1. Injecting Drug Users: A Global Problem Roger Detels, M.D., M.S.

2. Global Areas of Drug User- Transmitted HIV Europe North America (U.S., Canada) South America Southeast Asia (Thailand, Myanmar, Vietnam, northeast India, Indonesia) China (originally Yunnan, now all provinces; highest in Yunnan, Guangxi and Xinjiang)

3. Golden triangle in southeast Asia 05.15.2013

4. Major heroin-producing locations 05.15.2013

5. Global Injecting Drug Use Statistics (2008) Number of countries with documented injectors: 148 Areas lacking statistics: Africa, Middle East, western South America Prevalence estimates possible: 61 countries Estimated number of injectors worldwide: 15.9 million Estimated number of HIV-positive injectors worldwide: 3.0 million Countries with most injectors: China, USA, Russia

6. Prevalence of injecting drug use Mathers BM, et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet 372:1742, 2008.

7. Prevalence of HIV infection among injecting drug users Mathers BM, et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet 372:1744, 2008.

8. Role of Drug Use in Spread of HIV in Asia

9. Relationship of Drug Use to HIV Spread to Other Groups Rapid spread (Thailand, Myanmar, NE India) Initially slow spread among older addicts, followed by rapid spread in younger addicts (Vietnam) More recent increase in female injectors (Vietnam, China) Spread to “bridge” populations

10. Characteristics of Drug Users in Asia Remain as a member of the family Remain as a member of the community High failure rate for rehabilitation centers (90+%) Increasing number of drug replacement and needle exchange programs Recent increase in other drugs for injecting Increasing non-injection (club) drug use, especially among MSM

11. Trends in HIV prevalence (%) among IDUs in three sites in India. Sources: Sarkar et al. (1993), Joseph (1996), Tamil Nadu State AIDS Control Society Report on Sentinel Surveillance (2005), Panda et al. (2002a), and West Bengal State AIDS Prevention and Control Society, Sentinel surveillance reports, 1994-2003. Note: The prevalence data for Manipur before 1994 are not based on sentinel surveillance dataSarkar et al. (1993)Joseph (1996)Panda et al. (2002a) Panda S and Sharma M. Needle syringe acquisition… Substance Use & Misuse 41:953-977, 2006

12. Prevalence of HCV among IDUs in South Asia

13. Drug Use Intervention Strategies Needle exchange programs Drug replacement programs (e.g. methadone) Cognitive behavioral therapy (identify and address triggers and situations) Contingency management: reward (i.e., pay) for negative urine tests Community intervention

14. Comparative equipment-sharing behavior by locations with and without outreach-based interventions in Bangladesh (2002). (From Panda et al., 2002a). Source: Panda et al., 2002Panda et al., 2002a Panda S and Sharma M. Needle syringe acquisition… Substance Use & Misuse 41:953-977, 2006

15. There are currently an estimated 740,000 people living with HIV in China. http://www.avert.org/aidschina.htm http://www.avert.org/aidschina.htm

16. Wu et al., Community-based trial to prevent drug use in Yunnan, China. Am J Publ Hlth 92:1952-1957, 2002.

17. Intervention Methodology (1) Study sites: Longchuan, southern Yunnan Selection of intervention and control areas: 19 villages matched on prevalence of drug use and HIV, number of drug users, geographically separated Theoretical framework: behavioral change model, Bandura’s social learning theory

18. Wu et al., Community-based trial to prevent drug use in Yunnan, China. Am J Publ Hlth 92:1952-1957, 2002.

19. Intervention Methodology (2) Intervention strategies Recruitment of official and informal leaders and police Multiple approach: school, family, community, clinic Activities  Workshops  Games and videos with anti-drug messages  Literacy classes  Agriculture classes  School programs  Visits to detox centers  Establishment of youth centers  Youth work core  Skits

20. Non-drug- Non-injecting Injecting Injecting & sharing using youths drug users drug users equip. drug users Intervention points Intervention activities: Comprehensive Introduce farming Evening class and Integrating drug/ intervention skills into villages and entertainment AIDS prevention activities on to assist drug/AIDS to assist drug/AIDS into school drug/HIV prevention; youth prevention curriculum prevention in corps, youth center villages Community-based Intervention to Reduce Drug Use

21. Evaluation of Intervention Comparison of incidence of drug initiation Retrospective cohort, October 1995-Feb 1997 Retrospective cohort, May 1997-Sept 1998 Data collected Demographics Initiation of drug use, injecting-sharing Sexual behavior Response rate: intervention villages 91%, control villages 88%

22. VariableAttributable Risk Reduction Incidence Reduction Ratio* P-value All males 15-49 yrs -99%2.7<0.05 Males 15-19 yrs-479%>216 § <0.001 Single-301%>291 § <0.001 Dai ethnicity-61%>60 § <0.001 Jingpo ethnicity Illiterate -301% -616% >196 § >61 <0.001 *Incidence change in intervention group/Incidence change in control group § Change at baseline set at -0.01 (incidence increased in control area) Significant Incidence Changes in New Male Drug Users in Intervention and Control Villages

23. Conclusion Community intervention can be useful for preventing initiation of drug use, but not for preventing progression to injection use

24. Has the intervention been sustained? Yes

25. Requirements for Successful Needle Exchange Programs Local political and community support Cooperation of security officials; e.g., police Dissemination of knowledge of availability to injecting population Magnitude/scale sufficient to reduce community reservoir of infectious syringes/needles Supportive, empathetic staff Ready availability; e.g., “dial-a-needle” Supportive services; e.g., counseling, referral, etc. Recognition and support for exchange program staff

26. Requirements for Successful Drug Replacement Programs Political and community support Police non-interference/support Committed, rewarded staff No entry restrictions to program Sufficient dosing Drug monitoring Supportive services; e.g., counseling, referral, etc. Outcomes – abstinence, reduction? Measuring impact appropriately; what is the correct denominator?