Social-structural contexts of needle and syringe sharing behaviours of HIV-positive injecting drug users in Manipur, India: a mixed methods investigation.

Venkatesan Chakrapani,Murali Shunmugam,Robert Dubrow,Peter A Newman

doi:10.1186/1477-7517-8-9

Abstract

BackgroundFew investigations have assessed risk behaviours and social-structural contexts of risk among injecting drug users (IDUs) in Northeast India, where injecting drug use is the major route of HIV transmission. Investigations of risk environments are needed to inform development of effective risk reduction interventions.MethodsThis mixed methods study of HIV-positive IDUs in Manipur included a structured survey (n = 75), two focus groups (n = 17), seven in-depth interviews, and two key informant interviews.ResultsOne-third of survey participants reported having shared a needle/syringe in the past 30 days; among these, all the men and about one-third of the women did so with persons of unknown HIV serostatus. A variety of social-structural contextual factors influenced individual risk behaviours: barriers to carrying sterile needles/syringes due to fear of harassment by police and "anti-drug" organizations; lack of sterile needles/syringes in drug dealers' locales; limited access to pharmacy-sold needles/syringes; inadequate coverage by needle and syringe programmes (NSPs); non-availability of sterile needles/syringes in prisons; and withdrawal symptoms superseding concern for health. Some HIV-positive IDUs who shared needles/syringes reported adopting risk reduction strategies: being the 'last receiver' of needles/syringes and not a 'giver;' sharing only with other IDUs they knew to be HIV-positive; and, when a 'giver,' asking other IDUs to wash used needles/syringes with bleach before using.ConclusionsEffective HIV prevention and care programmes for IDUs in Northeast India may hinge on several enabling contexts: supportive government policy on harm reduction programmes, including in prisons; an end to harassment by the police, army, and anti-drug groups, with education of these entities regarding harm reduction, creation of partnerships with the public health sector, and accountability to government policies that protect IDUs' human rights; adequate and sustained funding for NSPs to cover all IDU populations, including prisoners; and non-discriminatory access by IDUs to affordable needles/syringes in pharmacies.

Highlights

Few investigations have assessed risk behaviours and social-structural contexts of risk among injecting drug users (IDUs) in Northeast India, where injecting drug use is the major route of HIV transmission
Survey participants were a convenience sample recruited primarily from the Manipur Network of People living with HIV (MNP+); some were recruited from other non-governmental organizations (NGOs) that provide prevention and treatment services to IDUs in Imphal
Successful and effective HIV prevention and care programmes for IDUs in Northeast India may be contingent on several enabling contexts: supportive government policies on harm reduction, including in prisons; an end to harassment by the police, army, and anti-drug groups, with a combination of education for these entities about harm reduction, creation of partnerships with the public health sector, and accountability to government policies that protect IDUs’ human rights; adequate funding for needle and syringe programmes (NSPs) to cover all IDUs in an intervention area, including those who are HIV-positive, and IDUs in prisons; non-discriminatory access by IDUs to affordable needles/syringes in pharmacies; and family and societal acceptance of IDUs, including those who are HIV-positive, through family counselling and public sensitisation campaigns

Summary

Introduction

Few investigations have assessed risk behaviours and social-structural contexts of risk among injecting drug users (IDUs) in Northeast India, where injecting drug use is the major route of HIV transmission. Injecting drug users (IDUs) are among the highest priority subpopulations for HIV prevention identified by the National AIDS Control Organization (NACO) in India [1]. In Northeast India, injecting drug use is the major route of HIV transmission [2]. A small state in Northeast India with a population of about 2.3 million, is among the Indian states with the highest HIV prevalence, with 1.39% of women attending antenatal clinics found to be HIVinfected [3]. In 1998, the estimated number of IDUs in Manipur was 15,000-20,000 [4]; estimated HIV seroprevalence among IDUs in 2006 was 19.8% [3]

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Conclusion