Panos AIDS Information Information Sheet No. 21, May 1998

Up to 10% of all HIV infections worldwide are contracted from contaminated needles or other injecting equipment, according to UNAIDS. The great majority of such infections are associated with intravenous, and generally illegal, drug use.

Of the one hundred countries who report the injecting of usually illegal drugs for recreational purposes, eighty report associated incidences or epidemics of HIV infection. Globally, 22% of the world's HIV/AIDS population inject drugs. A wide range of substances can be injected including cocaine, amphetamines, tranquillisers, barbiturates as well as a variety of pharmaceutically produced opiates of which heroin is the most common and well known.

Sharing a syringe or needle with someone infected with HIV to inject substances into your own blood stream is a more efficient way of contracting the virus than almost any other. Sex provides another link between drug use and HIV infection. In one survey of 13 major cities, the vast majority of injecting drug users with regular partners reported never using condoms. Because intravenous drug users do not only have sex with other such drug users, they can often form an essential "bridgehead" for HIV to spread to a more general population.

An engine for the spread of HIV in America and Europe

In some areas of the world, intravenous drug use has been the main engine for the spread of HIV. In North America it accounted for at least 25% of the AIDS cases up until 1994 and represented the second largest risk category for AIDS. The US National Institute on drug abuse conservatively estimated in 1990 that over 700,000 people in the US currently injected drugs and that over 3.33 million people have injected at some point in their lives.

In Eastern Europe, injecting drug use is the prime driving force in the spread of HIV. The number of drug users has escalated in just a few years, especially in Russia. Vladimir Yegorov, the leading drugs expert at the Russian Ministry of Health, estimates that there are between 500,000 and 700,000 injecting drug addicts nationwide - ten times higher than the 1995 estimate of 64,000 addicts and over twenty times higher than in 1990. "Two or three years ago, we had one drug user for every ten kids with a drinking problem", says Pyotr Belaskov, a doctor in a narcotics treatment centres in Moscow. "Now it's the other way round."

As the number of addicts has risen, so too has the number of people living with HIV, the virus which causes AIDS. In 1995 1,542 people in Russia were known to be HIV-positive; just 3 of these had contracted the virus through drug injection. By the end of 1997, the great majority - 62% - of the 4,500 reported cases of HIV infection were drug users. Similarly in the Ukraine HIV prevalence among injecting drug users rose from 1.4% - 13% in just eight months in 1995.

In Europe too injecting drug use has been one of the main routes of transmission. Between 1991 and 1994 AIDS cases due to injecting drug use increased by 52%.

An essential catalyst for spread of HIV in Asia

While in Europe and North America, injecting drug use has been a major component of a limited AIDS epidemic, in Asia - especially South East Asia - injecting drug use provided the essential catalyst for a much larger epidemic. HIV is firmly established among injecting drug users in Cambodia, Myanmar and Thailand. In Malaysia and Vietnam more than three out of every four HIV infections are attributed to intravenous drug use.

Drug injecting in Asia only began in the 1980's. Injecting drug use was first detected in Bangkok in 1987 and spread to the north and along the border between southern Thailand and Northern Malaysia. By 1989 HIV infection from injecting drug use was identified in Myanmar, the Yunnan province of China, Manipur state of India and in Singapore in 1990. The South East Asian experience shows just how quickly HIV can spread through populations of drug users - the proportion of injecting drug users with HIV was 1% in Bangkok, Thailand in 1988 and 30% nine months later; at several sites in Myanmar in 1989 it was 17% and by 1993 it was over 80%, and in Manipur in India it was zero in 1989 and 50% in 1990. In Thailand, about 45,000 new illicit drug consumers are reported each year, most of whom are between 20 and 35 years old.

Patterns of infection in East, South and South East Asia are influenced by their proximity to what is known as the 'Golden Triangle' which is an area of heroin production located at the border between the Peoples Democratic Republic of Lao, Myanmar and Thailand and to its distribution routes.

Another major heroin producing region is known as the 'Golden Crescent' which is where Pakistan's north west frontier meets the Badakhshan area of Afghanistan and the Baluchistan area of Iran, although there is little evidence so far of HIV prevalence in these areas, it remains a danger. In Pakistan, one 1995 survey estimated that HIV among drug users on Lahore was 12% and a 1993 Pakistan government survey estimated there were 3 million drug abusers in Pakistan, of whom 51% were taking heroin.

Could drugs be a problem in Africa?

Experience from Asia and East Europe shows that drug use can become established very rapidly and can lead to major HIV epidemics. Although there is very limited evidence of injecting drug use in Africa, experts have recently warned that the threat of a rise in such drug use on the continent is real. "Many [sub-Saharan African] cities are trafficking routes for cannabis, heroin, cocaine and other psychotropic substances", argued a recent study documenting injecting drug use in Africa. "Trends in drug misuse in sub-Saharan Africa indicated the potential diffusion of injecting drug use with major and severe implications for the future transmission of HIV and other blood-borne diseases", said the report. Another study found that drug injecting had been reported in C|te d'Ivoire, Nigeria, Gabon, Ghana, Mauritius, Senegal, South Africa, Tanzania, Uganda and Zambia.

While there is no evidence linking the current terrible HIV epidemic in Africa with injecting drug use, experts warn that the spread of injecting drug use, followed by a very rapid increase in HIV, can happen in just a few years, as happened in South East Asia in the late 1980s. At the same time, groups most vulnerable to HIV infection in Africa - such as truck drivers, commercial sex workers, unemployed young people, people in the military - are also those groups most likely to start injecting drugs if and when they become available.

If proximity to drug trading routes is a risk factor for increasing drug abuse then Africa may be vulnerable. A major route between Asia, Europe and North America runs through Nigeria. Nigeria has a growing consumption of heroin, although little evidence of injecting as yet, although this may change. Efforts to stop the trade has shifted the route to C|te d'Ivoire, Zambia and Zimbabwe. Some reports of poppy growing have emerged from Benin and Cameroon. Injecting drug behaviour may be a great danger especially in countries where HIV/AIDS is already widespread such as Zimbabwe and Zambia. Not least due to the likelihood that due to lack of syringes any that are available might be used many times among many people.

South America - intravenous drug use a leading factor in HIV transmission

Injecting drug use is one of the main routes of transmission of HIV in South America. In the Caribbean and Central America injecting drug use has been reported on a comparatively small scale.

As many as half of certain groups of drug users in Argentina and Brazil are HIV positive. The south western Brazilian state Mato Grosso do Sul (which lies on a cocaine smuggling route) had a five fold increase in AIDS cases between 1987 and 1991 largely attributable to fast increasing levels of injecting drug use.

In South America local cocaine production has lead to serious local cocaine problems with some injecting. In Brazil this has been linked with HIV. Injection may well become more widespread.

Reducing HIV spread among drug users

There are many examples of attempts to minimise the transmission of HIV among drug users. Thailand has established programmes among IV drug using communities which entail "peer group" counselling sessions for those who attend as well as outreach programmes. The programmes advise on how to clean syringes safely and affordably with bleach and they hand out condoms. The programmes give a range of treatments from detoxification to encouraging smoking rather than injecting, to promoting cleaning and not sharing needles. Success is difficult to measure but HIV rates have stabilised at around 40%. The programme did have problems with peer educators - they trained several hundred but found the drop out rate to be 50% with many returning to drug taking.

Such treatment programmes alone do not provide an effective way of controlling HIV among injecting drug users. Many will continue with risky behaviour (i.e. sharing needles, using unclean equipment) unless they are provided with the means to change (i.e. provided with access to sterile equipment or bleach). Safe injecting can be very expensive and sterile equipment difficult to obtain which is part of the reason why such drug users share equipment. This is especially the case in developing countries where getting sterile needles for legitimate medical needs is often a problem and even access to bleach may be difficult. This is a problem in Myanmar, for example, where many addicts go to a professional injector who injects one person after another with a needle attached to some tubing or an eyedropper. In Ho Chi Minh City in Vietnam there are similar establishments known as 'shooting booths'. In Manipur in north east India 97% of injectors share equipment. Often the possession of a syringe can lead to arrest which is a further disincentive to safe practices.

Needle exchange programmes - encouraging drug use or an essential step to containing HIV?

Many AIDS and drug control organisations advocate removing legal barriers to the buying and carrying of sterile equipment. In April 1998, the US Clinton administration endorsed the principle of giving clean needles to drug addicts in order to reduce transmission of HIV. "A meticulous scientific review has now proven that needle-exchange programs can reduce the transmission of HIV and save lives without losing ground on the battle against illegal drugs", announced the US Secretary of Health, Donna Shalala.

The issue has aroused intense controversy in the US, with other members of the US administration arguing against sanctioning such programmes fearing that they can encourage drug use. A recent delegation from the office of the US government's "drug czar", General Barry McCaffrey, on the Canadian city of Vancouver argued that although more than 2.5 million clear needles were given out in 1997, the death rate from illegal drugs had rocketed. "Vancouver is literally swamped with drugs", the delegation reported. "With an at-risk population, without access to drug treatment, needle exchange appears to be nothing more than a facilitator for drug use".

Despite such concerns, AIDS organisations in the US have enthusiastically welcomed the governments endorsement. "The Administration has put science and principle ahead of politics to save lives with Secretary Shalala's determination on needle exchange", said Dr Mathilde Krim, chairman of the Board of the American Foundation for AIDS Research (AmFAR). "AmFAR funded research showed that needle exchange reduces HIV infection by two thirds among injection drug users within three years and does not increase drug use", she added.

Such programmes have provoked similar controversy in almost every country in which they have been introduced, and many authorities have refused to allow them. Certainly, not all such programmes have been successful, as the Vancouver situation would suggest. There are also reasons other than poverty or a lack of information which lead intravenous drug users to share needles and syringes - in some places, for example, sharing equipment is part of the culture of drug addiction. And few programmes can be expected to work in isolation from other HIV/AIDS prevention actions, such as providing access to condoms.

Most of the evidence nevertheless seems to suggest that needle exchange programmes do not encourage drug use and can be successful in reducing HIV infection, in some cases dramatically. In Bangkok, 90% of injecting drug users surveyed under one such programme reported changing their behaviour in order to reduce their risk of HIV, with 80% saying they were obtaining sterile equipment instead of sharing. HIV prevalence then stabilised at 40% - about half the level reached in neighbouring countries where syringes and information were less available. A recent study compared HIV among IV drug users in 81 cities in North America, Europe, Asia and the South Pacific. In the 52 cities without needle exchange programmes HIV increased 5.9% per year on average while it declined by 5.8% in the 29 cities that had such programmes. A needle exchange programme launched in Nepal in 1992 has helped to hold prevalence among Kathmandu's 1,500 IV drug users at less than 2% at the same time that HIV has soared in other Asian countries along the drug trade routes.

Two evaluations covering six industrialised countries failed to find any evidence that numbers of injecting drug users rose, or that the number of improperly discarded needles rose. Most studies show that when injecting drug users are given information and access to sterile equipment through needle exchange programmes for example they do adopt safer practices.

Copyright (c) 1998 - PANOS. Reproduced with permission. Reproduction of this article (other than one copy for personal reference) must be cleared through the Permissions Desk, PANOS, panoslondon@gn.apc.org.
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