National Drug Observatory Report

Republic f Mauritius Ministry f Health and Quality f Life Natinal Drug Observatry Reprt, March 2018 Natinal Drug Observatry Reprt [1] March 2018

[2] Natinal Drug Observatry Reprt, March 2018

Natinal Drug Observatry Reprt, March 2018 Cntents Page 2 Frewrd 4 Acr0nyms 5 Secnd reprt f the Natinal Drug Observatry 6-9 Executive Summary and general bservatin Chapter 1 HEALTH EFFECTS OF DRUG USE IN MAURITIUS 1.1 Pattern and trend f inpatient treatment cases f drug users, in public health institutins 12-14 Pattern and trend f drug-related inpatient treatment cases, in public health institutins 14-15 Age distributin f drug users treated as inpatients, in public health institutins 15-17 Reprted substances used, amng drug users treated as inpatients, in public health institutins 17 Inpatient treatment cases in public health institutins, due t prblems fllwing multiple drug use 18 Diseases and health prblems reprted at public health institutins, due t drug use 18 Inpatient treatment cases in public health institutins, due t prblems fllwing new psychactive substances 19-21 Drug-related Inpatient treatment cases, in public health institutins, by district f residence f patient 1.2 Drug use, Hepatitis C and HIV cncentrated epidemics 22 Drug injectin and Hepatitis C 23-24 Drug injectin, HIV and Hepatitis C linkages 24-25 Hepatitis C mrbidity and mrtality 1.3 Injecting drug use 25-26 Peple wh inject drugs as the driving agent f the natinal cncentrated HIV epidemics 26 Characteristics f peple wh inject drugs 26 Injecting practices amng peple wh inject drugs 24 Mde f initiatin t injecting drugs 26-27 Risky behaviurs amng peple wh inject drugs 27 1.4 Deaths due t drug use Chapter 2 THE HEALTH RESPONSE TO DRUG USE 28-29 The Needle Exchange Prgramme (NEP) and the Methadne Substitutin Therapy Prgramme 29-31 The Subxne Prgramme and the Cdeine Phsphate Prgramme 31-33 Preventin against drug use Chapter 3 SITUATION OF DRUG USE AND TRAFFICKING IN MAURITIUS 3.1 Drug cntrl by the Mauritius Plice Frce 34 The Mauritius Plice Frce reprted drug ffences 35-40 Arrests by Plice ADSU 3.2 Seizures f drugs by the Mauritius Revenue Authrity (MRA) Custms 41 Drug seizure cases by the MRA Custms 41-42 Value f drugs seized by the MRA 43-44 Quantity f drugs seized by the MRA 44 3.3 Drug use in educatinal institutins Chapter 4 IMPRISONMENT AND THE JUDICIARY CONVICTED DRUG OFFENCES 45-46 Cnvicted drug ffences, reprted by the Judiciary 46-47 Drug ffences, reprted by the Mauritius Prisns Services Chapter 5 REHABILITATION CENTRES 48-49 The rehabilitatin set up and activities and general bservatins frm Rehabilitatin Centres 50 Reference 51 ANNEX - Ministry f Yuth & Sprts drug-related activities [3]

Natinal Drug Observatry Reprt, March 2018 Acrnyms ADSU CUT (NGO) CYC HCV IBBS ICD 10 MOH&QL MRA NDCM NDO NEP NGO PWID Anti-Drug Smuggling Unit (Mauritius Plice Frce) Cllectif Urgence Txida Crrectinal Yuth Centre Hepatitis C Virus Integrated Bilgical and Behaviural Surveillance Internatinal Classificatin f Diseases, 10th Revisin Ministry f Health and Quality f Life Mauritius Revenue Authrity Natinal Drug Cntrl Masterplan Natinal Drug Observatry Needle Exchange Prgramme Nngvernmental Organizatin Peple Wh Inject Drugs [4]

Natinal Drug Observatry Reprt, March 2018 Secnd reprt f the Natinal Drug Observatry This reprt refers t the ne-year perid, frm July 2016 t June 2017. Additinal infrmatin and data fr earlier perids are als included fr trend analysis purpses. Indicatrs are cnstructed using essentially secndary data. As a result, mst indicatrs are f reprted nature and shuld be used with careful interpretatin given that they relate t institutinal and administrative settings and perfrmances. This reprt attempts t give a picture f the drug situatin in Mauritius by examining available factual and reliable drug-related data and infrmatin in the fllwing areas; health prblems resulting frm drug use, measured mainly thrugh admissins in public health institutins; specific diseases epidemics linkage with drug use, using rutine service data as well as past surveys; the health respnse t drug use, thrugh health prgrammes; the gvernment natinal drug cntrl and law enfrcement activities, thrugh data btained frm the Mauritius Plice Frce and the Mauritius Revenue Authrity Custms; drug ffences and imprisnment, thrugh data btained frm the Mauritius Prisns Services and published reprts f the Judiciary; and finally service-delivery-based bservatins n the drug situatin frm NGOs. Data related t inpatient treatment cases have been prvided by the Health Recrds Divisin f the Ministry f Health and Quality f Life. Acknwledgements The Natinal Drug Observatry wishes t express its gratitude t the fllwing rganizatins: The Mauritius Plice Frce and its Anti-Drug Smuggling Unit (ADSU); the Mauritius Revenue Authrity (MRA) Custms; the Mauritius Prisns Services; the Judiciary; the Health Recrds Divisin f the Ministry f Health and Quality f Life; the Health Statistics Unit f the Ministry f Health and Quality f Life; the Harm Reductin Unit f the Ministry f Health and Quality f Life; Rehabilitatin centres: Dr Idriss Gmany Centre, Plaine Verte; Crysalid, Bambus; Centre de Slidarité Pur Une Nuvelle Vie, Rse Hill; Actresa, Calebasses; Centre d Accueil de Terre Ruge ; Etile d Espérance, Mka ; Help de- Addictin, Cassis; Grupe A de Cassis ; Renaissance, Maheburg ; and Sangram Sewa Sadan, St Paul; The Ministry f Educatin and Human Resurces, Tertiary Educatin and Scientific Research; Statistics Mauritius; and all thse wh have cntributed t this reprt. [5]

Natinal Drug Observatry Reprt, March 2018 Executive summary Health effects f drug use In 2015 and 2016 there were respectively 552 and 914 inpatient treatment cases in public health institutins fr drug prblems and in the first six mnths f 2017, there were 689 crrespnding cases (638 male cases, 51 female cases). In public health institutins, whilst a percentage increase f 66% was bserved amng drug-related inpatient treatment cases, frm 2015 t 2016, between the 2 nd semester perid f 2016 and the 1 st semester perid f 2017, a crrespnding increase f 47% was bserved, frm 469 cases t 689 cases respectively. Cmbining different surces f infrmatin, especially, health institutins and drug cntrl agencies, there is evidence t say that the current drug use picture in Mauritius is characterized by the cnsumptin f a variety f substances, namely; Herin-(0pi0id), Cannabis, Cannabinids-(THC in cannabis), Hashish-(Cannabis resin), Methadne-(0pi0id), Ccaine-(Cca leaves -stimulant), Methamphetamine-(Central nervus systemstimulant), Ecstasy-(Methylenedixymethamphetamine-MDMA), Rivtril-(Clnazepam-benzdiazepine drug), Valium-(Diazepam-benzdiazepine drug), Mgadn-(Nitrazepam-benzdiazepine drug), Panadeine- (Paracetaml+CdeinePhsphate-piid), Cugh syrup, Tramadl-(Pain-treatment- piid), New psychactive substances, Subutex-(Buprenrphine-piid), Nva-(Pregabalin), amng ther unspecified substances. Fr the ne-year perid, frm July 2016 t June 2017, significant inpatient treatment cases f suspected multiple drugs use were reprted in public health institutins, namely; using methadne with herin/brwn sugar; herin with rivtril; alchl with new psychactive substances; buprenrphine with rivtril; drug injectin while n methadne; herin (brwn sugar) with new psychactive substances, Nva with cugh syrup, amngst thers. In the first six mnths f 2017, ut f the 689 inpatient treatment cases reprted in public health institutins due t drugs prblems, at least 44% f cases were prblems fllwing use f suspected new psychactive substances and at least 17% inpatient cases were assciated with use f piids and piates, while, at least 6% inpatient treatment cases were reprted as prblems fllwing use f cannabis, amngst thers. Fr the ne-year perid, frm July 2016 t June 2017, in public health institutins, drug-related inpatient treatment cases fr teenagers (10-19 years) accunted fr 19%. Fr the ne-year perid, frm July 2016 t June 2017, in public health institutins, ut f 536 knwn inpatient treatment cases related t suspected use f new psychactive substances, teenaged drug users accunted fr 23% and 28% were in the age grup 20-24 years, while, 50% were aged 25 years and ver. Amng drug-related inpatient cases in public health institutins, just arund half (53%) f cases were reprted t be frm urban areas, against 47% frm rural areas. Fr the ne-year perid, frm July 2016 t June 2017, drug users have undergne inpatient treatment in public health institutins, fr the fllwing health prblems; mental and psychtic disrders including acute psychsis; auditry hallucinatin; cnfusinal state; depressin; anxiety; drug verdse cmplicatins; uncnsciusness; fits; vertig; palpitatin; breathlessness; vmiting; nausea; abdminal pain; headache; weakness; dizziness; agitatin and restlessness; sleepiness; dyspnea; withdrawal syndrme; suicidal tendencies; abnrmal aggressive disrders; and slurred speech. Addictin t herin during pregnancy was als reprted amng drug-related inpatient treatment cases. Based n infrmatin prvided n death certificates and applying the principle f selecting the underlying cause f deaths accrding t the Internatinal Classificatin f Diseases (ICD 10) f the Wrld Health Organizatin, 17 deaths were assigned t drug use in 2015 as cmpared t 23 in 2016. 18 deaths due t drugs have been registered in the perid January t June 2017. [6]

Natinal Drug Observatry Reprt, March 2018 Three previus IBBS surveys carried ut amng peple wh inject drugs respectively in 2009, 2011 and 2013, shwed that Hepatitis C (HCV) was abve 95% amng this high-risk grup, while, the rate f cinfectin with HIV and HCV was 44% in the 2013 IBBS survey. In 2016, public labratries HCV psitivity rate was 33.0 per 1,000, with 1,279 psitive cases thrugh 38,756 tested specimens. Frm 2004 t 2016, the number f labratry psitive hepatitis C cases, has decreased by 53%, frm 2,713 cases t 1,279 cases, while, the psitivity rate has decreased by 35% fr the same perid 2004-2016, frm 51.0 per 1,000 (peak f the epidemic) t 33.0 per 1,000 tested specimens. Hepatitis C treatment thrugh the use f Direct Antiviral Agents (DAA) is prvided t patients accrding t the eligibility criteria established by the MOH & QL. Currently, Hepatitis C infected patients are being treated and fllwed up at the Medical Unit, Victria Hspital. The prprtin f peple wh inject drugs (PWID), amng annual newly detected HIV cases, was at its peak in 2005, that is, 92%, it has thereafter declined t reach 33% in 2016. Fr the first six mnths f 2017, PWID was 41% f the annual newly detected HIV cases. Peple wh are actively injecting drugs are estimated t be arund 5,000 and an estimated 40% f this high-risk ppulatin is infected with HIV. Health respnse t drug use As at June 2017, 4,021 peple were n the Methadne Substitutin Prgramme, thrugh 42 methadne dispensing sites acrss the Island, including 3 sites within the prisns services. Between 2012 and 2016, the number f syringes distributed thrugh the Needle Exchange Prgramme (NEP), has increased by 312% t reach a ttal f 697,861 syringes distributed in 2016, with 47% dne by the Ministry f Health and Quality f Life (MOH&QL) and 53% by NGOs. A Subxne-Naltrexne-based detxificatin prgramme started at Maheburg Hspital, in January 2016, with a 12-bed facility. At the end f June 2017, 457 cases, including 82 repeaters, have been admitted at Maheburg Hspital fr the prgramme. 80% were herin injectrs against 20% herin smkers. On the ther hand, an nging Cdeine Phsphate treatment prgramme is cnducted by five NGOs in cllabratin with the MOH&QL wh in additin prvides medicatins, as well as, medical and health persnnel fr the prgramme. Since April 2016, the Ministry f Health and Quality f Life has launched a natinal drug use preventin campaign, with a team cmprising f Nursing Officers and Health Care Assistants. This campaign fcuses n several frnts, namely; schlchildren and nn-schlchildren; cmmunities; wrkplaces and the public at large. 1,013 awareness sessins in schl settings were rganized, with 48,417 participants. 6,828 participants were sensitized thrugh 155 drug-related preventin sessins n a range f subjects such as; peer educatin initiatin in schls; frums and rehabilitated drug addicts cnfessins; nn-schlchildren educatin; and educatin in yuth centres and yuth assciatins. 20,784 participants were embraced in Cmmunity Centres thrugh 463 awareness sessins and 17,850 persns at main bus statins and cmmercial centres, in 9 sessins. Drug ffence and drug cntrl Based n data btained frm the Mauritius Plice Frce, between 2012 and 2014, the annual drug ffence rati was n average 2.8 reprted drug ffences per 1,000 inhabitants. Frm 2015 t 2016, the number f drug ffences registered, decreased by 3% frm 3,468 t 3,370, resulting in stabilizatin f the drug ffence rate t 2.7 per 1,000 ppulatin. [7]

Natinal Drug Observatry Reprt, March 2018 In 2015 and 2016, there were respectively 1,772 and 1,776 reprted Plice ADSU arrests fr drug ffences and 1,133 arrests were reprted fr the perid January t June 2017. Out f the 1,133 arrests by Plice ADSU fr drug ffences, frm January t June 2017, 838 arrests (74%) were arrests fr pssessin f drugs, 278 arrests (25%) were fr dealing f drugs, 12 arrests (1%) were fr mney laundering and 5 arrests were reprted fr causing bstructin t Plice. Fr the perid January t June 2017, ut f 1,116 Plice ADSU arrests (i.e excluding arrests due t mney laundering and bstructin t Plice), herin ffences accunted fr 38%, fllwed by cannabis, 30%, cannabinids, 20%, cultivatin f cannabis, 5%, sedatives/tranquilizers, 4%, methadne, 2%, buprenrphine, less than ne percent and finally hashish, ccaine and methamphetamine, less than ne percent. There was a percentage increase f 19% in the number f arrests by Plice ADSU fr the 1 st semester f 2017 with respect t the previus 2 nd semester f 2016. Fr the same tw semester perids, arrests fr pssessin f drugs increased by 14%, arrests fr dealing f drugs increased by 34% and arrests fr bstructin t Plice increased by 25%. Twelve arrests were reprted fr mney laundering in the 1 st semester f 2017 as cmpared t 3 crrespnding arrests in the 2 nd semester f 2016. Amng ther drug cntrl activities f the Plice ADSU, 14,866 plants f cannabis were uprted during the perid January up t June in 2017. In 2015 and 2016, 72,300 and 72,100 plants f cannabis were uprted respectively. During the first semester f 2017, the Mauritius Revenue Authrity (MRA) Custms carried ut 42 drug seizure cases as cmpared t 32 cases in the secnd semester f 2016. Seizures f drugs fr the ne-year perid, July 2016 up t June 2017, by the MRA, amunted t Rs 2.73 billin, ut f which, Rs 2.66 billin (97%) were seized in the first semester f 2017. The amunt f drugs seized in 2015 and in 2016 were Rs 178.5 millin and Rs 170.4 millin respectively as cmpared t Rs 2,656.6 millin (Rs 2.7 billin) fr the first six mnths f 2017. Fr the first six mnths f 2017, ut f the Rs 2,656.6 millin f drugs seized by the MRA, Rs 2,614.9 millin (98.4%) were related t herin seizures. 10.7 kg and 9.9 kg f herin were seized by MRA Custms in 2015 and in 2016 respectively as cmpared t 174.3 kg in the first six mnths f 2017, that is, a percentage increase f 1661% fr the 1 st semester f 2017 with respect t the whle year 2016. Regarding cannabis, 9.4 kg and 3.1 kg were seized in 2015 and in 2016 respectively as cmpared t 50.1 kg in the first six mnths f 2017, that is, a percentage increase f 1516% fr the 1 st semester f 2017 with respect t the whle year 2016. Furthermre, 78 units f cannabis seeds were seized in 2015, 500 units in 2016 and 111 units in the first semester f 2017. 5.4 kg f hashish were seized in 2015, 0.1 kg in 2016 and 3.1 kg in the first six mnths f 2017. In 2015, 0.3 kg f new psychactive substances were seized against 0.1 kg in 2016 and 2.1 kg in the first six mnths f 2017, that is, a percentage increase f 2000% fr the 1 st semester f 2017 with respect t the whle year 2016. 1.3 kg f ccaine was seized in 2016, while, n seizures invlving this drug was reprted in 2015 and in 2017(as at end f June). [8]

Natinal Drug Observatry Reprt, March 2018 There were n reprted seizures f psychtrpic substances by the MRA in 2015, as cmpared t seizures f 2,256 units (tablets) in 2016 and 1,529 units in the first six mnths f 2017. There were n reprted seizures f ecstasy by the MRA in 2015 against seizures f 2,256 units (tablets) in 2016 and 1,529 units in the first six mnths f 2017. Drug ffence and imprisnment Out f 2,140 admissins in prisns, in the first semester f 2017, drug-ffence imprisnment accunted fr 6%. Amng drug-ffence admissins, 68% were assciated with pssessin f drugs, 14% with dealing f drugs, 15% with drug trafficking and 3% fr imprtatin f drugs. During the first six mnths f 2017, amng drug-ffence imprisnment, mst admissins were due t herin-related ffences, 47%, and cannabis-related ffences, 69%, fllwed by new psychactive substances ffences, 14% and ecstasy, 8%. There were als very few cases, arund ne percent, fr ther specified drug ffences, while, a significant prprtin f drug-ffence admissins were reprted with unspecified drugs, 17%. 2,222 cnvicted drug ffences were reprted by the Judiciary, in 2016, as cmpared t 2,363 in 2015. In 2016, mst cnvicted drug ffences were given fines, 87%, against 10% imprisnment and 3% cmbined fr prbatin, cmmunity services and cnditinal & abslute discharges. 57% f the 2,222 cnvicted drug ffences reprted by the Judiciary, in 2016, were assciated with cannabis-related ffences, that is, cultivatin, pssessin and cnsumptin f cannabis. Drug use in schls Fr the first half f 2017, 19 cases f suspected illicit drug use, invlving mre than 35 students in 17 educatinal institutins, were reprted, as cmpared t 43 students cncerning 9 educatinal institutins in the first half f 2016. General bservatin In Mauritius, even if drug ffences represent nly 6% f all ffences (excluding rad traffic ffences), evidence-based infrmatin shws that there are sme drug cncerns in the cuntry, specifically in terms f health, scial and ecnmic implicatins. Each year, arund 3,000 drug ffences are reprted by the Mauritius Plice Frce, abut 2,000 cnvicted drug ffences are reprted by the Judiciary. Regarding health, at least a thusand drug-related inpatient treatment cases are nw expected annually at the public health institutins, while, nearly half f whm usually attend the specialized Mental Health Care Centre. Amng patients receiving drug-related care, a high prprtin (abve 90%) is fund in the age grup 15-49 years, that is, an imprtant age segment f the active labr frce. The natinal Hepatitis C and HIV epidemics are high-risk grups cncentrated epidemics and are drug-use driven. The psitive utcmes f the existing preventin and harm reductin prgrammes need t be maintained by cnslidating and adapting the prgrammes. On the ther hand, cntrl by the authrities shws that imprtatins f majr illicit drugs are increasing, in terms f quantity and values. In additin, Plice arrests due t mney laundering are increasing. Inpatient treatment cases fllwing drug abuse are increasing annually at public health institutins and drug abuse is causing a range f health prblems such as; mental and behaviural disrders as [9]

Natinal Drug Observatry Reprt, March 2018 well as ther systemic diseases. Since April 2016, in additin t the existing drug treatment and preventin prgrammes, the Ministry f Health and Quality f Life is implementing a strng natinal drug use preventin campaign amng schlchildren and nn-schlchildren, at wrkplaces and in the public at large. The bjective f these prgrams is t build new and at the same time t strengthen existing prtective factrs and t reverse r reduce risk factrs, particularly amng the yuth. Inpatient treatment cases in public health institutins have revealed that varius categries f drugs are being used, namely; narctics, hallucingens, depressants, stimulants and ther psychactive drugs, amngst thers. Health prblems fllwing suspected use f new psychactive substances cnstitute ne f the majr reasns fr drug-related inpatient treatment in public health institutins. Triangulatin f infrmatin indicates that, female drug users generally accunt fr 5% t 10% f drug users in Mauritius. Fr instance, 6% f the knwn suspected new psychactive drug inpatient cases were females. It was 9% amng herin cases and 6% amng cannabis cases. On the ther hand, all IBBS surveys carried ut s far have shwn a prprtin f 5% t 10% f female injectrs amng the whle ppulatin f peple wh inject drugs. Peple in need f inpatient treatment, due t drug prblems, are frm all age grups, ranging frm teenagers t adults aged abve 50 years ld. It is mst frequent amng abusers in the 20-34 years age grup, thugh there is a greater cncentratin within the 25-34 years age grup. In additin, drugrelated inpatients cme frm all parts f the cuntry, the impact in the rural areas being as substantial as in the urban nes. Furthermre, Mauritian drug users are chsing an assrtment f drugs and substances namely, herin, cannabis, cannabinids, hashish, methadne, ccaine, methamphetamine, ecstasy, Rivtril, Valium, Mgadn, Panadeine, Cugh syrup, Tramadl, new psychactive substances, buprenrphine and Nva, amngst thers. The particular interest in the benzdiazepines class f drug is als t be nted. Plydrug use is causing quite a number f health harms t thse wh are addicted. Multiple drugs use is indicating the strng drug dependence nature f sme drug users, nt t mentin the aggravated situatin f drugs being taken with alchl cncurrently r sequentially. Fr instance, inpatient treatment cases at public health institutins have revealed circumstances where herin has been used with alchl, thus adding the risk f verdsing. Other surces f infrmatin reprted t the Natinal Drug Observatry are assciating multiple drugs use t the pr quality f street drugs available. The increasing circulatin f new psychactive substances is als cntributing t plydrug use. Hepatitis C (HCV) amng peple wh inject drugs (PWID) was fund t be high, abve 95%. In additin, amng this high-risk ppulatin, 44% were c-infected with HIV and HCV. High psitivity rates f labratry tested Hepatitis C amng patients, as cmpared t the lw psitivity rates in the general ppulatin, bserved thrugh bld dnrs labratry tests, is an indicatin f a natinal cncentrated hepatitis C epidemic. In Mauritius, deaths registered due t hepatitis C is lw, arund 10 deaths yearly, while, 9 in 1 deaths due t hepatitis C are acute cases against ne chrnic case. Management f Hepatitis C (HCV) and HIV c-infectin shuld cnsider the health vulnerabilities f individuals tuched by this cnditin. Fr instance, amng the HCV-HIV c-infectin issues are; firstly, the shrter interval fr the develpment f liver diseases as cmpared t HCV mn-infected patients; secndly, the replicatin f HCV which is enhanced in the presence f HIV c-infectin; thirdly, sme studies have fund HCV-HIV c-infectin t be assciated with an increased risk f death cmpared with HCV mn-infectin, amngst thers. The prprtin f peple wh inject drugs, amng the annual newly detected HIV cases, has declined drastically since 2011. HIV transmissin in this high-risk ppulatin has been brught under cntrl thrugh the Harm Reductin prgrammes. The natinal HIV epidemic is still a cncentrated ne. The [10]

Natinal Drug Observatry Reprt, March 2018 ppulatin size f peple wh are actively injecting drugs is estimated t be arund 5,000 6,000. Cntinuus mnitring f this high-risk grup, thrugh Integrated Bilgical and Behaviural Surveillance studies (IBBS) every tw years, remains vital since it currently represents arund 40% f newly detected HIV cases and that the prevalence f HIV amng this key ppulatin is estimated t be arund 40%. Cllabratin and partnership in drug preventin and treatment prgrammes between the public and the private sectr is nging. Gvernment and NGOs interactins in the Needle Exchange Prgramme (NEP) and in the Cdeine Phsphate Prgramme are examples f the public-private sectr cllabratin. Including NGOs in the demand reductin strategies and inviting cnsultatin f NGOs at all levels f the plicy is vital. Based n the regular and cnstant rate f mnthly drug-ffence arrests by Plice ADSU, especially fr pssessin f drugs (mnthly average f 131 arrests), cupled with the steady increase f peple seeking hspital drug-related inpatient treatment, there is an indicatin that there is a cntinuus dynamic supply f drugs. [11]

Natinal Drug Observatry Reprt, March 2018 Chapter 1 Health effects f drug use in Mauritius This chapter gives an accunt f the different health prblems encuntered by sme Mauritians fllwing drugs use, fr the ne-year perid July 2016 t June 2017. Infrmatin cmpiled and analyzed n drugrelated inpatient treatment cases in public health institutins, shws evidence f hw drug use can hurt health. It shws hw drug use can affect the bdy, leading t varius diseases such as mental disrders as well as ther systemic diseases. In additin t inpatient treatment cases in public health institutins, this chapter cnsiders ther infrmatin such as injecting drug use which causes harms when using and sharing dirty injecting equipment, resulting in transmissin f HIV infectin and hepatitis C. 1.1 Inpatient treatment cases in public health institutins due t drug use prblems 1.1.1 Pattern and trend f inpatient treatment in public health institutins due t drug use prblems Fr the ne-year perid, frm July 2016 t June 2017, there were 1,158 cases treated as inpatients in public health institutins, due t drug use prblems, ut f which, 7% were female cases. Frm 2015 and 2016, inpatient treatment cases in public health institutins fllwing drug use prblems, increased by 66% (66% amng males and 56% amng females), that is, frm 552 cases t 914 cases. Between the 2 nd semester perid f 2016 and the 1 st semester perid f 2017, inpatient treatment cases in public health institutins, fllwing drug use prblems, increased by 47% (+46% amng males and +65% amng females). Fr the same perid, there were increases fr almst all kind f drugs used and als acrss all age grups, particularly amng male inpatient cases in the age grup 25-34 years, that is, a percentage increase f 52% between the tw semester perids fr this age grup. Fr the ne-year perid July 2016 up t June 2017, reprted inpatient treatment cases fr drug prblems at Brwn Sequard Mental Health Care Centre accunted fr nearly 50% f all reprted drug related inpatients treatment cases in all public health institutins. Frm 2011 t 2016, at Brwn Sequard Mental Health Care Centre, inpatient treatment cases due t drug abuse have increased frm 65 cases in 2011 t 300 cases in 2016. Fr the first six mnths f 2017, 337 drug-related inpatient treatment cases have been reprted at this same care centre. [12]

First quarter 2015 2nd quarter 2015 3rd quarter 2015 4th quarter 2015 1st quarter 2016 2nd quarter 2016 3rd quarter 2016 4th quarter 2016 1st quarter 2017 2nd quarter 2017 Number f admissins 1st semester 2nd semester 1st semester 2nd semester 1st semester Natinal Drug Observatry Reprt, March 2018 Table 1 Public Heath Institutins Inpatient treatment cases due t cmplicatins fllwing drug use by semester perid January 2015 - June 2017 2015 2016 2017 Percentage change f reprted inpatient treatment cases Year 2016 /Year 2015 1st semester 2017 / 2nd semester 2016 Male 207 297 401 438 638 +66% +46% Female 15 33 44 31 51 +56% +65% Bth sexes 222 330 445 469 689 +66% +47% Figure 1 Public Health Institutins Inpatient treatment cases due t cmplicatins fllwing drug use Quarterly trend, January 2015 - June 2017 400 FEMALE 320 318 300 200 100 0 67 9 140 MALE 126 171 267 233 205 134 18 26 17 14 22 29 Quarterly perid (Jan 2015 - Jun 2017) [13]

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017(As at June) Number f admissins Natinal Drug Observatry Reprt, March 2018 Figure 2 Brwn Sequard Mental Health Care Centre Cases treated as inpatients due t mental and behaviural disrders fllwing drug use 2005-2017(As at June) 350 300 287 316 250 200 183 MALE 150 100 50 0 94 105 61 38 49 49 59 56 38 43 3 3 9 2 2 4 6 7 3 5 11 13 21 FEMALE 1.1.2 Age distributin f drug users treated as inpatients, in public health institutins Fr the ne-year perid, frm July 2016 t June 2017, the age distributin f patients fr drug-related inpatient treatment cases in public health institutins, was as fllws; 2% were aged 10-14 years, 17% were aged 15-19 years, 28% were aged 20-24 years, 31% were aged 25-34 years, 18% were aged 35-49 years and 4% were aged 50 years and abve. Thus, inpatient treatment cases were essentially in the age band 15-49 years fr male cases, 93%, while it was essentially in the age band 15-34 years fr female cases, 91%. In public health institutins, fr the ne-year perid, frm July 2016 t June 2017, drug-related inpatient treatment cases fr teenagers (10-19 years) accunted fr 19% f all drug-related inpatient cases (18% amng male teenagers, 33% amng female teenagers). Table 2 Public Heath Institutins Inpatient treatment cases due t cmplicatins fllwing drug use ONE-YEAR PERIOD: JULY 2016 TO JUNE 2017, by age grup & sex f patient Bth Age grup (Years) Male Female sexes Percent 10-14 years 22 5 27 2.3 15-19 years 169 22 191 16.5 20-24 years 300 22 322 27.8 25-34 years 339 25 364 31.4 35-49 years 197 6 203 17.5 50 years & abve 49 2 51 4.4 TOTAL 1,076 (92.9%) 82 (7.1%) 1,158 (100.0%) 100.0 [14]

Natinal Drug Observatry Reprt, March 2018 35 years & abve, 22% Figure 3 Public Heath Institutins Inpatient treatment cases due t cmplicatins fllwing drug use ONE-YEAR PERIOD: JULY 2016 TO JUNE 2017, by age grup f patient 20-34 years, 59% (10-19 years) 19% Table 3 Public Heath Institutins Inpatient treatment cases due t cmplicatins fllwing drug use by age grup & sex f patient and semester perid, (July December) 2016 (January-June) 2017 Male Female Bth sexes Percent Male Female Bth sexes Percent Age grup (Years) 10-14 years 10 2 12 2.6 12 3 15 2.2 15-19 years 78 10 88 18.8 91 12 103 14.9 20-24 years 123 9 132 28.1 177 13 190 27.6 25-34 years 130 6 136 29.0 209 19 228 33.1 35-49 years 78 3 81 17.3 119 3 122 17.7 50 years & abve 19 1 20 4.3 30 1 31 4.5 TOTAL 438 31 469 100.0 638 51 689 100.0 (93.4%) (6.6%) (100.0%) (92.6%) (7.4%) (100.0%) 1.1.3 Suspected substances reprted, amng drug users treated as inpatients, in public health institutins Infrmatin cllected frm public health institutins, indicates that frm July 2016 t June 2017, Mauritian drug users have been n a range f substances. Amng the reprted specified suspected drugs used, there were the fllwing: Herin (Brwn sugar), Buprenrphine, Cannabis, Rivtril, Valium, Mgadn, Panadeine, Cugh syrup, [15]

Natinal Drug Observatry Reprt, March 2018 Ccaine, Methadne, Tramadl, New psychactive substances, and Nva. Suspected use f new psychactive substances related t hspital inpatient treatment cases have been reprted under varius names as fllws: La pussière tmbée C est pas bien Batte dans la tête Ramb Strawberry Murder Wasabi Black Mamba Résine Simin The Table belw gives the distributin f drug-related inpatient treatment cases in public health institutins, by substances used, fr the perid July 2016 t June 2017. Althugh a substantial prprtin (30%) f inpatient cases was reprted with unspecified drugs, the use f new psychactive substances appeared t be ne f the majr reasns why drug users have sught after hspital care. Table 4 Public Health Institutins Inpatient treatment cases due t cmplicatins fllwing drug use By type f drug & semester perid, July 2016 t June 2017 Drug First semester 2017 Secnd semester 2016 Ttal (One-year perid) July 2016 - June 2017 Percent New psychactive substances 305 231 536 46.3% Opiids and piates 120 79 199 17.2% Cannabis 38 25 63 5.4% Medicinal 3 5 8 0.7% Buprenrphine 0 1 1 0.1% Unspecified (including multiple drugs) 223 128 351 30.3% TOTAL 689 469 1,158 100.0% [16]

Age grup Natinal Drug Observatry Reprt, March 2018 Table 5 Public Heath Institutins Inpatient treatment cases due t cmplicatins fllwing drug use by type f drug & sex f patient One-year perid, July 2016 - June 2017 Drug Male Female Bth sexes Percent New psychactive substances 504 32 536 46.3% Opiids and piates 181 18 199 17.2% Cannabis 59 4 63 5.4% Medicinal 8-8 0.7% Buprenrphine 1-1 0.1% Unspecified drugs (Including multiple drugs) 323 28 351 30.3% TOTAL 1,076 82 1,158 100.0% Table 6 Public Heath Institutins Inpatient treatment cases due t cmplicatins fllwing drug use by type f drug & age grup f patient One-year perid, July 2016-June 2017 DRUG Cannabis Medicinal New psychactive substances Opiids and piates Buprenrphine Unspecified (Including Multiple drugs) Ttal Percent 10-14 years 4 0 14 1 0 8 27 2.3% 15-19 years 16 2 108 18 0 47 191 16.5% 20-24 years 20 2 148 56 0 96 322 27.8% 25-34 years 16 3 160 76 0 109 364 31.4% 35-49 years 5 0 90 35 0 73 203 17.5% 50 years & abve 2 1 16 13 1 18 51 4.4% Ttal 63 8 536 199 1 351 1,158 100.0% 1.1.4 Inpatient treatment cases in public health institutins, due t multiple drugs use Cases f multiple drugs use were reprted as fllws: taking methadne with herin/brwn sugar; herin with rivtril; brwn sugar with caustic sda; alchl with new psychactive substances; buprenrphine with rivtril; drugs injectin while n methadne; herin (brwn sugar) with new psychactive substances, Nva with cugh syrup; amngst thers. [17]

Age grup Natinal Drug Observatry Reprt, March 2018 1.1.5 Diseases and health cmplicatins reprted at public health institutins due t drug use Fr the ne-year perid, frm July 2016 t June 2017, amng drug-related inpatient cases in public health institutins, several diseases assciated with mental and behaviural disrders were reprted, namely; auditry hallucinatin, psychtic disrders, acute psychsis, cnfusinal state, depressin and anxiety, amngst thers. Drug users treated as inpatients als presented the fllwing symptms, namely; uncnsciusness, fits, vertig, palpitatin, breathlessness, vmiting, nausea, abdminal pain, headache, weakness, dizziness, agitatin and restlessness, sleepiness and dyspnea. Other cnditins which have necessitated inpatient treatment cases in public health institutins, fllwing drug use, were withdrawal syndrme, suicidal tendencies, abnrmal aggressive disrders and slurred speech. Addictin t herin during pregnancy was als reprted amng drug-related inpatient treatment cases. 1.1.6 Inpatient treatment in public health institutins fllwing cmplicatins due t suspected use f new psychactive substances Fr the ne-year perid, July 2016 t June 2017, ut f 1,158 inpatient treatment cases in public health institutins, at least 536 cases, 44%, were specified as suspected use f new psychactive substances, ut f which, female inpatient cases accunted fr 6%. It is t be nted, as already mentined, that 30% f all drugrelated inpatient cases were reprted with unspecified drugs. Out f the 536 knwn inpatient cases f suspected new psychactive substances, 3% f cases were assciated t patients aged 10-14 years, 20% were aged 15-19 years, 28% were aged 20-24 years, 30% were aged 25-34 years, 17% were aged 35-49 years and 3% were aged 50 years and ver. Thus, amng the knwn inpatient cases f suspected use f new psychactive substances, in public health institutins, teenagers (10-19 years) inpatient cases accunted fr 23%. Table 7 Public Heath Institutins Inpatient treatment cases due t cmplicatins fllwing suspected use f new psychactive substances One-year perid, July 2016 t June 2017, by age & sex f patient Female Percent Male Percent Bth sexes Percent 10-14 years 2 6.3% 12 2.4% 14 2.6% 15-19 years 11 34.4% 97 19.2% 108 20.1% 20-24 years 6 18.8% 142 28.2% 148 27.6% 25-34 years 9 28.1% 151 30.0% 160 29.9% 35-49 years 3 9.4% 87 17.3% 90 16.8% 50 years & abve 1 3.1% 15 3.0% 16 3.0% Ttal 32 100.0% 504 100.0% 536 100.0% [18]

Natinal Drug Observatry Reprt, March 2018 1.1.7 Inpatient treatment cases in public health institutins fllwing cmplicatins due t drug use, by district f residence f patient Fr the ne-year perid, frm July 2016 t June 2017, the distributin f the place f residence f drug users attending public health institutins, fr inpatient care, indicates that drug use was scattered in almst all areas f the Island f Mauritius, even if sme regins were mre affected than thers. Drug users admitted t public health institutins were predminantly frm the tw districts cnstituting the urban regin, namely, Prt Luis and Plaines Wilhems. Nearly ne-quarter f drug-related inpatient cases were frm Prt Luis and 28% were frm Plaines Wilhems, making a ttal prprtin f 53% fr urban cases against 47% fr rural cases. Each rural district represented respectively 3% t 10% f all drug-related inpatient cases in the Island. The district f Savanne had the lwest prprtin f admitted drug-users with nly 3% f all inpatients cases in the Island. One percent f drug-related inpatient treatment cases, in public health institutins, were frm crrectinal centres and frm prisns. Table 8 (a) Public Heath Institutins Inpatient treatment cases due t cmplicatins fllwing drug use One-year perid, July 2016 t June 2017 by place f residence & sex f patient Place f residence Male Percent Female Percent Bth sexes Percent Prt Luis 264 24.5% 22 26.8% 286 24.7% Pamplemusses 101 9.4% 7 8.5% 108 9.3% Rivière du Rempart 58 5.4% 3 3.7% 61 5.3% Flacq 100 9.3% 5 6.1% 105 9.1% Grand Prt 51 4.7% 2 2.4% 53 4.6% Savanne 33 3.1% 2 2.4% 35 3.0% Plaines Wilhems 302 28.1% 24 29.3% 326 28.2% Mka 53 4.9% 2 2.4% 55 4.7% Black River 103 9.6% 13 15.9% 116 10.0% Crrectinal centres 11 1.0% 2 2.4% 13 1.1% Ttal 1,076 100.0% 82 100.0% 1,158 100.0% [19]

Prt Luis Pamplemusses R du Rempart Flacq Grand Prt Savanne Plaines Wilhems Mka Black River Crrectinal centre/ prisn Prt Luis Pamplemusses R du Rempart Flacq Grand Prt Savanne Plaines Wilhems Mka Black River Crrectinal centre/ prisn Natinal Drug Observatry Reprt, March 2018 Table 8 (b) Public Heath Institutins Inpatient treatment cases due t cmplicatins fllwing drug use One-year perid, July 2016 t June 2017 by place f residence & suspected substances used (Number f inpatient treatment cases) PLACE OF RESIDENCE OF PATIENT TOTAL DRUG Cannabis 6 8 3 15 5 6 10 2 8 0 63 Medicinal 2 1 0 0 2 1 2 0 0 0 8 New psychactive substances 145 50 28 32 27 12 156 24 53 9 536 Opiids and piates 49 21 7 28 6 4 49 12 22 1 199 Buprenrphine 1 0 0 0 0 0 0 0 0 0 1 Unspecified 83 28 23 30 13 12 109 17 33 3 351 TOTAL 286 108 61 105 53 35 326 55 116 13 1,158 (Percentage inpatient treatment cases) PLACE OF RESIDENCE OF PATIENT TOTAL DRUG Cannabis 2% 7% 5% 14% 9% 17% 3% 4% 7% 0% 5% Medicinal 1% 1% 0% 0% 4% 3% 1% 0% 0% 0% 1% New psychactive substances 51% 46% 46% 30% 51% 34% 48% 44% 46% 69% 46% Opiids and piates 17% 19% 11% 27% 11% 11% 15% 22% 19% 8% 17% Buprenrphine 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Unspecified 29% 26% 38% 29% 25% 34% 33% 31% 28% 23% 30% TOTAL 100%% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% [20]

First semester 2017 Secnd semester 2016 One-year (July 2016 - June 2017) First semester 2017 Secnd semester 2016 One-year (July 2016 - June 2017) First semester 2017 Secnd semester 2016 One-year (July 2016 - June 2017) First semester 2017 Secnd semester 2016 One-year (July 2016 - June 2017) First semester 2017 Secnd semester 2016 One-year (July 2016 - June 2017) First semester 2017 Secnd semester 2016 One-year (July 2016 - June 2017) First semester 2017 Secnd semester 2016 One-year (July 2016 - June 2017) First semester 2017 Secnd semester 2016 One-year (July 2016 - June 2017) First semester 2017 Secnd semester 2016 One-year (July 2016 - June 2017) First semester 2017 Secnd semester 2016 One-year (July 2016 - June 2017) First semester 2017 Secnd semester 2016 One-year (July 2016 - June 2017) Natinal Drug Observatry Reprt, March 2018 Table 8 (c) Public Heath Institutins Inpatient treatment cases due t cmplicatins fllwing drug use One-year perid, July 2016 t June 2017 by place f residence, semester perids & suspected substances used [Cntinue with next table belw fr further districts). Number f inpatient cases Prt Luis Pamplemusses R. D. Rempart Flacq Grand Prt DRUG Cannabis 4 2 6 7 1 8 1 2 3 7 8 15 1 4 5 Medicinal 1 1 2 1 0 1 0 0 0 0 0 0 1 1 2 New psychactive substances 90 55 145 30 20 50 12 16 28 14 18 32 14 13 27 Opiids and piates 37 12 49 10 11 21 2 5 7 13 15 28 4 2 6 Buprenrphine 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 Unspecified 57 26 83 17 11 28 13 10 23 20 10 30 7 6 13 TOTAL 189 97 286 65 43 108 28 33 61 54 51 105 27 26 53 Cntinue frm abve Savanne Plaines Wilhems Mka Black River Crrectinal Centres All public health Institutins DRUG Cannabis 5 1 6 8 2 10 0 2 2 5 3 8 0 0 0 38 25 63 Medicinal 0 1 1 0 2 2 0 0 0 0 0 0 0 0 0 3 5 8 New psychactive substances 7 5 12 95 61 156 14 10 24 23 30 53 6 3 9 305 231 536 Opiids and piates 3 1 4 24 25 49 10 2 12 16 6 22 1 0 1 120 79 199 Buprenrphine 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 Unspecified 8 4 12 65 44 109 9 8 17 24 9 33 3 0 3 223 128 351 TOTAL 23 12 35 192 134 326 33 22 55 68 48 116 10 3 13 689 469 1,158 [21]

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Number f psitive cases 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Rate / 1,000 Natinal Drug Observatry Reprt, March 2018 1.2 Drug use, Hepatitis C and HIV epidemics 1.2.1 Hepatitis C and drug injectin The link between drug use and hepatitis C has been widely dcumented by many cuntries and cmmunities and is nw evident glbally. Hepatitis C is a disease f the liver caused by the hepatitis C virus (HCV), which if nt reslved can lead t chrnic liver disease such as cirrhsis. HCV which affects millins f peple, glbally, is cmmunicable and is spread by cntact with infected bld r ther bdily fluids. In Mauritius, three Integrated Bilgical and Behaviral Surveillance (IBBS) surveys carried ut in 2009, 2011 and 2013 have shwn that, at each pint f time, abve 95% f peple wh inject drugs were HCV infected, althugh these studies als shwed a decrease in the size f this high-risk ppulatin frm 10,000 t 5000 active drug injectrs. The evlutin f the natinal Hepatitis C cncentrated epidemic is prtrayed thrugh the trend f psitivity rates f this pathgen cnfirmed thrugh tests carried ut in public labratries frm 2000 t 2016. The peak f the Hepatitis C epidemic was bserved in 2004 when 2,713 psitive cases were fund amng 52,713 specimens tested, that is a psitivity rate f 51.0 per 1,000 and has since then cnstantly decreased t reach a psitivity rate f 27.2 per 1,000, thrugh 55,158 specimens tested in 2011. N further decrease has been bserved as frm 2011 t 2016 in the psitivity rate, althugh it decreased in abslute numbers, respectively frm 1,502 cases t 1,279 cases. In 2016, HCV psitivity rate was 33.0 per 1,000 with 1,279 psitive cases ut f 38,756 specimens tested - (excluding bld dnrs in 2016). Figure 4 (a) Island f Mauritius Trend f Hepatitis C psitivity rate /1,000 specimens tested in public labratries, 2000-2016 51.0 27.0 37.0 27.0 33.0 Public labratries psitivity rate f Hepatitis C per 1,000 specimens tested 3000 Figure 4 (b) Public Labratries (40,000-60,000 tested specimens yearly) Number f psitives cases f Hepatitis C, 2000-2016 2,713 2000 1000 911 1,279 0 [22]

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Natinal Drug Observatry Reprt, March 2018 1.2.2 Drug injectin, HIV and Hepatitis C linkages In Mauritius, the Hepatitis C epidemic curve has fllwed almst the same pattern and trend as the HIV epidemic, thus indicating peple wh inject drugs as the driving element f the natinal Hepatitis C cncentrated epidemic (See figure 5(a) belw). The methadne substitutin treatment set up in Mauritius as frm 2006, cupled with prvisin f sterile injecting equipment, thrugh needle and syringe prgrammes, have been the determinant preventin measures that have cntributed t the cntrl f the HIV epidemic and at the same time have curbed dwn the Hepatitis C epidemic. It shuld be nted that, while a drastic decline in the number f annual newly detected HIV cases is bserved as frm 2011 t 2016 (see chart belw), n anther hand, fr the same perid, the psitivity rates f Hepatitis C thrugh public labratries have remained cnstantly arund 30 per 1,000. In 2015, psitivity rate f hepatitis C, in public labratries, was 120 per 1,000 amng patients (1,700 psitive cases ut f 14,125 specimens tested), while, it was 3 per 1,000 amng bld dnrs (133 psitive cases amng 46,617 specimens tested) indicating a cncentrated hepatitis C epidemic. In 2013, HIV and Hepatitis c-infectin was 44% amng peple wh inject drugs. 27.0 3% 14% 68% 88% 51.0 Figure 5 (a) Republic f Mauritius Peple wh inject drugs (PWID) as a percentage f annual newly detected HIV cases and Hepatitis C psitivity rate/1,000, in public labratries,2000-2016 92% 72% 74% 31.0 68% 30.0 33.0 % PWID n annual newly detected HIV cases Hepatitis C Lab psitivity rate per 1,000 815 455 433 Figure 5 (b) Republic f Mauritius Newly detected HIV cases, by sex 2000-2017(As at June) Male Female 32 59 167 106 135 190 151 155 190 121 (As at June) 109 132 107 129 73 (As at June) The high prevalence f HCV can be explained by the high-risk drug injecting practices that were bserved amng peple wh inject drugs. Fr instance, 90% f PWID reprted injecting herin in the three mnths previus t the 2013 IBBS survey. 63% percent f them reprted injecting drugs daily; mre than tw thirds [23]

Natinal Drug Observatry Reprt, March 2018 (69%) reprted injecting tw r mre times in a day and nly 25% had never shared a needle/syringe previusly used by smene else and 25% had never shared injecting equipment such as ckers, vials, cntainers in the three mnths previus t the 2013 IBBS survey. 1.2.3 Hepatitis C mrbidity and mrtality In 2016, based n the Internatinal Classificatin f Diseases (ICD 10), 12 deaths were registered due acute hepatitis C and all were in the age band 30-64 years. Frm 2010 t 2016, 68 deaths (63 males, 5 females) due t hepatitis C have been registered amng adults aged 30 years & ver, ut f which, 61 deaths were acute cases against 7 chrnic cases. The three tables belw give details f the mrbidity and mrtality trend f hepatitis C frm year 2005 t 2016. Fr instance, in 2016, there were 1,279 psitive hepatitis C cases detected by public labratries (excluding tests amng bld dnrs) and 11 inpatient treatment cases were reprted in public hspitals due t hepatitis C, while, 13 deaths were registered due t hepatitis C in whle Island f Mauritius. Table 9 HEPATITIS C Trend f public labratries psitivity rates, mrbidity and mrtality, 2005 2016 YEAR Number f specimens tested in public labratries Number f psitive cases Psitivity Rate (%) Number f deaths registered in Island f Mauritius Cases treated as inpatients in public health institutins 2005 42,899 1,952 4.6 2 2 2006 55,135 2,026 3.7 1 6 2007 54,842 1,839 3.4-6 2008 54,262 1,660 3.1 5 5 2009 51,773 1,735 3.4 4 5 2010 54,950 1,637 3.0 7 6 2011 55,158 1,502 2.7 14 12 2012 57,586 1,598 2.8 7 13 2013 61,665 1,713 2.8 11 7 2014 58,951 1,901 3.2 5 10 2015 60,742 1,833 3.0 11 19 2016 38,756 1,279 3.3 13 11 Hepatitis C Table 10 Island f Mauritius Deaths registered due t Hepatitis C (Acute and Chrnic) amng adults aged 30 years and ver 2010 2011 2012 2013 2014 2015 2016 Male Female Male Female Male Female Male Female Male Female Male Female Male Female Acute 5 1 12-5 - 10 1 4 1 9 1 11 1 Chrnic 1 2-2 - - - - - 1-1 - Ttal 7 14 7 11 5 11 13 Table 11 Island f Mauritius [24]

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Natinal Drug Observatry Reprt, March 2018 Cases treated as inpatients in gvernment general hspitals Hepatitis C (Acute and Chrnic) amng adults aged 30 years and ver 2010-2016 Hepatitis C 2010 2011 2012 2013 2014 2015 2016 Male Female Male Female Male Female Male Female Male Female Male Female Male Female Acute 5 1 12-8 5 4 3 1 5 7 1 2 1 Chrnic - - - - - - - - 2 2 7 4 5 3 Ttal 6 12 13 7 10 19 11 1.3 Injecting drug use 1.3.1 Peple wh inject drugs (PWID) as the driving agent f the natinal HIV epidemic At the beginning f the HIV epidemic, the mde f transmissin f the HIV virus was mainly hetersexual. The escalating incidence as frm year 2000 was prpelled by PWID acting as the main mde f transmissin. The gradual shift in mde f transmissin frm hetersexual t PWID became flagrant in 2003 when 68% f the new cases were detected amng the PWID as cmpared t nly 14% in 2002. The shift gt t its peak in 2005, 92%, and declined t 68% in 2011. In 2016, PWID accunted fr 33% f the annual newly detected HIV cases as cmpared t 35% in 2015. Fr the first six mnths f 2017, it was 41%. Based n the UNAIDS Spectrum, the number f peple living with HIV was estimated t stand arund 7,900 in 2016, with an HIV prevalence f 0.87% amng the Mauritian ppulatin age 15-49 years. 2.00 1.60 1.20 0.80 0.40 Figure 6 Republic f Mauritius Estimated HIV prevalence (%) amng adult 15-49 years 1987-2016 1.80 1.14 1.22 0.87 0.47 0.52 0.00 Male Female Bth sexes Tw Integrated Bilgical and Behaviral Surveillance (IBBS) surveys, carried ut in the years 2009 and 2011 prvided an estimated ppulatin size f arund 10,000 active PWID in Mauritius. Anther similar survey, carried ut in 2013, prvided an estimated ppulatin size f 5,000 active PWID. An estimate f the PWID ppulatin size in 2016, using the UNAIDS Spectrum, is arund 5,000 6,000 active injectrs. It is t be [25]

Natinal Drug Observatry Reprt, March 2018 highlighted that ver 6,500 PWID have been induced n methadne since 2006 and as at June 2017, arund 4,000 PWID were n the methadne maintenance prgramme. 1.3.2 Characteristics f peple wh inject drugs The IBBS study, carried ut in 2013, revealed that male drug injectrs made up 93% f the ppulatin f peple wh inject drugs against 7% female drug injectrs. The majrity f drug injectrs, 80%, were aged between 20 49 years fr bth sexes. Thse aged 15 19 years cnstituted 7% amng female injectrs and less than 1% amng male injectrs. Regarding their educatinal attainment, it was bserved that at least 95% f drug injectrs had reprted that they have nt cmpleted the secndary educatin cycle. Cncerning civil status, nly 2% f PWID were widws r widwers and the remaining 98% f this ppulatin was equally distributed within thse wh were singles, thse living in cmmn whether civilly r religiusly and thse divrced r separated cuples. 85% f PWID reprted they have ever been arrested by plice and mstly, 69%, fr drug-related prblems, while, 21% were arrested fr larceny, 6% fr vilence, 3% fr prstitutin and 2% fr ther matters. 81 % f thse that have ever been arrested have ever been incarcerated, which means that rughly 70% f PWID have ever been incarcerated. Mst drug injectrs started injectin in the age grup 15 19 years (43%), 27% started in the age grup 20 24 years, 23% started as frm 25 years and abve. 7% started under the age f 15 years. The median duratin n injecting drug use was 18 years with 11% wh claimed a duratin f 30 years and abve f drug injectin practice. Regarding the age f initiatin t drugs, it is wrth underlying the link between injecting drug and nn-injecting drug practice. In fact, 95% f PWID reprted they have ever used nn-injecting drug and nce they have started with this type f drug use, 16% have started with injecting practices n the same year, 15% have started injecting ne year after the first nn-injecting drug, 34% have started injecting 2 4 years after first the nninjecting drug, 20% have started injecting 5 10 years after first the nn-injecting drug and finally nly 7% have started with injecting drug mre than 10 years after first nn-injecting drug use. 1.3.3 Mde f initiatin t injecting drug The 2013 IBBS survey shwed that the age at first injecting drug use was independent f the mde f initiatin, i.e. age at first drug injectin was nt assciated with whether injecting drug initiatin was dne by a friend, in a grup r the drug user himself/herself. On the ther hand, a significant decrease was bserved frm 85% in 2011 t 68% in 2013 with respect t the percentage f thse wh used t inject drug with anther persn r use t inject in a grup. Frty-three percent f PWID reprted they have been initiated t injecting drug practice by a friend while 32% reprted the initiatin was made n their wn. 18 % admitted they had started injecting drugs within a grup (nt in prisn). Only 5% have had their first injecting drug by a partner. 1.3.4 Injecting drug practices Accrding t the 2013 IBBS survey, the tw main places chsen by drug users t inject were at hme (63%) and n unccupied land (32%) and the remaining 5% at ther miscellaneus spts. In the 2013 IBBS survey, 69% f PWID were estimated t inject drugs mre than nce n any particular day. Althugh a majrity (80%) f them reprted they used sterile equipment, it was bserved that injecting mre than nce in a day slightly increased the prbability f using nn-sterile equipment. Furthermre the use f sterile r nn-sterile equipment was fund t be independent f the persn wh injected the drug user. It is t be nted that usually 81% f PWID were self-injecting their drug and 15% were dne by any friend f the drug user, while, very few (4%) were dne by either a peer r ther persns. 23% f PWID reprted they have ever had drug verdse. [26]