5. Regional Recommendations

Diffusion of pharmaceutical injecting: There are regional variations in drug use patterns. For example, injecting drug use is well established in India, Nepal and Bangladesh but there is relatively less injecting drug use in Bhutan and Sri Lanka. Yet, opioid users in all the five countries abuse pharmaceutical drugs like propoxyphene and buprenorphine. Diffusion of pharmaceutical drugs in the region is a major concern that needs to be urgently prioritised.

Transitions from licit to illicit use: Most drug users have used licit drugs like alcohol before starting to use opioids and injectable drugs. Since there is a time lag between the age at onset of licit drug use and opioid use, opportunity must be explored for designing and implementing interventions to prevent licit drug users from shifting to opioid and injecting drug use.

Transitions to and from non-injecting to injecting of opioids: There are significant numbers of non-injecting opioid users in all the five countries. Switching from non-injecting to injecting methods of administration and a transition from injecting to non-injecting methods is common among drug users. Hence prevention interventions targeting non-injecting drug users must be considered critical to prevent transitions to injecting.

High levels of injection-related risk behaviours: Among the IDUs recruited, lending and borrowing of injection equipment are common in India, Nepal and Bangladesh, countries with high prevalence of injecting drug use. Persistent injection-related risk behaviours contribute significantly to the HIV epidemic amongst the IDUs. To halt the epidemic, scaled-up HIV prevention efforts targeting the injection related risk behaviours (e.g., needle syringe programmes) are absolutely essential. The median injecting frequency by IDUs is twice per day and this information should be considered while implementing needle syringe programmes. Unsterile injection practices are common in the region as revealed by the prevalence of abscesses among the IDUs. Primary medical care for managing abscesses should become an integral component of HIV prevention interventions for drug users.

Sexual risk behaviours among drug users: Drug users in the region are sexually active and have a median of two sexual partners. Condom • use with any partner is low, particularly with regular sexual partners. The sexual transmission of HIV from and to injecting drug users and their regular sexual partners should be addressed in all future HIV interventions targeting IDUs. Symptoms of sexually transmitted infections are common and hence STI screening and treatment should be provided in comprehensive HIV interventions for drug users.

Interface between different risk groups: Drug users often have sex with sex workers and unprotected sex with them is common. Further, drug use before commercial sex is often reported by drug users and this is bound to compromise safe sex behaviours. The interface between sex work and drug use can fuel the HIV epidemic and this aspect has to be effectively addressed in order to prevent the spread of HIV. Many drug users in the region report anal sex with other men and it is apparent that there are significant overlaps between the different most at-risk populations.

Knowledge relating to HIV/AIDS transmission: Most drug users are aware of knowledge and their knowledge relating to contaminated needles and unsafe blood related HIV transmission is good. A considerable proportion of drug users are still ignorant about mother-to-child transmission as well as transmission through breast feeding. Most drug users in the region do not believe that HIV+ persons could be identified by appearance. Knowledge relating to HIV/AIDS transmission is low in Sri Lanka where HIV prevalence in the population is also low at present. Awareness programs in the region should aim at increasing the knowledge relating to HIV/AIDS transmission.

HIV Risk perception: Despite fair levels of knowledge relating to HIV/AIDS, many drug users in the region do not perceive themselves to be.at risk of acquiring HIV. Enhancing the risk perception of drug users through individual or group counselling must be considered important.

HIV testing: A sizeable proportion of drug users have not been tested for HIV and all efforts need to be taken to organise and provide HIV testing for drug using populations. Given that most of the drug users and their regular sex partners who have not been tested for HIV as yet, were desirous of undergoing the HIV test, voluntary counselling and testing (VCT) for drug users and their sexual partners should be scaled up.

Disclosure to partners: Many drug users are willing to disclose the HIV+ results to their regular partners. Disclosure should be assisted through disclosure counselling for HIV+ drug users, particularly for women drug users who are HIV+.

Service delivery for drug users: A majority of drug users in the region have been treated for drug dependence. Organising and providing treatment for drug dependence is important and in future evidence-based drug treatment (e.g., opioid substitution therapy) should be implemented on a priority basis and scaled up in the region. Most drug users in the region do not believe that they are treated as well as non-drug using persons in Government facilities. Similarly a majority of drug users are of the opinion that the treatment at private health care systems is also discriminatory. It is essential to establish user-friendly services in order to attract and retain drug users in prevention/ treatment interventions.

Regular sex partners: Despite having drug users/IDUs as their primary partners, only a fifth of the female regular sex partners in the five countries reported using a condom during their last sexual intercourse. Condoms continue to remain the primary protective device against sexual exposure to HIV. Hence it is important to understand the factors associated with condom use in order to plan effective responses to promote condom use amongst the female regular sex partners.