Needle Syringe Acquisition and HIV Prevention Among Injecting Drug Users: A Treatise on the “Good” and “Not So Good” Public Health Practices in South Asia

Abstract

This article describes the prevalence of HIV/AIDS and other bloodborne infections is well established among injection drug user (IDU) populations in South Asia (SA). IDU populations in SA are diverse and display different demographic and socioeconomic profiles. The current provision of sterile injecting equipment as part of public health initiatives is suboptimal. Although some needle and syringe exchange programs (NSEPs) operate in the region, pharmacies and “friends” continue to be a major source of syringe acquisition. It is suggested that the cost of syringes in the region is significantly higher in real terms than in several other countries and negatively impacts on the ability of IDUs to acquire needles and syringes. In addition, existing NSEPs offer poor coverage both at the population and individual level. Their effective functioning is hampered by resource constraints, ambivalent policy positions, little attention to quality, and environmental factors. Secondary syringe exchange is a nascent phenomenon in SA that needs to be adequately documented and evaluated. Urgent attention needs to be given to developing alternative models of needle syringe delivery to scale-up HIV prevention interventions for IDUs. This study was conducted in the first quarter of 2004 and updated in 2006. We used key informants, previously unpublished and published data from research studies, and interventions programs, service statistics, and primary data to inform this study.

Keywords:

• Bangladesh
• HIV prevention in IDUs
• India
• needle and syringe acquisition
• needle and syringe exchange
• Nepal
• Pakistan
• secondary exchange
• South Asia

Notes

¹UNODC has been known in the past as United Nations Office of Drug Control and Crime Prevention (UNODCCP) and United Nations Drug Control Program (UNDCP). Where references are made to UNDCP or UNODCCP, they reflect the name of the organization at the time the document was published.

²The Golden Crescent is located along Pakistan's northwest-frontier, where it borders the Badakshan area of Afghanistan and the Baluchistan area of Iran. The Golden Triangle is situated in South East Asia between Myanmar, Thailand and the Lao People's Democratic Republic.

³The journal's style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be abused. Editor's note.

⁴Opiates are drugs derived from opium, such as morphine or heroin. An opioid is a synthetic narcotic that has opiate-like qualities but is not derived from opium (Dorland's Pocket Medical Dictionary, 1995). Soon after the development of synthetic entities with morphine-like actions, the term “opioid” was introduced to refer in a generic sense to all drugs (natural and synthetic). Some writers, however, continued to use the term “opiate” in a generic sense and in such contexts the two terms are used interchangeably (Gilman et al., 1985: 492).

⁵Smack is a commonly used term for “brown sugar” in many parts of India. “Chasing” refers to inhaling the fumes from heroin heated on an aluminum or metallic foil.

⁶The term “iatrogenic” means, caused by medical intervention. Buprenorphine was regularly used by doctors for detoxifying drug users in India. After being discharged from treatment centers, many drug users continued to use it to counter the effects of withdrawal and as a form of self-medication. Others continued to use it in the mistaken belief that it would cure their “smack” addiction.

⁷In some cities only IDUs were selectively recruited for this survey, such as in Chennai, however, the high proportions indicate the widespread prevalence of injecting drug use, even in non-metropolitan parts of India.

⁸A joint HIV prevalence study by John Hopkins University, Baltimore and SHARAN (a Delhi-based NGO) in the Yamuna Bazaar area of Delhi in 1998 showed a 44.5% prevalence of HIV among IDUs. Sentinel surveillance site had recorded a prevalence of 5% in Delhi during the same time indicating heterogeneity in HIV prevalence among IDUs in different parts of the same city which has been recorded from other settings as well.

⁹Exceptions to this do exist. For example, the NGO SHARAN espouses harm reduction beyond abstinence and has provided drug substitution therapy to its clients since 1999.

¹⁰The Narcotic Drugs and Psychotropic Substances (NDPS) Act 14/11/1985 was justified inter alia, by the implemental obligations to being a party to the UN conventions. It constitutes the legal framework for drug demand and supply reduction in India.

¹¹These data were collected as part of fieldwork for the coauthor's (M. S.) Ph.D. dissertation in Imphal, (Manipur, India) in 2000 from seven NGOs operating NSEs.

¹²These data were collected as part of the corresponding author's (M. S.) Ph.D. dissertation in 2000 at the NSE operated by the NGO SHARAN in Delhi. Calculations are based on a mean injecting frequency of 3.19 per day.

¹³It has been noted that those IDUs who inject Spasmo-Proxyvon or other drugs (which involves crushing tablets or dissolving the contents of capsules) tend to use a 2- or 5-ml syringe.

¹⁵In February 2004, the exchange rate was approximately 29 roubles to 1 U.S.$.

¹⁴In February 2004, this was equal to 10–13 cents to the U.S.$.

¹⁶The long running Russian–Afghan War and the Gulf War of 1991, both led to changes in trafficking routes, along with the need to create new markets to replace those that had become inaccessible due to conflict. Hence, Delhi became a conduit for heroin coming out of southwest Asia (Dorabjee, 1995).

¹⁷The needles and syringes provided by CSRD are funded with public funds provided by the Kerala State AIDS Control Society, which in turn is funded by the National AIDS Control Organization of India.