There are more than half a million people who inject drugs (PWID) in the South-East Asia Region (SEAR). The majority of countries in the Region have a significant injecting drug use problem and several countries have reported much higher national HIV prevalence rates among PWID—most notably Indonesia, Myanmar, Nepal, Thailand, and some regions of India.
In SEAR, HIV prevalence among PWID is frequently above 20-25% and has remained consistently high. High-risk behaviour by PWID, such as sharing of contaminated needles and syringes, has become a major determining factor in the course of the HIV epidemic.
In South-East Asia there has been increased awareness of harm reduction as a public health approach to reduce the HIV prevalence and address the health needs of PWID. The harm reduction approach, with its close alliance with health promotion and public health, has been endorsed globally by the United Nations. In SEAR, it is increasingly being viewed with understanding and greater acceptance.
Coverage of harm reduction interventions remain insufficient to have impact on the HIV epidemics among PWID in most countries in SEAR. Epidemiological studies have shown an association of needle and syringe programmes (NSP) and opioid substitution therapy (OST) with reduced HIV risk and transmission. Despite increases and expansion of NSP and OST services, the level of coverage in SEAR shows overall less than a third of PWID are reached by NSP even once a year, and less than 5% receive OST.
An assessment of the current situation of HIV and injecting drugs and national responses has been undertaken by the WHO Regional Office for South-East Asia. The countries are Bangladesh, Maldives, Indonesia, Myanmar, Thailand, Nepal and India. Using current available data it is hoped the country profiles will contribute towards an improved comprehensive understanding of the issues, be useful for advocacy, and generate
further harm-reduction responses in countries under review.
We hope that Member States and partner agencies will find this report on HIV and injecting drug use relevant, useful and contribute further to meeting the health needs of PWID.
Executive summary
Since the 1990s the majority of countries in the South-East Asia Region have experienced a significant injecting drug use problem, accompanied by explosive rates of HIV at some sites.
Over time the national response has increasingly been to implement various harm reduction interventions to reduce the HIV prevalence and address the health needs of people who inject drugs (PWID). This assessment examines the current situation of HIV and injecting drugs and of the national responses. The focus is on countries with a high and medium burden of illicit drug injecting. In most of these countries PWID are either HIV infected or have the potential for being infected. The countries reviewed are Bangladesh, India, Indonesia, Maldives, Myanmar, Nepal and Thailand.
Epidemiology of injecting drug use and HIV
* Most countries under review have a long history with various types of drugs, with injecting drugs most commonly identified from the 1980s and 1990s onwards.
• The estimated population of PWID can be wide ranging: Bangladesh (20 000–40 000); India (106 000–223 000); Indonesia (200 000–253 000); Maldives (300–2000); Myanmar (60 000–90 000); Nepal (17 000–24 000); and Thailand (38 000–57 000).
• PWID are primarily concentrated in urban settings but with increased surveillance and research the geographical locations of PWID identified have expanded.
• High-risk behaviours are consistently found among PWID. Significantly high rates of sharing injecting equipment are mostly widespread, and more so in Bangladesh and India. In Kathmandu valley, Nepal, a sharp decline in sharing injecting equipment is seen, from 56% in 2002 to 7% in 2009.
* Unsafe sex among PWID is common, and inconsistent condom use whether it is with a permanent partner, casual partner or a female sex worker is widespread. Condom use with a regular sexual partner tends to be low compared to other sexual partners. Sexual relations with female sex workers are common.
• Data on prevalence of sexually transmitted infections (STIs) among PWID tended to be limited. Where available, rates of STIs are generally not very high compared to other
most–at-risk groups such as female sex workers, men who have sex with men and transgender people.
• Injecting drug use has significantly contributed to the spread of HIV in Indonesia, Myanmar, Nepal, and northeast India.
• HIV prevalence among PWID is mostly high but varies widely among countries: Bangladesh (7% in Dhaka); India (9.19%); Indonesia (52%); Maldives (0%); Myanmar (37.5%); Nepal (21% in Kathmandu); and Thailand (48%).
• Wide variations of HIV prevalence within countries can be found, for example in Myanmar (Myitkina 54% and Taunggyi 12.5%) and in India (Manipur 28.65% and Uttar Pradesh 2.64%)
• HIV prevalence among PWID has remained consistently high in Indonesia, India (some regions), Thailand and Myanmar, is rising in Bangladesh, and declining in Nepal.
• Many PWID are currently incarcerated and at risk of becoming HIV infected in closed settings.
National response
Each country has drug control legislation to address drug use issues and each has an HIV policy linked to national HIV strategic plans in which prevention, care and treatment of PWID are overall given a priority, to varying degrees.
In recent years the policy environment has changed substantially, so that harm reduction interventions are increasingly viewed with understanding and greater acceptance.
• Harm reduction interventions as a means to address HIV among PWID are increasingly accepted as the appropriate public health model for PWID. This is despite, at times, the criminalization of drug use overshadowing HIV prevention
efforts for PWID.
• Needle and syringe programmes (NSP) are found in all countries reviewed except Maldives. Despite an overall expansion of NSP and an overall increase in the number of needles and syringes distributed, coverage of NSP was mostly low: less than a third of PWID are reached by NSP at
least once over a 12 month period in South-East Asia.
• Opioid substitution therapy (OST) programmes offering methadone and buprenorphine, or sometimes both, are found in all countries under review except Bangladesh. Yet, the numbers of PWID having access to and availability of
OST remains very low (less than 5%). and considerably less than those able to secure clean injecting equipment.
• Overall coverage of harm reduction interventions as part of a comprehensive package of services has increased compared to previous years. But the vast majority of PWID do not receive services to meet their general health needs.
• The overall number of PWID who are also HIV-infected and able to access antiretroviral therapy is small despite the fact that in some countries PWID have the highest rates of HIV prevalence.
• Despite a large number of incarcerated PWID, current HIV prevention interventions to address the needs of PWID are limited inside closed settings.
Recommendations
Various recommendations have been developed for each country profile but broad-based future priority themes for the Region are as follows:
• Urgently increase coverage and strengthen comprehensive harm reduction interventions, including needle and syringe programmes, opioid substitution therapy, voluntary counselling and testing, accessibility and availability of anti-retroviral therapy, and ensuring that standards for
quality services meet the needs of PWID.
• Greater effort and focus is needed on the promotion of condom use by PWID to minimize the sexual transmission of HIV, and to address the health needs of spouses, regular partners and paid sexual partners of PWID due to inconsistent condom use.
• HIV prevention and harm reduction interventions inside closed settings are needed including provision of oral substitution therapy, access to a reliable supply of condoms, and access to broad-ranging health services including HIV care, support and treatment.
• Despite increased acceptance of harm reduction
interventions, greater advocacy efforts with appropriate government sectors and the wider community are required to ensure increased commitment, funding, and to enhance
government ownership of harm reduction programmes.
• Increased training opportunities are needed in various aspects of harm reduction interventions for those directly serving the needs of PWID to ensure improved HIV prevention efforts and provide adequate, quality care, support and treatment for PWID.
• There is a need to improve strategic information by improving mapping and size estimations for PWID and expanding surveillance as required. Better tools and building capacity are needed for measuring the use of preventive and treatment services by PWID.
Introduction
There are over 500 000 people who inject drugs (PWID) in South-East Asia, with many involved in high-risk behaviour such as the sharing of non-sterile injecting equipment, and this has contributed towards the overall HIV epidemic in several countries of the Region. PWID have some of the highest prevalence of HIV of any of the high-risk population groups in the Region.
Since the 1990s HIV prevalence has remained consistently high among PWID. Documented evidence of the dual epidemic of HIV and injecting drug use, combined with ongoing advocacy efforts, have led to national responses and the implementation of various harm reduction interventions. Despite the harm reduction interventions in place, current data show such measures have a limited reach and are not sufficiently scaled up to match the size of the problem.
Aim of assessment study
The purpose is to collect and analyse the latest information on people who inject drugs, the associated links with the HIV epidemic, and the national responses. This information will be used to advocate for greater efforts and resources to be channeled into harm reduction interventions.
Objectives
(1) To map the epidemiology of injecting drug use in South-East Asia.
(2) To describe and analyse the nature and extent of surveillance among PWID in South-East Asia.
(3) To describe the nature and extent of HIV infection, STIs, and associated risk behaviours among PWID in South-East Asia.
(4) To identify the scale and coverage of effective interventions for PWID, in both the governmental and nongovernmental sector responses, to the HIV epidemic in South-East Asia.
(5) To identify programmatic and research (information) gaps in our understanding of the HIV epidemic and national responses, and sug gest specific recommendations for a scaled-up response.
Countries selected for review
Countries with a high and medium burden of illicit drug injecting and HIV infection were reviewed in the South-East Asia Region.
The countries are Bangladesh, India, Indonesia, Maldives, Myanmar, Nepal and Thailand.
Methodology
Conduct desk-based literature review using some key words: HIV prevention, treatment and care, injecting drug use, Asia, South-East Asia, harm reduction, needle syringe, drug substitution therapy, surveillance, and response. Use search engines such as PubMED, WHO, UNAIDS documents, and various Internet search engines. For further information contact has made with the UN reference group for injecting drug use, national AIDS control programmes and state AIDS control programmes, regional harm reduction networks for programme information, Global Fund website for country programme information (grant performance reports), and WHO country office focal points. An analysis of the literature and identifying gaps was undertaken for additional data. Collaborative work with WHO country focal points and official government counterparts was undertaken during the peer review process for comments.