EXECUTIVE SUMMARY   

Injecting drug use (opioids and pharmaceuticals) and HIV associated with injecting drug users (IDUs), has diffused rapidly in the South Asian region. Further, the sexual transmission of HIV from the IDUs to their non-injecting sexual partners has been established. Developing appropriate responses to this emerging problem requires a rapid situation and response assessment (RSRA) of drug users and their regular sexual partners. The United Nations Office on Drugs and Crime Regional Office for South Asia (UNODC ROSA) is implementing a regional project RAS/H13: Prevention of transmission of HIV among drug users in SAARC Countries. Through this project, a RSRA of HIV related risk behaviours, adverse health consequences, knowledge and attitudes relating to HIV/AIDS amongst drug users and their regular sex partners was carried out in five South Asian countries, namely, Bangladesh, Bhutan, India, Nepal and Sri Lanka.

Mentor agencies were identified in these countries and given the responsibility of coordinating with the partner Non Governmental Organizations (NG0s). Forty NGO partners were involved in the RSRA in these five countries (India: 24; Nepal: 6; Bangladesh: 5; Sri Lanka: 4; and, Bhutan: 1). In each assessment site, the RSRA team recruited drug users and their regular sex partners and administered the survey questionnaire that was developed specifically for this assessment. Overall, the RSRA reached 9,465 current drug users (India: 5,800; Nepal: 1,330; Bangladesh: 1,090; Sri Lanka: 1,045; and Bhutan: 200) and 4,612 of their female regular sex partners (India: 3,328; Sri Lanka: 708; Nepal: 417; Bangladesh: 136; and Bhutan: 23) for the assessment.

Bangladesh: Many survey participants were in the age group of 21-30 years (60%), married (57'%), employed (83%) and illiterate (27%). Most of the drug users (97%) were current users of heroin by non-injecting method and 28% of the drug users were IDUs. Transitions from and to injecting drugs are common. The IDUs had a median frequency of injecting twice a day, and the lending (43%) and borrowing (39%) of needles and syringes was common. The drug users were sexually active with a median number of two sex partners and anal sex was also reported. Condom use during last sexual act with any partner type 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. Nineteen percent of the drug users reported genital ulcers in the past year. Despite having high levels of knowledge related to HIV transmission, only 49% 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 yet tested, most (89%) desired to undergo HIV testing. Only nine percent of the drug users were of the opinion that they would be treated as well as the non-drug users in the government health care settings.

More than one third (35%) of the regular sex partners of drug users used drugs. Only one in ten (10%) regular sex partners had used condoms during the last sexual act. A very small proportion (3%) of sex partners had been tested for HIV.

Bhutan: Half of the drug users (50%) that participated in the survey were in the age group of 21-30 years, 16% were married, 24% were employed and 3°/o were illiterate. The majority of drug users were currently using alcohol (75%) and cannabis (67°%. Nineteen percent of the RSRA participants had ever injected drugs. The proportion of participants reporting condom use with different sex partners during the last sexual act was: casual, non-commercial, non-regular partners (55%); commercial sex partners (55°%; and, regular sex partners (37%). Only a third (34%) of the drug users believed that they were at risk of getting infected with HIV. Thirty-nine percent of the drug users had been tested for HIV.

India: One half of the drug users who participated in the survey were in the age group of 21-30 years, 48% were married, 15% were illiterate and 62% were employed. Many drug users were currently using alcohol (80%) followed by cannabis (76%), injectable buprenorphine (76%), heroin by injecting (76%), heroin by non-injecting method (smoking) (70%) and propoxyphene (64%). There was a time lag between the age of onset of licit drug use and age of onset of opioid use. Sixty-two percent of the participants were IDUs and of the IDUs, about three-fourths were current injectors with a median frequency of injecting thrice a day. More than three-fourths (78%) of the IDUs had switched to injecting from non-injecting methods of drug administration. The lending and borrowing of syringes and needles was reported by 51% and 46 % of the participants respectively during the latest injection episode. Nearly a third (32%) of the drug users reported abscesses during the previous 6 months; more than a fifth of the drug users reported abscesses during the previous month. The drug users were sexually active, with a median number of two sex partners and anal sex was not uncommon. Condom use during last sexual act with any partner was low. Only 21%, 23% and 20%of the 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 genital ulcers in the past year. Only about a third (32%) of the drug users believed that they were at risk of getting infected with HIV. More than a fifth (22%) of the drug users had been tested for HIV. One third (33%) of the drug users had been treated ever for drug dependence.

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. Eighteen percent of the regular sex partners had been tested for HIV.

Nepal: About two-thirds of the drug users (66%) who participated in the survey were in the age group of 31-40 years, a third (33%) were married, 5% were illiterate and 35% were employed. A majority of drug users (88°/o) were currently using cannabis followed by alcohol (87°/o), injectable buprenorphine (85%), heroin by smoking (76%), heroin by injecting (75%), propoxyphene (65%) and opium (65%). A majority of the users had been initiated into alcohol and cannabis use before the age of 16 years and there was a gap of more than 2 years before they were initiated into opiate use. Eighty percent of the participants were IDUs and 79% of the IDUs were current injectors and 76% of them injected a cocktail of drugs. The median frequency of injecting was twice a day. Most (92% of the drug users had switched to injecting from non-injecting methods of drug administration. The lending and borrowing of syringes and needles was reported by 38% and 24% of the participants respectively during the latest injection episode. Nearly a fourth (24% of the drug users reported abscesses during the previous 6 months. The drug users were sexually active, with a median number of two sex partners and sex with other males was not uncommon. 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. Twelve percent of the drug users reported genital ulcers in the past year. Despite high levels of knowledge related to HIV transmission, only just over a third (35%) of the drug users believed that they were at risk of getting infected with HIV. Nearly a third (32%) of the drug users had been tested for HIV. Forty percent of the drug users had been treated ever for drug dependence.

Twenty-nine percent of the regular sex partners used drugs. Only 37% regular sex partner had used condoms during the last sexual act. Most (88%) of the sex partners were aware of HIV/AIDS but only 23% of the regular sex partners believed that they were at risk for acquiring HIV. Fourteen percent of the sex partners had been tested for HIV.

Sri Lanka: About half of the drug users (49%) who participated in the survey were in the age group of 21-30 years, 52% were married, 86% were employed and 6% were illiterate. Most of drug users (93%) were currently using heroin by non-injecting method (smoking), followed by the use of alcohol (81%), cannabis (80%) and propoxyphene (36%). Only 4% of the participants had ever injected drugs. The drug users were sexually active, with a median number of two sex partners and sex with other males was not uncommon. Condom use during latest sexual act with any partner was low. Only 31% , 28% and 14% of the participants reported condom use with casual, non-commercial, non-regular partners commercial sex partners and, regular sex partners respectively. More than a third (36%) of the drug users believed that they were at risk of getting infected with HIV. Sixteen percent of the drug users had been tested for HIV. Less than a fourth of the drug users (23%) had been treated ever for drug dependence.

Only twelve percent of the regular sex partners had used a condom during the latest sexual act. Seventy percent of the regular sex partners had heard of HIV/AIDS but only 17% of the regular sex partners believed that they were at risk for acquiring HIV. Fourteen percent of the sex partners had undergone HIV test.

Recommendations for all countries: The RSRAs have demonstrated that it is possible to reach out to the hidden populations of drug users as well as their regular sexual partners. The assessments yielded valuable information that can guide future interventions targeting drug users and their regular sexual partners in this region. Future interventions should aim to:

•    Prevent the transitions from licit drug use like tobacco and alcohol to opioid use.

•    Prevent the switch to injecting by the non-injecting opioid users.

•    Include targeted interventions for drug users that address both the injection and the sex related risk behaviours.

•    Promote condom use among the drug users and their regular sexual partners. This is an important challenge. Multi level intervention at the individual, couple and community level interventions are needed to deal with this vital issue.

•    Include comprehensive HIV prevention interventions for drug users that provide community outreach for drug users and their sexual partners, an increased access to sterile injection equipment (e.g., needle syringe programmes), promote condom use with all sexual partners, primary medical care for abscess management, treatment for sexually transmitted infections (STIs) and voluntary counselling and testing (VCT).

•    Provide drug dependence treatment, in particular, evidence based treatment like opioid substitution treatment needs to be implemented and scaled up in the region.