4.3 India

4.3.1 Sample description

In India, 5,800 drug users (61°/0 of the total sample of 9,465 drug users from South Asian countries) participated in the RSRA. Table 14 describes the socio-demographic characteristics of the drug users from India.

A half of the drug users (50%) that participated in the survey were in the age group of 21-30 years with a median age of 30 years (range 11-80). Only a small proportion of female drug users (5%) were recruited for the assessment. Of the drug users nearly a half (48°/0) were married, 15% were illiterate, 62% were employed and 4 % homeless.

4.3.2 Drug use and risk behaviours

Table 15 describes the types of drugs used by the ever and current users. In terms of ever use of drugs, alcohol, cannabis and heroin were the commonly used drugs. Many drug users were currently using alcohol (80°/0) followed by cannabis (76%), injectable buprenorphine (76%), heroin by injecting (76%), heroin by non-injecting method (smoking) (70%) and propoxyphene (64°/0). Users were initiated to alcohol and cannabis before the age of 18 years and the age of onset for opioids like opium, heroin, propoxyphene and buprenorphine was after 20 years.

Of the 5,800 drug users who participated in the assessment in India, 4,163 (73%) used drugs always or at times in groups. Forty-six percent of them used drugs with less than three friends. Changing drug using groups was common and was reported by a more than a half of drug users (52%). The median frequency of drug use in the sample was three (range 1-39).

Table 16 describes the drug use related characteristics of the injecting drug users (N = 3,562). About three-fourths (72°/0) of the IDUs were current injectors and 43°/o of them injected a cocktail of drugs. The median frequency of injecting in the sample was three (range 1-24). More than three-fourths (78°/o) of the drug users switched to injecting from non-injecting methods of drug administration. Lending and borrowing of syringes and needles was common and was reported by 51% and 46°/o of the participants respectively during the last injection episode. More than two-thirds (69%) of the participants 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 half (51%) of drug usL.s. Nearly a third (32°/0) of the drug users reported abscesses during the past 6 months; more than a fifth of the drug users reported abscesses during the past month. Fifty-seven percent of the drug users have stopped injecting and reverted back to non-injecting methods of administration.

Table 17 describes the sexual behaviour characteristics of the drug users that participated in the assessment. Most (87°/0) of the participants had sexual experience and the median age at first sex was 19 (range 11-46). 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 21°/o , 23°/o and 20°/o of the participants reported condom use with casual, non-commercial, non-regular partners; commercial sex partners; and regular sex partners respectively. Eighteen percent of the drug users reported anal sex and 46% of the drug users reporting anal sex had a male partner. Drug use before the last sex with regular sex partners was common (60°/0), followed by with casual, non-commercial, non-regular partners (54%) and commercial sex partner (45°/0).

4.3.3 Adverse health consequences

It can be observed from the Table 18 that the participants reported the following symptoms related to sexually transmitted infections during the past 12 months: discharge from the genitalia (15°/0); ulcer on/around genitalia (13°/0); and, pain/burning sensation during urination (30°/0). More than a half (52%) of the drug users sought any treatment for any of the above symptoms during the past year.

4.3.4 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 19. Most (89°/0) of the drug users were aware of HIV/AIDS. The knowledge of HIV transmission among the participants were: through contaminated injection equipment (79°/0); by blood transfusion from an infected person (80°/0); from HIV infected mother to her unborn child (64%); and, through breast-feeding by a HIV infected mother (49%). Only a small proportion (12°/0) of drug users believed that they could recognise an HIV infected person by appearance. Nearly three-fourths (73%) knew that condoms protect against HIV. Despite high levels of knowledge related to HIV transmission, only about a third (32°/0) of the drug users believed that they were at risk of getting infected with HIV. More than a fifth (22°/0) of the drug users had been tested for HIV; among those not tested as yet, 42°/0 desired to undergo HIV testing. The drug users in the survey were of the opinion that they would share the results of the HIV test with their regular partner if tested positive (27°/0) or negative (33°/0). A third (33°/0) of the drug users had been treated ever for drug dependence. Sixty-two 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 44% and 54% 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.

4.3.5 Regular sex partners of drug users
A total of 3,328 regular sex partners were recruited and completed a rapid situation and response assessment questionnaire. The median age of the regular sex partners was 29 years (range 14-70 years). A sizeable (73%) proportion of them were married and more than a fourth of them were illiterate (28%). Forty-one percent of the regular sex partners of drug users were employed and 8 °/o were engaged in commercial sex. A fifth (20°/0) of the regular sex partners used drugs. Only 2 2 (p/o of the regular sex partners had used condoms during the last sexual act. Seventeen percent of the regular sex partners used drugs before their last sexual act. Fourteen percent of the regular sex partners reported anal sex. White vaginal discharge (39°/0), ulcer on the genitalia (16°/0) and pain/burning sensation while passing urine (35')/0) was common. Nearly three-fourths of the sex partners (74%) had heard of HIV/AIDS but only a fourth (25%) of the regular sex partners believed that they were at-risk for acquiring HIV. More than half (53%) of the sex partners believed that condoms protected against HIV infection. A small proportion (18°/0) of the sex partners had undergone HIV testing.

4.3.6 Recommendations

•    Nearly half of the drug users were married and hence all drug user interventions should target the drug users as well as their regular sex partners.
•    As 15% of the drug users were illiterate, appropriate HIV prevention IEC materials should be developed to reach out to the illiterate populations.
•    As most of the IDUs used heroin by non-injecting method before transiting to injection, interventions to prevent transitions to injecting should target the non-injecting drug users.
•    IDUs often lent and borrowed syringes and needles; focus should, therefore, be on reducing injection related risk behaviours of drug users to halt the escalation of HIV among IDUs.
•    Many drug users were young persons between 21-30 years of age and were sexually active with a median number of two sexual partners. Anal sex by male drug users with other men was not uncommon. Despite the knowledge that condoms protect against HIV, condom use with any partner, in particular, regular sex partners was low. Interventions targeting drug users should always target sexual behaviour and promote consistent condom use with all sexual partners.
•    Drug use before sex with regular and casual sex partner was common and since drug use can compromise 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.
•    Since a fifth of the drug users had abscesses currently, comprehensive interventions for drug users should include primary medical care of managing abscesses.
•    Most drug users 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 through breastfeeding was inadequate. More than two-thirds of the drug users did not believe that they are at-risk of getting infected with HIV and efforts should be directed towards 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, and among those not yet tested, many 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 hence services should become more user-friendly for the drug users in order to attract and retain them in services.