Injecting drug use in India and the need for policy and program change

Finding a way forward with the community: qualitative inquiry in the generalized HIV epidemic in Mizoram, India

Introduction

Mizoram, the northeastern State of India bordering Myanmar, is presently witnessing a burgeoning generalized HIV epidemic along with the highest State-level HIV prevalence among female sex workers (FSWs, 24.7%) and people who inject drugs (PWID,19.8%) in the country. The present study was conducted against such background to understand the current situation of HIV prevention and care services in Mizoram, and capture community voices as well as concerns so that the way forward could be informed appropriately.

Methods

The study period was October through December 2020 (in the midst of COVID-restrictions) in the districts of Aizawl, Mamit, Kolasib, Lunglei, and Champhai where HIV prevalence crossed 1% among ante-natal clinic (ANC) attending women. Contrastingly, the national average HIV prevalence among ANC attendees is 0.24%, which formed the basis for selecting the aforementioned five high burden districts for this current inquiry. In-depth-interviews were conducted with community members and youth leaders, vulnerable and general population groups as well as HIV-program officials. Interviews were recorded, transcribed, translated and later coded for analysis following thematic approach.

Results

The emerging issues were grouped in three thematic layers; (1) HIV vulnerability, (2) challenges pertaining to prevention and care services, and (3) program elements and future roadmap. Discrimination at the community level, unfriendly behavior of some of the HIV-service staff, occasional interruption in supplies of anti-retroviral treatment and sterile syringes and needles were voiced as deterrents to accessing HIV prevention and care services by the participants. Community engagement, based on restorative approach rather than retribution and ensuring enhanced performance of the district AIDS program control units emerged as necessary programmatic elements.

Conclusion

This inquiry highlighted macro-social and structural forces contributing to stigma and discrimination toward people at risk of HIV. It is urgent that HIV-services are re-aligned through de-centralized district level innovations and creation of safer spaces at the physical, societal and familial level. These, even during the time of stress such as a pandemic, would help health services to remain resilient. HIV outreach, sensitization of the community leaders and health-care professionals through strategic communication and ownership of the communities in these endeavors appeared paramount.

Addiction habits in a rural cohort of injection drug users and effects on serum lipid profile: Analysis of a repeated measures study from an eastern state of India

Background Injecting drug use (IDU) is associated with several cardiometabolic risks. We aimed to measure the independent effects of IDU behaviour and related factors on serum lipid profile among people who inject drugs (PWIDs). Methods We did a longitudinal study with six follow-up measurements at an interval of 2 months among 104 PWIDs from 11 selected hotspots under two blocks in West Bengal, India. Generalized estimating equations with robust standard errors analysed the effect of addiction habits on lipid profile parameters. Results The mean (SD) age of the participants was 27.6 (5.24) years, 36.5% married and 44.3% were unemployed at the time of recruitment. At the baseline, the mean (SD) body mass index (BMI) and fasting blood sugar (FBS) were 20.0 (1.82) kg/m2 and 112.0 (15.90) mg/dl, respectively. The mean duration of drug use was 2.5 (1.20) years. While 62.5% had normal triglyceride (TG), 14.4% had high total cholesterol (TC) and 69.2% had dyslipidaemia at the baseline. Adjusted for age, BMI, FBS and other addiction-related variables, models showed that longer duration of drug use (>3 years) resulted in higher levels of TG, higher TC-to-high-density lipoprotein ratio and dyslipidaemia. Tobacco use and high FBS level were also risk factors for dyslipidaemia. Conclusions Higher duration of IDU, tobacco use and higher FBS were associated with deranged lipid profile among PWIDs.

P, Kumar P, Rajan S, Arumugam E. Spatial heterogeneity of risk factors associated with HIV prevalence among men who inject drugs in India: An analysis of the data from the integrated bio-behavioral surveillance, India

People who inject drugs (PWID) are India's third-largest vulnerable population to human immunodeficiency virus (HIV) infection. PWID in India are confined to certain geographic locations and exhibit varying injecting and sexual risk behaviors, contributing considerably to increasing HIV trends in specific regions. Spatial heterogeneity in risk factors among vulnerable PWID influences HIV prevalence, transmission dynamics, and disease management. Stratified analysis of HIV prevalence based on risk behaviors and geographic locations of PWID will be instrumental in strategic interventions. To stratify the male PWID based on their risk behaviors in each state and determine the HIV prevalence for each stratum. The behavioral data and HIV prevalence of the national integrated biological and behavioural surveillance (IBBS), a nationwide cross-sectional community-based study conducted in 2014 to 2015, was analyzed. Data from 19,902 men who inject drugs across 53 domains in 29 states of India were included. Women who inject drugs were excluded at the time of IBBS, and hence PWID in this study refers to only men who inject drugs. PWID were categorized based on their risk profile, and the corresponding HIV prevalence for each state was determined. HIV prevalence was the highest (29.6%) in Uttar Pradesh, with a high prevalence of risk behaviors among PWID. High HIV prevalence ranging between 12.1% and 22.4% was observed in a few states in East and North-East India and most states in central and North India. Unsafe injecting and sexual practices were significantly (P < .05) associated with higher HIV prevalence and more significantly in National Capital Territory of Delhi (P < .001). Unsafe injecting practices among PWID were proportionally higher in Western and Central India, whereas unsafe sexual behaviors were widespread among most states. Unsafe sexual practices among male PWID were common. The high prevalence of unsafe injecting had significant HIV infection and transmission risks in Western and Central India. The results emphasize the need for stratified, region-specific interventions and combination approaches for harm reduction among PWID. Strengthening the measures that facilitate the reduction of high-risk behaviors, adoption of safe practices, and utilization of HIV services will positively impact HIV prevention measures among PWID.

HIV epidemic in Mizoram, India: A rapid review to inform future responses

Background & objectives

Mizoram, a northeastern State of India bordering Myanmar, is home to several tribal clans under the ethnic group Mizo: Renthelei, Ralte, Paite, Lai, Hmar, Lusei, Mara, Thado and Kuki. Mizos also reside in the neighbouring northeastern States of Tripura, Assam, Manipur and Nagaland. The majority of Mizo people outside India live across the border in the neighbouring Chin State and Sagaing Region of Myanmar. Over the last decade, Mizoram witnessed a concerning level of rise in HIV prevalence among the general population. The present rapid review was conducted to identify various interventions that could help curb this rising trend.

Methods

An electronic search strategy with broad domains of 'HIV/AIDS', 'key population', 'community engagement' and 'interventions in Mizoram' using PubMed, Embase and Cochrane was adopted; grey literature were also accessed. Evidence, thus gleaned, were synthesized.

Results

Twenty eight resource materials comprising articles, reports and dissertations contributed to the current review. Changing tribal social support structure, early initiation of drugs, sexual debut at an early age and drug-sex interface were identified as factors associated with the progression of HIV epidemic in the State. Issues pertaining to the migration of people across the borders and easy access to drugs continue to be of concern. Churches and youth leaders have a strong influence on the society, at times even constraining access of key population groups to HIV prevention and care services. Tackling stigma and discrimination, ensuring uninterrupted HIV services and creation of an enabling environment in this context seems urgently needed. Incarcerated people in the State have been found with a high level of HIV infection and their linkages with prevention and care services need strengthening.

Interpretation & conclusions

This review underscores the importance of drawing upon successful intervention examples from the past such as 'Friends on Friday' and Red Ribbon Clubs. Active engagement of community-based organizations in programme planning, implementation and monitoring is essential. Establishment of harm reduction interventions for general and key populations paired with strategic communication appear to be the need of the hour.

Defining “High-risk Sexual Behavior” in the Context of Substance Use

Introduction: Sexual behavior is a behavior exhibited by individuals to gratify one of their basic needs, that is the sexual need. Often the way in which sexual behavior is practiced may lead to negative consequences. However, the definition of a sexual behavior as risky varies with regards to culture, gender, age, and the threshold.

Objectives: This review aims to study different definitions of high-risk sexual behavior available in literature, the differences in the prevalence of various risks associated with risky sex in substance-using population as compared to general population, and eventually formulating a tentative definition of “high-risk sexual behavior” in the context of substance use. Current evidence and results of literature search as we have entered into the epidemic of human immunodeficiency virus globally, it is important clinically as well as from the public health perspective to define high-risk sexual behavior discretely helping the researchers quantify the burden and the clinicians focus on the population at risk. High-risk sexual behavior has often been discussed and studied in various studies till date. However, literature lacks a discrete definition of high-risk sexual behavior. Risky sex (or high-risk sexual behavior) has been variably defined in different studies. Majority of the definitions in the studies focus on sexually transmitted infection, especially human immunodeficiency virus. A few studies talk about unintended pregnancies or abortions.

Conclusion: The association between high-risk sexual behavior and substance use has been well established. Further research is warranted to obtain a definition which has greater precision and clinical utility, and which can be integrated in preventive and promotive pursuits.

Unsafe injecting practices, sexual risk behaviours and determinants of HIV among men who inject drugs: Results from Integrated Biological and Behavioural Surveillance in India

In India, while an overall reduction in HIV is achieved among most key populations, the continued higher prevalence among people who inject drugs (PWIDs) is an area of concern. This paper analyses unsafe injecting and sexual risk behaviours in male PWIDs according to HIV status and also examines the determinants of HIV infection in this high-risk group. Data from India's Integrated Biological and Behavioural Surveillance, conducted across 29 Indian states and Union Territories among 19,902 male PWIDs, were used. Informed consent was obtained and men aged 15 years or more, who used psychotropic substances or drugs in the past three months for non-medical reasons were recruited for the survey. Results from the multivariable analysis suggest that drug use debut at age 25 years or above (adjusted odds ratio [AOR]: 1.41, confidence interval [CI]: 1.05-1.88), engagement in drug use for a longer duration (AOR: 1.81, CI: 1.32-2.48), injecting three times or more per day (AOR: 1.53, CI: 1.1-2.12), sharing of needle/syringes (AOR: 1.34, CI: 1.02-1.76), self-reported sexually transmitted infections (AOR: 1.55, CI: 1.12-2.14) and higher self-risk perception for exposure to HIV (AOR: 2.08, CI: 1.58-2.75) increase the likelihood of HIV infection. Sustained higher prevalence, unsafe injecting and risky sexual practices are major challenges which may prevent India from reaching the 'end of AIDS' by 2030. This underscores the need for adoption of a tailored, evidence-driven HIV prevention approach that adequately addresses local needs to limit the spread of HIV within this population, and thereby prevents the onward transmission of HIV to the general population.

Drug resistance in malaria, tuberculosis, and HIV in South East Asia: biology, programme, and policy considerations

Malaria, tuberculosis, and HIV present unique challenges in the control of antimicrobial resistance, and require targeted policies, say Samiran Panda and colleagues