Injecting Drug Users: A Global Problem

Roger Detels, M.D., M.S.

Global Areas of Drug User-Transmitted HIV

• Europe

• North America (U.S., Canada)

• South America

• Southeast Asia (Thailand, Myanmar, Vietnam, northeast India, Indonesia)

• China (originally Yunnan, now all provinces; highest in Yunnan, Guangxi and Xinjiang)

Golden triangle in southeast Asia

05.15.2013

Major heroin-producing locations

05.15.2013

Global Injecting Drug Use Statistics (2008)Number of countries with documented injectors: 148

Areas lacking statistics: Africa, Middle East, western South America

Prevalence estimates possible: 61 countries

Estimated number of injectors worldwide: 15.9 million

Estimated number of HIV-positive injectors worldwide: 3.0 million

Countries with most injectors: China, USA, Russia

Prevalence of injecting drug use

Mathers BM, et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet 372:1742, 2008.

Prevalence of HIV infection among injecting drug usersMathers BM, et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet 372:1744, 2008.

Role of Drug Use in Spread of HIV in Asia

Relationship of Drug Use to HIV Spread to Other Groups

• Rapid spread (Thailand, Myanmar, NE India)

• Initially slow spread among older addicts, followed by rapid spread in younger addicts (Vietnam)

• More recent increase in female injectors (Vietnam, China)

• Spread to “bridge” populations

Characteristics of DrugUsers in Asia

• Remain as a member of the family• Remain as a member of the community• High failure rate for rehabilitation centers (90+

%)• Increasing number of drug replacement and

needle exchange programs• Recent increase in other drugs for injecting• Increasing non-injection (club) drug use,

especially among MSM

Trends in HIV prevalence (%) among IDUs in three sites in India. Sources: Sarkar et al. (1993), Joseph (1996), Tamil Nadu State AIDS Control Society Report on Sentinel Surveillance (2005), Panda et al. (2002a), and West Bengal State AIDS Prevention and Control Society, Sentinel surveillance reports, 1994-2003. Note: The prevalence data for Manipur before 1994 are not based on sentinel surveillance data

Panda S and Sharma M. Needle syringe acquisition… Substance Use & Misuse 41:953-977, 2006

Panda S and Sharma M. Needle syringe acquisition… Substance Use & Misuse 41:953-977, 2006

Prevalence of HCV among IDUs in South Asia

Drug Use Intervention Strategies•Needle exchange programs•Drug replacement programs (e.g. methadone)•Cognitive behavioral therapy (identify and address triggers and situations)•Contingency management: reward (i.e., pay) for negative urine tests•Community intervention

Comparative equipment-sharing behavior by locations with and without outreach-based interventions in Bangladesh (2002). (From Panda et al., 2002a). Source: Panda et al., 2002

Panda S and Sharma M. Needle syringe acquisition… Substance Use & Misuse 41:953-977, 2006

There are currently an estimated 740,000 people living with HIV in China. http://www.avert.org/aidschina.htm

Wu et al., Community-based trial to prevent drug use in Yunnan, China. Am J Publ Hlth 92:1952-1957, 2002.

Intervention Methodology (1)

Study sites: Longchuan, southern Yunnan

Selection of intervention and control areas: 19 villages matched on prevalence of drug use and HIV, number of drug users, geographically separated

Theoretical framework: behavioral change model, Bandura’s social learning theory

Wu et al., Community-based trial to prevent drug use in Yunnan, China. Am J Publ Hlth 92:1952-1957, 2002.

Intervention Methodology (2)Intervention strategies• Recruitment of official and informal leaders and police• Multiple approach: school, family, community, clinic• Activities

Workshops Games and videos with anti-drug messages Literacy classes Agriculture classes School programs Visits to detox centers Establishment of youth centers Youth work core Skits

Non-drug- Non-injecting Injecting Injecting & sharingusing youths drug users drug users equip. drug users

Intervention points

Intervention activities:

Comprehensive Introduce farming Evening class and Integrating drug/

intervention skills into villages and entertainment AIDS preventionactivities on to assist drug/AIDS to assist drug/AIDS into schooldrug/HIV prevention; youth prevention curriculumprevention in corps, youth centervillages

Community-based Intervention to Reduce Drug Use

Evaluation of InterventionComparison of incidence of drug initiation• Retrospective cohort, October 1995-Feb 1997• Retrospective cohort, May 1997-Sept 1998Data collected• Demographics• Initiation of drug use, injecting-sharing• Sexual behavior

Response rate: intervention villages 91%, control villages 88%

Variable Attributable Risk Reduction

Incidence Reduction Ratio*

P-value

All males 15-49 yrs

-99% 2.7 <0.05

Males 15-19 yrs -479% >216§ <0.001

Single -301% >291§ <0.001

Dai ethnicity -61% >60§ <0.001

Jingpo ethnicity

Illiterate

-301%

-616%

>196§

>61

<0.001

<0.001

*Incidence change in intervention group/Incidence change in control group§Change at baseline set at -0.01 (incidence increased in control area)

Significant Incidence Changes in New Male Drug Users in Intervention and Control Villages

ConclusionCommunity intervention can be useful

for preventing initiation of drug use, but not for preventing progression to

injection use

Has the intervention been sustained?

Yes

Requirements for Successful Needle Exchange Programs

•Local political and community support

•Cooperation of security officials; e.g., police

•Dissemination of knowledge of availability to injecting population

•Magnitude/scale sufficient to reduce community reservoir of infectious syringes/needles

•Supportive, empathetic staff

•Ready availability; e.g., “dial-a-needle”

•Supportive services; e.g., counseling, referral, etc.

•Recognition and support for exchange program staff

Requirements for Successful Drug Replacement Programs

• Political and community support• Police non-interference/support• Committed, rewarded staff• No entry restrictions to program• Sufficient dosing• Drug monitoring• Supportive services; e.g., counseling, referral, etc.• Outcomes – abstinence, reduction?• Measuring impact appropriately; what is the correct denominator?