4.4 Nepal

4.4.1 Sample description

In Nepal, 1,330 drug users (14% of the total sample of 9,465 drug users from South Asian countries) participated in the rapid assessment. Table 20 describes the socio-demographic characteristics of the drug users from Nepal.

About two-thirds of the drug users (66%) who participated in the survey were in the age group of 31-40 years with median age of 25 years (range 13-63). Only a small proportion of female drug users (4%) were recruited for the assessment. Of the drug users, a third (33°/0) were married, five percent illiterate, more than a third (35%) employed and a very small proportion (2°/0) were homeless.

4.4.2 Drug use and risk behaviours

Table 21 describes the types of drugs used by the ever and current users. In terms of ever use of drugs, cannabis, alcohol and heroin were the most commonly used drugs. Majority of drug users (88%) were currently using cannabis followed by alcohol (87%), injectable buprenorphine (85°/0), heroin by smoking (76°/0), heroin by injecting (75°/0), propoxy-phene (65%) and opium (65%). Users were initiated to alcohol and cannabis before the age of 16 years and the age of onset for opioids like opium, heroin and buprenorphine was after 18 years.

Of the 1,330 drug users who participated in the assessment in Nepal, 1,209 (91°/0) used drugs in groups always or at times. Forty-nine percent of them used drugs with one to five friends. Changing drug using groups was very common and was reported by most drug users (82%). The median frequency of drug use in the sample was three (range: 1-10).

Table 22 describes the drug use related characteristics of the injecting drug users (N 1,060). More than three-fourths (76%) of them injected a cocktail of drugs and 79°A) of the IDUs were current injectors. The median frequency of injecting was two. Most (92%) of the drug users switched to injecting from non-injecting methods of drug administration. Lending and borrowing of syringes and needles was not uncommon and was reported by 38°/0 and 24% of the participants respectively during the last injection episode. More than half (56%) of the participants reported cleaning their injection equipment 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 fifth (21%) of drug users. Nearly a fourth (24%) of the drug users reported abscesses during the past 6 months. About two-thirds (65%) of the drug users had stopped injecting drugs and reverted back to taking drugs through non-injecting methods.

Table 23 describes the sexual behaviour characteristics of the drug users who participated in the assessment. Most (87%) 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 (range 0 — 25). Condom use during last sexual act with regular sex partner was low. Fifty-six percent, 51% and 34% of the survey participants reported condom use with

casual, non-commercial, non-regular partners; commercial sex partners; and regular sex partners respectively. Thirteen percent of the drug users reported anal sex and 53% of the drug users reporting anal sex had a male partner. Drug use before the last sex with casual, non-commercial, non-regular partners was common (82%), followed by with commercial sex partner (75%) and regular sex partners (14°/0).

4.4.3 Adverse health consequences
It can be observed from the Table 24 that the participants reported the following symptoms related to sexually transmitted infections during the past 12 months: discharge from the genitaliam(5c1/0); ulcer on/around genitalia (12WD); and, pain/burning sensation during urination (12°/0). Twelve percent of the drug users sought any treatment for any of the above symptoms during the past year.

4.4.4 Knowledge and attitude 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 25. Almost all (99°/0) of the drug users were aware of HIV/AIDS. The knowledge of HIV transmission among the participants were: through contaminated injection equipment (87°/0); by blood transfusion from an infected person (95°/0); from HIV infected mother to her unborn child (79°/0); and, through breast-feeding by a HIV infected mother (49%). Only a small proportion (7°/0) of drug users believed that they could recognise an HIV infected person by appearance. Most (93°/0) knew that condoms protect against HIV. Despite high levels of knowledge related to HIV transmission, only just more than a third (35°/0) of the drug users believed that they were at risk of getting infected with HIV. Nearly a third (32°/0) of the drug users had been tested for HIV; among those not tested as yet, a half (50%) desired to undergo HIV testing. More than a third of the drug users were
of the opinion that they would share the results of their HIV test with their regular partner if tested positive or negative (36°/0). Forty percent of the drug users had been treated ever for drug dependence. Most (88%) 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. Thirty nine percent 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.

4.4.5 Regular sex partners of drug users

A total of 417 regular sex partners were recruited and completed a rapid situation and response assessment questionnaire. The median age of the regular sex partners was 25 years (range 14- 57 years). Most of them (79%) were married and nearly a fourth of them were illiterate (25°/0). Forty-three percent of the regular sex partners of drug users were employed and 14 % were engaged in commercial sex. Twenty-nine percent of the regular sex partners used drugs. Only 37% of the regular sex partners had used condoms during their last sexual act. Nearly a fourth (24°/0) of the regular sex partners used drugs before their last sexual act. Only 5°/0 of the sex partners reported anal sex. White vaginal discharge (28°/0), genital ulcer (9°/o) and pain/burning sensation while passing urine (22%) was common. Most (88°/0) of the sex partners had heard of HIV/AIDS but only 23% of tile regular sex partners believed that they were at-risk for acquiring HIV. Seventy-three percent of the sex partners believed that condoms protected against HIV infection. A small proportion (14%) of the sex partners had been tested for HIV.

4.4.6 Recommendations

•    As most of the drug users were illiterate, appropriate HIV prevention IEC materials should be developed to reach out to these drug using 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.
•    Lending and borrowing syringes and needles was not uncommon and hence focus should be on reducing injection related risk behaviours of drug users to halt the escalation of HIV among IDUs.
•    Many drug users were sexually active with a median number of two sexual partners. 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, including regular sex partners.
•    Drug use before sex with casual and 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.
•    Since, nearly a fourth 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 are 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 hence efforts should be directed towards enhancing the risk perception.
•    There is a great need to provide HIV testing for the drug users as most drug users have not been tested for HIV, and among those not yet tested about a half 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; hence services should become more user-friendly for the drug users in order to attract and retain them in services.