Injecting Drug Use and HIV/AIDS in India: An Emerging Concern 7 December 2004 New Delhi

The Extent, Pattern and Trends of Drug Abuse in India, National Survey Methodology The Extent, Pattern and Trends of Drug Abuse in India, National Survey National Household Survey (NHS) Drug Abuse Monitoring System (DAMS) Rapid Assessment Survey (RAS) Focused thematic studies Drug Abuse among Women Drug Abuse in Border Areas Drug Abuse in Prison Population HIV/AIDS-IDU nexus Triple burdens (drug use per se, HIV, HIV-related health burdens Hep, TB, opportunistic infections, abscesses etc.) Competes with scarce beds Cost of ARV ($1/day) Cost of oral substitution ($2/day) Costs of Targeted Intervention against IDU risk reduction intervention HIV/AIDS time bomb – orphans / widows – crime costs of ‘unsocialized’ street orphans (children, school drop-outs)

Extent of IDU -- Prevalence of ever injecting NHS DAMS General population Treatment seeking (12-60) years 0.1% 14% RAS Thematic studies IDU reported in all IDU found in different fourteen sites populations (women, 43% ever injected prisoners) and in different settings (border areas) HIV/AIDS-IDU nexus Triple burdens (drug use per se, HIV, HIV-related health burdens Hep, TB, opportunistic infections, abscesses etc.) Competes with scarce beds Cost of ARV ($1/day) Cost of oral substitution ($2/day) Costs of Targeted Intervention against IDU risk reduction intervention HIV/AIDS time bomb – orphans / widows – crime costs of ‘unsocialized’ street orphans (children, school drop-outs)

Drugs that are injected Heroin Propoxyphene (Spasmoproxyvon* -Dextropropoxyphene plus Dicyclomine) Buprenorphine alone or in combination with other drugs Injectable opiates like Morphine, Pethidine and Pentazocine (Fortwin*) Diazepam (Calmpose*) Promethazine (Phenargan*) Chlorpheniramine (Avil*) * The trade names mentioned do not imply a pejorative connotation HIV/AIDS-IDU nexus Triple burdens (drug use per se, HIV, HIV-related health burdens Hep, TB, opportunistic infections, abscesses etc.) Competes with scarce beds Cost of ARV ($1/day) Cost of oral substitution ($2/day) Costs of Targeted Intervention against IDU risk reduction intervention HIV/AIDS time bomb – orphans / widows – crime costs of ‘unsocialized’ street orphans (children, school drop-outs)

The switch from non-injecting to injecting Shift from inhaling vaporised heroin to injectable pharmaceuticals occur at the following times: when heroin is scarce when the cost of heroin is increasing when there is an observable reduction in purity levels when police enforcement is vigilant Easy availability and the low cost of injectable pharmaceuticals facilitate the switch to injecting. HIV/AIDS-IDU nexus Triple burdens (drug use per se, HIV, HIV-related health burdens Hep, TB, opportunistic infections, abscesses etc.) Competes with scarce beds Cost of ARV ($1/day) Cost of oral substitution ($2/day) Costs of Targeted Intervention against IDU risk reduction intervention HIV/AIDS time bomb – orphans / widows – crime costs of ‘unsocialized’ street orphans (children, school drop-outs)

Direct sharing of injection equipment Non-sharing Sharing 90% 50% HIV/AIDS-IDU nexus Triple burdens (drug use per se, HIV, HIV-related health burdens Hep, TB, opportunistic infections, abscesses etc.) Competes with scarce beds Cost of ARV ($1/day) Cost of oral substitution ($2/day) Costs of Targeted Intervention against IDU risk reduction intervention HIV/AIDS time bomb – orphans / widows – crime costs of ‘unsocialized’ street orphans (children, school drop-outs) 0% Amr Ban Trm Ahm Del Imp Kol Che Jam Shl Dim Hyd Mum

Sharing of injection equipment during the last episode of injecting Non-injectors or ex-IDUs 3,129 HIV/AIDS-IDU nexus Triple burdens (drug use per se, HIV, HIV-related health burdens Hep, TB, opportunistic infections, abscesses etc.) Competes with scarce beds Cost of ARV ($1/day) Cost of oral substitution ($2/day) Costs of Targeted Intervention against IDU risk reduction intervention HIV/AIDS time bomb – orphans / widows – crime costs of ‘unsocialized’ street orphans (children, school drop-outs) 1,519 744 775 Current IDUs Non-sharing

Indirect sharing HIV/AIDS-IDU nexus Triple burdens (drug use per se, HIV, HIV-related health burdens Hep, TB, opportunistic infections, abscesses etc.) Competes with scarce beds Cost of ARV ($1/day) Cost of oral substitution ($2/day) Costs of Targeted Intervention against IDU risk reduction intervention HIV/AIDS time bomb – orphans / widows – crime costs of ‘unsocialized’ street orphans (children, school drop-outs) Sharing heroin from same bottle cap (‘cooker’), Chennai

Syringe acquisition 100% Pharmacy 50% Friends 0% Amr Jam Shl Dim Hyd HIV/AIDS-IDU nexus Triple burdens (drug use per se, HIV, HIV-related health burdens Hep, TB, opportunistic infections, abscesses etc.) Competes with scarce beds Cost of ARV ($1/day) Cost of oral substitution ($2/day) Costs of Targeted Intervention against IDU risk reduction intervention HIV/AIDS time bomb – orphans / widows – crime costs of ‘unsocialized’ street orphans (children, school drop-outs) Friends 0% Amr Jam Shl Dim Hyd Ban Trm Ahm Del Imp Che

Injecting settings Heroin injecting in a public toilet, Chennai HIV/AIDS-IDU nexus Triple burdens (drug use per se, HIV, HIV-related health burdens Hep, TB, opportunistic infections, abscesses etc.) Competes with scarce beds Cost of ARV ($1/day) Cost of oral substitution ($2/day) Costs of Targeted Intervention against IDU risk reduction intervention HIV/AIDS time bomb – orphans / widows – crime costs of ‘unsocialized’ street orphans (children, school drop-outs) Heroin injecting in a public toilet, Chennai

Sexual behaviours among injectors "I guess my sex interest is declining. My concern is about withdrawals and I am always looking for my fix. The last time I had sex was with a sex worker two weeks ago. I was worried about becoming impotent... I wanted to test my potency... how can I attempt with my wife? It is better to try and work it with a sex worker. I did that... somehow she helped me to come through successfully. I am a bit relieved now." An IDU from Chennai HIV/AIDS-IDU nexus Triple burdens (drug use per se, HIV, HIV-related health burdens Hep, TB, opportunistic infections, abscesses etc.) Competes with scarce beds Cost of ARV ($1/day) Cost of oral substitution ($2/day) Costs of Targeted Intervention against IDU risk reduction intervention HIV/AIDS time bomb – orphans / widows – crime costs of ‘unsocialized’ street orphans (children, school drop-outs)

Sexual behaviours among injectors Many drug users in Kolkata (79%) and Imphal (74%) reported sex with sex workers. Average number of non-spouse sex partners of drug users in Mumbai during the last year was three. Consistent condom use with sex workers is low. Many drug users are married. Condom use with regular sex partners is uncommon. HIV/AIDS-IDU nexus Triple burdens (drug use per se, HIV, HIV-related health burdens Hep, TB, opportunistic infections, abscesses etc.) Competes with scarce beds Cost of ARV ($1/day) Cost of oral substitution ($2/day) Costs of Targeted Intervention against IDU risk reduction intervention HIV/AIDS time bomb – orphans / widows – crime costs of ‘unsocialized’ street orphans (children, school drop-outs)

RISK RINGS HIV Clients of FSWs FSWs IDUs DRUG ABUSE AND HIV/AIDS “Feminization” of the epidemic Non-substance using sex partners of clients of sex workers Non-substance using Sex Partners of Substance users Clients of FSWs Substance Users FSWs IDUs HIV Regular Sex Partners of FSWs RISK RINGS

Major health consequences HIV/AIDS Tuberculosis STIs Abscess Overdose Hepatitis HIV/AIDS-IDU nexus Triple burdens (drug use per se, HIV, HIV-related health burdens Hep, TB, opportunistic infections, abscesses etc.) Competes with scarce beds Cost of ARV ($1/day) Cost of oral substitution ($2/day) Costs of Targeted Intervention against IDU risk reduction intervention HIV/AIDS time bomb – orphans / widows – crime costs of ‘unsocialized’ street orphans (children, school drop-outs) IDU-related abscess care, Chennai

Treatment-seeking behaviour among injectors A majority of drug injectors not in touch with formal services Reasons for dissatisfaction with treatment - cost - ‘felt needs’ of the drug users not addressed Many drug injectors prefer maintenance treatment with sublingual buprenorphine Treatment facilities are required for the adverse health consequences faced by IDUs HIV/AIDS-IDU nexus Triple burdens (drug use per se, HIV, HIV-related health burdens Hep, TB, opportunistic infections, abscesses etc.) Competes with scarce beds Cost of ARV ($1/day) Cost of oral substitution ($2/day) Costs of Targeted Intervention against IDU risk reduction intervention HIV/AIDS time bomb – orphans / widows – crime costs of ‘unsocialized’ street orphans (children, school drop-outs)

Summary Injecting drug use is more often reported from urban areas and N.E. states Commonly injected drugs are heroin, buprenorphine, diazepam and propoxyphene; these are often used in combination High risk behaviours often accompany injecting drug use HIV infections among injecting drug users are also generally high Other adverse health consequences and drug overdoses are frequent Intervention strategies are required urgently HIV/AIDS-IDU nexus Triple burdens (drug use per se, HIV, HIV-related health burdens Hep, TB, opportunistic infections, abscesses etc.) Competes with scarce beds Cost of ARV ($1/day) Cost of oral substitution ($2/day) Costs of Targeted Intervention against IDU risk reduction intervention HIV/AIDS time bomb – orphans / widows – crime costs of ‘unsocialized’ street orphans (children, school drop-outs)

Recommended interventions Reach out to drug injectors and provide services Educate the drug user Encourage drug dependence treatment Establish a hierarchy of risk reduction strategies to prevent HIV among IDUs Develop specific strategies to prevent transitions to injecting HIV/AIDS-IDU nexus Triple burdens (drug use per se, HIV, HIV-related health burdens Hep, TB, opportunistic infections, abscesses etc.) Competes with scarce beds Cost of ARV ($1/day) Cost of oral substitution ($2/day) Costs of Targeted Intervention against IDU risk reduction intervention HIV/AIDS time bomb – orphans / widows – crime costs of ‘unsocialized’ street orphans (children, school drop-outs)

Recommended interventions Strengthen peer-driven interventions Provide primary health care for drug injectors Reduce risky sexual behaviour among drug users Voluntary HIV counselling and testing Design interventions for special populations Ensure that the approach is comprehensive HIV/AIDS-IDU nexus Triple burdens (drug use per se, HIV, HIV-related health burdens Hep, TB, opportunistic infections, abscesses etc.) Competes with scarce beds Cost of ARV ($1/day) Cost of oral substitution ($2/day) Costs of Targeted Intervention against IDU risk reduction intervention HIV/AIDS time bomb – orphans / widows – crime costs of ‘unsocialized’ street orphans (children, school drop-outs)

END HIV/AIDS-IDU nexus Triple burdens (drug use per se, HIV, HIV-related health burdens Hep, TB, opportunistic infections, abscesses etc.) Competes with scarce beds Cost of ARV ($1/day) Cost of oral substitution ($2/day) Costs of Targeted Intervention against IDU risk reduction intervention HIV/AIDS time bomb – orphans / widows – crime costs of ‘unsocialized’ street orphans (children, school drop-outs)