June, 2004

Prevention and Control of HIV/AIDS among Injection Drug Users in Pakistan: a great challenge

  S. A. Shah  ( Enhanced HIV/AIDS Control Program, Government of Sindh ,Karachi. )
A. Altaf  ( Department of Community Health Sciences, Aga Khan University, Karachi. )

According to the national survey on drug abuse in 1993 there were about three million drug users in the country representing 2.3% of the total population of Pakistan.1 With estimated annual growth rate of 6.4%, total number of drug abusers in the country in 2004 could be estimated to almost five million. The 1993 study also estimated that 51% drug abusers were taking this narcotic product, the most common drug abused in the country and 93% heroin abusers were believed to take heroin either by filling in cigarettes or by inhalation. At that time only 1.8% heroin addicts (mainly in Karachi) administered heroin in the form of injections.1 However, according to the results of National Assessment Study on Drug Abuse Situation in Pakistan, conducted in year 2000 it was estimated that about 60,000 drug addicts were using drugs through injections. Studies conducted in 2002 with drug addicts at two different localities of Karachi suggest 80-100% addicts are using heroin via injections.2,3 There is an increasing shift from inhalation to injection drug use (IDU) among addicts. Possible reason for shifting to injection drug use could be one or some of the contributing factors: 1.Change in heroin quality - heroin currently available in the market cannot be used through inhalation and can only be used via injection 2. Limited availability of heroin (cost effectiveness) 3. Return of Pakistanis from other countries where they have been introduced to injections and where injecting drug use is more common 4. Use of psychotropics The Challenge ahead Research studies conducted around the world clearly suggest that IDUs are at increased risk of acquiring and transmitting blood borne infections including HIV/AIDS. More over, injection drug use is a very efficient mode of transmission of HIV and has provoked "kick start" to generalized HIV epidemic in some parts of the world such as Manipur, India.4 Cross sectional studies2,3 conducted among IDUs in Karachi documented high risk behaviors such as: · Sharing of syringes
· Shooting drugs in groups (80%)
· High prevalence of HCV (86%-94%)
· High prevalence of syphilis (13-16%)
· Low use of condom (15%)
· Commercial blood donation (19-31%)
· Indulging in commercial sex (20-30%)            The first reported outbreak of HIV infection in Pakistan happened in Larkana, a small town of Sindh province. Nineteen injection drug users (IDUs) were positive for HIV infection.5 Continued surveillance by the Provincial AIDS Control Program suggest that this number has increased to 45 (up to February 2004).             Soon after the Larkana outbreak, HIV surveillance in other cities of Sindh, Karachi, Hyderabad and Sukkur showed very low prevalence of HIV. However, from January 2004 to 30th April 2004 about 65 IDUs have been tested HIV positive out of a total of 930. These 930 IDUs are registered clients at Drop in Centers (DICs) which are established under the harm reduction program with assistance of DfID (Department for International Development, British Government) and are receiving service package to reduce their vulnerability for HIV infection. These services include syringe exchange, peer education, counseling, condoms, antiseptic dressing on wounds and abscesses, syndromic management of sexually transmitted infections and primary health care. Other social services such as bathing, tea, clothes and a sitting place to relax are also provided at the DICs.             In spite of comprehensive harm reduction program, there has been hardly any statistically significant change in risky behavior of IDUs revealed through research studies conducted to assess impact of harm reduction program.2,3 Although at the time of one of the study only one IDU tested positive for HIV infection2 but from January 2004 IDUs have started testing positive for HIV infection. These are at least one year old registered clients of DIC under the harm reduction program. Monitoring reports of funding agencies (DfID and UNODC) providing support to these DICs show satisfaction over quality of services provided to IDUs at these centers. Above mentioned facts indicate that harm reduction program is not producing the desired results in terms of preventing HIV/AIDS among this high risk group. The issue has been carefully and meticulously discussed with service provides, NGOs and other public health specialists and the consensus is that in the absence of comprehensive rehabilitation program for IDUs including provision of economic opportunities (skilled or unskilled jobs) and a high relapses rate harm reduction programs will not achieve the objectives (prevention of HIV/AIDS among this high risk group). How to Face the Challenge Coordinated collaborative efforts by all stake holders including Provincial and Federal Government, Civil Society, Anti Narcotic Force, UN Agencies, donors and media are crucial to face this challenge. Drug abuse is not just a health problem but it is a serious social issue which has consequences beyond health and emergence of HIV/AIDS has not only compounded this problem but has provided new dimensions to this old issue. We recommend consolidated collaboration on this national problem to develop comprehensive and sustainable interventions.
1. National Survey on Drug Abuse in Pakistan; Pakistan Narcotics Control Board. Islamabad, 1986; Summary; pp(iii).
2 Altaf A, Shah SA, Memon A. Follow up study to assess and evaluate knowledge, attitude and high risk behaviors and prevalence of HIV, HBV, HCV and Syphilis among IDUs at Burns Road DIC, Karachi. 2003; External report submitted to UNODC.
3 Ghauri AK, Shah SA, Memon A. Follow up study to evaluate change in KABP and Sero-prevalence of HIV, HBV, HCV and Syphilis among IDUs at DIC, Essa Nagri,Karachi. 2003; External report submitted to UNODC.
4 Eicher AD, Crofts N, Benjamin S, et al. A certain fate: spread of HIV among young injecting drug users in Manipur, north-east India. AIDS Care 2000;12:497-504.
5. Shah SA, Altaf A, Mujeeb SA, et al. An outbreak of HIV infection among injection drug users in a small town in Pakistan: potential for national implications. Int J STD AIDS 2004;5:209.

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