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

2. 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)

3. Extent of IDU -- Prevalence of ever injecting
NHS DAMS
General population Treatment seeking
(12-60) years
0.1% %
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)

4. 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)

5. 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)

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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)

12. 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)

13. 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

14. 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

15. 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)

16. 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)

17. 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)

18. 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)

19. 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)