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 Mainte

nance Treatment for Opium Dependents

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

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

China

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 )

报告 HIV/AIDS 传播途径构成 (2007)Transmission mode (2007)

MTCT1.2%

Other0.5%

Sex17.7%

IDU39.1%

Plasma19.9%

Blood4.3%

Unknown17.4%

MTCT1.6%

Others0.9%

Blood4.9%

Plasma6.8%

Unknown15.1%

IDU29.9%

Sex40.9%

Increased sex transmission

Cumulative (Until Aug2007)

New reported in 2007 (Jan-Aug,2007)

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 )

异性传播21. 95%

同性传播2. 06%

注射毒品32. 83%

采血（浆）13. 62%

输血（制品）3. 45%

母婴传播1. 08%

不详25. 00%

累计报告 2008 年新报告

异性传播40.3%

同性传播5.9%

注射毒品27.9%

采血（浆）4.8%

输血（制品）2.9%

母婴传播1.3%

不详16.9%

报告 HIV/AIDS 传播途径构成

报告 HIV/AIDS 传播途径构成 (2008)

Transmission mode (2008)

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 )

毒品使用类型（ 2008 年）Types of Drugs Used in China,2008

New- type drugs16. 1%

Heroi n78. 0%

Opi um1. 8%

Morphi ne0. 5%

Dol ant i n0. 8%

Mar i j uana1. 0%

others1. 8%

Heroi n Opi um Mari j uana Morphi ne Dol ant i n New- type drugs others

Resource: Annual Report on Drug Control in China, 2008.

(China National Narcotics Control Committee)

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

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

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。

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.

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。

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%

组织管理结构国 家 工 作 组

省 级 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

卫生部公安部 国家药监局卫生厅公安厅省级药监局省级疾病预防控制中心

秘 书 处 中国疾病预防控制中心性艾中心

当地工作组

Organizational Structure

State MMT Working Group

Provincial MMT Working Group

Methadone Formulation Unit

MMT Clinics

MMT Clinics

MMT Clinics

MMT Clinics

Ministry of HealthMinistry of Public SecurityState FDAChina CDC

Department of HealthDepartment of Public SecurityProvincial FDAProvincial CDC

Secretariat

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.

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

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

青海2 甘肃

21

吉林2

贵州54

广西56

广东50

湖南48

江西12 福建

9

浙江27

江苏13

陕西18

宁夏3

新疆27

四川36

湖北37

安徽

云南67

北京9

海南23

重庆26

上海98

2008

河南1

天津内蒙

3 1山西3

23 个省（自治区、直辖市） 600 个门诊

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)

　　

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

858

320

503

600

2004 2005 2006 2007 2008. 12

维持治疗累计和在治人数Cumulative patients treated versus currently receiving treatm

ent （ 2004-2008 ）

12098116

3734526165

97554

57947

178684

93773

2004 2005 2006 2007 2008.12

Accumulated累计人数 On-treatment 在治人数

时间Time

门诊数量# of clinics

累计治疗人数# of cumulative patients

在治人数# currently receiving treatment

年保持率Annual Retention Rate

门诊平均治疗人数average # of patients receiving treatment/ clinic08.12 600 178,684 93,773 69.5% 156

08.1 503 104,867 61,557 71.4% 122

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

省份Province

门诊个数No# of Clin

ics

累计治疗人数No# of Accum

ulated

正在治疗人数No# of on-tre

atment

平均每门诊在治人数No# of average on-tre

atment/clinics

年保持率 *（ % ）Annual Retention Rat

e (%)

北京 -Beijing 9 1694 777 86 80.4

吉林 -Jilin 2 202 112 56 78.9

上海 -Shanghai 12 3361 2061 172 74.9

江苏 -Jiangsu 13 5476 3490 268 83.1

浙江 -Zhejiang 29 5853 2750 95 66.9

安徽 -Anhui 12 1881 849 71 63.4

福建 -Fujian 10 4054 2390 239 69.7

江西 -Jiangxi 12 3252 1956 163 80.3

河南 -Henan 4 214 126 32 59.7

湖北 -Hubei 42 14724 11111 265 82.1

湖南 -Hunan 52 17549 7948 153 62.3

广东 -Guangdong 51 14029 6664 131 64.8

广西 -Guangxi 60 13014 6040 101 66.4

海南 -Hainan 25 6326 2412 96 53.5

重庆 -Chongqing 31 7941 4864 157 75.3

四川 -Sichuan 39 15409 8088 207 74.8

贵州 -Guizhou 56 20063 9630 172 61.2

云南 -Yunnan 67 16820 8316 124 73.5

陕西 -Shanxi 18 10915 6468 359 75.1

甘肃 -Gansu 21 5423 3330 159 72.2

青海 -Qinghai 5 442 229 46 79.0

宁夏 -Ningxia 3 2034 1140 380 66.4

新疆 -Xinjiang 27 8008 3022 112 53.9

全国 -China 600 178684 93773 156 69.5

08 年12 月全国社区药物维持治疗工作进展情况

The MM

T Program im

plementation at provincial –level in 2008

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

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)

咨询 Council ling

小组活动 Group Activity

同伴教育 Peer Education

激励机制 Incentive

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

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

76. 8

23. 527. 1

41. 5

7. 2

37. 0

97. 1

14. 37. 9

58. 159. 4

16. 8

95. 8

38. 2

93. 1

57. 3

38. 2

2. 9

12. 9

0

10

20

30

40

50

60

70

80

90

100

1过去 个月 I nj ect i ng drug use有注射吸毒

i n l ast one month

3过去 个月因吸毒违法犯罪

Drug- rel ated i l l egal off encesi n l ast three month

有工作 Empl oyment opportuni ty

与家庭关系改善Posi t i ve changes i n fami l y

rel at i ons

对维持治疗满意Sati sfi ed wi th the MMT

treatment

(%)

百分比

(N0=10657)基线

1 (N1=10089)年

2 (N2=3747)年3 (N3=830)年

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。

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.

地震中的门诊和服药人员 MMT clinics and clients during the aftershocks

救援 Succor 依从性　 Adherence

捐款 Donation 奉献 Dedication

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 36,000 injecting drug users monthly.

发放针具（ Distributed Needles ）： 1,173,764

回收针具（ Collected needles ） : 1,060,497

针具交换项目The progress of the NEP in 2008

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 harmon

ious 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

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 concentr

ated use NEPs

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

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 lev

el.

多部门合作尚未形成有效的合力 Need to further enhance multi-sectoral cooperatio

n at the local level.

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.

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 interventio

ns and support provided to clinics

美沙酮维持剂量偏低 Improve the dosing of Methadone

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 nee

ds 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.

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 Contr

ol Law and the related regulations

保障药品供应和安全 Guarantee methadone supply and safe manage

ment

提高门诊管理和服务质量Improve access to, and the quality of MMT services

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 clini

cs 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 communit

y 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 progra

ms.

提高门诊管理和服务质量Improve access to, and the quality of MMT services 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

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 o

f 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 i

ntervention and social support.

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

加强维持治疗督导力度和效果Reinforce monitoring and evaluation

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 operatio

n

利用数据结果提供决策依据 To provide evidence-based experience to inform furthe

r policy development

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

谢谢！