SADC HIV and AIDS Best Practice Series

Methadone Substitution
Therapy Program in Mauritius

March 2008
Contents
Acknowledgements ... …………………………………………………………………… 3
Acronyms ……. ………………………………………………………………………….. 4

1. In Context ………....................................................................................... 5

2. Supporting the SADC HIV and AIDS Best Practice Framework……….. 6

2.1 Documenting HIV and AIDS Best Practice ………………………………… 6
2.2 In Harmony with SADC Framework for HIV and AIDS
Best Practices ……… ………………………………………………………….. 6
2.3 SADC Best Practice Criteria and Definition . ………………………………… 7

3. Methodology ……… ………………………………………………………….. 9

4. Background . …………………………………………………………………… 11
4.1 Linking Injecting Drug Use and the HIV Epidemic…………….……............ 11
4.2 Injecting Drug Use and the HIV epidemic in Mauritius……………………… 12
4.3 Methadone Substitution Therapy for Injecting Drug Users…………………. 13

5. A “Ray of Hope” for Injecting Drug Users in Mauritius ………………. 15

5.1 Programme Start-up……………………………………………………............ 15
5.2 Programme Description………………………………………………………… 16
5.3 Elements of a Best Practice……………………………………………........... 19
5.4 Key Programme Successes……………………………………………........... 25
5.5 Challenges……………………………………………………………………….. 28
5.6 Lessons Learnt …….. ………………………………………………………….. 29

6. The Way Forward … ………………………………………………………….. 31

7. Conclusion……………………………………………………………………… 34

References………………………………………………………………………............ 36

Annexes………………………………………………………………………………….. 37
Annex I: Methodology……………………………………………………. 37
Annex II: Data Collection Tools…………………………………….……. 40
Annex II: Best Practice Score Card……………………………………... 47
Annex IV: Peer Review Team: Terms of Reference (TORs) and
Composition……………………………………………………. 51
Annex V: Best Practice Documentation Training: Programme
Evaluation Brief and Participants ….. ……………………….. 53

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Acknowledgments
The Southern Africa Development Community (SADC) would like to acknowledge
Southern Africa HIV and AODS Information Dissemination Service (SAfAIDS), for the
documentation of the Mauritius Methadone Substitution Therapy Program, as one of
the Best Practices from four member states (Mauritius, South Africa, Zambia and
Zimbabwe). The documentation process of this report, would not have been possible
without the support and guidance of the Mauritius Ministry of Health and Quality of Life
(MOH & QL), the AIDS Unit, and the National AIDS Secretariat.

Special gratitude is extended to Dr. Maryam Timol, Dr. Ahmad Saumtally and Dr.
Fayzal Sulliman, for their consistent support throughout the data collection and
verification processes of the in-country mission. Thanks are due also to Ms. Sara
Soobhani, Mr. Mahadoo, Dr. Pathack, Ms. Saddul and other staff at the Mauritius
National AIDS Sectretariat and AIDS Unit, for promptly facilitating the data collection
process and other logistics that were necessary for the success of the in-country
mission. Thanks goes also to staff at the Barkly Centre, Dr.Idris Ghommaney Centre,
and Sangram Centre.

Sincere appreciation is extended to the interviewed clients on methadone substitution

therapy, and their families, without whose trust and openness, the consultants would
not have been able to discern the core dynamics of this unique programme in
Mauritius.

We are indebted to the Minister of Health and Quality of Life, for his gracious welcome
to the consultancy team that collected the data for the compilation of this report, and for
giving them an audience during their visit to the country.

This Best Practice document has been authored by Rouzeh Eghtessadi and Chrispin
Chomba of SAfAIDS, with support from Lois Chingandu (Executive Director, SAfAIDS)
and Sara Page (Deputy Director, SAfAIDS). Editing of the report was done by Vivienne
Kernohan (SAfAIDS) and Benhilda Chanetsa.

3
Acronyms

AIDS Acquired Immune Deficiency Syndrome

ART Antiretroviral Therapy

HIV Human Immunodeficiency Virus

IDU(s) Injecting Drug Use(s)

MERD Monitoring, Evaluation, Reporting and Documentation

MOH&QL Ministry of Health and Quality of Life

NATReSA National Agency for Treatment and Rehabilitation of

Substance Abusers

NGOs Non-Governmental Organisations

PILS Prevention Information et Lutte contre le Sida

SADC Southern Africa Development Community

SAfAIDS Southern Africa HIV and AIDS Information Dissemination

Service

UNODC United Nations Office on Drugs and Crime

VCCT Voluntary Confidential Counselling and Testing

WHO World Health Organization

4
1. In Context
The Member States of SADC have been responding to the HIV epidemic for more than
two decades. The combined experiences of the Member States is over 200 years yet
these rich experiences have not been fully harvested or systematically documented to
guide the Member States and the region at large, in the design and implementation of
HIV and AIDS interventions. One of the most useful avenues for strengthening the
response is through member states sharing Best Practices on HIV and AIDS, between
and within themselves. This will guide and maximise efficiency and effectiveness in
responses to the various facets of the epidemic.

SADC is fully committed to the challenge of controlling the epidemic and the Maseru
Declaration on Combating HIV and AIDS recognises “ – that within the SADC Region,
there have been successes and Best Practices in changing behaviour, reducing new
infection and mitigating the impact of the HIV and AIDS pandemic, and that these
successes need to be rapidly scaled up and emulated across the SADC Region”. Both
the SADC Strategic Plan and the Business Plan on HIV and AIDS advocate the sharing
of best practices between and within Member States.

To provide a systematic working definition for a SADC HIV and AIDS Best Pratice, and
standardise documentation metholodogy, the SADC Framework for Developing and
Sharing Best Practice on HIV and AIDS was designed. In line with this aim, SADC, in
2007, commissioned the documentation of Best Practices in four Member States:
Mauritius, South Africa, Zambia and Zimbabwe, where best practices had been
identified through a comprehensive selection process, involving Governments and
National Co-ordinating bodies.

The documentation of these Best Practices will stimulate and encourage the exchange
of ideas, and increase collaboration and co-ordination among the multiple actors and
institutions responding to the epidemic across the region. It is against this backdrop
that the Mauritius “Methadone Substitution Therapy Programme”, under the National
AIDS Secretariat and the AIDS Unit of the Ministry of Health and Quality of Life, has
been documented as a Best Practice.

5
2. Supporting the SADC HIV and AIDS Best Practice
Framework
2.1 Documenting HIV and AIDS Best Practices
For HIV and AIDS organisations, best practice documents are important for sharing
knowledge, experiences and lessons learnt, both internally and externally.

“Don’t reinvent the wheel, but learn in order to improve it, and
adapt it to your terrain to make it work better.” While this
metaphor is clearly too simple, it certainly captures the
essentials of what Best Practice is all about.”
- Aidsnet

“Best Practice” documents are unique documents that describe and evaluate - against
specific criteria - detailed elements of a programme, project or activity which have
contributed towards successful interventions in the response towards HIV.

Best Practices can be viewed as a continuous process “ A Best Practice on HIV and AIDS is a
of learning, feedback, reflection and analysis of what body of knowledge about an aspect of HIV
works (and what does not work), and the reasons why. prevention, treatment or care based on
The purposes of documenting a Best Practice include practical experiences and lessons learnt in a
to: maturing field and which can be replicated
• avoid duplication of effort (within the same target to improve the quality of an intervention
area) by sharing information and lessons learnt whose objective is the mitigation of one
• promote knowledge exchange and learning to aspect of the HIV epidemic”
improve and adapt effective strategies of - SADC Framework for Developing and
intervention, within specific environments Sharing Best Practices on
HIV and AIDS

2.2 In Harmony with the SADC Framework for HIV and AIDS Best Practices
The SADC Framework describes a Best Practice on HIV and AIDS as one that has four
essential components: body of knowledge; practical experiences and lessons learned;
replication; and mitigation.

The SADC Best Practice Business plan envisages the development of a database of
Best Practices, and towards this end, a series of Best Practices among Member States
is being identified and documented to meet the seven Best Practices Criteria stipulated
by SADC.

Thus the overall purpose of this document is to share how, and to what extent, the
Mauritius Methadone Substitution Therapy (MST) Programme meets the seven SADC
criteria of Best Practices, and whether it can be replicated by the
multitude of actors and institutions responding to the epidemic
across the region. Ultimately, the SADC Best Practices should
catalyse increased collaborations and co-ordination – within and
among Member States - towards a sustained and effective
response to HIV and AIDS, in keeping with the Maseru Declaration.

6
2.3 SADC Best Practice Criteria and Definition
The SADC Framework for HIV and AIDS Best Practices, defines the primary purposes
of a Best Practice as a practical instrument that facilitates sharing within and between
Member States in order to assist local authorities to scale-up interventions based on
what is known to work – through documenting, understanding and appreciating good
experiences; facilitationg learning of what works and what does not; sharing
experiences; and assisting replication of small and successful interventions on a larger
scale.
The criteria are explained in detail below:
1. Effectiveness
A Best Practice must have clear objectives guided by identified commuity needs
obtained through a baseline stud and it must have evidence that it is achieving
these objectives. The community participates from project inception to
implementation, monitoring and evaluation of the project.

2. Ethical Soundness
An ethical practice is one that upholds social principles and professional conduct.
An intervention is a Best Practice if it does not violate human rights, respects
confidentiality as a principle, embraces the concept of informed consent, applies
the “do no harm” principle, and works towards the protection of the interests of
various vulnerable groups.

3. Cost Effectiveness
Cost of delivery for a cost effective programme is proportionate to available
resources, that is, “the capacity to produce desired results with a minimum
expenditure of energy, time or resources.1” The intervention should have in place,
cost saving and reduction systems. The programme should provide a standard
package of HIV prevention, treatment or care products and services, at a
reasonable cost. This should result in an improvement in the quality of life of an
increased number of community members. Efficiency measures the capacity of the
programme to produce desired results with the minimum expenditure of energy,
time and resources.

4. Relevance
All HIV interventions need to take cognisance of the specific context in which they
are taking place, noting cultural, religious and other norms, as well as political
systems and the socio-economic environment, in so far as they affect vulnerability,
risk behaviour, or the successful implementation of a response.

5. Replicability
Inherent in a Best Practice is its ability to be copied, and its need to discover
interventions that set an example.

6. Innovativeness
A Best Practice may demonstrate a unique and more cost effective way of
implementing a programme.

7. Sustainability
Sustainability is the ability of a programme or project to continue to be effective
over the medium to long-term. This can be strengthened through community
ownership of the project, and through skills transfer. Sustainability should take into
cognisance financial sustainability, marketing and awareness building of the
project.
1
International Federation of the Red Cross and Red Crescent Societies. Best Practice Document,
2006

7
 Figure 1: Framework for SADC HIV and AIDS Best Practices

HIV and AIDS Programme Area:

Prevention * ARV treatment * Care * Treatment Literacy * Children *
Co-ordination * Media * Condom use * HIV testing * Political leadership *
PMTCT * Education

National Coordinating
Authority/AIDS Council

SADC
HIV and AIDS
Unit

SADC
Best Practice
Database

SADC
Member States

This Best Practice document, marks a step towards operationalising the above
Framework and:
• Validates the Mauritius Methadone Substitution Therapy (MST) programme as
an HIV and AIDS Best Practice
• Adds to the body of knowledge on harm reduction strategies that have worked,
and key elements thereof
• Stimulates replication of programmes that simultaneously respond to injecting
drug use (IDU) and HIV risk reduction

8
3. Methodology
The methodology applied for this documentation was based on the SADC Framework
for HIV and AIDS Best Practices. The design sought to determine and confirm the four
essentials for the identified Best Practice, by assessing its:
• Contribution to the body of knowledge in the area of injecting drug use and
the HIV and AIDS risk reduction response
• Ability to offer practical experience and lessons learned from its
implementation in Mauritius
• Extent of replicability within Mauritius and in other similar settings; and
• Contribution to the mitigation of injecting drug use as a factor in the spread
of HIV, and impact mitigation of AIDS in Mauritius.

In accordance with the SADC Framework, for this programme to be classified an HIV
and AIDS Best Practice, it needed to demonstrate the following criteria:

• Effectiveness: by showing achievement of clearly outlined objectives

• Ethical Soundness: by illustrating the upholding of human rights and
meeting the universally accepted ethical standards
• Cost effectiveness: by showing that it is efficient and does not waste
resources
• Relevance: by taking cognisance of the specific context within which it is
being implemented, taking into account cultural, religious and other norms
• Replicability: by displaying characteristics that make it easy to copy
• Innovativeness: by showing a new way of implementing a programme that is
more effective and saves resources
• Sustainability: by displaying the ability to continue to deliver benefits

The following data collection methods were employed, using a triangulation approach:

• Focus Group Discussions (10 FGDs conducted with programme clients,

their families and programme implementers),
• Key Informant Interviews (7 interviews with NAS, MOH&QL staff, including
the Honourable Minister, and NGO management),
• Programme Implementer Interviews (8 interviews were held with
programme implementers and leadership),
• Literature review (programme and national records and documents)
• Observation data (site visits)

The Table in Annex I outlines the methods of data collection, the data collection
instruments, the target groups, the sample size and the method of analysis.

Prior to the documentation process, a stakeholders’ consultative meeting was held at

country level to introduce strategies for the documentation process and to gain the
consensus required to facilitate the documentation. During this meeting, the Country
Peer Review Team was established and it subsequently reviewed the Best Practice
document and endorsed it. The Peer Review Team comprised representatives from the
Ministry of Health and Quality of Life (MOH&QL), the National AIDS Secretariat (NAS),
groups of people living with HIV and AIDS (PLHIV) and NGOs working with IDUs within
the MST programme. See Annex IV.

9
Skills building sessions on HIV and AIDS Best Practice documentation and an
introduction to the SADC Framework on HIV and AIDS Best Practices were conducted
for HIV and AIDS implementers and managers from MOH&QL AIDS Unit, the NAS,
and various civil society and PLHIV organisations in the country. See Annex V for
details relevant to this training. The purpose of this training was to consolidate a pool of
human resources in basic HIV and AIDS Best Practice documentation, based on SADC
guidelines.

10
4. Background
4.1 Linking Injecting Drug Use and the HIV Epidemic
Globally, heterosexual transmission is by far the most common way of transmitting HIV.
However, injecting drug use remains an even more ‘efficient’ mode of HIV
transmission. HIV transmission occurs through needle-sharing among injecting drug
abusers, in the absence of needle sterilisation. The practice of needle sharing is
particularly widespread in poorly resourced communities, where abusers are unable to
access or acquire fresh injecting equipment, and a number of injecting drug users
(IDUs) rely on one circulating needle. Needle-sharing is further exacerbated in settings
where IDUs are heavily stigmatised and thus the habit is driven underground. The
other risk factor for HIV transmission among IDUs – and their partners - is the
behavioural effect brought on by the intoxication the drugs cause. With reduced
inhibition and ability to make rational choices and decisions, intoxicated IDUs are at
higher risk of engaging in unsafe sexual practices, increasing their chances of being
infected with HIV. Meanwhile, the life style of known IDUs, which is generally
ostracised, prevents them from accessing information that would normally empower
them to make informed decisions on how to prevent HIV infection through sexual
intercourse.

In the past decade, the changing pattern of drug use from opium smoking to heroin
injecting has set the scene for massive outbreaks of HIV infection among IDUs, their
partners and children. Experiences in countries such as China, Vietnam, Russia and
Ukraine, have revealed that once HIV enters the injecting drug use population, a
country can expect a large and sustained epidemic. The combined effect of the
expected impact of injecting drug use and HIV and AIDS, on socio-economic
development, is substantial.

Injecting drug use, has been officially established in Mauritius for over a decade, and
heroin (as well as brown sugar, an adulterated form of heroin) has been available in the
country since the 1980s. While heroin is the most commonly abused drug among drug
users, other illegal drugs accessed on the island include Subutex (buprenorphine
tablets, which are injected instead of the conventional method of sub-lingual ingestion),
marijuana, and White Lady (whose primary constituent is heroin). Harm reduction
strategies that have been employed to date include stoppage or reduction of:
• use of contaminated injecting equipment;
• sharing of injecting equipment; and
• drug misuse

The broader goals of these harm reduction strategies seek to stop or reduce unsafe
sexual practices; encourage health consciousness and stable lifestyles and retain
contact for sustained rehabilitation.

People with both opioid dependence and HIV infection, are often doubly stigmatized. In
many countries they are excluded from the provision of antiretroviral treatment in spite
of the evidence that individuals with opioid dependence benefit from appropriately
administered HIV and AIDS drug treatment, just as do individuals without opioid
dependence. Programmes that integrate substitution maintenance therapy for opioid
dependence with HIV and AIDS treatment and care, should therefore be encouraged.
Directly observed therapy for opioid dependence also provides an opportunity for the
implementation of directly observed antiretroviral therapy, as well as therapy for
opportunistic infections such as tuberculosis.

11
The transmission of HIV through injecting drug use in Mauritius, was identified in 2002,
and subsequently an Action Plan for IDUs (2003-2008) was developed, which
proposed a three-pronged strategy, consisting of HIV and AIDS legislation; Methadone
Substitution Therapy and establishment of a Needle Exchange Programme. Since
2002, the HIV epidemic in Mauritius has experienced a shift in the main mode of
transmission, from heterosexual, to injecting drug use. Evidence shows that it is
increasingly difficult to contain the epidemic among IDUs once a prevalence of 10% is
reached. Therefore, prevention and control measures targeting this group of the
Mauritian population remains critical, from both an injecting drug use and an HIV
perspective. As has been shown in Hong Kong, Nepal, Australia, Canada, and other
countries with a similar pattern of risky behaviour, rapid spread of HIV among IDUs can
be avoided.. Key risk reduction factors among IDUs include: acknowledgment of IDU
as a social problem, early intervention, including harm reduction, as well as demand
and supply reduction strategies.

Another effect of illicit drug use felt socially in Mauritius, has been the increase in IDU-
related crime, in the form of drug trafficking and unauthorised possession of syringes
and drugs. The problem is also associated with increased fiscal spending; in Mauritius,
a prisoner costs the government approximately USD10 per day, excluding the financial
social assistance provided to the spouses and families of detainees.

The government passed the Dangerous Drugs Act (2000), to address these issues.

4.2 Injecting Drug Use and the HIV epidemic in Mauritius: An Overview
At the end of 2006, the estimated population of Mauritius was 1,245,000, with life
expectancy at birth being 75 years for women, and 69 years for men. An estimated
4,100 people were living with HIV, less than half of whom were women aged 15 years
and over. The first case of HIV in Mauritius was documented in 1987, and until 2001,
there was a slow increase in the number of new infections. Thereafter, HIV incidence
rates began to double every year. Epidemiological data has revealed that over 70% of
notified HIV positive cases have been infected through injecting drug use. New cases
of HIV escalated notably in 2004.

Until 2001, heterosexual transmission was the main mode of transmission and the shift
to injecting drug use as the primary mode of HIV transmission was recognised in 2003.
In 2003, 86% of reported HIV infections were among IDUs. When an epidemic of
Hepatitis C broke out among IDUs in 2004, the need to address HIV prevention among
the IDU population was reinforced. It became clear that needle exchange was taking
place between IDUs, and that the risk of HIV transmission within this population has
been significantly heightened. As at December 2006, a total number of 2,716 cases of
HIV have been detected, of which 2,587 are Mauritians. The sex ratio of infections is
4.5 male to 1 female.

Following the identification of the first case of HIV on the island, the Government has
manifested commitment and diligence in its response to the epidemic, through the
establishment of numerous structures and mechanisms for prevention, control and
impact mitigation. Achieving Millennium Development Goal Six – combating HIV and
AIDS, malaria and other diseases – remains the aim of successive national strategic
plans in Mauritius. The National Strategic Framework (NSF) 2007–2011 has been
conceived to respond to the findings of the Biennial UNGASS report 2005, the
Universal Access consultative meeting hosted in February 2006. The government
endorses the Three Ones Principles, which guides the effective and efficient use of
resources in response to the epidemic at national level.

12
In 1997, the Ministry of Health and Quality of Life established the National AIDS
Control Programme (NACP) in order to provide guidance for national HIV and AIDS
responses, and has subsequently developed and implemented several consecutive
national and regional plans. The National Day Centre for the Immuno-suppressed
(NDCCI) at Bouloux Area Health Centre, Cassis, was established in 1999, to offer
specialist care, treatment and support services to people living with HIV. These
services include providing antiretroviral therapy (ART), treatment for common
opportunistic infections, voluntary counselling and testing (VCT), prevention of mother-
to-child transmission of HIV (PMTCT), and post-exposure prophylaxis (PEP). During
the same period, services at the Central Virology Laboratory were also upgraded to
cater for the epidemic.

In 2001, Mauritius elaborated its first multi-sectoral HIV and AIDS response framework
for 2001-2005. The AIDS Unit of the MOH&QL served as the Secretariat to facilitate
the implementation of this framework. The chairmanship and coordination of the Multi-
sectoral Strategic Plan 2001-2006, lies under the Prime Minister of Mauritius, and has
the support of all relevant line ministries and government departments. In 2005, a
situational analysis was carried out and validated in July 2006, paving the way for the
formulation of an Action Plan for PLHIV, which was integrated into the NSF 2007-2011.
The HIV and AIDS Act came about in December 2006, and is an important tool for
fighting the epidemic. The Act provides an effective legal framework for implementing
the Needle Exchange Programme and facilitates the full enjoyment of human rights by
PLHIV, by eliminating all forms of discrimination against them.

Civil society has offered valuable contributions to the national response to HIV and
AIDS. Institutions and organisation working within reproductive health and family
planning services, began mainstreaming HIV prevention activities into their core
agenda, and in 1996 a non-governmental organisation (NGO) “Prevention, Information
et Lutte contre le Sida (PILS)”, was established to specifically address HIV and AIDS
issues on a national scale. The main thrust of civil society has been to: ”drive epidemic
related regional and national networking and lobbying; address related illicit drug use;
empower PLHIV; scale-up the involvement of young people in the response to the
epidemic at community level, and engage the media fraternity in mass awareness
raising. The Mauritius Family Planning and Welfare Association (MFPWA) and Action
Familiale, the leading civil society organisations in Sexual and Reproductive Health and
Family Planning, developed strategies to promote awareness and prevention, targeting
youth, women and workplaces.

4.3 Methadone Substitution Therapy for Injecting Drug Users

Methadone is a synthetic opioid, typically administered orally as a liquid. It is the
medication most commonly used in substitution therapy for opioid dependence.
Methadone maintenance treatment is also an extensively researched treatment
modality. There is strong evidence from research and monitoring of service delivery,
that substitution maintenance therapy with methadone (methadone maintenance
treatment), is effective in reducing illicit drug use, mortality, the risk of the spread of HIV
and of criminality and in improving physical and mental health and social functioning.
Furthermore, higher doses of methadone are associated with greater reductions in
heroin use than either moderate or low doses. Methadone maintenance treatment is
associated with a low incidence of side-effects and with substantial health
improvements. Around three-quarters of people who commence substitution
maintenance therapy with methadone respond well.

13
Methadone Substitution Therapy is harm reduction-oriented, and the only criteria for
inclusion in MST must be a definitive diagnosis of opioid dependence. As methadone
substitution therapy enters its fifth decade, opioid treatment programmes (OTPs) are
drawing from lessons learnt from past successes and failures to continuously improve
the method. Since its inception, MST has reflected an increase in understanding, an
increase in skills and standards, the retreat of stigma and greater interest on the part of
physicians, as the method becomes the norm for OTPs. However, today’s methadone
patients differ from those of the past, as the HIV and hepatitis C epidemics have
brought additional complexity to the treatment. Provision of MST Services to IDUs
living with HIV is not an option in Mauritius - it is a “ Must Do”.

There is scientific evidence that substitution maintenance therapy is a cost-effective

treatment modality, comparing favourably with other health care interventions, such as
medical therapy for severe hypertension, or for antiretroviral therapy (ART). MST has
proven effective in terms of retention in treatment, reduction of drug use, improvement
of psychological and social functioning, and reduction of high risk injecting and sexual
behaviours. Thus the MST programme in Mauritius is being given serious
consideration as an HIV prevention measure as well as a programme for individuals
with opioid dependence who are already infected with HIV, to enable them to minimise
the risk of further transmission of HIV, and to stabilise their underlying condition.

14
5. A “Ray of Hope” for Injecting Drug Users in Mauritius
“This methadone (programme) has given me hope, I am now 46 years old and
have been using heroin and other drugs since I was 13 years old, and nothing
has helped me. I have been to prison many times and now I am paralysed and
I have HIV. But this programme is my ray of hope, it has changed my life. I now
have my wife back after so many years, and people are looking at me and
seeing me as a human being. I have the hope and happiness to live life again,
and forget the hell that drugs had put me in”
– 46 year old MST programme client

The aim of the Methadone Substitution Therapy programme in Mauritius is primarily to

treat drug abusers using an oral form of opiate (methadone), thus preventing the
transmission of HIV infection through injecting drug use. The programme also aims to
project the improvement of the quality of life of IDUs as a human right. An anticipated
proxy impact of the programme is the reduction in drug-related crime in the country.
The MST programme aligns with the focus of the Mauritius National HIV and AIDS
strategy and specifically allies with its harm reduction and prevention approaches. The
MST programme currently managed at the Detoxification Centre at Barkly, is in its pilot
phase, and in its ten month lifespan has recruited over 1,000 clients.

5.1 Programme Start-up

Mauritius launched its MST programme in November 2006 and piggy-backed it on the
leverage offered by other country MST experiences: lessons learnt, challenges and
successes and adoption of a programme suited to its specific environmental context.
While the programme was launched in an ‘emergency response’ fashion, managers
and implementers engaged in regular programme-component audits, reviewing
progress and timely identification of anomalies. Steps were also taken to prepare the
necessary cadres for managing the programme and establishing structures to support
its operation.

An overview of the steps towards the programme highlights the following events:
• In 2001, glimmers of the MST concept appeared. A handful of clinicians
working with IUDs, mindful of the looming hazard injecting drug use would
have on the country’s HIV epidemic, joined up with PLHIV, to embark on
mass media activities, targeting the general population as well as political
leaders. This advocacy stance was based on extensive research and
experiences gained by experts in the country.
• In 2004, outcomes of a Rapid Assessment Report of Substance Abuse in
Mauritius, further reinforced the need to urgently tackle the IDU problem
using an effective intervention method, such as methadone or
buprenorphine.
• In 2005, the United Nations Office on Drug Control (UNODC) held
deliberations with the government of Mauritius, to prompt the
operationalisation of the MST programme
• Findings and recommendations from the above assessment, coupled with
the advocacy efforts, secured the necessary political backing to establish
and embark on the MST programme in Mauritius, through Cabinet approval
in February 2006
• The MOH&QL then consulted a series of international experts and received
extensive technical guidance, as a prelude to the establishment of the MST
programme.

15
 • In 2006, an external assessment of the organisations and centres working in
the field of drug abuse treatment; as well as of general health facilities on
which the programme would be based, was conducted to ascertain capacity
gaps and strengths
• A follow-up to this was the holding of consultative meetings and induction
sessions with personnel from the National Agency for Treatment and
Rehabilitation of Substance Abusers (NATReSA), the Pharmaceutical
Services, the AIDS Unit and other relevant departments and committees in
the MOH&QL
• Expert training workshops were hosted in 2006, for over 80 medical and
para-medical personnel, including physicians, nurses, psychologists,
pharmacists and dispensers, staff from the AIDS Unit, as well as
rehabilitation officers, on:
o management of opiate abusers and prescription of methadone
o possible problems and challenges posed by prescribing
methadone
o examples of Best Practices and lessons learnt from similar
interventions in other countries, and strategies towards
adaptation of the intervention within the local cultural and
developmental setting
o principles of risk minimisation and practical application in
prevention and care work, related to the MST
• A sound procurement and dispensing system was established
• The establishment of policy frameworks and guidelines for the introduction
of an efficient and cost-effective MST programme for opiate abusers in the
country, was guided by various regional and international documents and
standards
• The National Detoxification Centre, also known as Barkly Centre, was
identified as the centre for client induction into the programme.

5.2 Programme Description

The MST programme involves three major stages (selection and recruitment; induction
and follow-up), which not only address the IDU problem, but systematically integrate
HIV and AIDS responses.

The overall management of the programme is in the hands of the MOH&QL and a
special committee that reviews the programme at least monthly. The daily
management of the Detox Centre is by the MST Programme Manager and a team of
expert nurses, doctors, clinical psychologists and other support service
representatives. Management of the induction phase is primarily carried out by the
Detox Centre management team. The selection phase is done by the NGOs and is an
out-patient exercise, while the induction phase takes place at the Detox (Barkly)
Centre, as an in-patient activity, while the final phase (follow-up) is an outpatient
activity, that involves the methadone distribution points, managed by the chief
pharmacist, as well as NGO visits, and is overseen by the NGO management teams in
collaboration with the MST Programme Manager.

The three phases of the MST programme involve:

¾ Selection and recruitment (of clients for in-client methadone induction). This is
carried out by non-governmental organisations (NGOs) operating under the
National Agency for the Treatment and Rehabilitation of Substance Abusers. A list
of clients who have voluntarily expressed interest in the programme, is submitted
by the NGOs to NATReSA for screening and co-ordination, prior to the submission
of the final list to the National Detoxification Centre (NDC).

16
 IDUs voluntarily express their interest (self-referral) in joining the programme at the
substance abuse NGO session they attend.

During this six-week phase, the following activities take place before a client is
accepted into the programme:
• Interested clients are given a thorough overview of the programme, what it
entails and the conditions for staying in the programme
• Regular sessions are held with the client and his family to address the
above. Attendance by family members is a ‘must’. if attendance by either
client or family members falters after two sessions, that client will not be
considered for the current in-take
• Acceptance of the client’s participation by family members has to be
ascertained, to ensure that on completion of the induction process, the
family will continue to play a supportive role in facilitating the client’s re-
integration into society
• The seriousness of the client’s determination to commit to the programme
is assessed

¾ Induction
This is an in-client phase lasting 14 days. Initially, it lasted 21 days, but it was found
to be just as effective within 14 days, and this was adopted as a cost-reduction
strategy.

Following a thorough assessment of the client and urine testing, they are started on
a low dose of methadone. Over four to six hours and reassessment,, a second
dose is administered depending on the presence of withdrawal symptoms. For the
next four-to-five days, titration of the dose of methadone is carried out until an
optimal dose is reached, where the client feels reasonably comfortable and is free
of withdrawal symptoms.

During this phase, ancillary support services are availed, including: services of a
medical doctor, 24 hours a day, of a social worker, of psychosocial support, as well
as development of negative peer resistance skills; HIV voluntary, confidential,
counselling and testing (VCCT) services; awareness raising on healthy eating
habits; and HIV education.

It is during this phase that other services are integrated, primarily focused on HIV
prevention, positive living and impact mitigation of AIDS, and appropriate referrals
begin to take form. Access to these services is free and they include:
• HIV related (clinical services and health education)
• Nutrition education
• Psychology and psychiatric sessions
• Social etiquette and social rehabilitation sessions (social worker)
• Treatment for opportunistic infections
• Dental care

The integration of these ancillary and HIV and AIDS services in this phase, is
particularly beneficial for clients, and creates a critical link between the dual
responses to IDU and HIV prevention, care, support and treatment.

17
¾ Follow-up
Once the induction phase is complete, clients are stabilised on a fixed dose of
methadone, and referred back to the NGO which originally referred them for follow-
up rehabilitation and psychosocial support. Clients collect their daily dosage from
one of fiive dispensing units, established at the level of regional hospitals.
Dispensing is done under the direct supervision (DOTS) of staff present at the
dispensing point.

During this phase, clients are expected to attend sessions every two weeks at the
substance abuse NGO they access. Families are involved in this process and their
concerns and feedback are noted for prompt pre-emptive action. A ‘flying-squad’ is
in place to conduct regular community outreach, follow-ups and random urine tests
during this phase. The substance abuse NGOs also support clients in looking for
and securing employment, and advises them on starting income generating
projects for economic sustainability - relevant referrals and recommendations of the
client are also made in this regard.

The details of the programme implementation are embedded in the MST

programme Protocol on Co-operation between the MOH&QL and the Ministry of
Social Security, National Solidarity and Senior Citizens Welfare and Reform
Institutions. The three main NGOs involved in referral and follow-up support of the
MST clients, are: Dr. Idris Ghoomany Centre in Port Louis, Sangram Sede Sadan
Centre in St.Paul, and Cassey Help de addiction in urban Port Louis, which are all
Day Care Centres for IDUs.

Programme funding is entirely government based, and is managed primarily by the

MOH&QL. The programme currently reaches only male IDUs, as there is no
infrastructure available for the female IDUs during the in-client (induction) phase. In
Mauritius, female clients may only be seen by female clinical staff, and
infrastructure needed for the induction phase must be clearly differentiated from
that used by male peers. Clients between the ages of 18 and 60 years are
accepted into the programme. The programme could pose health problems for
clients over the age of 60, such as cardiac problems. Their ability to physiologically
tolerate methadone is also very poor. Methadone is also not scientifically
recommended for anyone below the age of 16. Much research was carried out to
identify the lowest physiological risk to clients, prior to setting these criteria.
The Barkly Centre is highly secured, for the protection of the clients, and also for
avoidance of infiltration by drug traffickers, intent on causing programme failure and
client-relapse. No uniforms are worn by staff – to create a relaxed environment and
remove barriers between staff and clients. This measure has been proven to place
clients at their ease.

(Left) Figure 2: Staff at Barkley

Centre – implementers of the MST
programme

(Below) Figure 3: Clients during the

Induction phase at Barkly Centre

18
5.3 Elements of a Best Practice

“ One client, I remember well, his wife came looking for me one day and in
tears, expressed her deep gratitude for the programme. She was now seeing
her husband arrive home for the first time in over 12 years, not high on drugs.
There was not one day in the past decade that he had not come home high on
drugs. Instead, he is now bringing home food and money.

Another success story that comes to mind is that of a man who had injected
heroin everyday for the past 35 years, and he had tried many ways to stop, and
nothing had helped him. It is now a straight month that he has not injected and
has no desire to inject.

As I walk down some of the city streets (Port Louis), I see clients from the
programme now making a decent living – simple, but at least decent – as
vendors, or having started small income generating projects that reach out to
other IDUs, and also provide for their families”
– Manager of Barkly Centre

Multiple facets of the methadone substitution therapy programme in Mauritius

demonstrate its credible documentation as a Best Practice in HIV and AIDS
programmeming in the SADC region, as per the seven SADC criteria.

Of specific note is the programme’s sensitivity to HIV positive clients, who are given
preference during the selection phase and specialised attention and support during
both the induction and follow-up phases. During the exit interviews at the induction
phase, the opinions of HIV positive clients are given great consideration during
management decision-making, thus displaying the programme’s active efforts of
applying the principles of meaningful involvement of people living with and affected by
HIV (MIPA). HIV positive clients who have disclosed their status are encouraged to be
‘client supporters’, for those who have not disclosed or who have recently disclosed,
their HIV positive status.

Interrogation of the following facets of the MST programme in Mauritius, reflects the
credibility of the MST programme in Mauritius as an HIV and AIDS Best Practice.

1) Effectiveness:

“This programme hits at the heart of our social problems, it takes care of the
drug abuse problem and lowers the risk of HIV transmission, unlike previous
programmes that had less realistic or lasting effects and focused only on
education and awareness raising. We can see change now.” – MOH&QL
personnel

“ This is a MAGIC (methadone therapy)” – shared by four clients from

different substance abuse NGOs

The MST programme was designed in congruence with existing national responses to
both injecting drug use and the HIV epidemic. Its objectives are clear and they align
with the overall goals of the National Strategic Framework (NSF) 2007 – 2011, and
strategic objectives 3, 5, 6 and 8 under this framework.

Though the programme is in its infancy, some effectiveness has been identified at
community level and among clients who have passed through the programme. Initially,
the larger community was highly sceptical of the value of introducing an MST
programme for IDUs, given the gross stigmatisation of drug abusers.

19
However, the manifestation of rapid positive change in the lives of IDUs who had
entered the programme, has brought about significant community acceptance and
support. Without community support and integration, the long-term efficacy of any
developmental programme that targets social ills, remains at risk. Contributing factors
towards this transformation in community perspectives included:

• the advocacy role that programme clients adopted within their environments,
and
• the engagement of clients’ families in the programme’s implementation.

“My son does not steal anymore. I had been locking everything in the house
for years and years. Now I can leave everything open and feel free, he never
takes anything and has taken a simple job, with little pay, but at least some
money. And what makes me even happier is that he is using his pay to take
care of his wife and child as well. He even bought a new pair of shoes for
himself. My son never used to buy anything and was always dirty and using
very old things. Now he is looking so smart.”
– a tearful, yet proud, mother of a client who entered
the programme six months prior to the interview

The programme has contributed to a reduction in recent illicit drug-related arrest, and
thus in crime rates (theft for money to buy drugs, drug trafficking, drug abuse-related
sex work), with an average of 6,000 arrests annually, versus the reported 200,000 per
annum noted in the IDU Status Rapid Assessment Report of 2004.

Given the high vulnerability of IDUs to HIV infection, the programme is reducing the risk
both to the IDUs and to the wider population of Mauritius with whom IDUs interact. It is
also carrying out HIV awareness and prevention measures for the families of IDUs and
encouraging the uptake of VCT.

2) Ethical Soundness:
The primary target audience and beneficiaries of the programme are injecting drug
users. This simplifies target plans. However, targeting sub-groups of IDUs, such as
prisoners and sex workers is as yet at a basic level, and plans are underway to
mobilise resources to cater for these high risk (injecting drug use and HIV
transmission) groups, as a human rights response.

The programme capitalises on volunteer interest by IDUs, and is not based on

mandatory or manipulative approaches. The concept of confidentiality is adhered to
across all programme phases, from both the drug user and HIV perspectives. All client
records are kept secure and are handled within confidentiality protocols.

“ No, no, I was not forced into this, I heard about this new programme from
the television when it was being started and I thought maybe it will hel,p so I
came and asked to be registered. We are not forced to do anything. But if we
do not take our dosage for some time, we will need to stop the programme.
And that is a rule for our benefit and it is very good.” – client in the
programme, eight months after entry

“ Here (Barkly Centre) we are treated with so much kindness and respect. I
never had this in the community for more than ten years now. Everyone,
even the police always found a reason to hit me or insult me like an animal.
When I came here, even when I am being difficult, the doctors and nurses
are really kind and they listen and want to help our minds, not just our drug
problem” – client in induction phase at Barkly Centre

20
 “We have freedom of expression – it is here [substance abuse NGO, within
the follow-up phase of the programmem]) that we can share how we feel and
we can trust” – client in follow-up phase of programme

HIV positive clients who express interest in joining the programme are given first
preference, as long as they fulfil the conditions of the selection and preparatory phases
of the programme. Their HIV status remains confidential, while counselling to
encourage either whole or partial disclosure, is intensive.

Some clients are of varied sexual orientation (among them men who have sex with
men) but this information is treated with confidentiality and clients’ specific information
needs are addressed by staff during the critical induction phase.

3) Cost-effectiveness:
MST has proven cost-effective in the long-term. The introduction of this programme in
Mauritius builds on this evidence. Opioid dependency treatment is effective in reducing
illicit opioid use and its associated health and social costs. Treatment is considerably
less expensive than the alternatives, such as not treating people with opioid
dependence, or imprisonment. According to several conservative estimates, every
dollar invested in opioid dependence treatment programmes may yield a return of
between USD4.00 and USD7.00 in reduced drug-related crime, criminal justice costs
and theft, alone. When savings related to health care are included, total savings can
exceed costs by a ratio of 12:1.

The programme has taken an integrated approach and seeks to address IDU needs
beyond their addiction, incorporating social etiquette needs and gaps in information on
HIV, and nutrition. This strategy avails multiple service provision to clients, under one
framework of programmeming, thus improving the overall quality of life of the IDUs who
access the programme’s services. Once a client enters the programme, follow-on
service provision is timely and consistent.

At implementation level, regular programme audits (internal) by the MST programme

implementers and managers has enabled identification of areas for cost reduction
without compromising service quality and availability. Though the current distribution of
resources for the programme is not reaching all who need it (Women IDUs and
prisoners), restructuring and expansion plans are being drafted to address this. The
programme has massive potential for a multiplier effect of programme service provision
and this has been recognised by both implementers and policy makers.

4) Relevance:
The shift in HIV transmission from heterosexual to IDU transmission, implied that
national and community HIV and AIDS-related interventions needed to make a similar
shift. The introduction of the MST programme in the country has been key in shifting
HIV response strategies. Having secured both political and traditional leadership
commitment and community support, the programme’s objectives are responding to the
social challenges prevalent in communities in Mauritius. The relevance of the
programme is manifest in the overwhelming demand for services by IDUs, and their
families.

“The IDU issue in Mauritius had reached a dangerous level, and if this
programme had not been introduced when it was, we could have been facing
a massive HIV problem in the country, especially in our prisons. I am looking
forward to see it grow and grow and reaching all drug users in this country” -
staff member at MOH&QL

21
The relevance of the programme was reinforced by clients:

“At last we have something that is taking care of our heroin problem and also
other problems we have developed because of the drugs, like losing our self-
esteem, and our ability to take care of our appearance and future needs and
of our families. This methadone (programme) is helping us to be ‘proper’
people in our communities again” – male client in programme

“ I was tired of being treated like a dog, and I could not stop myself (from
injecting heroin). And also the abuse from the police, they were always
beating us, even if we are doing nothing wrong. I lost my wife to a policeman
after he arrested me and sent me to prison. But now I am getting my wife
back and my life will be better” – client in programme

“ This programme will help me to save my money, and have better health,
working as a good human being not getting arrested. I want to give a good
example to my children – they need a good father. Now I am happy because
I can be that, after such a long time living in a hell of heroin” – client in
programme, father of two children and previous prison detainee

“They have taught us (through the programme) how to act properly again in
public. I can now SMS (short message sending on mobile phone) my
girlfriend and be romantic and I look forward to getting married. My friend he
now talks decently and he is not rough and loud when we go out to places.
People now see us properly “ – young male client in programme

“The government has taken a good decision on giving us this programme,

Thanks be to God” – client in programme

Although the programme has not as yet been extended to female IDUs, its relevance
for this group is clear.

Meanwhile, the programme has also manifested its relevance to HIV positive and at-
risk IDUs, through the services offered during the induction and follow-up phases that
continue providing support to HIV positive clients, in terms of timely and appropriate
referral, as well as treatment support.

The programme’s ability to overcome the widespread stigma against the integration of
IDUs into society, and to drive forward the programme’s objectives, is relevant to any
HIV and AIDS-related intervention that other countries in the region endeavour to
introduce into their communities.

5) Replicability:
The programme has been socially and culturally accepted and adapted to the country
context, taking into consideration, various environmental factors. The programme’s
clinical elements are well-documented, making it simple for clinicians from other
programmes to adapt it to their own context. With regular internal monitoring, the
programme has identified various areas for scale-up to ensure that it is effective and
that plans are in place to:

• renovate the Barkly Centre wards to include female facilities and help promote
service delivery to female IDUs
• expand infrastructure at the Barkly Centre to accommodate additional clients,
per each induction phase

22
 • promote further consultation and lobbying of UNODC, WHO and UNAIDS for
additional capacity building, so as to widen the pool of skilled personnel to roll-
out the programme, in response to the identified demand
• increase methadone dispensing points to alleviate potential overload of existing
dispensing points, and to ease travel logistics for clients, many of whom are
currently unemployed and not receiving timely welfare support to facilitate daily
travel to dispensing points, distant from their areas of residence

The programme’s multi-disciplinary approach presents a practical model for regional

programme adoption, that seeks to address multiple social ills using the mainstreaming
of one core problem, in this case injecting drug use.

Figure 4: Family and Community

members sharing perspective on
the MST programme, Port Louis

Figure 5: Focus Group

Discussions with the MST
Programme Clients from the
Substance Abuse and PLHIV
NGOs, Port Louis

6) Innovativeness:
In Mauritius, the MST is a new approach to opiate treatment, and to date, its
implementation has revealed its adaptability to the Mauritian context. Programme
implementation is based on scientific grounding and is contributing to the body of
knowledge on drug dependency responses in the country. The programme
implementers at Barkly Centre are constantly alert to opportunities for adapting the
programme’s elements so as to improve cost-effectiveness.

A unique way in which the programme reaches the IDU population, a population that
often exists underground, is through the programme’s clients and their families, who
adopt a peer advocate role on entry into the programme, and advertise the benefits of
the programme with other IDUs in their neighbourhood.

23
 “ We are now telling others who used to be part of our group that they can
now come and get help, and we push them to do this, really, we must do this
because our problem is a big one and we want our lives back, and want to
see others also get this methadone”
- 24 year-old programme client

“ This has changed the life of my son, he has become so responsible and
polite now, and I have been telling the other mothers in my church so that
they can send their son’s here , even though they are still hiding their drug
problem. This is a real source of hope for us. We have suffered too much”
– aged mother of programme client, who was a heroin user for
over 15 years prior to entering the MST programme

The programme has taken into consideration various religious and cultural issues. A
recent example has been the adjustment of times for collecting doses, to accommodate
Muslim clients during their fasting period (dispensing time moved from 6am to 4am).
While this had huge implications for service provision logistics (as the daily methadone
dose administration is DOTS), it was creatively managed to enable adherence to daily
dosage by fasting clients.

Expansion of its initially IDU-specific services to include referral and ancillary services
that provide an all-inclusive package for injecting drug use, HIV, nutrition, psychosocial
and STI services, illustrates the creativity and multi-disciplinary pattern of the
programme roll-out. The majority of clients who entered the programme were
previously unaware of their HIV status, while those who knew they were HIV positive
were unaware that they could access free antiretroviral treatment at the National Day
Care Centre for the Immuno-suppressed (NDCCI) in Bouloux. The programme has
played a key role in linking HIV positive clients to HIV VCCT and ART services and
follow-up schemes.

7) Sustainability:
Programme ownership by the community, and especially by the programme’s
beneficiaries – the IDU population – is apparent. The community’s acceptance of the
programme is significant for its sustainability, since it influences service demand, as
well as the desired outcome of social integration of clients who enter the programme.

Though current staffing complement at Barkly Centre is meagre – presenting the risk
of burn-out – efforts to facilitate skills transfer is taking place and funds have been
secured by the MOH&QL to broaden the human resource base to match the supply-
demand increase anticipated during programme scale-up. The enthusiasm and
dedication displayed by the programme implementers offers a sound base for the
programme’s sustainability as well as its long-term success.

All funding for the programme is channelled through the government and audits and
finance reporting is conducted by the national auditing structures, with little involvement
of implementers. However, the latter do have platforms for influencing and informing
programme-related financial decision-making and forecasting.

Marketing and awareness raising around the programme is primarily done by the IDU
population itself. This is a unique aspect of the programme, and is a cost-beneficial
strategy, as peer-to-peer influence yields a higher and speedier response, than service
provider-to-beneficiary approaches. Where the media has been employed for
programme marketing, language and all other awareness-raising modalities should be
appropriate and should send the correct, consistent and appropriate message based
on the facts and realities of the country.

24
5.4 Key Programme Successes

“ This is the first methadone intervention launched successfully in Africa,

which may have a small IDU population compared to Asia, the Middle East
and other regions, but still this is unique”
– clinical doctor in Mauritius

The establishment of the programme, with evident political and community commitment
in its execution, is in itself evidence of the success of the programme. Launching a
programme of this nature, given that it requires guaranteed provisions for sustainability,
and in the face of widespread stigma against the channelling of large amounts of
resources (both human and financial ) into a programme for drug abusers, is by no
means a simple task.

“A foot in the door is success in itself. Policy makers and community

members alike are convinced that putting all this money into IDU reform is
not a waste and the initial outrage at the idea, has now been converted into
active support for the programme’s success”
- a member of the Mauritius National AIDS
Secretariat (NAS) management team

Another success at a macro-response level, is that through participation in the MST

programme, IDUs in Mauritius are now presented with opportunities for screening,
counselling and referral for additional health services, beyond opioid treatment.
Although the Methadone Substitution Therapy programme in Mauritius has been in full
operation for less than 12 months, there have been notable successes within this
period, which should be viewed as key factors for sustainability and replicability by
future programmes.

IDU Reform has become a Reality

Following the implementation of various initial OTPs, which did not avail heroin users a
holistic and sustained rehabilitation package, the MST programme has evidenced
significant positive change in the lives of Mauritian heroin users. The programme has
facilitated psychosocial and economic relief, and stability for IDUs and their immediate
families, on a scale that previous OTPs in the country were unable to attain. Many
IDUs have begin engaging in income generating activities – providing for their families
and manifesting responsible social behaviour. In certain pockets of society, this has
contributed to a reduction in IDU related stigma and discrimination, and IUDs
previously treated as outcasts have been reintegrated into community life.

Families of clients specifically highlighted how the clients had changed their deviant
behaviour, and following the programme, how they had become more trustworthy and
responsible with family assets.

“ I see him [grandson] as a patient who needs my love and he will get better,
especially now that he is on methadone. He is polite now, and clean, and I
don’t cry so much, for worrying about him” – grandmother of male client

“ I have known all drugs, there is no drug I have not taken, since I was 15
years old. I tried to stop, and even tried to kill myself, but I loved my drugs
more. I was a slave to them. But now I am happy, I can change and be a
good person in my community. I can love my wife and children. They have
suffered so much “ – 41 year old client

“ He [client] is now a better son. It has been hard for my wife and me. We
had to rush every morning and look for 200.00rupees so he can get his

25
 drugs. Otherwise he would get angry, what could we do? Now we are able to
look forward to his future, and he will marry one day” – father of client

The comprehensive package offered by the MST programme has instilled high levels of
hope and determination within IDUs for adopting a “new life”, free of drugs. This was
evident throughout the documentation process and was testified to by clients, their
relatives, and service providers, at both the IDU day care centres, and at the Detox
Centre. Many IDUs, having gone though previous opioid therapy programmes, and
having failed to rehabilitate, had resolved that drug use rehabilitation was not an
attainable reality. The outcomes of the MST programme have reversed this attitude,
resulting in an overwhelming demand for the programme’s services.

Responses to Injecting Drug Use and HIV - Synchronised versus Parallel

The dual response framework of IDU interventions and the response to HIV via the
programme, is both unique and integral to its success and sustainability. The
programme has taken full cognisance of the critical links between the two epidemics:
drug abuse and HIV, and has integrated HIV prevention, care and support efforts within
the MST programme.

Acceptance by IDUs that they have a ‘drug problem’ is a vital step on the road to
seeking treatment. Through the programme, a second crucial step is encouraged
among those living with HIV, that of status disclosure, of post-testing.

“ I did not know that I can get treatment for HIV, and now this programme is
helping me stop heroin and also to get treatment from Boloux and I feel
healthy and ready to live again” – HIV positive client in programme

Client engagement in Programme Dynamics

Clients who enter the programme, are engaged within a rights-based context at all
stages of the programme. Recruitment is voluntary and involves a thorough induction
process that systematically informs clients – and their families – of the components,
expectations and possible outcomes of entering the programme. Clients are placed in a
responsible position during the programme, and during the follow-up period, are
integrated into advocacy and peer support structures by NGOs whose focus is injecting
drug use.

“ They (programme implementers) shared everything so openly with me and I

now have learnt a lot and know how to stay in the programme, and they
discuss everything with us and listen to us and want to help us be better
people” – client in programme

“Because I am consulted always, I can also learn more and then tell others
the facts because many are saying lies about this programme and do not
know the facts about methadone” – client in programme

“ I must stay in this programme, I know I will. Because if I don’t then I go back
to my life of hell, and I will be living a dangerous life, always scared of getting
arrested and trying to find money for the drugs and no one wanting to love
me or give me a job. I am staying in this programme and will do everything
needed. I come to my sessions and take my dosage daily” – a programme
client determined to change

26
Breaking a Dual Silence
The MST programme approach has provided a dual avenue for acceptance and
disclosure, for both HIV infection and injecting drug use. It not only brings to the fore
the acceptance by IDUs that there is “a problem’ for which a solution is available, but
also encourages HIV testing of clients and subsequent referral for care, treatment and
support, and promotes HIV prevention awareness among those who are HIV negative.
A message of ‘hope’ has been generated by the MST programme, for IDUs, particularly
those living with HIV and who may be on treatment.

“ I can now share my HIV status and openly get my family to support me, as
now that I am not taking heroin I am able to help in the home and take care of
myself, my dressing and my health. Before I was always hiding and didn’t care
what I was eating and didn’t want to take my HIV medicines” – male client in
the programme, living with HIV

“They (IDUs who have accessed the MST programme) are now able to access
HIV services, and disclose to their relatives because they know how to live
positively now, and their adherence to treatment is supported more because
they are conscious of having a healthy lifestyle as they are no longer ruled by
the drugs (heroin)” – staff member at Barkly Centre

Implementers’ Positive Resolve

The dedication of implementers in the MST programme, is clearly apparent. During the
induction phase, having to manage the severe violence manifested during withdrawal
and non-compliance and the complexity entailed in the monitoring and administration
of methadone, is taxing on staff’s mental and physical well-being. Yet staff morale
remains high and peer counselling and de-stressing sessions are carried out to fuel this
dedication. Having witnessed first-hand how effective the MST is on clients,
implementers are determined to maintain quality service provision, since many have
witnessed the disappointments associated with previous OTPs such as abstinence and
codeine-based interventions.

“Here we learn to dress normally and be clean and we are treated kindly. We
are so happy with the staff” – client in induction phase attesting to
the positive demeanour of the Barkly Cente staff

“ We may not be getting much money and our work is very hard, sometimes
we are faced with a lot of violence by new clients, but we care and we know
that we must stay strong and they need our help.” – Barkly Centre staff
member

Figure 6: Clients sharing their hopes for the programme and their eventual social
integration

27
5.5 Challenges
As in all HIV and AIDS Best Practice interventions, areas for consolidation are
identified, to fortify the Best Practice and to assure continuity in its effective and
sustainable implementation. While the MST programme has had significant successes
and stands as an exemplary measure in its effective influence on the lives of heroin
drug users in the country, like any programme, it is faced with some challenges that
deserve attention from the management of the programme which also needs to test the
political will that drives the programme’s estimated sustainability.

IDU Waiting List for Service Access

Due to the overwhelming demand for this programme and the multi-disciplinary
services it renders its clients, the current waiting list for entry may be as long as six
months. If this challenge is not addressed promptly, it poses several adverse
implications, such as:
• Loss of interest by those IDUs on the waiting list, who are currently willing to
rehabilitate – the longer they have to wait for service access through the
programme
• Continued risk of HIV infection, transmission or mortality by wait-listed IDUs
• Community apathy towards the programme, as service delivery and access fail
to respond to demand

MST Access by Female IDUs

While the initial phase of the programme was designed to cater for male IDUs, the
gender imbalance among clients to whom the MST programme service is rendered,
calls for immediate recourse. This has been recognised by programme implementers
and management at both the Barkly Centre and MOH&QL. Currently, the programme
does not reach any female IDUs, and thus the female IDU population is clearly
disadvantaged. Often these are relatives of the male IDUs accessing the programme.
When male IDUs complete the programme and return to their homes, an IDU female
spouse may present a relapse risk, and counter the client’s efforts to remain
rehabilitated and to attain sustained social integration. In terms of HIV prevention
within the family and prevention of re-infection between partners, the exclusion of
female IDUs counters the efforts made by the MST programme, particularly where
female partners remain unconvinced of the need to practice safer sex or avoid
practices such as unhygienic needle-sharing.

Injectind Drug Use-related Stigma and Discrimination – A Counter to Socio-

economic integration
The Morality Certificate, carried by all Mauritian citizens, indicates whether one has been
charged with a criminal offence. IDUs, who have successfully completed the MST programme
and, who within the follow-up and rehabilitation phases, seek employment, often face gross
discrimination within the employment sector. Many IDUs have been charged with injecting
drug use-related criminal offences, such as theft, or possession of drugs or syringes, and this is
reflected on their Morality Certificates. Potential employers want to see these certificates prior
to engagement of an employee, and this often results in persistent unemployment for clients
who have undergone the MST programme. This leads to too much idle time for clients and to
resulting demoralisation which consequently places them at the risk of a relapse.

“ We want to work and we want to care for our families, but we are not given
jobs. You see, I was in prison and so when I go to look for a job they ask for my
Morality Ccertificate and then they see I was in prison and then I don’t get the
job. This is very hard for us, and for my friends as well” – client from first
batch of programme induction phase, 8 months into the programme

28
Scale-up of IDU Prevention Efforts
While the MST programme is primarily focused on the care, treatment and
rehabilitation of IDUs, there was evidence of minimal harmonisation with injecting drug
use prevention strategies at national level.

Programme Staff Burn-out

As the MST programme expands, there is need for ample and skilled human resource
provision at clinical and rehabilitation levels. Currently, implementing staff work long
hours and are driven more by dedication and commitment, than by remuneration. The
number of skilled staff allocated to the programme remains minimal, and raises the risk
of burn-out and expert-fatigue, which may potentially compromise the quality of service
delivery necessary for a programme of this nature. The concept of volunteerism, as a
backstopping service, remains unexplored.

Figure 7: Participants from the Best

Practice Documentation Training

5.6 Lessons Learnt

Following the challenges and successes gained in the past ten months of programme
implementation, various lessons have been learnt. These can act as information tools
for improved execution of the MST programme in Mauritius, as well as other IDU
interventions to be established in future. The following are some identified lessons
learnt:

Reinforcing MST Effectiveness

The programme has reinforced previously documented success stories of MST as an
effective opioid treatment option. Clients who had been IDUs for 20 years or more and
had explored various OPTs, yet failed to rehabilitate, have testified that the MST
programme has “made the difference they never thought could be made”. The
programme is well accepted by IDUs and its execution is viewed as systematic and
valuable. While previous OPTs had high relapse rates, the relapse rate for this
programme has been minimal to date.

Cost-effective Adjustments
Various adjustments have been made to the programme’s operations but without the
quality of service delivery being in any way compromised. These have been
necessitated either by the client or by the cost factor. These changes in logistics not
only enhanced service delivery for clients, but also cut additional costs for the
programme at the Barkly Centre.

29
IDU and HIV Interventions must Align
The programme proves that an opioid treatment programme such as the MST
programme can be effectively integrated with the national HIV and AIDS strategic
responses and directions – providing an all-inclusive package of services to a
population at risk.

Comprehensive Client and Family Engagement

The consistent and active engagement of clients throughout the MST programme, from
pre-programme entry through to post-programme follow-up, remains fundamental:
• for their own sustained rehabilitation
• as they represent a critical mass of advocates who stand as a force of change
within the IDU population, and
• as an HIV prevention and treatment adherence strategy

Over the duration of the programme, it has been realised that the systematic
involvement of IDUs and their families within all programme elements, contributes
extensively to its acceptability, effectiveness and eventual sustainability. The
involvement of the client’s family has played a key role in reducing injecting drug use-
related stigma and discrimination in the community, as well as in increasing the
acceptance of efforts made by ex-IDUs to rehabilitate.

Integration of Ancillary Services

As the programme evolved, the need for ancillary services became increasingly
apparent. These included provision of:
• HIV and AIDS education sessions;
• the services of a psychologist; and
• nutrition guidance and awareness raising

These programme elements were gradually and timeously mainstreamed into the initial
protocol of the programme and have the proven ability of fortifying the primary thrust of
the MST programme, especially in terms of injecting drug use rehabilitation, HIV risk
reduction and promotion of healthy eating habits for both HIV positive and negative
clients.

Crime Reduction: A Long-Term Cost-Effective National Outcome

Society as a whole, benefits from Substitution Maintenance Therapy, through
reductions in the incidence of criminal behaviour and in costs to the health and criminal
justice systems. There remains a strong case for investing in the MST programme, as
the savings extrapolated from treating an individual far exceed the costs. With the
reduction in the number of IDUs, the demand-supply chain of drug trafficking will
eventually fade.

“We want to stop taking these drugs, but we know that those who are
providing them to us are not happy about this Methadone programme
and they want it to fail so that they can keep making money.”, were
among strong sentiments raised by clients, indicating the strong push
towards reversing the positive impact of the programme. Additionsal
statements including: “That is why we are desperate to get jobs - then
we can fight them (drug traffickers) and prove that there is a solution
for our problem and bring others into this solution, till this devil’s habit
[drug abuse] is ended in Mauritius”, testify to clientele determination to
re-integrate as productive members of their community.

30
6. The Way Forward
“Drug users who do not enter treatment are up to 6 times more likely to
become infected with HIV than those who enter and remain in
treatment.” – HIV AND AIDS Action Plan for Injecting Drug Users

The quote above emphasises the ethical responsibility of the government of Mauritius
towards facilitating the expansion of the MST programme so it reaches the estimated
20,000 IDUs in the country. The MOH&QL in Mauritius has already acknowledged
many of the gaps and areas for redress shared through this document, and have
begun taking notable steps towards establishing mechanisms for resolving these MST
programme- related anomalies. However, to affirm the programme as a sustained Best
Practice, and an intervention that has evidently unveiled a tremendous opportunity of
hope for heroin users, the following propositions and recommendations are presented:

Urgent Expansion of MST to Vulnerable Groups

• Currently, the MST programme reaches male IDUs, who comprise the larger
percentage of IDUs in the country. However, there is need to urgently scale-up
service delivery to the female IDU population as well as the prison population.
The sex worker population in Mauritius consists primarily of females, over 70%
of whom are IDUs, demonstrating the vulnerability of this group to HIV infection.
Many IDUs are imprisoned because of their habit, while prisoners are at risk of
becoming IDUs because of the nature of their environment. Without the
presence of a needle exchange programme, the risk of HIV transmission within
this population is extremely high, and expands to the rest of the community,
upon their release from incarceration. Meanwhile, deeply entrenched social
standards marginalize sex workers, prisoners and ex-prisoners and seriously
limits their access to quality health service. Through the MST programme, these
barriers to IDU and HIV services will be removed.

• It is is proposed that the MOH&QL and the Office of the Prime Minister, revise
the MST Protocol to involve a gender sensitive approach to the programme’s
execution and an expansion of the programme to specifically vulnerable and
high-risk groups: women, sex workers, prisoners and institutionalised persons.

Establishment of a Systematically Operational Monitoring, Evaluation, Reporting

and Documentation (MERD) System
• The programme has a well-defined monitoring and evaluation (M&E) system for
its clinical components. However, its community and social reach necessitates
the establishment of clear and operational M&E tools and protocols that
facilitate regular and standardized data collection and analysis from clients and
community members at different stages of the programme and thus the
programme needs to be consolidated and regularised. Data collection and
analysis from the induction phase (Barkly Centre), the follow-up phase (drug-
abuse focused NGOs), through to management levels (AIDS Unit and NAS)
needs to be systematically conducted. Timely documentation of programme
events, embedded within a methodical reporting framework is paramount to the
programme’s sustainability, especially its fiscal future.

• In the absences of the proposed regularization and standardized MER system,

and consistent documentation of the programme at each phase of
implementation, policy makers and implementers remain compromised in
making timely and informed decisions around the programme’s dynamics and
its sustainability. This is a proposition for the AIDS Unit and the Barkly Centre
management team

31
Social Reintegration Protocol
• Social integration of clients who have entered the MST programme is the most
critical stage of the programme, as it defines whether relapse or effective
societal integration takes place. With the continued inability of the majority of
clients to secure gainful employment, due to stigma and a criminal record
reflected on their Morality certificates, there is continued risk of relapse by
clients. Unemployment leads to idle time and psychological stress and fuels a
vicious cycle of temptation for clients to revert to drug use for lack of other
forms of social relief and occupation. Social integration strategies can be drawn
from other global experiences. However, in Mauritius, this process may require
legal review around employment, criminal recording and anti-discriminatory
laws, and their subsequent operationalisation.

• Revision of the national employment policy and anti-IDU stigma and

discrimination legislation, is a vital step towards establishing structures and
attitudes that facilitate the sustained social integration of clients who have
entered the MST programme and are determined to reform into productive
citizens. This proposition prompts intensive advocacy efforts by the NGOs
responding to substance abuse, NAS and the AIDS Unit.

Integration of Criminal Justice System

• The tension between law enforcement objectives and public health concerns is
often too arduous to resolve with regard to injecting drug use. Nevertheless,
both ethical principle and proven health practice designate that drug control
policies do indeed reduce HIV risk faced by IDUs, and that they should
therefore not be deprived of access to quality and timely health care, or to
sterile injecting equipment.

• To reinforce the effectiveness and sustainability of the Methadone Substitution

Therapy programme in Mauritius, thus ensuring client security upon post-
programme entry, it is advised that members of the criminal justice system
(including the police force and narcotic forces) be consistently sensitized on the
MST programme elements, their long-term societal benefits and the
expectations of how this sector will deal (non-harassing behaviours) with IDUs
who have reformed and seek social integration.

Scale-up of IDU prevention and stigma and discrimination programmeming

• While the MST programme is an effective OPT in the country, its integration
with injecting drug abuse prevention programmes is not evident. In the absence
of triangulation with prevention programmeming, the programme will only result
in an adverse outcome for illicit drug use, while causative factors remain at
play. Prevention remains the core of any public health and developmental
intervention. Strategies to counter IDU-related stigma and discrimination should
be embedded in prevention programmes, as they are aggressively scaled-up.
This is being proposed to the National AIDS Secretariat and the AIDS Unit of
the MOH&QL.

32
Programme Audit and Evaluation
• Conducting a mid-term evaluation of the programme would be beneficial for
both programme implementers, and the political commitment backing up the
programme. Findings from the evaluation exercise would serve as an evidence
base for moves directed towards informing sustainability strategies for the
programme. To reinforce these strategies, a financial audit of the programme is
also necessitated, and it should take into cognisance, the estimeated expense
of such an OTP, and the fiscal implications on its sustainability, once scale-up
has been effected.

Reinforce Clinical and Psychosocial Support

• The combination of heroin dependence and HIV infection can result in the
occurrence, and recurrence of particular HIV-related opportunistic infections;
the masking of HIV-related symptoms by substitution medication; and
interactions between opioid substitute medications and medications used to
manage HIV infection. IDUs are more likely to be non-adherent to their
antiretroviral therapy (ART) regimens. These facts demand assertive and
unswerving clinical and psychosocial address of IDUs on antiretroviral therapy,
and this should be reinforced in the training and refresher courses for staff
implementing the MST programme. By integrating additional ancillary services
that promote adherence to ART and medical follow-up, the programme will
contribute to slowing the progression of the HIV disease in its HIV infected
clients.

33
7. Conclusions
Opioid dependence is a complex condition that often requires long-term treatment and
care. No single treatment modality is effective for all people with opioid dependence.
Adequate access to a wide range of treatment options should be offered in response to
the varying needs of people with opioid dependence. Substitution Maintenance
Treatment is a dependable, safe and cost-effective modality for the management of
opioid dependence. Repeated and rigorous evaluation has demonstrated that such
treatment is a valuable and critical component of moves towards the effective
management of opioid dependence and for the prevention of HIV among IDUs. There
is mounting evidence that improved outcomes from opioid Substitution Maintenance
Therapy arise from timely entry into treatment, longer duration and continuity of
treatment, as well as adequate doses of medication. Individuals with opioid
dependence benefit from Substitution Maintenance Therapy through increased stability
and through improved wellbeing and social functioning. The MST programme in
Mauritius illustrates how feasible these prescribes are and it has realized meaningful
lifestyle reform, within a short space of time, among IDUs who have entered the
programme. However, for relapse prevention purposes, certain concrete mechanisms
for social integration, such as access to skills building and employment, as well as IDU
prevention and stigma reduction programmes, are paramount. People receiving
substitution therapy can make significant progress in their physical and emotional lives,
as well as in their relationships with others and their ability to contribute meaningfully to
their community and society at large. This has been evidenced through the Methadone
Substitution Therapy programme in Mauritius, where clients, their families and service
providers, can testify to how clients in the programme, have reformed and begun to
pursue meaningful socio-developmental lifestyles.

Provision of MST for opioid dependence is an effective HIV prevention strategy. Once
HIV has been introduced into a local community of IDUs, there is the possibility of
extremely rapid spread. Through the MST programme, IDUs in Mauritius are now able
to enjoy an OTP integrated with multi-disciplinary HIV preventive interventions and
services, as well as with those for the treatment and care of IDUs living with HIV. This
integrated approach presents valuable lessons in creating a dual response to IDU and
HIV in the country. The programme has taken notable measures to :
- Reach an “underground” population at a rapid rate in a short period of time, thus
generating large numbers of IDUs demanding MST and loyal to the programme
- Establish clear protocols and systems to ensure procurement, administration and
monitoring of methadone
- Engage a pool of diversely skilled staff, including psychologists, clinicians with
experience in managing IDU clients, social workers, and community mobilisers – in
an integrated fashion that addresses IDU needs beyond their mere drug addiction
- Avail skills, through training, to health care staff primarily managing and
implementing the MST programme.
- Ensure that clients are better informed on the new OPT and are actively engaged
in their own treatment regimes
- Create a pool of long-term MST clients who can function as treatment allies to
health practitioners, and as effective advocates for their fellow clients
- Promptly establish counter strategies where programme anomalies are identified
during the programme roll-out
- Respond to co-occurring addictions, such as Subotex injecting drug use
- Engage the community, in particular families of IDUs, in the programme dynamics
- Closely integrate the programme with civil society services for drug abusers in the
country
- Identify expansion needs, and areas for cost-effective adjustments throughout
implementation

34
The Methadone Substitution Therapy programme in Mauritius, is a unique OTP, which
has successfully instilled a sense of trust, hope and determination to rehabilitate
among the general IDU population. This is a strong indication that relapse levels will be
significantly lower than OTPs introduced previously. It is successfully integrating a
variety of other disciplines in service provision and awareness raising for the IDU
population, including HIV testing, treatment and care services, and nutrition awareness.

In summary, the MST programme’s effectiveness, demonstrated in the rapid and

positive changes that have occurred in the lives of IDUs who had entered the
programme, has brought for it, significant community acceptance and support. In
addition, the programme has contributed to a reduction in recent illicit drug-related
arrests and crime rates. The programme is ethically sound in that it takes account of
the varying sexual orientation and treats patients’ matters with absolute confidentiality.
Efforts to encourage disclosure of HIV status are also being done in an ethically
acceptable manner. Those areas in which it is lacking (treatment of women and other
marginal groups such as prisoners) have been identified and plans are on hand to
address them. The programme has been applied in a cost effective manner and its
integrated approach has had the effect of reducing expenditure by the state on other
related aspects of opioid dependence. The programme has also been applied in a
flexible manner that has seen cost reductions without impacting on effectiveness.

The programmes’ relevance is without doubt and it has widespread support both from
political and traditional leaders and also within the communities themselves. Its
integrated approach to HIV and MST has had the effect of reducing stigma against
both the HIV positive and IDU populations. The programme has been well documented
and includes challenges faced and solutions adopted, allowing other countries to
replicate it in a manner appropriate to their own environments. The programme is
innovative in that it involves the IDU’s family in the treatment, ensuring community buy-
in as well as appropriate support for the client. In addition, the programme has adopted
changes to improve cost-effectiveness (in reducing the live-in phase of the programme)
and has been adjusted to fit in with clients’ specific religious needs. The expansion of
the service to take into account the full range of needs and its integration of HIV care
and prevention strategies, is also a significant innovation.

Because the programme has proved cost-effective and enables IDU’s to return to their
communities as productive members, it is popular and therefore sustainable, and has
IDUs and their families advertising the programme themselves. Its effect in reducing
costs in other areas of government expenditure and in improving social conditions by
reducing drug related crime are also aspects which will encourage government to
sustain the programme. Plans are in place to ensure additional human and
professional resources, the lack of which represents the most serious threat to the
programme’s sustainability. The Mauritius MST programme meets all the SADC criteria
for a Best Practice and it can be replicated in any SADC country, where it is required,
whether on a small or large scale. As seen, HIV transmission via injecting drug use can
quickly overtake heterosexual transmission as the primary means of transmission if the
infected IDU population reaches a critical mass.

The vision of this document is to inspire other countries and programmes to

reciprocally mainstream HIV and AIDS related services and drug abuse response
services into their strategic plans and activities. It is hoped that through sharing this
document with a wide population across SADC, members states, civil society groups
and the private sector, can replicate and adapt this model of response as a practical
method towards reducing risk of HIV transmission through injecting drug use, and
promoting the public health welfare of the communities they serve.

35
References
1. Methadone treatment at Forty, Clinical Perspective - Methadone Treatment, Ira
J, Marion, (2006)
2. HIV AND AIDS Action Plan for Injecting Drug users, Republic of Mauritius
(2003-2008)
3. HIV prevention and care for Injecting Drug Users in Republic of Mauritius,
UNODC, (2005)
4. Patterns and trends in alcohol and other drug use in Mauritius (Phase I and VII
reports), Mauritius Epidemiology Network on Drug Use (MEDNU (2001-2005)
5. Protocol on cooperation between Ministry of Health and Quality of Life and the
Ministry of Social Security, National Solidarity and Senior Citizens Welfare &
Reform Institutions (2006)
6. Rapid Assessment Report on Substance Abuse in Mauritius (2004)
7. Technical support to advice the Government of Mauritius on the Introduction of
Methadone for the Treatment of Opiate Dependence and training medical staff
in the use of methadone, WHO (2006)
8. The HIV AND AIDS Epidemic in Mauritius, PILS, (2006)
9. The National Strategic Framework (NSF), (2007-2011)
10. The National HIV AND AIDS Strategy, Mauritius Ministry of Health and Quality
of Life (2001 – 2005)
11. United Nations Joint Programmer on HIV AND AIDS (UNAIDS) Report on the
Global AIDS Epidemic, (2006)
12. WHO/UNODC/UNAIDS position paper on Substitution Maintenance Therapy in
the Management of Opioid Dependence and HIV AND AIDS Prevention (2004)
13. WHO country cooperation strategy, HIV prevention and care for IDUs report
from UNODC, (Mauritius, 2004-2007)

36
Annexes
Annex I: Methodology

Data Collection
To validate the Mautitiian Methadone Substitution Theraphy Programme as a Best
Practice, in accordance with the SADC criteria, SafAIDS developed a Best Practice
Scorecard (See Annex 3). SafAids utilised both quantitive and qualitative methods of
data collection and analysis. The overall approach to data collection was participatory,
using focus group discussions, key informant interviews, observation and in-depth
interviews. Representatives of all the stakeholders of the project were involved after
being identified and selected by MMSTP. A review of literature was also undertaken
to identify gaps in information that were to be filled in through collection of primary data
using programme and national records and documents. Data collection tools were
developed including a consent form for obtaining written consent for photographs.

In-depth interviews: Individual in-depth interviews were conducted with key

informants including policy makers, project implementers (MMSTP staff) and
stakeholders – to obtain information on programmes, management systems, resource
and financial management and the existence and functionality of the programme.
Stakeholders were interviewed to solicity from them, information on external relations
between MMSTP, funding partners, government sectors and local authorities at various
levels.

Focus Group Discussions: Ten focus group discussions (FGDs) were conducted with
programme beneficiaries, IDUs, client family members and Programme implementers.
Discussions with these respondents were held to gain an understanding of their
perceptions of the ethical soundness, appropriateness, relevance and impact of the
MSTP. Information on the level of community involvement in the initiative was also
gathered from these groups.

Seven key informant interviews were held with NAS and MOH&QL staff, including the
Honourable Minister, and the NGO management. Eight interviews were held with
programme implementers and their leadership. Observational site visits were also
made.

Best Practice Scorecard: The SADC Best Practice criteria focuses on seven
elements that a programme or project has to meet for it to be considered a Best
Practice. These elements are: effectiveness, ethical soundness, relevance,
innovativeness, replicability, cost effectiveness and sustainability. SAfAIDS developed
some variables under each of the seven elements to allow for a thorough scrutiny of
programme activities for programme validation as a Best Practice. As such, the Best
Practice Scorecard is not a data collection tool, but a data analysis and validation tool.

Data Collection Tools

Three data collection instruments were used for collecting data including FGD guides
for beneficiaries, interview guides for implementers, and interview guides for key
informants. For ethical reasons, consent was obtained from all interviewees and all
those with photos used in this report or archived for future use, signed a consent form.

37
Data Analysis and Interpretation
Data collected was transcribed and analysed through triangulation and an appreciative
mode of enquiry. Collected data was entered into the scorecard data for analysis, and
information was presented in graph form assessing the project against the SADC Best
Practice criteria (effectiveness, ethical soundness, cost effectiveness, relevance,
replicability, innovativeness and sustainability).

Validation of the Methadone Substitution Therapy programme as a Best Practice was

based on the following guide:

The seven SADC Best Practice criteria were each further broken down into a number
of key elements that best constituted the specific criteria. For example, the criteria of
effectiveness was first broken down into the three main elements, namely: project
design/structure; community involvement; and monitoring and evaluation. These
elements were further broken down to a number of variables. The variables were then
scored at the time of assessment using a 0-4 scale as follows:

4 Excellent
3 Very good
2 Good
1 Just satisfactory
0 Needs urgent attention
n/a Not applicable to the project

The scores for all the variables per criteria were added up and converted into
percentages. The total possible score is 100%. Validation of a Best Practice is based
on the following interpretation of the scores:

Total Score (%) Interpretation

80 or better Truly a Best Practice

65-79 A Best Practice that needs minor improvements in certain areas
50-64 A good practice because of specific areas – but it may not be a
total package. It can be documented but it needs major
improvements for it to qualify as a Best Practice
Below 50 Not yet a Best Practice but has potential to become one

38
 Documentation Methodology framework

Method Tool Target/Data Number Sampling Method of

Source Method analysis
Literature Checklist of • www search At least 20 Purposive Scoring on
review key engines, on relevant selection checklist
documents IDU and HIV documents and Score
for review interventions were Card
• Programme reviewed
and national
data sources
Focus Group FGD guide • Programme’s 10 FGDs Random Scoring by
Discussions beneficiaries- were held selection, as themes
(FGDs) IDUs, client per specific
‘sfamily country
members
• Programme
implementors
Interview – Interview Programme 8 Purposive Score Card
Programme guide implementers and interviews selection
Implementers the leadership were
conducted
Interviews – Interview • National – 7 Purposive Themes and
Key Informants guide NAS, AIDS interviews selection scoring
Unit, MOH&QL were held
• Community
level – NGOs
Observation Digital • Programme Several As -
camera and NGO sites per target appropriate
• Beneficiaries group
and
implementers

39
Annex II: Data collection tools

SADC Project - Documentation of HIV and AIDS Best Practices among Member States
Interview Guide: Key Informants

EFFECTIVENESS

1. What is the purpose or aim of the project/programme?

2. How does the aim or goal of the project/programme relate or fit into the national HIV
and AIDS strategic plan?

3. What are the strategies for achieving the goal? (Probe for implementation plans,
services rendered and defined target groups – geographic and demographic
catchments)

4. How are the services of the project/programme, accessed by beneficiaries? (Probe for
clarity on community outreach plan or disbursement / distribution plan,)

5. What systems are in place to ensure effective implementation? (Probe financial,

programmeming, procurement, human resource allocation, equipment, staff
development, skills transfer and project sustainability)

6. How does the approach of the project/programme integrate with other programmes i.e.
inclusion of other services, multitasking? (Probe to see whether or not the programme is
vertical and assess multiplier effect- does one stone kill many birds?)

7. How were the priorities of the project/programme determined? (Probe for information on
needs assessments, community and other stakeholder involvement, project addressing
urgent needs of community)

8. How is the community involved in the project/programme? (Probe participation in

planning, monitoring, implementation and evaluation and for information on
mechanisms put in place to solicit feedback from community groups – probe for other
ways that community contributes to the project, assess project acceptability – social,
political, cultural and religious)

9. How does the project/programme take into cognisance gender dynamics at community
level (probe for composition of structures, participation and beneficiaries)

10. How is the project/programme monitored? (Ask for monitoring tools if any and
frequency e.g. coverage, reporting forms, tally sheets, monitoring committees, quality
assurance or quality bench marks)

11. How is the project/programme evaluated? (Measurement of impact – probe for

knowledge of main indicators and baseline information, frequency of conducting
evaluations)

12. Who are the implementers of the project/programme? (Probe for information on sectoral
expertise amongst staff, volunteers, out sourcing as necessary, adequacy of staff, roles
and responsibility)

40
ETHICAL SOUNDNESS

13. How does the project/programme ensure inclusion of vulnerable groups? (probe for
value statement on how interests of young people, women, CSWs, LGBTI, people living
with disabilities and PLHIV are taken care of)

14. What policies are in place to ensure that the project/programme upholds and respects
human rights? (probe for policy or consideration of confidentiality, informed consent
and safety issues)

15. What policies are in place to ensure continuity of services? (probe for systematic
weaning or phase out strategies, skills transfer)

16. What policies are in place to ensure equitable distribution of services? (Do those with
greatest need access the service?)

17. How is the project/programme audited and who does the auditing? (probe for
transparency i.e. project allowing for both internal and external programme and financial
audits, frequency of audits)

REPLICABILITY

18. What do you think is the most unique aspect of this project/programme?

19. Ask for any other additional information deemed relevant but not covered in the
questions

20. What are some of the success stories that can be shared?

21. What are some of the challenges of the project/programme?

22. What are some of the lessons learnt? And how have these learning points been used to
strengthen the project/programme?

23. What plans are in place to scale up the project/programme? (to reach more
beneficiaries or to have more impact on currently reached beneficiaries)

SUSTAINABILITY

24. How is the vision of the project/programme aligned with current trends? (national and
regional trends, epidemic, economic, developmental - political correctness- MDGs,
Universal access etc)

25. What is the funding pattern of donors? (basket funding, % of funding from local sources
and donors,)

INNOVATIVENESS

26. How does the strategy of the project/programme ensure financial sustainability? (probe
for information on fundraising strategies, user fee, community initiatives)

27. What do you see as the future of the project/programmemme?

THANK YOU FOR YOUR TIME, SUPPORT AND PATIENCE

41
 SADC Documentation of HIV and AIDS Best Practices among Member States

Focus Group Discussion Guide (FGD): Communities/Beneficiaries

Introduce the purpose of the FGD, and get verbal consent. Assure FGD members that the
information they shall share will be treated anonymously.

Effectiveness
1. What is the purpose or aim of the project ? (goal, objectives)

2. How were you involved in the establishment of the project /programme?

(conceptualisation, consultations, needs assessment, prioritization of needs, relevance
of needs, usefulness, timeliness of project/programme, planning)

3. What do you think are the benefits of this project/programme for you as women / men /
young people and your communities?

4. How do you view this project/programme? (is this YOURS, ownershipwith you,
imposed, or donor driven, or neutrally accepted because you don’t have a choice)

5. How do the services/activities of the project/programme cater for the needs of different
age-groups, sexes, and social classes within your community?

6. How does the project/programme take into cognisance gender dynamics in your
community? (probe for composition of structures, participation and beneficiaries – girls,
boys, women & men and benefits)

7. How has access to the services/activities of the project/programme been influenced by

the economic or political trends in your community?

8. How are the project/programme implementers working with you to determine

project/programme needs in order to meet your needs?

9. How are you participating in the implementation of the project/programme and in

checking that the project/programme is progressing well (monitoring and evaluation
processes)?

10. How do you share your feedback or feelings about the services/activities you are
receiving, with the project/programme implementers? How often?

12. How does your community contribute towards the services/activities that this
project/programme offers? (cash, kind, other support, eg advice and networking)

13. Describe the process that takes place when community members want to access the
services /activities provided by the project/programme. (probe should be specific to the
BP you are documenting , this will measure how implementers are ‘doing things’ eg are
human rights being adhered to etc.)

14. What factors hinder your community members from accessing the services, or engaging
in the activities that this project/programme is offering?

15. What would you like to be done in this project/programme, for it to be of greater benefit
to your community?

42
Cost Effectiveness
16 Are services provided in a timely manner?

17 Is there an increase in the number of people in this community whose lives have been
changed as a result of benefiting from the programme?

18. Is there a positive life story that you can share with us?

19. Is the service provided, cost effective? How can it be improved?

20. Do you find that the project has adequate personnel providing the service? (numbers
and skills.)

Relevance
21. What are the views of your traditional and religious leaders on this project/programme?
(project was introduced to traditional systems, consensus sought, part of consultative
process, commitment and support offered by traditional systems)

22. Are all the services provided, necessary? Which ones are not?

Ethical Soundness
23. Are your rights and those of others respected in this programme? Explain.

24. In your opinion, is there a fair distribution of services between men and women, rich
and poor, married and unmarried, adults and children ?

25. Is there transparency in the operations of this organisation?

26. Do you feel that the organisation and its staff are accountable to beneficiaries

27. Are people treated with respect, and are their opinions listened to by programme

staff?

Innovation
28. In your opinion, is this programme creative and innovative, different from other
projects?

29. Can you share with us a story that demonstrated this innovation?

Sustainability
30. Do you think this programme should contine in the absence of donor support? Why?
(has there been skills transfer in the community, is community contributing to the
programme in cash or kind?)

31. Is the programme well known in the community?

32. What are some of the challenges you faced in this programme and how have yourselves
and the NGOs addressed these challenges?

THANK YOU FOR YOUR TIME, SUPPORT AND PATIENCE

43
 SADC Project - Documentation of HIV and AIDS Best Practices among Member
States

Interview Guide: Project/programme Implementers

After adequate introduction and explanation of purpose of exercise, point out that interview may take up to
one hour. There may be need to have some documents handy to clarify issues during or after interview.

EFFECTIVENESS
1. What is the purpose or aim of the project/programme?

2. How does the goal (aim) of the project/programme relate to, or fit into, the
National HIV and AIDS strategic plan?

3. What are the strategies for achieving the goal? (Probe for implementation
plans, services rendered and defined target groups – geographic and
demographic catchments)

4. How do beneficiaries access the services of the project/programme? (Probe for

clarity on community outreach plan or disbursement / distribution plan)

5. What systems are in place to ensure effective implementation? (Probe financial,

programmeming, procurement, human resource allocation, equipment, staff
development, skills transfer and project sustainability)

6. How does the approach of the project/programme integrate with other

programmess i.e. inclusion of other services, multitasking? (To see whether
programme is vertical, assess multiplier effect – ‘does one stone kill many
birds?’)

7. How were the priorities of the project/programme determined? (Probe for

information on needs assessments, community and other stakeholder
involvement, project addressing urgent needs of community?)

8. How is the community involved in the project/programme? (Participation in

planning, monitoring, implementation and evaluation – probe for information on
mechanisms put in place to solicit feedback from community groups – probe for
other ways in which community contributes to the project, assess project
acceptability – social, political, cultural and religious)

9. How does the project/programme take into cognisance gender dynamics at

community level? (Probe for composition of structures, participation and
beneficiaries)

10. How is the project/programme monitored? (Ask for monitoring tools, if any, and
frequency e.g. coverage, reporting forms, tally sheets, monitoring committees,
quality assurance mechanisms or quality bench marks)

11. How is the project/programme evaluated? (Measurement of impact – probe for

knowledge of main indicators and baseline information, frequency of conducting
evaluations)

12. How is monitoring and evaluation data used? (frequency of use for project
review, timeous dissemination to relevant stake holders?)

44
13. Who are the implementers of the project/programme? (Probe for information on
sectoral expertise amongst staff, volunteers, out-sourcing as necessary,
adequacy of staff, roles and responsibility)

ETHICAL SOUNDNESS

14. How does the project/programme ensure inclusion of vulnerable groups?

(Probe for value statement on how interests of young people, women, CSWs,
LGBTI, people living with disabilities and PLHIV are taken care of)

15. How are human rights upheld or respected during establishment and
implementation of the project/programme? (Probe for policy, consideration of
confidentiality, informed consent and safety issues)

16. How are continuity of services, support or care ensured after end of current
funding cycle? (Probe for systematic weaning or phase-out strategies, skills
transfer mechanisms)

17. How is equitable distribution of services ensured? (Those with greatest need
access the service?)

18. How is the project/programme audited and who does the auditing? (Probe for
transparency i.e. project allowing for both internal and external financial audits,
frequency of audits)

COST EFFECTIVENESS

19. How are the resources of the project/programme distributed? (Admin versus
programme costs)

20. How is the service-cost measured within this project/programme? (Probe for
methods of tracking inputs/outputs in relation to outcomes so as to enable
calculation of cost per client)

21. To what extent are available resources adequate for supporting service delivery
to the project/programme? (Probe for adequacy of human and financial
resources, equipment and supplies)

22. What are the cost saving and cost reduction measures of the
project/programme? (use of low cost, improvised substitutes, engaging
volunteers for some of the services, does it have an increased financial burden
on beneficiaries)

23. To what extent does cost sharing take place in the project/programme? (user
fees, payment of some of the services like training, transport)

24. What is included in the minimum care package of the service/s provided by the
project/programme? (compare with the standard care package policy for the
country, procedure guides)

25. How timely is the delivery of services?

45
REPLICABILITY

26. How are the activities and processes of the project/programme documented?
(get copies of reports, case studies collected, documentaries, manuals, books
etc)

27. What are some of the success stories that can be shared on the positive impact
or influence of the project’s services on beneficiaries?

28. What are some of the challenges of the project/programme?

29. What are some of the lessons learnt from this project/programme, and how
have they been used to strengthen the project/programme?

30. What plans are in place to scale-up the project/programme? (to reach more
beneficiaries or to have more impact on currently reached beneficiaries, quality
& quantity)

SUSTAINABILITY

31. How is the vision of the project/programme aligned with current trends?
(national and regional trends, epidemic, economic, developmental - political
correctness- MDGs, Universal access etc)

32. How is the project/programme marketed to stakeholders? (assess for active

education and awareness building amongst stakeholders, language and
medium used, are you getting the expected responses?)

33. How does the strategy of the project/programme ensure financial sustainability?
(probe for information on fundraising strategies, user fee, community initiatives)

34. What do you see as the future of the project/programme?

INNOVATIVENESS

35. What do you think is the most unique aspect of this project?

36. Ask for any other additional information deemed relevant but not covered in the
questions above.

37. Share with us a success story that demonstrates the success of your
programmee.

T H A N K Y O U FOR YOUR TIME, SUPPORT AND PATIENCE

46
 Annex III: Best Practice Score Card - Rating for Mauritius
MST Programme

SADC Project - Documentation of HIV and AIDS Best Practices among Member
States
Key Assessment Tool – Score Card

* This Score card is measured from a total of 100

Variable Data Source n/a 0 1 2 3 4

1. EFFECTIVENESS (19/25 points = 76%)

1.1 Project/Programme Design/Structure
(8.25/ 10.0 marks )
Goal/s is/are clearly articulated and well understood by Interviews/ FGDs/ X
beneficiaries and implementers.(1) Litreview
Project/programme is in line with the National HIV and AIDS Lit. review / X
strategic plan (0.5) Interviews
Strategies are in place and clearly articulate how the goal can be Lit. review/ X
achieved/supported by clear implementation plan. (0.5) Interviews
Clear strategies are in place to evaluate impact of the project (0.25) Lit. review/ X
Interviews
Project/programme has clear results as defined by implementers, Lit. review/ X
beneficiaries and stakeholders and in line with original objectives(1) Interviews
Project’s /programme’s services/activities are clearly defined. (1) Lit. review X
Project/programme has clear systems in place (financial, Lit. review/ X
community outreach, distribution/disbursement, equipment). (1) Interviews
Baseline/assessment ground-work was undertaken prior to Lit. review X
project’s /programme’s commencement. (1)
Project/programme has clearly defined targets. (0.5) Lit. review X
Project’s/programme’s objectives are SMART. (0.5) Lit. review X
Project/programme embraces an integrated approach (vs vertical). Lit. review/ X
(0.5) Interviews
There is sectoral expertise to manage and implement the Interviews X
project/programme. (1)
1.2 Community Involvement (7.75 / 10 marks)
Project’s/Programme’s priorities are based on actual needs of the Lit. review/ X
community – evidence of needs assessment done. (1) Interviews/ FGDs
Community knows and understands the objectives of the Interviews/ FGDs X
project/programme. (1)
Community participated in the initiation/conceptualisation of the Lit. review/ X
project/programme, setting priorities. (0.25) Interviews/ FGDs
Community participates in the project’s/programme’s planning, Lit. review/ X
monitoring and evaluation. (0.25) Interviews/ FGDs
Community participates in the project’s/programme’s Lit. review/ X
implementation, as volunteers or paid staff. (1) Interviews/ FGDs
There is a sense of ownership of the project/programme, among Lit. review/ X
communities. Community feels the project and its outcomes Interviews/ FGDs/
belong to them. (1) Observation
Community contributes in cash or in kind towards Lit. review/ X
project’s/programme’s activities. (1) Interviews/ FGDs
There is gender sensitivity in community participation. (both men Interviews / FGDs X
and women are involved equally). (0.5) Observation
Community is satisfied with the project’s/programme’s services. Interviews / X
(both men and women) (2) FGDs/
Observation

47
 1.3 Monitoring and Evaluation (M&E) (3/5 marks)
Systematic methods of tracking inputs and outputs are in place. Lit. review/ X
(0.5) Interviews
Key stakeholders, including the community, participated in the Lit. review/ X
development of the project’s/programme’s indicators. (0.25) Interviews/ FGDs
Project/’sprogramme’s activities are periodically monitored and Lit. review/ X
evaluated including coverage. (0.25) Interviews
Quality assurance/quality benchmarks are in place and are being Lit. review/ X
followed. (0.5) Interviews
Participatory monitoring and evaluation methods are being used Lit. review/ X
that include the community. (0.25) Interviews/ FGDs
M & E (impact, assessments, outputs) data are analysed Lit. review/ X
periodically. (0.25) Interviews
Results of impact evaluations are used to make meaningful Interviews X
adjustments to the project/programme. (1)

Variable Data Source n/a 0 1 2 3 4

2. ETHICAL SOUNDNESS (8.5 /10 points = 85%)
Confidentiality, as a principle, is upheld in interactions with Lit. review/ X
project’s/programme’s service beneficiaries. (1) Interviews/ FGDs
The interests of vulnerable groups (LGBTI, people living with Interviews/ FGDs X
disabilities, CSWs), are respected and protected. (1)
Project/ programme does not directly or indirectly violate human Interviews/ FGDs X
rights. (1)
Project/programme has a Value Statement for protection of Lit. review/ X
interests of various vulnerable groups. (0.5) Interviews/ FGDs
Project/programme always embraces the concept of informed Lit. review/ X
consent when dealing with human beings as participants. (1) Interviews/ FGDs
There is evidence of equitable distribution of Lit. review/ X
project’s/programme’s resources (finances, geographic Interviews/ FGDs
distribution, sex). (0.5)
The autonomy of clients is protected and respected during Lit. review/ X
project/programme roll-out. (1) Interviews/
Observations
There is an ethical standard (“do no harm” principle) embedded in Lit. review X
the project’s/programme’s policies. (0.5)
There is a minimum service provision package (clearly defined, Lit. review/ X
access irrespective of colour, creed, sex, religion, political Interviews
affiliation). (1)
Project/programme is transparent (allows for external and internal Lit. review/ X
programmematic and financial audits). (1) Interviews
3. COST EFFECTIVENESS (8.75/12 points = 72.9%)
Distribution of project’s/programme’s resources is cost effective Lit. review/ X
(administration versus programmeming) and is proportionate to Interviews
available resources. (0.75)
There is evidence of increased number of community members Lit. review/ X
whose quality of life has been improved by the Interviews
project’s/programme’s resources and services. (1)
There is evidence to enable calculation of ‘cost per client’ Lit. review/ X
measure. (cost known) (2) Interviews
A standard package is provided at a reasonable cost. (2) Lit. review/ X
Interviews
Services are delivered in a timely manner. (0.5) Interviews/ FGDs X
There are adequate human resources for programme’s activities Interviews X
(0.25)
The strategy used by the project/programme has resulted in Lit. review/ X
multiplier effects (cost - benefit). (0.25) Interviews/ FGDs
Project/programme has introduced cost saving / reduction Interviews/ FGDs X
systems. (2)

48
4. RELEVANCE (10/12 points = 83/3%)
Project/ programme is socially and culturally acceptable. (1) Interviews / FGDs X
Project/programme takes cognisance of specific contexts (literacy, Interviews / FGDs X
messaging, lifestyle, economic, political, approach, environmental
factors, risk groups and areas). (1)
Project/ programme does not conflict with the religious norms of Interviews / FGDs X
the community and has support from political and traditional
leadership. (0.75)
Beneficiaries perceive the project/programme as relevant and Interviews / FGDs X
timely in addressing their most urgent needs. (2)
The project/ programme is in line with demographic, social, Interviews / FGDs X
political, and economic trends. (1)
Project/programme addresses gender dynamics. (0.25) Interviews / FGDs X
Project is appreciated by vulnerable groups. (2) Interviews / FGDs X
Project/programme is perceived as valuable and credible by the Interviews / FGDs X
community. (2)
5. REPLICABILITY (7.75/10 points = 77.5%)
Project/programme can be replicated in similar contexts. (1) Lit. review / X
Interviews
Project/programme sets an example for similar programmes. (0.5) Interviews X
Project/ programme is adaptable in different contexts and levels Interviews / X
using local resources. (1) Observations
Project/programme is replicable in part or in totality. (2) Lit. reviews/ X
Interviews
Project/programme exhibits evidence of proper documentation in Interviews / X
terms of goals, processes, evaluation, cost and resources. (0.25) Observations
Project can be scaled-up to reach more beneficiaries. (2) Interviews / X
Observations
Project can be scaled-up to improve quality of service (1) Interviews / X
Observations
6. INNOVATIVENESS (6.75/10 points = 67.5%)
Project/programme is unique (different methodology from other Lit. review/ X
organisations). (1) Interviews/ FGDs/
Observations
Project/programme has a new way of reaching beneficiaries. (1) Interviews/ FGDs X
The utilisation of available resources is done in a creative manner. Interviews/ FGDs/ X
(0.75) Observations
The strategy of implementation, used by programme Interviews X
implementers, is innovative. (2)
Project/ programme concept is new to the community (as Interviews/ FGDs X
perceived by the community). (1)
Project/programme is contributing to the base of knowledge. (0.25) Lit.rev/ interviews X
Project’s/programme’s approach and systems are Lit. review X
scientifically/economically sound and safe. (0.75)
7. SUSTAINABILITY (14.75/20 points = 73.8%)
7.1 Programme sustainability (7.5/ 10marks)
Project/ programme is supported by beneficiaries, community Lit. review/ FGDs/ X
ownership, contributions in cash and kind. (2) Interviews
The community expresses confidence that the programme will FGDs X
continue without donor support. (2)
Skills transfer takes place in relation to the project/programme. Lit.. rev/ Interviews X
(0.5)
Project’s/programme’s vision is in line with the development Lit. review/ X
patterns of HIV and AIDS and national trends (social, economic & Interviews/ FGDs
cultural (1)
Project’s/programme’s vision is in line with national trends (social, Lit. review/ X
economic and cultural) (1) Interviews
Planning and implementation takes into account the issue of Lit. review/ X

49
sustainability. (sustainability plan) (1) Interviews
7.2 Financial sustainability (4.75/7marks)
Project/programme implementers are aware of potential donors Interviews X
(local and international). (0.25)
There exists a positive attitude and willingness to achieve Interviews/ X
sustainability. (1) Observations
Project/programme has the ability to access diversified resources Interviews X
to contribute to its services/activities. (fundraising plan in place)
0.5)
Cost sharing mechanisms are built into service delivery where Lit. review/ X
appropriate. (1) Interviews

A percentage of financial support comes from the community, Lit. review X

organisation has had stable funding over time. (2)
7.3 Marketing and Awareness Building (2.5/3 marks)
Project/programme is actively marketed to stakeholders and Lit. review/ X
funders. (1) Interviews
Project/programme actively educates and builds awareness Lit. review/ X
amongst stakeholders about its own services/ activities. (0.5) Interviews
Appropriate language is being used in information, education and Lit. review/ FGDs X
implementation programmes. (1)

TOTAL 75.5%

4 Excellent
3 Very good
2 Good
1 Just satisfactory
0 Needs urgent attention
n/a Not applicable to the project

• Total score above 80% is truly a Best Practice

• Total score from 65% – 79% is a Best Practice that needs minor
improvements in certain areas ( Rating for the Mauritius MST
programme)
• Total score from 50% - 64% is a good practice because of specific areas –
but it may not be a total package. It can be documented but it needs major
improvements for it to qualify as a Best Practice
• Total score below 40% - 50% is not yet a Best Practice but has the potential
to become a Best Practice
• Any score below 40% is not a Best Practice and should not be documented

50
Annex IV: Peer Review Team: terms of reference (TORs) and
Composition

SADC Secretariat Commissioned Project - Documentation of HIV and AIDS Best

Practices among Member States
TERMS OF REFRENCE FOR PEER REVIEWERS
1. Background
The Member States of the SADC have been responding to the HIV epidemic for more than
two decades. The combined experiences of the Member States is over 200 years, yet
these rich experiences have not been fully harvested and systematically documented to
guide the Member States and the region at large, in designing and implementing HIV and
AIDS interventions. Documentation of experiences in addressing the epidemic remains
limited.

With most Member States now approaching the third decade of battling with the epidemic
with varied success, it is becoming urgent that more attention be focused on strategies that
deliver the highest returns. One of the most useful avenues for strengthening the response
is through sharing of Best Practices on HIV and AIDS between and within Member States.
This will ensure that Member States avoid the pitfalls experienced by others. Further, if
appropriately applied, Best Practices will guide in maximizing efficiency and effectiveness in
response. The Maseru Declaration on Combating HIV and AIDS recognizes that “…within
the SADC Region there have been some successes and Best Practices in changing
behavior, reducing new infections and mitigating the impact of the HIV and AIDS pandemic,
and that these successes need to be rapidly scaled up and emulated across the SADC
region”. In addition, both the SADC Strategic and Business Plans on HIV and AIDS
advocate for the sharing of Best Practices between and within Member States.

Following development of a Framework for Developing and Sharing Best Practices on HIV
and AIDS in the SADC region, its prompt operationalization has now become imperative, so
as to enable the directive of the Heads of State and Government through the Maseru
Declaration for Scaling Up Best Practices. In addition, documenting Best Practices will also
assist in facilitating the achievement of universal access to prevention, treatment, care and
support in accordance with the Brazzaville Commitment that all Member States have
signed. The initial documentation shall take place in four Member States: Mauritius, South
Africa, Zambia and Zimbabwe, where Best Practices have already been identified. The
documentation will incite greater debate, and exchange of ideas and increase collaboration
and coordination among actors and institutions working in the area of HIV and AIDS in the
region.

A critical stage in this documentation process is the in-country Peer Review mechanism.
Southern Africa HIV and AIDS Information Dissemination Service (SAfAIDS), a regional
Information Dissemination service, with extensive experience and expertise in HIV and
AIDS information documentation, dissemination and communication, has been
commissioned, under the Regional Support for an Expanded Multi-sectoral Response
to HIV AND AIDS in the SADC Region Project, to document the four selected HIV and
AIDS Best Practices. This activity is being conducted in close collaboration with the National
AIDS Commissions (or similar bodies) in each focus country.

51
2. Documentation Process Overview
SAfAIDS, in collaboration with country NACs or any other coordinating body, shall:
- Conduct a country stakeholders’ meeting to introduce the project
- Offer capacity building support to country stakeholders, through a two-day basic
training course on HIV and AIDS Best Practice Documentation and Communication,
thus creating a pool of in-country Best Practice documenters
- Document the country Best Practice and collate data collected and analysed into a
Best Practice Report
- Share the country’s Best Practice Report with the country Peer Review Team,
selected during the stakeholders’ meeting, for review
- Finalise the country Best Practice Report, incorporating feedback from the country
Peer Review Team, and share the final product with SADC

3. Peer Review Teams – Structure and Composition

3.1 A Peer Review Team shall be established in each country. The Team shall comprise
representatives of in-country:
- National AIDS Commissions (or similar body)
- Ministries of Health, or other relevant Government bodies
- People Living with HIV (PLHIV)
- Civil Society (NGOs) working in the area of HIV and AIDS, and with specific focus
on the area related to the country Best Practice
- HIV and AIDS researchers or community-based intervention experts
3.2 Each Peer Review Team shall comprise no more than 5 peer reviewers

4. Peer Reviewer - Terms of Reference

4.1 Each member shall participate in the following activities, to be hosted by the country
NAC, in collaboration with SAfAIDS:
- Stakeholders’ meeting
- HIV and AIDS Best Practice Documentation Training
4.2 Each member shall receive a draft Best Practice Report, for review, from SAfAIDS, and
this shall be their primary working document
4.3 The Team shall design their Peer Review Strategy
4.4 The Team shall utilize the Best Practice Score Card, provided to them by SAfAIDS,
during the review process
4.5 Review comments from each member shall be collated into a Review Report, to be
shared with SAfAIDS at the end of the review process, in Microsoft Word and on a CD-
ROM

5. Peer Review - Time Frame

The review process shall take no longer than 3 days, following receipt of the draft
country Best Practice Report from SAfAIDS.

______________________ _____________________ ___________________

for and on behalf of SAfAIDS for and on behalf of NAC Peer Reviewer
Country ……………… Country……………
Date……………… Date……… Date …………

52
 Annex V: Best Practice Documentation Training: Programme, Evaluation
brief and Participants’ details

Training Programme
Ministry of Health & Quality of Life (MOH&QL), AIDS Unit and Southern Africa HIV and
AIDS Information Dissemination Service (SAfAIDS

National Training on Best Practice Documentation of HIV and AIDS Projects/Programmes

10 - 11 September 2007, Port Lois, Mauritius

Day 1
TIME ACTIVITY FACILITATOR
08.00 – 08.30 Registration AIDS Unit
08.30 – 08.45 Introductions MOH&QL & SAfAIDS
Welcome Remarks
08.45 – 09.15 Overview of Documentation Project SAfAIDS
• Meeting objectives
• Selection process of Best Practice
• Process with SADC
• Role of SAfAIDS

Discussion
09 15 – 09.45 Process of Documentation SAfAIDS
• Criteria
• Scorecard
• Data collection and analysis methodology
• Report collation
09.45 – 10.00 Role of Peer Review Team SAfAIDS
• Selection

10.00 – 10.15 Way Forward MOH&QL

• Training
• Feedback strategy
10.15 – 10.45 TEA
10.45 - 13.00 Documenting HIV and AIDS Best Practices (Part I) SAfAIDS
• Why document a Best Practice?
• Developing a Documentation plan
• Citeria for selecting a Best Practice
• Documentation Process of a Best Practice

Discussion
13.00 – 14.00 LUNCH
14.00 – 15.30 Documenting HIV and AIDS Best Practices (Part II) SAfAIDS

Discussion
15.30 – 15.45 TEA
15.45 – 16.30 Planning of field visit – breaking into groups SAfAIDS
16.30 – 16.45 Wrap up of Day 1 SAfAIDS

Logistics for Day 2

53
 Day 2
TIME ACTIVITY FACILITATOR
08.00 – 08.10 Overview of Day 1 SAfAIDS/Group
Leaders
Re-grouping
08.10 – 11.00 Documentation - field practice in groups

11.00 – 13.00 Preparations for Group presentations

13.00 – 14.00 LUNCH

14.00 – 15.30 Group Presentations (Part I) SAfAIDS/Groups
• Introduction and planning process applied
• Methods applied
• Experience of data collection and tool utilization
• Documentation workplan (were more time
allocated for the process)
• Learning points

Discussions
15.30 – 15.45 TEA
15.45 – 16.30 Group Presentations (Part II) SAfAIDS/Groups

Discussions
16.30 – 16.45 General Comments SAfAIDS

Evaluation
16.45 –17.00 Closing MOH&QL, AIDS
Unit

Evaluation Brief - Participant’s Training feedback:

- While 95% of participants felt that the training was very useful (none of the
participants reported the training was not useful), all participants were of the
view that the training period was too short and more time was needed to
effectively explore the tools and cycles relating to HIV&AIDS Best Practice
documentation.
- The majority of participants (76%) felt that their expectations of the training had
been fully realised, and the remainder (14%) were neutral, and would have liked
more time to explore the tools
- All participants reported having been availed ample opportunity to share and
participate during the training sessions
- Following the field practicum, participants revealed that the tools shared for
Best Practice documentation data collection purposes were simple to use,
easily adaptable to different programmes and comprehensive in design.

54
 Participants’ details

NAME ORGANISATION TELEPHONE EMAIL

Participants
Dr. Amita Pathack National AIDS +230 2138326 [email protected]
Secretariat (NAS),
Director
Anouchka Saddul NAS, Advocacy +230 2502016 [email protected]
Officer
Marlene Ladinlu Chysalide Centre , +230 4525509 [email protected]
Director
Nundoo Madhav AIDS Secretariat , +230 7638011 [email protected]
AIDS education
nurse
Motah Sagar Prisons Department, +230 4016600 [email protected]
principle hospital
officer
Ramanand Sudhun HELP drug addiction +230 2111835 -
centre, social worker
Mohanpersad BARKLY Detox +230 734 0181 -
Balmukund Centre (National
Detox Centre/NDC)
Ramdawor Ravin SSS Day Care +230 9177734 -
Centre, social worker
Sarah Soobhany AIDS Secretariat , +230 2138166 [email protected]
AIDS educator
Jaishree Mohit NATresa +230 2108017 -
Dhiren Moher PILS, president +230 2107075 [email protected]
Fayzal Sulliman NDC/MOH +230 7606574 [email protected]
Adursh Nayeck Min. of Education +230 6015200 [email protected]
Dr. Ponnoosamy MOH & Quality of +230 2112442 [email protected]
Rengananden Life, community
physician
Indrasen Mahadoo AIDS Unit, MOH, +230 2123224 [email protected]
coordinator
Facilitators
Chrispin Chomba SAfAIDS, Monitoring, +260 977888828 [email protected]
Evaluation and
Research Specialist
Rouzeh Eghtessadi SAfAIDS, Public +263 4 3361 93/3 [email protected]
Health Specialist +263 912 395 430 [email protected]

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