|Drug Use and HIV Vulnerability (UNAIDS, 2001, 238 p.)|
|Chapter 3: India|
Injecting drug use is well established in a number of cities in India and it will be difficult to slow or prevent the trend towards injection as an increasingly favoured method of drug administration. Injecting drug use is increasing in many areas of India especially among young males living in socio-economically disadvantaged areas. The number of drug users is sufficiently high as to present a major additional source for fuelling the HIV epidemic in India.
Risk behaviour such as the sharing of drug injection equipment is highly prevalent among people who use drugs, presenting an environment in which an explosive spread of HIV and other blood borne diseases such as hepatitis B and C is inevitable. It is not a question of whether this might occur, rather, how quickly and how extensively this will be.
Knowledge of HIV and ways to reduce risk is inadequate among most drug use sub-populations.
The risk of HIV transmission from injecting drug users to sexual partners is high and behavioural change strategies adopted to date to reduce this risk have been minimal.
Sero-prevalence among injecting drug users in some northeastern states of India is among the highest in the world. Recent evidence suggests escalating rates among slum dwellers in Delhi.
National documents of importance such as the National AIDS Prevention and Control Policy and the NACO Country Scenario Report, 1997-98 reflect less than adequate identification and description of the nature and level of risks and their determinants which drug use and drug injection might pose in fuelling the HIV epidemic in India.
There has been no exploration to date of the influence of drug use networks and their dynamics on the diffusion of at risk injecting behaviour nor on the influence of the socio-political environment. For example, whether legislation, public policy, law enforcement and interdiction activity are supportive of, facilitate and promote lower risk behaviour or alternatively, whether they hinder and make it less likely, and whether law enforcement and interdiction activity renders drug injection more likely by increasing the price and reducing the average purity of illicit of drugs.
Currently adopted law enforcement and supply reduction strategies may have contributed to the shifts in drug use and methods of administration from those that posed less public health hazard to those posing greater hazard. This may also be serving to exacerbate HIV vulnerability or at least, hindering efforts aimed at reducing such vulnerability.
The introduction of the Narcotic Drugs and Psychotropic Substances Act (1985) which, among other things, banned the use of opium appears to have had a substantial influence on a shift to the use of heroin.
Narcotic or psychotropic drug use is itself illegal under Section 27 of the Narcotic Drugs and Psychotropic Substances Act (1985). This also appears to hinder some HIV prevention efforts.
National and state authorities responsible for HIV/AIDS prevention might helpfully pay more attention to addressing the hazards which licit and illicit drug use has potential to play in fuelling the HIV/AIDS epidemic in India.
Manipur State stands out as an example of what can and needs to be done to slow, stop and even reverse a drug-fuelled HIV/AIDS epidemic in India. Its drug and HIV/AIDS prevention policies are progressive and consistent with the international experience and empirical evidence on what works best. The challenge for the Government of India will be to adopt such policies and strategies more broadly while there is still time to limit the extent of a drug-related HIV/AIDS epidemic.
Unlike the situation in the north-eastern states, other state governments (which have responsibility for health policy and intervention) have been slow to recognise the threat which drug use poses and to adopt the necessary legislative and policy reforms which could support broad based efforts aimed at limiting drug-related HIV transmission.
Sterile injection equipment is difficult to access from the perspective of affordability, public policy and health and law enforcement sector practices and is serving to substantially amplify the hazards for HIV transmission.
There is incorrect understanding within government of the principles, methods and outcomes associated with the concept of harm minimisation and its approaches.
Some State AIDS Cells do not appear to understand or support the need for certain HIV/AIDS prevention approaches such as needle and syringe exchange.
The demand for drug treatment is very high but responses are in general inadequate, both in scale, accessibility, policy and practice.
Access to drug treatment is limited, be it abstinence oriented or substitution in nature, particularly among those living in poverty, those living in rural areas and those with special needs (e.g., women, people with children, homeless people, street children, sex workers).
There has been little or no real change in the model of drug de-addiction offered in India since the early 1980s, despite substantial anecdotal and empirically derived evidence that it is associated with poor treatment outcomes. Government has signalled an intention to reform drug treatment with greater emphasis on rehabilitation, however, these changes cannot of themselves prevent a drug-related HIV/AIDS epidemic.
Drug treatment is generally oriented towards abstinence and treatment is associated with limited reach and throughput of those who are in need and who might otherwise benefit from treatment, with high relapse rates and with limited beneficial public health impacts and outcomes over time.
Unhygienic and physiologically hazardous drug injection practices are common place and are associated with substantial health hazard and harm.
Inadequate attention has been paid to HIV vulnerability in prisons, where unsafe sex and unsafe drug injection may represent a major public health hazard.
There is inadequate information and understanding among key policy decision-makers in relation to methadone maintenance treatment.
The draft National AIDS Prevention and Control Policy endorses needle and syringe exchange as a legitimate strategy for preventing HIV transmission arising out of injecting drug use.
However, the draft National AIDS Prevention and Control Policy defines harm minimisation in a way that precludes optimum use of available HIV prevention strategies among people who use illicit drugs.
Prevention and treatment goals are oriented towards abstinence from drug use and this is serving as a specific barrier to potentially more effective health protection interventions.
The law as it exists at present when taken in conjunction with many policies and practices currently adopted by government and by the non government sector may be serving to hinder effective strategies and actions which could otherwise reduce or contain the risk for HIV transmission.
While the multi-dimensional nature of drug use and its determinants is recognised by National AIDS Control Organization (NACO), it also acknowledges the need for implementing multi-sectoral responses that have been long identified but not as yet acted upon.
Inadequate attention has been paid to supporting, facilitating and promoting the development of user self-organisations and their intimate involvement in drug and HIV prevention policy, planning and evaluation of strategies and activities for addressing drug use and related harms, including HIV/AIDS.
The government has favoured an outsourcing of services on the basis of a hypothesis that this could foster community development and more effective responses at the ground level. While there are obvious benefits associated with this approach, there are in addition serious risks if it is not accompanied by adequate attention to on-going standards development, service delivery guided by empirical evidence rather than personal opinion or commercial interests and to monitoring and evaluation of the delivery and effectiveness of interventions.
Many non-government organisations are working under extremely difficult circumstances, often left largely to their own devices and without technical and financial support in helping drug users at risk or already infected with HIV.
Regional harm reduction responses are required given the regional nature of the drug use and HIV risk phenomenon that is now prevalent (particularly in Bangladesh, Nepal, Myanmar and Pakistan).
There is a need for agencies of the United Nations system to work together and with the government in a more communicative, integrated and co-ordinated manner in addressing drug use problems as they impact on HIV vulnerability.