Injecting drug use is a major factor fuelling the HIV epidemic in the Asia Pacific region, accounting for 50 to 70 per cent of HIV infections in some countries. However, a miniscule percentage of injecting drug users in the region have access to oral substitution therapy due to several factors, including legal controls that criminalize users and drive them underground.
In order to stem the spread of HIV, it is imperative to provide early interventions, using different health care approaches, to target this largely hidden population, underlined experts at the 8th International Congress on AIDS in Asia and the Pacific (ICAAP) held in Colombo from August 19 to 23, 2007.
According to the UNAIDS Asia Pacific Regional Director, J.V.R. Prasada Rao, this highly vulnerable group of predominantly young people has long been driven underground by outdated criminalization, stereotyping and harsh discrimination. "The time has come to reach out to injecting drug users to step out of the darkness of stigma and demand an innovative approach to HIV prevention that upholds their human rights and dignity," he said.
Recognizing the need to scale up harm reduction and drug substitution programmes for this vulnerable group, UNAIDS, the UN Office on Drugs and Crime (UNODC) and WHO jointly announced an initiative to expand HIV prevention services to injecting drug users (IDUs). Called 'Prevention of Transmission of HIV Among Drug Users in SAARC Countries', the initiative aims to assist governments and communities in SAARC countries to reduce the spread of HIV among drug users and their regular sex partners.
The project will scale up prevention and care programmes, including drug substitution treatment and safer practices, using outreach to provide drug users with referrals to services, clean needles and syringes, confidential HIV counseling and testing and condom promotion.
The joint UN initiative prioritizes regional training to assist countries in establishing opioid substitution treatment. The substitution treatment entails administration under medical supervision of a prescribed medicine with similar action to the drug of dependence. Globally, the most widely employed substitution medicine among illicit drug users is methadone, prescribed in doses of around 60 to 80 mg per day, for the treatment of opioid dependence. Another medicine for substitution maintenance therapy is buprenorphine.
"Oral substitution treatment is an effective, safe and cost-effective method for the management of opioid dependence and must be integrated with other HIV prevention, treatment and care services as critical outreach among drug users," underlined Gary Lewis, Representative of UNODC's Regional Office for South Asia. "Certain South Asian countries are particularly vulnerable and need to establish pilot substitution programmes and widely disseminate the findings," he added.
Of the 13 million estimated IDUs in the world, 3.3 million live in South and South- east Asia, with wide variations in HIV prevalence within countries and the region. In South Asia, in particular, the increasing use of opioids, specifically heroin, and the diffusion of injecting drug use pose a major risk for the spread of HIV. NACO's 2006 surveillance figures show an increase in HIV infection among IDUs and MSM in India. In fact, the HIV positivity among IDUs has been found to be significantly high in Chennai, Delhi, Mumbai and Chandigarh. Besides, the states of Orissa, Punjab, West Bengal, Uttar Pradesh and Kerala also show high prevalence among IDUs.
According to the latest UNAIDS estimates, between 2.8 and 9.8 million people were living with HIV in Asia in 2006 and between 310,000 and 610,000 people became newly infected with the virus. Between 140,000 and 610,000 people died from AIDS-related illnesses in 2006.
The number of people receiving anti-retroviral therapy (ART) has increased more than three-fold since 2003 and reached an estimated 235,000 by June 2006. This represents about 16 per cent of the total number of people in need of ART in Asia. Only Thailand has succeeded in providing treatment to at least 50 per cent of those in need.
In India, the most recent estimates indicate that approximately 2.5 million people were living with HIV in 2005. According to the 2006 surveillance figures, HIV prevalence is showing signs of a slight decline among general population but pockets of high HIV prevalence continue to emerge in new areas. The 2006 surveillance figures also show an increase in HIV infection among several groups at higher risk of HIV infection such as IDUs and men who have sex with men (MSM).
The joint UN initiative is a nine-year project (2003-2012) that is divided into three phases, of which the second phase was launched at ICAAP. In its first phase in India, Oral Substitution Buprenorphine (OSB) was carried out at five participating centres - The All India Institute of Medical Sciences (AIIMS), Delhi, SHARAN (Delhi), Calcutta Samaritans (Kolkata), SASO (Imphal, Manipur) and Presbyterian Hospital (Aizawl, Mizoram).
According to UNODC data, the key findings of Phase 1 showed a 68 per cent retention rate of clients on OSB. Drug use even among those who were not consistent in using oral substitution reduced significantly from 27.8 days per month to 2.1 days per month over a six-month period. In the case of injecting drug users, only 14 per cent continued to inject drugs at the end of the same period.
These and other scientific evidence suggests that substitution treatment can help reduce criminality, infectious diseases and drug-related deaths while also improving the physical, psychological and social well-being of dependent users, says UNODC.
But the grim reality is that in many countries have limited access to drug- dependence treatment and HIV/AIDS prevention and care services for IDUs. Moreover, users of illicit drugs are commonly marginalized by communities and usually attempt to remain hidden from the authorities, especially law enforcement agencies.
Denial of treatment for drug users is rooted in the criminalization of drug use, points out Anand Grover of Lawyers' Collective, a Delhi-based NGO. "Treatment for drug users is guided not by clinical outcomes, but legal controls," he said, while speaking on the rights of IDUs to treatment during a session on Oral Substitution Treatment.
In an attempt to bring the needs and views of this vulnerable group onto the centrestage of the AIDS agenda, drug users in Asia used the conference to
launch their first regional coalition. Dubbed 'International Network of People Who Use Drugs' (INPUD-ASIA), it is led by Anan Pun, a founding member of Recovering Nepal, a drug-users network in the country.
"Through INPUD-ASIA, drug user communities in the region will be able to get support for activities such as advocacy and strengthen capacity of drug user representatives," he said. "We hope that this network will lead to greater inclusion of drug user communities in the universal access framework and to improvements in addressing their needs."
The network highlights that funding support for drug-related activities is lacking, despite the fact that drug use is a major driver of the epidemic. Out of US$8 billion spent on tackling HIV across the world each year, preventing the spread of the virus among drug users could cost as little as US$200 million per year. However, estimated coverage of harm reduction services for users in Asia dropped from just over five per cent in 2003 to about three per cent two years later, claims Pun.
To get around laws which criminalize the possession, distribution and dispensing of needles and syringes, a new UNODC study reviewed by Lawyers Collective's HIV/AIDS Unit suggests that SAARC countries utilize key provisions of the 1961 and 1971 International Narcotics Conventions pertaining to treatment. Under the UN Conventions, penal sanctions are central for drug-related offences.