Scaling Up HIV Scaling Up HIV Prevention among IDUs in Prevention among IDUs in

South Asia: South Asia:

the key issues & gapsthe key issues & gaps

Dr. M. Suresh Kumar Dr. M. Suresh Kumar MD DPM MPHMD DPM MPH

Chennai IndiaChennai India

Inter-country Consultation on Preventing HIV among IDUsScaling Up: From Evidence to Action

April 10 2007, Kolkata, India

Diffusion of injecting drug Diffusion of injecting drug use in South Asiause in South Asia

BhutanBhutan

(N = 200)(N = 200)BangladeshBangladesh

(N = 1090)(N = 1090)IndiaIndia

(N = 5800)(N = 5800)NepalNepal

(N = 1330)(N = 1330)Sri LankaSri Lanka

(N = 1045)(N = 1045)

Ever injectedEver injected 37 (18.5%)37 (18.5%) 300 (28%)300 (28%) 3562 3562 (62.1%)(62.1%)

1060 1060 (80.2%)(80.2%)

39 (3.8%)39 (3.8%)

Ever Injected Ever Injected heroinheroin

3 (1.5%)3 (1.5%) 46 (4.3%)46 (4.3%) 1623 1623 (28.3%)(28.3%)

606 (45.8%)606 (45.8%) 23 (2.3%)23 (2.3%)

Ever Injected Ever Injected BuprenorphineBuprenorphine

28 (14%)28 (14%) 295295

(27.5%)(27.5%)14661466

(25.6%)(25.6%)1013 1013 (76.6%)(76.6%)

6 (0.6%)6 (0.6%)

Ever Injected Ever Injected PropoxyphenePropoxyphene

32 (16%) 32 (16%) 3 (0.3%)3 (0.3%) 17131713

(29.9%)(29.9%)149 (11.3%)149 (11.3%) 39 (3.8%)39 (3.8%)

UNODC ROSA, 2007

Current pharmaceutical Current pharmaceutical drug use in South Asiadrug use in South Asia

6

154

1

1228

1115 1103

456

858

97

-100

100

300

500

700

900

1100

1300

Bangladesh India Nepal

Injected heroin Injected Buprenorphine Injected Propoxyphene

UNODC ROSA, 2007

Age at initiation of drug use Age at initiation of drug use in South Asiain South Asia

21 21

16

25

21 2120

24

1820

19

30

0

5

10

15

20

25

30

Bangladesh india Nepal

Heroin smoking Heroin injecting Proxyvon injecting Buprenorphine injecting

UNODC ROSA, 2007

HIV prevalence among HIV prevalence among IDUs in certain places, IDUs in certain places,

IndiaIndia

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

2000 2001 2002 2003 2004

Manipur

Tamilnadu

Mumbai

Delhi

West Bengal

NACO Sentinel Surveillance

HIV prevalence among HIV prevalence among IDUs in BangladeshIDUs in Bangladesh

1.40% 1.70%

4.00% 4.00%5%

7%

0.00%

2.00% 1.80%

0.00%1%

1.10%0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

10.00%

RoundII

RoundIII

RoundIV

RoundV

RoundVI

RoundVII

Central A

NW Fi

SE D

Ministry of Health and Family Welfare, Bangladesh

HIV prevalence among HIV prevalence among IDUs in NepalIDUs in Nepal

53% 50.10%

39.70%

56.70%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Kathmandu Eastern Terai Western Terai Pokhara

HIV Prevalence

Source: IBBS Study – NCASC/New Era/SACTS/USAID/FHI, 2003, 04

Injection related risk Injection related risk behaviour of IDUs – South behaviour of IDUs – South

AsiaAsia

UNODC ROSA, 2007

37.50%

23.70%

42.70%38.70%

50.90%45.90%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Nepal Bangladesh India

Lending needles, syringes last use Borrowing needles, syringes last use

Sharing injection Sharing injection equipment – new sites in equipment – new sites in

IndiaIndia

9%

33%

56.30%

21.90%

47.80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sharing inj equipment, last time use

Goa

Kerela - 3 sites

T Nadu - 3 sites

Mizoram - 4 sites

Uttar Pradesh - 13 sites

Project Network, SHARAN India, 2007

Sexual risk behaviour of Sexual risk behaviour of IDUs – South AsiaIDUs – South Asia

UNODC ROSA, 2007

25.90%22.80%

14.50%

21.30%23.00%20.30%

56.10%50.80%

33.80%30.60%28.10%

13.70%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Bangladesh India Nepal Sri Lanka

Condom use with non-commercial partner Condom use with Sex worker

Condom use with regular partner

Sexual risk behaviour of Sexual risk behaviour of IDUs – South AsiaIDUs – South Asia

69.50%

44.80%

75.30%

43.10%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Bangladesh India Nepal Sri Lanka

Drug alcohol use before last comercial sex

UNODC ROSA, 2007

IDU related interventions in IDU related interventions in South AsiaSouth Asia

InterventionIntervention BhutanBhutan BangladeBangladeshsh

IndiaIndia NepalNepal PakistanPakistan Sri LankaSri Lanka

Community Community outreachoutreach √√ √√ √√ √√ √√ √√

Needle Needle syringe syringe exchangeexchange

√√ √√ √√ √√

Opioid Opioid substitutionsubstitution √√ √√

ConventionConventional drug use al drug use treatmenttreatment

√√ √√ √√ √√ √√ √√

Coverage of IDUs with Coverage of IDUs with effective approaches in effective approaches in

South AsiaSouth AsiaCountryCountry CoverageCoverage

BangladeshBangladesh Coverage primarily by NGOs – Coverage primarily by NGOs – Care Bangladesh and other NGOsCare Bangladesh and other NGOs

BhutanBhutan No significant implementation of No significant implementation of effective approacheseffective approaches

IndiaIndia Project Network; Emmanuel Project Network; Emmanuel Hospital Association and SPYM’s Hospital Association and SPYM’s networknetwork

Targeted interventions of SACSTargeted interventions of SACS

NepalNepal NGO driven harm reduction NGO driven harm reduction projectsprojects

PakistanPakistan NGO driven harm reduction NGO driven harm reduction projects – Nai Zindagiprojects – Nai Zindagi

Sri LankaSri Lanka No significant implementation of No significant implementation of harm reduction projectsharm reduction projects

Scaling-up interventions in one yearScaling-up interventions in one year

DFID PMO Harm Reduction ProjectsDFID PMO Harm Reduction Projects

Delivery throughDelivery throughNetworksNetworks

Engagement of ‘peers’Engagement of ‘peers’Liaison with SACSLiaison with SACS

Comprehensive services and continuum of Comprehensive services and continuum of servicesservices

Clients referred to different services Clients referred to different services through Peer Led Interventions – SPYM, through Peer Led Interventions – SPYM,

IndiaIndia

1141

8764

6665

23633107

5299

3924

0

5000

10000

Referral Services

VCTC PPTCT Drug use treatment Primary health centre

STI treatment DOTS Abscess management To targeted interventions

Number of drug users / injecting drug user contacted through PLI - 67314

Comprehensive Services through Comprehensive Services through DICs – Project NetworkDICs – Project Network

26602060

3990

5094

935122

14861

0

2000

4000

6000

8000

10000

12000

14000

16000

North East Northeast Central andMaharastra

South Goa Total

NSEP Drug use treatment Other inteventions Total

Key issues in coverageKey issues in coverageKey issueKey issue BhutanBhutan BangladeshBangladesh IndiaIndia NepalNepal PakistanPakistan Sri LankaSri Lanka

PolicyPolicy xx xx xx xx xx xx

Intervention Intervention in placein place

xx √√ √√ √√ √√ xx

Coverage of Coverage of IDUsIDUs

-- Good in certain Good in certain places like places like DhakaDhaka

Example Example through DfID through DfID projects projects

InadequateInadequate Good practice Good practice but but sustainability sustainability threatenedthreatened

--

Special Special populationspopulations

-- Attempts to Attempts to reach women reach women drug users and drug users and partners of partners of IDUsIDUs

Attempts to Attempts to reach women reach women drug users drug users and partners and partners of IDUsof IDUs

Attempts to Attempts to reach women reach women drug users drug users and partners and partners of IDUsof IDUs

NKNK Attempts to Attempts to reach reach partners of partners of DUsDUs

Key issues in coverageKey issues in coverage

Key issueKey issue BhutanBhutan BangladeshBangladesh IndiaIndia NepalNepal PakistanPakistan Sri LankaSri Lanka

Human Human resourcesresources -- **** **** **** **** **

ProtocolsProtocols

√√

NGO NGO involvementinvolvement ****** ****** ****** ****** **

IDU IDU engagementengagement ****** ****** ****** ****** **

Major gaps in coverage of Major gaps in coverage of IDUs in South AsiaIDUs in South Asia

Lack of coordinated response to drug use related Lack of coordinated response to drug use related problemsproblems

NGO supported initiatives onlyNGO supported initiatives only

Lack of continued support to ongoing harm reduction Lack of continued support to ongoing harm reduction projects projects

Opioid substitution treatment coverage low in the Opioid substitution treatment coverage low in the region region

Next stepsNext steps

Policy briefsPolicy briefs

Coordinated efforts between different MinistriesCoordinated efforts between different Ministries

Government – NGO partnershipsGovernment – NGO partnerships

Scaled-up implementation of essential harm reduction Scaled-up implementation of essential harm reduction componentscomponents Operational guidelines Operational guidelines Standard protocols Standard protocols Continued support for harm reduction Continued support for harm reduction Expansion of services to women drug users, prisoners and other hidden Expansion of services to women drug users, prisoners and other hidden

groupsgroups

AcknowledgementsAcknowledgements

DFID PMO ProjectsDFID PMO Projects Emmanuel Hospital AssociationEmmanuel Hospital Association Project Network – SHARAN IndiaProject Network – SHARAN India SPYMSPYM

UNODC ROSAUNODC ROSA H-13 Project RSRAH-13 Project RSRA