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.