control Policy 2006, the Ministryof Home Affairs in its Drug Control Strategy (DCS 2066) with the objective of controlling thetransmission of HIV, Viral Hepatis C, and STI has clearly envisaged the expansion of OSTprogramme even within prisons of the country through the execution from government andprivate hospital as well as NGOs (NGO)s. Similarly, Drug Control Strategy 2066 with theobjective of controlling the transmission of HIV, Viral Hepatis C, and STI has also pointedlyenvisaged the provision of safe needle/ syringes and condoms through comprehensive outreachactivities of harm reduction program for PWID.2.2 Strategic FrameworkThe National HIV Strategic Plan (NHSP) 2016-2021, sets out strategies to fast-track Nepal’s HIVresponse towards achieving the 90-90-90 treatment targets by 2021 in order to end the AIDSepidemic by 2030. This Strategic Plan adheres to innovative Identify, Reach, Recommend, Test,Treat and Retain (IRRTTR) approach for all of its key populations (KPs) – that includes also PWID- to address the critical gaps in the prevention-treatment continuum by envisaging interventionsacross the entire HIV cascade, with a focus on case finding and case management.2.3 Population SizeThe latest Size Estimation of PWID was conducted in 2017 under the aegis of National Center ofAIDS and STD Control. According to this Size Estimation there are around 30,068 PWID in Nepalof which 89% (27,567) are male, and 11% (3,301)female (1).2.4 Harm Reduction Program for PWIDPursuant to its NHSPs, Nepal, over the last two decades, has been running a comprehensive HIVprevention programme for PWID. This is basically a defined package harm reduction servicesentailing of a) Needle Syringe programming, b) Condom promotion, c) HIV testing d) STItreatment, e) Naloxone distribution, f) Prevention and Management of Co-infections and Comorbidities. In addition to this, the harm reduction program also includes OST.2.4.1 Needle Syringe Programming (NSP)Nepal is one of the first countries in the region of South Asia Association of Regional Cooperation(SAARC) to recognize harm reduction interventions including needle-exchange as a strategy forprevention of HIV transmission among IDU. The first NSP program was reportedly set up as earlyas 1991 in Kathmandu Valley by LALS (2) .4Country Report Nepal

Currently Needle Syringe Program is being implemented with the abovementioned harmreduction package in 26 districts of the country. Investment Plans for the Implementation of theNational HIV Strategic Plan (NHIP) 2016-2021 sets both the coverage of reaching (with needlesyringe) and HIV testing of 90% (29,522) PWID by 2021. To this end, a total of 15249 PWID werereached with needle syringes and 11478 PWID were tested for HIV in the period of June 2016 July 2017 in Nepal (Fact Sheet -8-2017, The Needle Syringe Program isbeing guided by the National Targeted Intervention Operational Guidelines 2010– Injecting DrugUsers, published by NCASC.NHIP 2016-2021 stipulates the distribution of an average 10 needles/syringes per month for everyperson who injects drugs. However, number of needles and syringes distributed per person amongPWID who injects drugs per year has remained low over the years in Nepal as around 61 needlesand syringes were distributed per person per year in 2017 - nearly a half of that envisaged byNHIP (Global AIDS Monitoring Report 2017).2.4.2 Oral Substitution Therapy (OST)Key informant interview (KII) Methadone and Buprenorphine. OST coverage is targeted at 10%(3280) of the PWID population by 2021. Operation of these sites are guided by the following threeframeworks : Directives for Operation of OST, Ministry of Home Affairs 2070 Clinical Guideline for Opioid Substitution Therapy in Nepal, 2015 Standard Operating Procedure for Social Support unit in Methadone/ Buprenorphine, NepalDespite its very long history of OST in Nepal and expansion of service sites, the enrolmentandretention of service clients have remained one of the major challenges for the OST intervention(3).Country Report Nepal5

CHAPTER 3METHODOLOGY3.1 Study DesignThe study was done using a mixed methods research and it employed concurrent triangulationstrategy. Thus, during the research, quantitative data using community-based structured interviewand qualitative data using: i) Focus Group Discussion (FGD), ii) Key Informants Interview (KII),and iii) Facility Assessment (FA) were obtained simultaneously but independent of each other.Apart from all these, literature review is also one source of information of this study. The primarypurpose of adhering to a mixed methods research, in principal, is to subscribe to the concept ofconfirmation, corroboration or cross-validation within a single study. The data integration tookplace mainly during data interpretation and during data analysis also.3.2 Research LocationFor the purpose of this study, Kathmandu and Pokhara are the two cities selected in Nepalpremising upon the following criteria: The cities with the highest concentration of PWID in the country, Availability of NSP and OST services, and Consideration to available local capacity, available money and geographical access.3.3 SamplingThe study has adopted a two-tier approach entailing of 1) Facility-based information and 2)User level information. As such, facility-based information was gathered through: a) structuredfacility-based assessment, b) focus group discussion, and c) key informant interviews. Whilst, acommunity-based structured interview was used to interview PWID for the obtainment of userlevel information.3.3.1 Sampling for qualitative methodsFor the collection of data, the study conducted KII, FGD and FA among those NGOs which weredelivering services rel

International based in Nepal for their oversight during the entire study period. This study would not have been completed without support from teams at Recovering Nepal, SPARSHA, Dristi Nepal, Sathi Samuha and Community Support Group. In solidarity, Bishnu Fueal Sharma Executive Director Recovering Nepal

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