REFERENCE GROUP TO THE UNITED NATIONS ON HIV REFERENCE GROUP TO THE UNITED NATIONS ON HIV AND INJECTING DRUG USE

INTERNATIONAL HARM REDUCTION CONFERENCEINTERNATIONAL HARM REDUCTION CONFERENCEBANGKOK MAY 2009

Source: HIV and IDU Reference Group to the UN

Prevalence of IDU (%) 0.00 ‐

Injecting Drug Users in Bangladesh, 2008

Source: RSRA report Bangladesh: NASP, ICDDR,B, MRC Mode and Save the Children, USA

Source: HIV and IDU Reference Group to the UN

lower potency opioids are used such as codeine, nalbuphine dextropropoxyphene and low dose buprenorphine. Polydrug use is common.

Reasons for injecting pharmaceutical opioids:non-availability of heroin for smoking;y g;injecting less costly compared to heroin smoking;smoked/chased heroin failing to elicit the desired effect due to increased tolerance;increased tolerance;the influence of peers;in order to give up heroin smoking (learnt by those who were admitted for drug treatment and treated with buprenorphine admitted for drug treatment and treated with buprenorphine injection by the treating physicians)consistent quality and better “high” of the pharmaceuticals

d t th h i il bl th t tcompared to the heroin available on the streets.Source: HIV and IDU Reference Group to the UN

Drug trafficking routes in

Thakurgaon

INDIA •Over the past 15 years, a decline in use of natural opiates in India has b i d b i

Drug trafficking routes in Bangladesh

INDIA (Meghalaya )

Nilphamari

Rangpur

Lalmonirhat

KurigramDinajpur

Gaibandha

Joypurhat

NaogaonChapai

JamalpurSunamganj Sylhet

Tamabil

Jokigonj

Hili INDIA INDIA

been accompanied by an increase in pharmaceutical opioid injection.

E f il bilit f

INDIA INDIA(West Bengal)

(Tripura)

ChapaiNawabganj

Rajshahi Natore

Sirajgonj

Pabna

KishoreganjTangail

Dhaka

Moulvibazar

Habiganj

Goadagari

Sreemongal

B-Baria

Akhaura

Narsinghdi

Bhairab

ModhupurSolonga

INDIA

•Ease of availability of buprenorphine over the counter at pharmacies, its purity, andlower cost

Barisal

Pirojpur

JhalokathiBholal

ComillaBeanpolelower cost

•The first case ofbuprenorphine misuse was

MAYAN

Patuakhali

Bay of Bengal

buprenorphine misuse was documented in 1987 and the problem has been growing ever since. N

MAR

since.

Source: HIV and IDU Reference Group to the UN and RSRA report Bangladesh: NASP, ICDDR,B, and Save the Children, USA

a

Source: HIV and IDU Reference Group to the UN

0 200

Sikki (2)

Haryana (1)

Tripura (1)

32.4

0.40.20.2

Nagaland (8)

Jharkhand (1)

Bihar (2)

Sikkim (2)

HIV prevalence among injecting drug users was ≥5% in 17 of the 45 valid sentinel sites.

43.6

3.13

Assam (1)

Karnataka (1)

Mizoram (8)

Kerala (2)

Tamil Nadu, Maharashtra, Manipur, Chandigarh, Punjab, Orissa and Delhi had HIV prevalence ≥10% among

10.410

4.64.6

Orissa (1)

Delhi (2)

West Bengal (5)

Uttar Pradesh (1) injecting drug users

20 419.8

17.613.8

M h rashtra (1)

Manipur (4)

Chandigarh (1)

Punjab (2)

Orissa (1)

24.220.4

0 5 10 15 20 25

Tamil Nadu (2)Maharashtra (1)

% HIV +ve S NACO I di% HIV +veNOTE: Values in parentheses are the number of sentinel sites for each state.*The required sample size for each high risk group site was 250. Sites reporting data for less than 75 percent of this samplesize were excluded from the analysis.

Source: NACO, India

0.5Rawalpindi

12

9.5

2.5

1

Sargodha

Faisalabad

Lahore

Sialkot

p

Pakistan, 2005

26

25.4

19.8

12

Karachi

Hyderabad

Sukhar

Sargodha

0 7 14 21 28 35(%)

68

51.6 5260

80(%)

22

35

51.6 52

2232

12

34.7 34

8.7 11 1120

40Nepal, 2006-07

8.7

0Total Kathmandu Pokhara Eastern Terai West-far-west

Terai

10

Source: www.aidsdatahub.org

2003 2004-2005 2006-2007

HIV PREVALENCE IN DRUG USERS IN BANGLADESH, 2007

208

6508 drug users sampled from 28 citiesHIV found in six cities only

1110.510

15

20

4 44.9

7 7

4

5

6

7

8

77

4.9

1.744

1.4

7.1

0.511.3

5

10 %

1.41.7

0

1 0.80

1.10.60.9

2 1.81.7

00.8

0 0 20.30.81

0

1

2

3

4

%

0 50

1999-2000 2000-2001 2002 2003-2004 2004-2005 2006 2007

Dhaka (Male) Dhaka A1 Dhaka A2

000 0 0.20

1999‐2000 2000‐2001 2002 2003‐2004 2004‐2005 2006 2007IDU‐Dhaka IDU‐NarayanganjIDU‐Chandpur IDU‐TeknafIDU‐Ishwardi Heroin smokers‐DhakaCombinedmale Khulna Combined female Dhaka N ganj and TongiCombined male‐Khulna Combined female‐Dhaka, N.ganj and Tongi

Source: NASP Bangladesh HIV Surveillance 2007 (unpublished)

Source: www.aidsdatahub.org

IDUs buy sex, and have unprotected sexIDUs sell sex, and have unprotected sexIDUs have spouses or other non-commercial sex partners, and have unprotected sex

In Manipur, India 45% of the wives of HIV positive IDUs were found to be HIV infected within seven years of an HIV outbreak among IDUs (Panda et al. (2000). International Journal of STD & AIDS; 11(7): 468-473.

Source: Tim Brown, AIDS Commission Report, 2008

Source: Tim Brown, AIDS Commission Report, 2008

Source: Tim Brown, AIDS Commission Report, 2008

Source: Foss et al, 2007 Addiction 102:114-125.

NSP OST

Afghanistan √ no

Bangladesh √ pilot with MMT planned

Bhutan no no

India √ √

Maldives no √Maldives no √

Nepal √ √

Pakistan √ pilot with MMT planned

Sri Lanka no no

Source: UN Regional Task Force on IDU and HIV for Asia and the Pacific

Prevalence of IDUs and of HIV among IDUs is not uniform within a country

Epidemics can be delayed or averted if harm reduction services are put in place before the epidemic takes off

In order for services to be in place early on, information on the presence of IDUs in different parts of the country must be availableavailable

While reviewing the global epidemiology of HIV and IDU(Mathers et al 2008 Lancet) the secretariat of the HIV and (Mathers et al, 2008, Lancet), the secretariat of the HIV and IDU Reference Group to the UN commented “Still a major long-term problem: poor, missing data”

An alert system needs to be put in place

A ecdote e e o t d ei e i o eco d Anecdotes, news reports, drug seizures, prison records, etcconduct Rapid Situation and Response Assessmentsconduct Rapid Situation and Response AssessmentsStart services and monitor the programmeConduct research studies

Once some information becomes available, surveillance systems need to be put in place

Injecting Drug Users in Bangladesh, 2008

Source: RSRA report Bangladesh: NASP, ICDDR,B, MRC Mode and Save the Children, USA

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