4.1 Bangladesh

4.1.1 Sample description

In Bangladesh, 1,090 drug users (12% of the total sample of 9,465 drug users from South Asian countries) participated in the RSRA. Table 2 describes the socio-demographic characteristics of the drug users from Bangladesh.

Majority of the drug users (60%) that participated in the survey were in the age group of 21-30 years, with a median age of 30 years (range 16-60). Only a small proportion of female drug users (9%) were recruited for the assessment. More than half (57%) of the drug users were married, more than a fourth (27%) were illiterate, 83% were employed and, 11% were homeless.

4.1.2 Drug use and risk behaviours

Table 3 describes the types of drugs used by the ever and current users. Cannabis heroin and alcohol were the common ever used drugs. Most of drug users (97%) were current users of heroin by non-injecting method (smoking), followed by the use of cannabis (91%) and alcohol (62%). Users reported that they were initiated to alcohol and cannabis before the age of 20 years and the age of onset for opioids like heroin, opium and buprenorphine was after 20 years.

Of the 1,073 drug users that participated in the assessment in Bangladesh, 888 (83%) used drugs always or at times in groups. Fourteen percent of them used drugs with more than five friends. Changing drug using groups was uncommon and was reported by a small number of drug users (1%). The median daily frequency of drug use in the sample was two (range: 1-22).

Table 4 describes the drug use related characteristics of the injecting drug users (N = 300). Most (81%) of them injected cocktail of drugs and just more than a third (35%) of the IDUs were current injectors. The median frequency of injecting was two times in a day (range 1-4). More than two-thirds (69%) of drug users have switched to injecting from non-injecting methods of drug administration. Lending and borrowing of syringes and needles was common and was reported by 43% and 39% of the participants respectively during the last injection episode. Only 28% of the drug users reported cleaning their injection equipment before using with others during the last time they injected with others. Indirect sharing like sharing injection related paraphernalia (cooker, cotton, water and ampoules) was reported by more than a fourth (26%) of the drug users. A fifth (20%) of the drug users reported abscesses during the past 6 months. Sixty-three percent of the drug users had stopped injecting and reverted back to non-injecting methods of administration.

Table 5 describes the sexual behaviour of the drug users that participated in the assessment. Most (96%) of the participants had sexual experience and the median age at first sex was 18. During the past year, the participants had a median number of two sexual partners. Condom use during last sexual act with any partner was low. Only 26%, 23% and 15% of the participants reported condom use with casual, non-commercial, non-regular partners; commercial sex partners; and, regular sex partners respectively. Twenty-nine percent of the drug users reported anal sex and 60% of the drug users reporting anal sex had a male partner. Drug use before the last sex with commercial sex partner was common (70%), followed by with casual non-commercial, non-regular partners (19%) and regular sex partners (16%).

4.1.3 Adverse health consequences

It can be observed from Table 6 that the participants reported the following symptoms related to sexually transmitted infections during the past 12 months: discharge from the genitalia (16%); ulcer(s) on/around genitalia (19%); and, pain/burning sensation during urination (51%). Just more than a half (51%) of the drug users sought any treatment for any of the above symptoms during the past year.

4.1.4 Knowledge and attitudes in relation to HIV/AIDS

Variables related to knowledge and attitudes to HIV/AIDS of the drug users who participated in the study are described in Table 7. Most (96%) of the drug users were aware of HIV/AIDS.

The knowledge regarding modes of HIV transmission among the participants were: through contaminated injection equipment (84%); by blood transfusion from an infected person (87%); from HIV infected mother to her unborn child (72%); and, through breast-feeding by a HIV infected mother (64%). Only a small proportion (7%) of drug users believed that they could recognise an HIV infected person by appearance. More than three-fourths (76%) of the drug users knew that condoms protect
against HIV. Despite high levels of knowledge relating HIV transmission, only 49')/0 of the drug users believed that they were at-risk of getting infected with HIV. Even though, a very small (5%) proportion of drug users had been tested for HIV, among those not tested as yet, most (89%) desired to undergo HIV testing. Majority of the drug users were of the opinion that they would share results of HIV test with their regular partner if tested positive (58%) or negative (56%). Less than a half of the drug users (46%) had been treated ever for drug dependence. Fifty-nine percent of the drug users had been approached by someone to provide HIV prevention information. Many drug users believed that they would be treated differently from the non-drug using persons in the health care settings. Only 9 % and 3 5 % of the drug users were of the opinion that they would be treated as well as the non-drug users in government health care settings and private health care settings respectively.

4.1.5 Regular sex partners of drug users

A total of 136 regular sex partners were recruited and completed a rapid situation and response assessment questionnaire. The median age of the regular sex partners was 26 years (range 14- 50 years). Most of thenn (89%) were married and nearly a half (49%) of them illiterate. About three-fourths (72%) of the regular sex partners of drug users were employed and 2 3 % were engaged in commercial sex. More than a third (35%) of the regular sex partners used drugs. Only one in ten (10%) regular sex partners had used condoms during their last sexual act. A third (33%) of the regular sex partners used drugs before their last sexual act. Just over a third (34%) of the sex partners reported anal sex. White vaginal discharge (61%) and pain/burning sensation while passing urine (48%) was common. Most (98%) of the sex partners were aware of HIV/AIDS but only 6 0 % of the regular sex partners believed that they were at-risk for acquiring HIV. Two-thirds of sex partners believed that condoms protected against HIV infection. A very small proportion (3%) of sex partners had undergone HIV testing.

4.1.6 Recommendations

•    More than half of the drug users are married and hence all drug user interventions should target the drug users well as their regular sex partners.

•    As a fourth of the drug users are illiterate, appropriate HIV prevention information, education and communication (IEC) materials should be developed to reach out to the illiterate populations.

•    As most of the IDUs used heroin by non-injecti ng method before transiting to injection, interventions to prevent transitions to injecting should target the non-injecting drug users.

•    As IDUs often lend and borrow syringes and needles, reducing injection related risk behaviours of drug users should be considered critical to halt the escalation of HIV among IDUs.

•    Many drug users are young persons between 21-30 years of age and are sexually active with a median number of two sexual partners. Anal sex with men is also frequently reported by the nnale drug users. Despite the knowledge that condoms protect against HIV, condom use with any partner, in particular, regular sex partners is low. Interventions targeting drug users should always target sexual behaviour and promote consistent condom use with all sexual partners.

•    Drug use before sex with commercial sex partner was common and since drug use can compromise on the safe sex, this aspect should be considered in HIV prevention interventions.

•    Symptoms of sexually transmitted infections were not uncommon; screening for STIs and effective STI care should be integral components of HIV prevention efforts for drug users.

•    As a fifth of the drug users had abscesses, comprehensive interventions for drug users should include primary medical care of managing abscesses.
•    Most were aware of HIV and many were knowledgeable about needle related HIV transmission as well as unsafe blood transfusion; but, the knowledge relating to HIV transmission by mother-to-child transmission and breastfeeding was inadequate. These messages need to be an integral part of programmes for drug users and their sex partners.

•    More than a half of the drug users did not believe that they were at risk of getting infected with HIV and hence the focus should be on enhancing their risk perception.

•    There is a great need to provide HIV testing for the drug users given the fact that most drug users had not been tested for HIV but those not yet tested were desirous of getting tested for HIV.

•    Drug users felt that they were not being treated well both in government and private health care settings and services should become more user-friendly for the drug users in order to attract and retain them in services.