HIV in IDUs: should we bother?

Abstract

HIV and drug use continue to pose challenges in tandem*/like a bicycle with seats for two, one riding behind the other*/to the practitioners of public health as well as intervention researchers worldwide. For example, while cities in Australia have recorded a low HIV prevalence in injection drug users (IDUs) (Wodak and Lurie, 1997) and New York has reported declines in HIV incidence among IDUs (Des Jarlais et al., 2000), Kathmandu*/the capital city of Nepal*/has experienced initial containment followed by explosive spread of HIV among IDUs in the last 6 years (Pokharel et al., 2000). These challenges are made tougher by a few hurdles, such as the assumption that the HIV epidemic in heterosexuals is independent from that in IDUs and the intermittent switch from non-injection forms of drug use to injecting under various socio-political influences. Many national HIV/AIDS Control Programmes in developing countries also add to these challenges by having most of their resources spent on breaking the chain of transmission in the population groups who are vulnerable to getting HIV through sex and by having abysmally low support for interventions targeting injection drug users. The mainstay of this approach is formed by the belief that HIV epidemics in IDUs do not contribute significantly to the overall HIV epidemic. Evidence, however, suggests the contrary. Lowndes et al. (2003) identify an interplay of forces which contribute towards conditions favourable for the heterosexual spread of HIV in the Russian Federation, which since 1996 has witnessed a series of large and explosive HIV epidemics among IDUs in different cities. Such a rapid spread of HIV among IDUs reminds us of the HIV epidemic among IDUs in Manipur, a northeastern state of India sharing a border with Myanmar. This response looks back to the past when the epidemic happened in Manipur, as well as taking account of current research evidence to examine critically whether one really needs to bother about HIV epidemics in injectors. Twelve years ago, in the winter of 1989, an outbreak of HIV occurred among a large number of injection heroin users of Manipur (Sarkar et al., 1991). The virus not only infected more than 50% of the local IDUs within 9 months, but it spread into other population groups as well. Some 45% of the non-injecting wives of IDUs (Panda et al., 2000) and 1.2% of the antenatal clinic-attending women (representing female general population) in the state (NACO 1997 /1998) contracted the virus within the next 5 years. A small study from Manipur, conducted in 1997, recruited female sex workers operating from the streets of Imphal, the capital city (there is no brothel-based sex industry in Manipur) and revealed that while 20% of those who had never injected drugs were HIV positive, 57% of female injection drug users involved in sex work had HIV (Panda et al., 2001). About one-third of the female IDUs involved in sex work in this study had male IDUs as their regular sex partners. Lowndes et al. (2003) document a similar progression of HIV among different population groups in the Russian Federation, highlighting different links between IDU and non-IDU populations that may be responsible for generating a wider spread of HIV in countries where epidemic outbreaks first emerged among IDUs. While it took some time for policymakers to see how different pieces of information relating to the progression of HIV in Manipur were parts in one jigsaw puzzle, an early attempt to do so in Russia and elsewhere would certainly pay dividends for HIV prevention. Otherwise, a familiar story of the diffusion of injection drug use in a new area followed by rapid HIV spread among IDUs and subsequent spread to non-IDU population groups may repeat itself. The evidence generated through the randomised controlled trials in African countries on the role of improved STD management in reducing HIV incidence in the early phase of HIV epidemics (Grosskurth et al., 2000) emphasises how STIs could play a * Tel.: /91-332-5910-334; fax: /91-332-3376-290. E-mail address: samiran_panda@rediffmail.com (S. Panda). International Journal of Drug Policy 14 (2003) 83 /85