Injecting drug use is an important risk factor for HIV in India. The entire South Asian and South East Asian region has shown an alarming increase in injecting behaviour. While voluntary abstinence is the best cure, it has a poor success rate. We need to look at more innovative and effective approaches being successfully tried out elsewhere, says Eldred Tellis

By the end of 1999, a total of 136 countries had reported the presence of Injecting Drug Use (IDU) and of these, 114 countries reported HIV infection among Injecting Drug Users (IDUs).(1) More recently, the number of IDUs worldwide was estimated to be 13.2 million with over 10 million (78%) living in developing countries.(2)

According to the World Health Organisation, the sharing of HIV contaminated injecting equipment accounts for 5-10% of all adult infections worldwide and is a major cause of HIV transmission in some developing countries. The most effective way for HIV to spread is through blood-to-blood transmission and the IDU is an important vector. Once HIV is established among IDUs, the virus can easily spread to their sexual partners, or through commercial sex workers into the wider community.

The importance of injecting drug use (pharmaceutical and non- pharmaceutical) in driving the HIV and hepatitis C (HCV) epidemics is now widely recognised in South Asia and internationally. There are an estimated 3.3 million injecting drug users in South and South East Asia, and within this region a considerable proportion of injectors in India, Pakistan, Nepal and Bangladesh are using pharmaceuticals such as buprenorphine and dextropropoxene, often in cocktails with other drugs. Injecting drug practices are rapidly increasing across the region due to a number of factors such as stricter legislation and law enforcement leading to a scarcity of smokable heroine on the streets, accessibility and low cost of pharmaceuticals, and ease of administration.

Injecting drug use in India

Injecting drug use is a major driver of the epidemic in the north-eastern states of India. Recent data show that injecting drug users could constitute 1·9–2·7% of the adult population in Manipur and Nagaland. In addition to the known risks of HIV transmission through sharing injection equipment, sexual transmission is also important. In a sample of injecting drug users in the north-east, 75% were found to be HIV positive, most were under the age of 19 years, two-thirds were sexually active, and 3% reported using condoms.(12) The risk of HIV transmission to sexual partners and wives of injecting drug users has been documented across India.(5,9,10)

Monitoring the intersection and overlap of injecting drug user and sex worker networks is important for programming responses and tracking the spread to the general population.(8,13) Mapping exercises of the three north-eastern states show substantial numbers of female sex workers in urban/valley areas where injecting drug users are also in higher numbers. Data from one voluntary counselling testing centre suggests increasing HIV prevalence in female sex workers in Manipur.(7) Although population mobility between the north-east and the rest of India is limited, most goods travel to the north-east by road. Therefore, more understanding is needed of the sexual and drug injection networks of truckers, female sex workers, and injecting drug users in the north-east as a potential driver of the spread of HIV to other parts of the country.(11)

Injecting drug users are also found in most major cities in India outside the north-east and HIV prevalence rates ranging between 2% and 44% have been documented among them.(5,6,14–16) However, little is known about injecting drug user overlap with other risk groups in states outside the north-east.

Prevention programmes are effective and sustainable when implemented within a strong public health system and linkages to other programmes. Government services for sexually transmitted diseases (STDs) and basic HIV care require more resources for training and sensitisation of personnel to meet the needs of all high risk groups which include female sex workers, men who have sex with men, injecting drug users, and People Living with HIV/AIDS.

Drug treatment and HIV prevention

The treatment for drug users has, historically, been abstinence. Programmes based on abstinence range from detoxification to rehabilitation, and from primary care to after care. These are residential programmes and require 24-hour professional input which is not always provided on the budgets available. Also, with the problem of drug abuse having percolated to the lower socio-economic strata, the residential programmes which charge high fees (under the guise of mess charges) are out of reach for poorer drug users.

The Ministry of Social Justice and Empowerment (MSJE), provides grants to 400 ‘de-addiction centres’ (a name coined locally and not heard of anywhere else in the world), all over the country that provide one or two months’ treatment and can be said to be neither here nor there. Detoxification usually needs not more than two weeks, whereas rehabilitation would require about six months. A list of the centres in the country that are supported by MSJE can be found on www.nisd.gov.in

The most effective way of preventing HIV transmission among IDUs would be, undoubtedly, to abstain from drug use. Though many developed countries have tried abstinence, these efforts have not been very successful. The increase in the numbers of people injecting drugs worldwide shows that abstinence alone is not an effective strategy to reduce the transmission of HIV and other blood borne viruses (BBV). While programmes promoting voluntary abstinence should be encouraged, it may not be a realistic or achievable goal for all. Relapse after detoxification is common with the relapse rate often reaching 90% in the Asian region.

Detoxification is only an initiation into treatment and is not a complete treatment for addiction. Those who cannot access treatment and continue to inject drugs, or those who suffer a relapse, would need other practical methods for reducing the risks of HIV transmission. One of these is the ‘harm reduction’ approach and incorporates activities such as community outreach, the provision of new needles and syringes, condom provision accompanied by information on safer sexual practices, the provision of effective drug treatment, including substation therapy such as Methadone or Buprenorphine, voluntary counselling and testing (VCT) and life skill programmes.

Need for Needle and Syringe Programme (NSP)

The risk factor for HIV and other BBV transmission is not the injecting of the drug itself, but the sharing of injecting equipment with an HIV infected person or the re-use of contaminated needles and syringes. For those individuals who continue to inject drugs, the provision of needles and syringes through NSP reduces the need for sharing injecting equipment.

A study in 2002 from 103 cities in 24 countries showed that HIV infection rates declined by an average of 18.6% annually in 36 cities with needle and syringe programmes, while it increased by an average of 8.1% annually in 67 cities that did not have NSPs.(3)

Research from around the world has established that NSPs:

• are effective in the prevention of HIV
• do not increase drug use
• do not recruit new IDUs or lower the age of first injecting
• do not increase the number of needles discarded in the community
• are cost effective

Advocacy of needle and syringe programme highlight that:

• Most injecting drug users are not in treatment
• Reaching and providing injecting drug users with risk reduction materials and services is crucial to reducing the injection and sex related risks that HIV poses for them, their sexual partners, their families and their community
• They attract out of treatment injecting drug users to risk reduction services, increase referrals to treatment and results in less HIV transmission
• They significantly decrease the amount of discarded syringes in a community

Needle and syringe programmes need support from law enforcement officers who sometimes round up drug users who may be receiving services for prevention of HIV and force them into prisons where they may be even more vulnerable.

Adverse health consequences among injecting drug users

Heroin and other opioid dependence cause significant morbidity and mortality. Premature deaths due to overdose is common among opioid users. In those injecting opioids, there is an increased risk of blood-borne infections such as HIV, hepatitis B and C. Ever since the first report of HIV infection amongst IDUs in north-east India in 1989, there has been diffusion of HIV among IDUs in different parts of the country. In the HIV/AIDS epidemiological surveillance for the year 2005, HIV prevalence among IDUs was 5% in nine states.(17)

There is potential for sexual transmission of HIV from injecting drug users to their non-injecting regular sex partners.(5) The hepatitis C prevalence among IDUs is alarmingly high in many parts of the country: Chennai – 93%;(6) Imphal, Manipur – 90%,(18) Kolkata – 80%;(19) Mumbai 79% (sentinel surveillance figures of 2003) and Darjeeling district of West Bengal – 48%.(20) Apart from adverse health consequences, dependence on opioids results in significant costs to society through unemployment, homelessness, family disruption, loss of economic productivity, social instability and criminal activities.

Opioid substitution treatment: concept and objectives

Substitution pharmacotherapy, sometimes termed ‘maintenance treatment’, is replacing the drug being taken with another drug or a similar drug (for example, methadone for heroin users). It may also mean using the same drug but taking it in a different way, for example, sublingual buprenorphine to replace injecting of buprenorphine. The usual length of treatment can vary from six months to several years. Drug substitution aims to:

• lessen the risk of contracting or transmitting HIV/AIDS
• switch users from illicit drugs of indeterminate quality, purity and potency to legal drugs of known purity and potency
• minimise the risk of overdose and other medical complications
• switch from an injected to a non-injected substance
• reduce hazardous drug use such as sharing injecting equipment, poly-drug use, injecting crushed/filtered tablets
• reduce the need for addicts to commit crimes to support their drug habits and keep out of dangerous environment like prisons
• maintain contact with drug users
• provide counselling, referral and treatment
• help drug users stabilise their lives and reintegrate with the general community.

Effectiveness of opioid substitution treatment

Opioid substitution treatment (OST) is an efficacious, safe and cost-effective way of managing opioid dependence. Scientific evidence suggests that substitution treatment can help reduce criminality, infectious diseases and drug-related deaths as well as improve the physical, psychological and social well-being of dependent users.(21) Provision of substitution maintenance therapy should be integrated with other HIV preventive interventions and services, as well as with those for treatment and care of people living with HIV/AIDS.(22) A recent Cochrane review recommended that the provision of substitution treatment should be supported for opioid dependence in countries with emerging HIV and injecting drug use problems as well as in countries with established populations of injecting drug users.(23)

In India, the experience with sublingual buprenorphine indicates that the treatment is attractive to drug users, their families and communities. Further, the treatment has the potential to retain clients in treatment as well as link them with other services including conventional drug use treatment.(25,26) The post-marketing surveillance of sublingual buprenorphine from ten centres across India indicated less adverse effects and no reported deaths.(28)

Conclusion

In response to the increase in injecting drug use and its relation to the spread of HIV, we need to develop appropriate, strategic and pragmatic long-term approaches to help drug using populations. Pharmacological drugs like methadone and buprenorphine can improve options for maintenance treatment and relapse prevention. Given the evidence of the effectiveness of opioid substitution in preventing HIV among injecting drug users and its potential to improve the quality of life of drug users, opioid substitution needs to be implemented to scale in India. There should be a clear-cut policy in place to create an enabling environment for services to reach the ‘hidden’, marginalised, population.

References

1. UNAIDS Report on the Global HIV/AIDS epidemic, Geneva, UNAIDS, 2002.
2. Aceijas C, Stimson G V, Hickman M, Rhodes T, United Nations Reference Group on HIV/AIDS Prevention and Care among IDU in Developing and Transitional Countries.
‘Global overview of injecting drug users’, AIDS2004; 18:2295-303.
3. Health Outcomes International Pvt Ltd, ‘Return on investment in Needle and Syringe Programmes in Australia, Canberra’, Commonwealth Department of Health and Ageing, Australia, 2002. Available from: http://www.health.gov.au/pubhlth/publicat/document/roireport.pdf
5. Panda S, Kumar M S, Lokabiraman S, Jayashree K, Satagopan M C, Solomon S et al, ‘Risk factors for HIV infection in injection drug users and evidence for onward transmission of HIV to their sexual partners in Chennai, India’, Journal of Acquired Immune Deficiency Syndromes, 2005; 39 (1): 9-15.
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14. United Nations Office on Drugs and Crime, and Ministry of Social Justice and Empowerment, Government of India, ‘The extent, pattern and trends of drug abuse in India—national survey, 2004’, [cited 2006 Jul 3]. Available from: http://www.unodc.org/india/national_Survey.html
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16. Chatterjee A, Kumar M S, Abdul-Quader A S, ‘Targeted interventions in injecting drug users: Some experiences’ in Living with the AIDS virus—the epidemic and the response in India, New Delhi, Sage Publications, 2002.
17. National AIDS Control Organisation, HIV/AIDS epidemiological surveillance and estimation report for the year 2005, Delhi, National AIDS Control Organisation, Ministry of Health and Family Welfare, Government of India; 2006 Apr. Available from: http://www.nacoonline.org/
18. Devi KhS, Brajachand N, Singh H L, Singh Y M, ‘Co-infection by human immuno deficiency virus, hepatitis B and hepatitis C virus in injecting drug users’, The Journal of Communicable Diseases, 2005; 37(1): 73-7.
19. Sarkar K, Mitra S, Bal B, Chakraborty S, Bhattacharya S K, ‘Rapid spread of hepatitis C and needle exchange programme in Kolkata, India’, The Lancet, 2003; 361 (9365): 1301-2.
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22. WHO, UNODC, UNAIDS position paper ‘Substitution therapy in the management of opioid dependence and HIV/AIDS prevention’, Geneva, World Health Organisation, United Nations Office on Drugs and Crime, Joint United Nations Programme on HIV/AIDS; 2004.
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28. Ray R, Pal H, Kumar R, Maulick P, Mangala R, ‘Post marketing surveillance of buprenorphine, Pharmacoepidemiology and Drug Safety, 2004; 13(9): 615-9.

(Eldred Tellis is Director of the Sankalp Rehabilitation Trust, Mumbai, and a member of NACO’s Technical Resource Group for programmes related to injecting drug users. He has worked extensively in various parts of India and Asia developing and replicating programmes for IDUs.)

Infochange News & Features, February 2008