1. XVI International AIDS Conference
Expanding Access to Opiates (Morphine) for HIV/AIDS Pain Management in Zambia
XVI International AIDS Conference
August 13-18, 2006
Toronto, Canada
Gilbert Kombe, Abt Associates Inc., Bethesda, MD
Stella Nkhoma, Abt Associates, Lusaka, Zambia
Muriel M.Syacumpi, Abt Associates, Lusaka, Zambia
Makaria Reynolds, Abt Associates Inc, Bethesda, MD
Nadia Khan, Abt Associates, Inc, Bethesda, MD
Paurvi Bhatt, Abt Associates, Inc, Bethesda, MD
Catherine Chanfreau, Abt Associates Inc., Bethesda, MD

2. Discussion Issues Purpose and approach
Background on HIV/AIDS pain management
Why push for use of opiates (morphine) in pain management
Legal and policy barriers to pain management
Preliminary efforts underway
Summary and way forward

3. Purpose of Support for HIV/AIDS Response (SHARe) Project
SHARe is a USAID funded
project implemented by
John Snow International
and Abt Associates
Purpose
To improve the policy environment related to HIV/AIDS pain management in Zambia
USAID supporting palliative care

4. Key Questions SHARe is Addressing
What are the existing legal and policy mechanisms supporting the use of morphine in pain management?
What are the barriers to morphine prescription and administration by doctors and nurses?
How can we influence existing legislation to expand use of morphine in HIV/AIDS pain management?
What level of human resource capacity is needed to administer morphine?

5. SHARe’s Approach
Conducted comprehensive review of existing policies & legislation on the use of morphine in pain management
Held several consensus building meetings with key stakeholders including technical working groups, law enforcement, providers, and beneficiaries
Reviewed best practices in pain management from other low resource countries

6. Background on Pain Management in HIV/AIDS
Zambia has embraced the World Health Organization use of analgesics in HIV/AIDS (Step Ladder)
Currently, most facilities have the following opiates:
Nonsteroidal anti-inflammatory agents (NSAIDS)
Aspirin, pethindine
Opiates (codein, oxycodein, morphine)
Codein phosphate, Dihydrocodeine, Fentanyl patches, Morphine (injectable and powder)
Complimentary (acupuncture, massage)
Morphine used in cancer pain management

7. Pain Management is Vital for Common Conditions
Herpes Simplex
Myopathy
Neuropathy
Post herpetic neuralgia
Candida esophagitis
Avascular necrosis
Osteopenia
Pain prevalence Pre-HAART
Estimates varied between 53%-97% (Schofferman 1998, Singh, Fermie & Peters,1992, Breitbart et al 1996)
2. Pain prevalence post HAART
Estimates lower than 30% (Newshan, Bennett, Holman, 2000)

8. Rationale for Using Opiates in HIV/AIDS Pain Management
Growing recognition that narcotic drugs are absolutely necessary for HIV/AIDS pain management
Little national data on how HIV/AIDS pain is managed. Speculation about under-management of HIV/AIDS pain
With high prevalence of HIV/AIDS
Adult prevalence rate 17%, 1.2 million PLWHA
Only 51,000 people receiving ART out of the estimated eligible 200,000
Many HIV/AIDS individuals do not have access to palliative care
WHO estimates 50% of People Living with HIV/AIDS will suffer from severe, chronic pain

9. Major Challenges to Pain Management in Zambia (1)
Government level
Drug regulatory laws are outdated & require updating to keep up with current trends in HIV/AIDS management
Palliative care not addressed in National HIV/AIDS Policy
Inadequate staff to ensure availability of narcotic drugs (1 staff)
Although the law allows other health professionals to prescribe opiates, most health workers are not aware
PRA

10. Major Challenges to Pain Management in Zambia (2)
Health provider level
Fear of legal investigations by anti-narcotic agencies
Providers not informed about legal requirements
Reluctance by nurses and doctors to prescribe opioids for fear of addiction by patients
Hospices not aware of procedures to access morphine
Family & Patient Level
Cultural barriers
Stigma to using opiates at home
In India where morphine is widely used, there is no abuse of morphine on the street.

11. Preliminary Efforts SHARe is building consensus among key stakeholders
High level meetings with policy makers from Ministry of Health, Drug Enforcement Commission, National AIDS Council, Palliative Care Association of Zambia and others
Engaging broad base of stakeholder on policy development e.g. General Nursing Council of Zambia, Medical Council of Zambia, MOH (Director of Home Based Care, Director of Policy Development, Pharmacy Specialist), NAC
SHARe is working with advocacy groups (hospice and PLWHA organizations) to put the issue on the HIV/AIDS agenda

12. Preliminary Efforts
Supporting educational efforts to dispel myths about medical morphine usage among providers
Newly formed technical working group planning to develop guidelines on use of opiates in HIV/AIDS pain management
Reviewing import and distribution regulations regarding opiates
Streamlining the process of procurement
Improving forecasting of drugs
SHARe is documenting and applying best practices for morphine access, based on similar work implemented in Uganda and elsewhere
For example, in Uganda, nurses are allowed to prescribe and administer morphine for pain managment

13. Preliminary Efforts cont.
Facilitating dialogue between Ministry of Health, NAC, drug enforcement officials and others
Addressing issues of pain and palliative care in the community.
Encouraging the Drug Enforcement Commissions to re-evaluate policies and legislation related to morphine possession and administration

14. Summary and Way Forward
There is great need for simplification of the complex regulations on who can administer morphine and under what circumstances
There is a need for open, cross-sector dialogue among policy-makers, beneficiaries and civil society on use of morphine
Training of health providers in pain management is urgently needed

15. Thank you
Contact information
Stella Nkhoma, SHARe Deputy Chief of Party
Gilbert Kombe
Nadia Khan