Drug Injection and HIV/AIDS in Asia

MAP Report 2005

Drug injection is a strong driver of HIV The purpose of this booklet is twofold: also describes how those points should infection in Asia, notably parts of 1. to summarize what researchers have inform HIV prevention strategies. China, Indonesia and Vietnam, where learned about the epidemiology of the steepest recent rises in HIV infec- HIV/AIDS within Asian IDU networks; This is one of a series of three tions are seen among injecting drug and, programming-themed booklets based users (IDUs). HIV prevalence rates in 2. to discuss the programmatic impli- on AIDS in Asia: Face the Facts. The some IDU populations are extremely cations of those findings. other two are MAP Report 2005: Male- high, and the sexual behaviour of IDUs Male Sex and HIV/AIDS in Asia and MAP can provide a gateway for HIV to The central epidemiological issues Report 2005: Sex Work and HIV/AIDS in spread among non-injectors. were presented in detail in AIDS in Asia: Asia. Taken together, they provide Face the Facts, a report issued by the insight into how to respond to the It is essential for HIV prevention inter- Monitoring the AIDS Pandemic (MAP) behaviours driving the spread of HIV in ventions to take into account the Network in 2004. This publication Asia’s most at-risk populations. complexity of the relationship between follows up by highlighting points that drug injection and HIV transmission. relate specifically to drug injection. It Acknowledgments he members of the Monitoring the AIDS Pandemic Network (The TMAP Network), the grouping responsible for this report, are listed in Appendix 1. The MAP Network would like to thank several people who are not currently network members but who have contributed actively to this report. These people include: Jeanine Bardon, Myat Htoo Razak, Parvez Sazzad Mallick, Elizabeth Pisani, Kelly Safreed Harmon, Ganrawi Winitdhama, and Nigoon Jitthai. The MAP Network would also like to thank the governments of Asia and their development partners for generously sharing national HIV and behavioural surveillance data for this report. A number of institutions support the MAP Network ﬁnancially, including contributors to the preparation and printing of this report. They include: UNAIDS; WHO; and the Japanese Foundation for AIDS Prevention and, Ministry of Health, Labor and Welfare, Japan. Their support does not imply that they endorse the contents of this report. The text and graphics of the report are based on AIDS in Asia: Face the Facts, a report issued by the Monitoring the AIDS Pandemic (MAP) Network in 2004, prepared by Elizabeth Pisani and Tim Brown. Drug Injection and HIV/AIDS in Asia

The Map Reports 2005 Drug Injection and HIV/AIDS in Asia 1 Contents

Drug injection and AIDS in Asia: a summary 3 1. Introduction 4 2. How injecting drug use fuels Asian AIDS epidemics 6 A. Sharing of injecting equipment 6 Why high viraemia equals high risk of HIV infection 6 The knowledge-behavior disconnect 7 B. The sexual behaviour of injecting drug users 8 Selling sex to buy drugs: a lethal combination 8 The other side of the coin: drug injectors buying sex 9 C. Conﬁnement and incarceration 10 D. The relationship between HIV and other problems facing IDUs 10 3. From research to practice: translating the evidence into strategies for reducing HIV transmission in IDU networks 11 A. Changing behaviour around the sharing of injecting equipment 11 B. Preventing sexual transmission of HIV in IDU networks 12 C. Meeting the needs of IDUs in jails, prisons and other conﬁned settings 12 D. HIV prevention in the context of other problems facing IDUs 13 4. Protecting IDUs and other community members from HIV/AIDS by engaging them in prevention and care efforts 15 Appendix 1: Members of the Monitoring the AIDS Pandemic Network 16 Appendix 2: Sources used in this report 17

Notes about sources Because this document refers to data with great frequency, the sourcing of each individual data point cited would be impractical. The sources for surveillance data are consolidated in a list in Appendix 2. Any data point that is not individually sourced, or that is sourced to “national surveillance records” or “behavioural surveillance,” comes from the sources on that list. Data from stand-alone studies rather than from repeated surveillance efforts are individually referenced in endnotes that appear in Appendix 2. Sources for all ﬁgures are provided in Appendix 2.

2 Drug Injection and HIV/AIDS in Asia The Map Reports 2005 Drug injection and HIV/AIDS in Asia: a summary

Sharing injecting equipment is a very efficient way immediately obvious risks posed by HIV may of passing on HIV. Because of this, HIV prevalence seem less significant to them. Ensuring can rise rapidly among IDUs who share needles adequately scaled programmes to help drug users and syringes. In many Asian settings, needle and get off of and stay off of drugs is an important syringe sharing are very common. This clearly HIV prevention and care strategy in Asia. contributes to the very high levels of HIV in some Treatment and detoxification programmes for IDU populations. Even where the numbers of IDUs could be expanded and better utilized people injecting drugs are relatively small, their as settings for providing HIV prevention contribution to the overall HIV epidemic in a interventions, as well as medical care and country can be considerable. This is because IDUs treatment. Prisons are also settings where more may also pass on HIV infection sexually, creating a could be done regarding HIV prevention and “critical mass” of infections within sexual networks. care for IDUs. In a number of Asian countries, HIV From there, HIV can spread out more widely. prevalence among IDUs is already high. Hence, the provision of HIV treatment and prevention Major areas of concern that should guide HIV services to HIV-positive drug users is essential for prevention strategies targeting IDU networks effective national responses. include: (1) the sharing of injecting equipment; (2) the sexual behaviour of IDUs; (3) the confinement The major risk behaviours for HIV in Asia, injecting and incarceration of IDUs; and, (4) the relationship drug use, the buying and selling of sex and male- between HIV and other issues facing IDUs. male sex, are by no means mutually exclusive. In every Asian country where data are collected, drug All the scientific evidence suggests that large- injectors report more sexual activity, including scale programmes providing substitutes for sex between men, than other population groups, injected drugs and increasing access to clean and much of that sex is commercial, both bought needles and syringes will reduce new HIV infections and sold. Reducing risky sex among drug users among injectors. While these programmes often is a critical component of effective national HIV remain controversial politically, there are now programmes. good examples to suggest that they can be effective in Asian settings. For example, there was Modelling shows that in situations where HIV has a dramatic decrease in needle-sharing among remained low for years despite low condom use, IDUs when a needle and syringe exchange a sharp rise in HIV infection among drug injectors programme was started in Bangladesh. However, could “kick-start” an HIV epidemic that may in the vast majority of settings, programmes are otherwise have taken many decades to develop. not at a large enough scale to slow the spread of This is why it is essential to provide prevention the HIV/AIDS epidemic. Furthermore, access to services to IDUs before drug use-related HIV clean needles and syringes is often not enough, transmission begins to increase. for example, in several countries, injectors say Reducing HIV transmission in IDU networks that the real problem is being subjected to fines, will require stronger collaborations among arrest and imprisonment. If a country is serious communities, health workers, law enforcement about tackling HIV among IDUs, it must ensure workers, decision makers and drug users. All that drug users can safely access and utilize HIV stakeholders should be encouraged to recognize risk reduction services. that drug use-related HIV/AIDS is a global Another formidable obstacle to reducing HIV challenge requiring everyone to work together on transmission among IDUs is the presence of the same goal—reducing the impact of the HIV/ competing risks in their lives. Many drug injectors AIDS epidemic worldwide. report episodes of drug overdose and suicide attempts, and they also may be targeted for physical violence and at risk for various health problems. Compared to all of this, the less

The Map Reports 2005 Drug Injection and HIV/AIDS in Asia 3 1.Introduction Is HIV a Bigger Problem in the Sex Industry or in Drug-Using Populations? A needle that contains HIV-infected blood The groups with the highest HIV infection rates can introduce the virus directly into the in Asia are injecting drug users (IDUs). So why do bloodstream. Consequently, needle-sharing experts emphasize the role of commercial sex between infected and uninfected people is as one of the major drivers of HIV epidemics in one of the most efficient ways of spreading HIV. Asia? Because of the significance of the absolute Drug injection is emerging as the strongest numbers of people engaging in both types of initial driver of HIV infection in many parts of behaviours. In general, IDUs are more likely to be Asia, and the steepest recent rises in numbers infected with HIV than sex workers or their clients. of HIV infections are seen among IDUs. Parts of But because the overall numbers of people buying China, Indonesia and Vietnam have seen HIV and selling sex are much larger than the numbers infection rates take off among drug injectors in of people injecting drugs in most settings, more recent years. HIV infections overall will be transmitted sexually Subsequent to the rise in HIV infection than through drug injection. among IDUs, HIV rates also have risen in other populations with high-risk behaviours. It is clear that infections which have spread among Even where the numbers of people injecting drugs drug users through the sharing of unclean are relatively small, their contribution to the overall injecting equipment have then been passed HIV epidemic in a country can be considerable. This is on sexually to non-injectors and have played because IDUs may also pass on HIV infection sexually, a significant role in “kick-starting” rapidly- creating a “critical mass” of infections within sexual growing HIV epidemics in at least some sites in networks. From there, HIV can spread out more widely. all three countries shown in Figure 1. The rise The accompanying box on HIV prevalence in Jakarta, in HIV among sex workers in the same sites, Indonesia, dramatically illustrates how a relatively shown in the same figure, is slower, but no less small number of cases of HIV among IDUs can prominent. represent a threat to a very large group of people.

HIV has signiﬁcantly increased among drug injectors and female sex workers in some populations in Asia

Figure 1 HIV prevalence among IDU and FSW at selected sentinel sites in two countries, 1994-2003 Note that these data represent speciﬁc sites, and don’t necessarily reﬂect the situation across the whole of a country. But they do illustrate trends that have been observed in some areas.

4 Drug Injection and HIV/AIDS in Asia The Map Reports 2005 Most sexual infections in Jakarta would never have occurred if there had not been a “seed” infection transmitted through drug injection

Figure 2 HIV prevalence in Jakarta, Indonesia, with and without IDUs. Actual data to 2003, and projections with behaviour unchanged from 2003 levels

In China, HIV prevalence among IDUs was Guangdong and Guangxi in 2002, while in the measured at between 18 percent and 56 percent capital Beijing in the north, it was 6 percent. i, ii in six cities in the southern provinces of

The Long-term Impact of HIV Transmission city by the end of the decade. But the most within IDU Networks important ﬁnding is shown by the purple line at the bottom. That represents the development Data from the Indonesian capital Jakarta, a of the epidemic in Jakarta if there had been city of some eight million people, suggest the no HIV infections among drug injectors: there potential ramiﬁcations of an initially small-scale would have been virtually no epidemic. HIV epidemic among IDUs. In Figure 2, the blue line on the graph follows the actual course of The entire area shaded in yellow represents the epidemic in the city until 2003. Beyond that sexually transmitted HIV infections that point, HIV infection rates are projected into the originated at some point in the sharing of future on the assumption that risk behaviours unsafe drug injecting equipment. The virus among drug injectors, among male, female and might have been passed on to a non-injecting transgender sex workers, and among clients woman by her injecting boyfriend, or to a client of sex workers do not change from the levels who contracted the virus from a sex worker observed in surveillance performed in 2003. who was infected by an earlier client who used drugs. If that client had always used a clean This model shows that we can expect a very needle when injecting drugs, the entire chain rapid expansion of the epidemic in Jakarta in of transmission could have been avoided and this decade, with drug users accounting for more than 100,000 infections could have been around one-third of all HIV infections in the averted.

The Map Reports 2005 Drug Injection and HIV/AIDS in Asia 5 2. How injecting drug use fuels HIV among IDUs in Malaysia, India and Indonesia Asian HIV/AIDS epidemics In Malaysia, there is no formal sentinel There are many facets to the complex relationship surveillance among groups at high risk of HIV between injecting drug use and HIV. This infection. HIV and AIDS case reports indicate publication highlights four major areas of concern that 55 percent of people detected with HIV that should guide HIV prevention strategies between 1998 and 2001 were drug injectors, targeting IDU networks. but this reflects the fact that drug injectors are more likely to get tested for HIV (when in n Sharing of injecting equipment. detention or in rehabilitation services) than n The sexual behaviour of IDUs. other members of the population. A study n The confinement and incarceration of IDUs. carried out by a university in Penang found that 17 percent of IDUs who agreed to testing n The relationship between HIV and other issues were HIV-positive.iii facing IDUs. In India, IDU surveillance sites are confined largely to the northern states where injecting A. Sharing of injecting equipment is a common behaviour. However, recently Sharing of injecting equipment is a highly established sites in other cities show great efficient way of transmitting HIV because it cause for concern. Among IDUs in the southern enables the virus to bypass the body tissues that city of Chennai, for example, 26 percent of act as barriers to other forms of transmission. injectors were already infected with HIV when Through needles and syringes, HIV can pass a sentinel site was established in 2000, and by directly into the blood. This is one reason why HIV 2003 an alarming 64 percent of injectors were spreads so quickly among drug injectors. But there infected. is another reason, too. HIV is easiest to transmit to In Indonesia, the only HIV surveillance site for others when high levels of the virus are present in a drug injectors is in the capital, Jakarta, where person’s blood—a state known as high viraemia. one in two IDUs is already testing positive for the virus. But counselling and HIV testing Why high viraemia equals high risk of HIV services started by local NGOs in far-flung infection cities such as Pontianak, in West Kalimantan province on the island of Borneo, are finding High viraemia develops shortly after a person is alarmingly high rates of infection—above initially infected, before the body manufactures 70 percent of those who request testing are the antibodies that can help bring HIV partially discovering that they are infected with HIV. under control. And it happens again later, once This has led the local health department to the virus has successfully destroyed the body’s estimate that there are already 3,000 people immune system and the infected person begins living with HIV in the province, 2,300 of them to show signs of AIDS. IDUs.iv Soon after being infected, when there are no physical signs of infection and when even an HIV antibody test may show up negative because the Factors such as a lack of human capacity and body has not yet had time to marshal its defences, resources, poor public health practice and political risk behaviour probably continues as normal. denial have limited the availability of regular Because injectors who share injecting equipment surveillance data among drug injectors in some tend to do so with several other people in their countries. But the fact that there are no formal network, there is a strong likelihood that a number data does not mean there is no problem, as the of people will be exposed to HIV simultaneously. accompanying box above on IDUs in Malaysia, And if that occurs shortly after infection, when a India and Indonesia suggests. person’s viraemia is high, it is very likely that those exposures will result in new HIV infections.v Therefore, even a small number of “unsafe” injecting incidents can translate quickly into many new HIV transmissions.

6 Drug Injection and HIV/AIDS in Asia The Map Reports 2005 HIV prevalence is high even among people who have just started injecting

Figure 3 Percentage infected with HIV by duration of injection and by gender, Kathmandu Valley, Nepal, 2003

Figure 3 shows that in Nepal, the likelihood of being infected with HIV in fact rises the longer Different Definitions of Sharing Injecting an injector has been using drugs intravenously. Equipment—the Differences Matter for But most remarkable in Figure 3 are the very Prevention Efforts! high rates of infection among new injectors. By Practices involving the sharing of injecting the time someone has been injecting for a year equipment vary widely throughout Asia. It is (and some of the IDUs, represented by the lilac- sometimes difficult to make direct comparisons, coloured bar, have injected much less than a year) in part because the definitions of “sharing” there is a one-in-three chance that the person will differ. Injectors will generally not think they have acquired HIV. are “sharing” when they use a needle hidden This leads to one conclusion: in high-prevalence in a public place, which is a common practice settings, drug injectors need to adopt very high in Nepal, Indonesia and some parts of India, levels of safe injecting practices right from the and one that definitely fits the definition of start of their injecting careers if they are to sharing from the point of view of the HIV virus. be confident of avoiding infection. Obviously, (A needle may be concealed somewhere in a ceasing to inject at all will eliminate risk, but this is park, side street or toilet, and several injectors often very hard to accomplish. may use this same needle at different times during the course of a day.) There is also cause The knowledge-behaviour disconnect for concern when other injecting equipment such as cookers, spoons, cotton and rinse water It is tempting to say that IDUs share needles are shared. because they are poorly informed about the risk of contracting HIV. However, knowledge Experience has shown that survey questions gaps are comparatively rare among drug users based on sharing injecting equipment at last in Asia. Among over 1,800 IDUs interviewed in injection or sharing in a specific time frame behavioural surveillance in the Chinese province may greatly understate the true levels of risky of Sichuan, for example, nearly nine in 10 believed injection. In Nepal, for example, only 16 percent they could prevent HIV by not sharing needles, of male injectors said they had used a needle and 70 percent said a switch from injecting to or syringe that had been used by others in inhaling would be effective in avoiding infection. the last three injections, but when asked Close to 100 percent of injectors in India, specifically about public syringes, 22 percent Indonesia, Kazakhstan, Malaysia and Nepal knew said they had used them. Indeed, after home, that sharing equipment could spread HIV. public toilets were the second most commonly mentioned injecting site. Such knowledge is generally not translated into safe behaviour or even into a realistic assessment The definition of sharing injecting equipment of personal risk. Two-thirds of Indonesian IDUs who may seem to be splitting hairs, but it has claimed in a 2002 Behavioural Surveillance Survey important implications for HIV prevention that they were not at risk of infection because they programmes.

The Map Reports 2005 Drug Injection and HIV/AIDS in Asia 7 never shared injecting equipment went on (in are asked, there is one constant finding: even when the same survey) to report that they had shared the overall proportion of sex workers injecting equipment in the previous week. In Tamil Nadu, drugs is low, the overall proportion of female in southern India, 55 percent of those who shared drug users who sell sex is usually very high. needles said they felt at no risk of acquiring HIV. In China’s Sichuan province, for example, 47 There is clearly a mismatch between people’s self- percent of the 452 females included in behavioural perception and their actual behaviour. surveillance for IDUs said they had sold sex for money or drugs in the previous month. Condom B. The sexual behaviour of injecting drug users use was reportedly quite high in commercial sex, Data systems in Asia are beginning to reveal two important facts. The first is that the majority of How Many Asian Sex Workers are Shooting men and women in Asia do not engage in any Up? high-risk behaviours. The second is that those who do practise such behaviour very often engage in Rates are highest in Vietnam and northern more than one of them. India, while data from other countries also are cause for concern. For some time, it was believed that people who inject drugs are unlikely to be very sexually active. n Vietnam: Injection among sex workers In a few Asian countries, there is indeed evidence seems to be particularly well established that years of drug injection dampens sexual in Vietnamese cities. The fact that one sex activity. However, in every Asian country where worker in six was an injector in the capital data are collected, drug injectors report more Hanoi probably explains a large part of sexual activity than other population groups, the steep rise in HIV prevalence among much of which is commercial sex, both bought sex workers in the city since the late 1990s. and sold. This has very important implications for In 2000, behavioural surveillance in the HIV prevention. northern port city of Haiphong revealed that nearly 40 percent of all sex workers viii Selling sex to buy drugs: a lethal combination reported injecting drugs. The more non-injecting sex partners drug injectors n India: Of the places that have measured have, the more likely it is that an HIV infection drug injection among sex workers in Asia, acquired as a result of needle-sharing will be only the northern Indian state of Manipur spread to non-injectors. Because sex workers has recorded levels similar to those in usually have more partners than other people, the Vietnam. In Manipur, which has a well- most dangerous combination of risk behaviours is established IDU-driven HIV epidemic, 20 found among sex workers who inject drugs. percent of female sex workers said they injected drugs, according to behavioural In Ho Chi Minh City, Vietnam, about half of sex surveillance performed in 2001. In other workers who injected drugs are infected with north-eastern states, about half as many HIV, compared with only 19 percent of those who sex workers have reported injecting drugs. use drugs without injecting them, and 8 percent of those who don’t use drugs at all.vi Moreover, n China: In Sichuan province, 2.5 percent drug-using sex workers were about half as likely of sex workers said they injected drugs, to use condoms as those who didn’t use drugs, but among street-based sex workers the according to one large study.vii (Behavioural proportion injecting was twice as high, at surveillance found that street-based sex workers one in 20. Women selling sex on the streets who did not inject drugs were six times more likely reported the highest turnover of clients to use condoms than those who injected drugs of any subset of sex worker, as well as the and shared their injecting equipment with other lowest levels of condom use. users. In other words, the drug-using sex workers n Bangladesh: Fewer than 4 percent of most likely to be exposed to HIV were the ones female sex workers in any site reported not using condoms regularly.) injecting drugs, but up to one in five Almost everywhere, the population of female sex believe some of their clients were injecting, workers is much larger than the population of and between five and 10 percent reported female drug injectors. But whenever female IDUs regular partners who injected.

8 Drug Injection and HIV/AIDS in Asia The Map Reports 2005 although at 60 percent it was considerably below the norm reported by sex workers in the province. Male-Male Sex Condom use with regular partners was, however, This section has focused on the relationship far lower at 17 percent. In neighboring Yunnan, between drug injection and sex between men which has a long-established HIV epidemic among and women. But the epidemics driven by drug drug injectors, 21 percent of female IDUs sold sex. injection and by male-male sex also overlap. In They reported very high rates of condom use: 88 Indonesia, rates of drug injection among male percent said they used a condom with their last sex workers were higher than among other client. population groups. In all likelihood, these males were selling sex to ﬁnance their drug The other side of the coin: drug injectors use. Cambodia is a country generally thought buying sex to have escaped the burdens of drug injection, but as early as 2000 in a survey of MSM, mostly When IDUs living with HIV/AIDS buy sex, male sex workers, 3 percent had injected drugs this creates opportunities for the virus to be in the preceding 12 months.ix transmitted to the sex workers, who can then pass it on to other clients. The variation in consumption In Tehran, one-third of male IDUs were reported of commercial sex among male IDUs is captured to have sex with males, and in surveys of in Figure 4. The similarity between all but two of MSM in China, Pakistan and India, between 2 the sites is the dominant colour, red, representing percent and 4 percent of MSM also use drugs. unprotected sex. Only in Thailand is condom use In northern Thailand, MSM who use drugs are reported to be a norm among drug injectors at higher risk for HIV and hepatitis C compared when they buy sex, while in Nepal roughly half of to heterosexual men who use drugs. Some of injecting clients use condoms. those MSM reported having more sex with women and with female sex workers than with In many of these locations, drug injectors other men.x reported even higher levels of regular and casual partnerships and, as a rule, condom use in these Other issues relating to the spread of HIV partnerships was even lower than in commercial among MSM are discussed at length in another sex. In most cities included by India in behavioural booklet in this series, Male-Male Sex and HIV/ surveillance for IDUs, around one-quarter of AIDS in Asia. injectors said they lived with a wife or regular sex partner. In one of the cities, Chennai, as many as 46 percent of injectors were married or had live- in partners. This has probably contributed to the

Throughout Asia drug injectors buy sex. Except for Thailand, most of it is unprotected.

Figure 4 Percentage of male IDU buying sex in various cities, by consistent condom use in commercial sex *Sichuan: condom use at last commercial sex ** Bangkok: includes non-injecting drug users

The Map Reports 2005 Drug Injection and HIV/AIDS in Asia 9 fact that Chennai also has among the highest D. The relationship between HIV and other HIV prevalence rates among pregnant women in problems facing IDUs the country. Data from other Asian countries also There is a common idea that people share needles make it clear that many drug injectors are putting because needles are hard to find. But this is not non-injecting sex partners at risk of HIV infection. necessarily the case. The data show that even when knowledge is universal and needles are C. Confinement and incarceration available, around one in six injectors report recent IDUs report relatively high rates of imprisonment, sharing. In some other countries, the rate is much and this has important implications for HIV higher. In such situations, one needs to look for prevention programming. other reasons as to why injectors are continuing to expose themselves or their injecting partners In northern Thailand, 27 percent of IDUs said to the risk of HIV transmission. they had been in jail, even before the ongoing crackdown on drug dealers and users. In HIV is just one of many potential problems facing Indonesia, 12 percent of injectors reported in drug injectors, and it is by no means the most behavioural surveillance that they had been jailed. immediate. People can be infected with HIV for a This percentage rose to one-quarter for those in decade or more without showing any symptoms, the capital, Jakarta. Between 1997 and 2001, the let alone dying. Drug overdose, on the other number of drug-related cases in jail rose five-fold. hand, is a daily risk for injectors, and it can lead During that time, HIV prevalence among drug to immediate death. Very high proportions of injectors in sentinel surveillance in Jakarta rose injectors have experienced overdoses themselves, from zero to 47 percent. Subsequently, in the and an even higher proportion have friends or capital’s overcrowded jails, HIV prevalence started former injecting partners who have died from to rise two years later, from zero in 1999 to 25 overdose. percent in 2002. A common health problem for IDUs to contend Some of this rise in prevalence probably occurred with is injection abscess. This can occur at the site because people were more likely to have been of injection due to unsafe injection practices. If infected with HIV by the time they entered there is no timely treatment, injection abscesses prison. But there is evidence that some of the sometimes lead to gangrene that require rise in HIV prevalence rates in this population amputation of fingers, limbs or even penises. group is the result of risk behaviour occurring Add these issues to high rates of attempted inside jails. For example, among drug injectors suicide, along with beatings at the hands of in northern Thailand who had never been to jail, community vigilante groups, and one emerges HIV prevalence was 20 percent. Among those who with a picture of a life in which more immediate had been in jail but did not report injecting drugs threats overshadow the risks posed by an infection while in jail, 38 percent were HIV-positive after that causes disease at some comparatively distant release. Among those who said they injected in point in the future. For example, in a detailed jail, HIV prevalence was higher, at 49 percent. This ethnographic study in Nepal, 77 percent of IDUs does not prove that people contracted HIV in jail, spontaneously mentioned arrest and beatings by but it is strongly suggestive. the police as some of their biggest problems; HIV xii Another Thai study looked in greater detail at infection was barely mentioned as a life risk. factors associated with HIV infection in this population; it found that sharing needles in police holding cells before going to jail increased the likelihood of HIV infection two-fold.xi In several other Asian countries as well, incarceration of IDUs seemingly increases the likelihood of HIV transmission.

10 Drug Injection and HIV/AIDS in Asia The Map Reports 2005 3. From research to practice: China and Vietnam began a co-ordinated translating the evidence into programme to make needles and syringes more easily available to IDUs in 2002, working in the strategies for reducing HIV Chinese province of Guangxi, as well as across the transmission in IDU networks border in Vietnam’s Lang Son province. Outreach workers collect used needles and syringes from A. Changing behaviour around the sharing of IDUs for safe disposal, and provide vouchers that injecting equipment can be used to obtain new needles and syringes from participating pharmacies. The programme is Throughout the industrialized world and in many large enough to have an impact on the population developing countries, the scientific evidence level and, overall, needle-sharing in the previous shows that promoting easy, safe and consistent month fell from 61 percent to 30 percent among access to sterile injecting equipment for a high all IDUs surveyed in Guangxi.xiii proportion of all injectors cuts the transmission of blood-borne viruses such as HIV and hepatitis Elsewhere in China, the availability of needle B and C. However, there is political reluctance to and syringe accessibility programmes and other provide prevention services that include clean prevention services has contributed to a dramatic injecting equipment for IDUs, fuelled in part by fall in reported injecting equipment-sharing the notion that people who have never injected among injectors reached in behavioural before will start injecting simply because clean surveillance in Sichuan province. Reported needles are available. injecting equipment-sharing at last injection fell from 30 percent to 17 percent among male It is therefore worth mentioning that in a review injectors in 2002-2003, while in the same year it of over 400 surveillance reports and scientific fell from 24 percent to 15 percent among female papers undertaken for this report, no evidence IDUs. Nearly one-quarter of surveyed IDUs said was found that HIV prevention services for drug they had recently accessed a needle and syringe injectors, including the provision of clean needles, exchange programme. is associated with an increase in the number of people injecting drugs. However, the review did The clearest evidence that large-scale needle and find that in Asia, as in other continents, countries syringe exchange programmes (NSEP) can make and regions that have had the courage to promote life safer for injectors comes from Bangladesh, and safer injecting practices (including access to is shown in Figure 5. There is a striking association needles and syringes) are being rewarded with between participation in NSEP and lower rates lower risk behaviour. of sharing at injection. Figure 5 also suggests

Needle-exchange programmes promote healthy sexual behaviour as well as safe injection

Figure 5 Percentage of male IDUs in Bangladesh Northwest-A who share needles, report STIs, and seek treatment for STIs, by participation in needle-exchange programme in the last year. *Sexually active respondents **Respondents reporting STIs

The Map Reports 2005 Drug Injection and HIV/AIDS in Asia 11 another, perhaps more surprising, effect of this B. Preventing sexual transmission of HIV in NSEP. IDUs who used the NSEP were far less likely IDU networks to report symptoms of an STI in the previous 12 Although there has been more than enough months than people who did not access the evidence gathered on the risks of sexual NSEP, and were far more likely to seek adequate transmission of HIV among networks of IDUs medical treatment if they did have symptoms. and in the general population, a very limited By 2002, 88 percent of IDUs included in number of intervention programmes have made behavioural surveillance said they used the NSEP comprehensive attempts to reduce unsafe sexual services in that city. In three rounds of serological practices and unsafe injection practices among surveillance conducted at the NSEP site between IDU networks. Most intervention programmes 1999 and 2000, none of over 400 injectors for IDUs focus on unsafe injection practices, with tested at each round was found positive to HIV much less attention given to unsafe sexual test. (However, in the last round of surveillance, practices. However, there have been more conducted in 2003-2004, 4 percent [16 of 403] attempts in recent years to step up efforts to IDUs from a large geographic area tested HIV- prevent the sexual transmission of HIV through positive but none of the other 605 IDUs from other IDU networks. geographic areas tested HIV-positive in the same round.)xiv In Imphal, India, Social Awareness Service Organization (SASO) has been tirelessly working The lesson here is that it is imperative to advocate with IDUs for many years. SASO has added for, initiate and support large-scale needle- intervention programmes that emphasize the exchange programmes as well as to monitor the prevention of sexual transmission, early diagnosis quality of NSEP services in relation to HIV trends and treatment of STIs and counselling and in Asia. testing for sexual partners of IDUs. In Vietnam, HIV prevention programmes have started to focus on both sexual and injection transmission Combating the Harassment and Arrest of when they are making plans for programmes Drug Users targeting female sex workers who are IDUs. A few A significant barrier to promoting greater use intervention programmes have provided female of clean needles is the inclination of the police sex workers/IDUs in southern China with condoms and other sections of the community to punish and sterile injecting equipment, as well as services drug users. Some 43 percent of the Kazakh for the diagnosis and treatment of STIs. However, injectors who said they could not always current services addressing the prevention of get access to a clean syringe said they were sexual transmission of HIV in Asian IDU networks hampered by fear of arrest. In Indonesia, most need to improve, in terms of both quantity and injectors knew where to get needles, but close quality, to make a dramatic difference in the to nine in ten still shared. Two thirds of them response to HIV/AIDS in the region. Prevention of said they did not want to carry clean needles sexual transmission and prevention of injection- with them on the streets because this could be related transmission should be intertwined goals used as a pretext to arrest them for the illegal for any organisation that is working to prevent behaviour of drug injection. the spread of HIV among IDUs. It may be necessary to remove legislation that supports arrest and harassment, and it C. Meeting the needs of IDUs in jails, prisons is essential to train law enforcement officers and other confined settings in public health approaches to drug use, IDUs are often referred to as a “hard-to-reach commercial sex and other risky activities. This population”. Yet data from many countries means a far wider engagement with ministries suggest that there is one-place drug injectors of justice, security forces, prison systems and can be found in significant numbers: prison. other partners who have not traditionally been part of a public health response to HIV. Widespread incarceration of drug users should provide an opportunity for active HIV prevention programmes, both within prisons and as a preparation for release, when people who might have been newly exposed to the virus in jail are at very high risk for passing it on.

12 Drug Injection and HIV/AIDS in Asia The Map Reports 2005 Jails also provide an obvious entry point for change the environment in which these people medical treatment and care in Asia. Governments are living and programming to address their most and international agencies wishing to increase immediate physical health and mental health the availability of antiretroviral treatments for needs. A continuum of drug use prevention, drug HIV would do well to look to their prison systems. dependency rehabilitation, risk reduction and HIV Countries where tuberculosis (TB) is also common treatment is required to effectively reduce HIV may find high rates of HIV and TB co-infection infection and its consequences in the community. in jail, and may wish to step up TB treatment Jails and prisons previously were identified as and prophylaxis programmes in these settings. a logical setting for HIV prevention and health Referral systems between jail and services promotion activities because a large number of outside can help introduce essential health, IDUs are in incarceration in many countries in prevention and care services to people who might Asia. In addition to prisons, drug treatment and otherwise potentially be hard to track down in the detoxification programmes can serve as another community. important channel for providing HIV prevention and care services to IDUs. While the type and D. HIV prevention in the context of other availability of drug dependence treatment and problems facing IDUs rehabilitation programmes vary in different In the previous section entitled, “The relationship Asian settings, there are an extremely limited between HIV and other problems facing IDUs,” a number of places offering these services overall. note of caution is sounded about HIV prevention Some of the available “detoxification” services efforts targeting IDUs. It is important for HIV do not offer any medical intervention, such as prevention programme managers to recognize providing methadone as a substitution therapy, that some IDUs might be less concerned about and with duration of “treatment” often limited the danger of HIV infection than about other to 14 days. Even with substitution therapy (using more tangible dangers such as overdose, police substitution medication), the drug use relapse arrests and physical violence on the streets. HIV rate is high (about 95 percent in some countries) prevention initiatives are more likely to succeed in the absence of drug dependence treatment when they take this into account. counselling, relapse prevention and other follow-up, job training or social services. Waiting for people to quit using drugs before offering them HIV prevention services is not an Treatment and detoxification programmes effective strategy. Drug dependence treatment should devote more time to educating people programmes that help people to reduce and about basic risk reduction techniques such as eventually eliminate their dependence on drugs avoiding unsafe injection practices (not sharing are necessary and desirable. But relapse rates injecting equipment) and using bleach. Cleaning among participants in various drug dependence injecting equipment with bleach (if this is done treatment programmes are quite high (>90 correctly and consistently) can reduce the percent) overall. Since many IDUs find it extremely risk of HIV transmission. However, even in IDU difficult to quit and to remain abstinent from communities where needle-sharing is the norm, drug use on an ongoing basis, it is important to very few people use bleach to clean needles due consider the full spectrum of problems that they to practical difficulties. face while they are injecting or alternating between Treatment and detoxification programmes also abstinent and non-abstinent phases. could be a gateway to other essential prevention This situation has important programming and care services, including medical care. In implications. For example, in a community in Malaysia, over 90 percent of drug users in a which police officers routinely harass and arrest drug rehabilitation programme reported that IDUs, it might be insufficient to simply provide they had not received medical care in two years. HIV prevention services to IDUs. Their concerns One-quarter reported encountering difficulties about the danger posed by the police might limit accessing medical care when they needed it, in their capacity to focus on protecting themselves large part because there simply were no services from HIV. A comprehensive response to the situation that met their needs or because they were afraid would go beyond prevention education and the of being reported to the authorities as drug users. distribution of clean needles and of condoms. Additional tactics might include advocacy to

The Map Reports 2005 Drug Injection and HIV/AIDS in Asia 13 In a recent study of HIV-infected people being Treatment and Care Services for Drug Users prescribed antiretroviral treatment at two clinics and their Families in Kuala Lumpur, Malaysia, just 2 percent of In Imphal, Manipur, India, IDUs and their those prescribed antiretrovirals were IDUs, families have been provided with even though they made up 10 percent of those comprehensive treatment and care services presenting at the clinics, and 55 percent of under challenging circumstances and with reported HIV cases.xviii Asian governments and very limited resources. Initially, international organizations are increasingly services included substitution therapy pledging to ensure access to antiretrovirals, as (buprenorphine), abscess management, a well as to improve access to other types of care needle and syringe exchange programme, and support to people living with HIV/AIDS in and primary health care including STI their countries. Since a large proportion of HIV- treatment and directly observed therapy- infected Asians are IDUs, drug dependence short term (DOTS) for tuberculosis. The treatment centres seem to provide an obvious services are provided through drop-in centers opportunity for accessing some of those who need (DICs) operated by the Social Awareness HIV-related treatment and care the most. Service Organization (SASO) (a community Furthermore, developing prevention organization founded by former drug users) programmes that involve HIV-infected drug in collaboration and with support from users can be a valuable strategy for effectively the local government, communities and communicating prevention messages to some some international assistance. Later, more community members. The box to the left provides services were added, including HIV voluntary compelling evidence of how well drug treatment counselling and testing; a programme for the programmes can broaden their agendas in prevention of mother-to-child transmission of response to participants’ concerns. HIV; prophylaxis and treatment of HIV-related The community has an important role to play opportunistic infections; and, treatment with in addressing HIV/AIDS issues in the context of antiretroviral therapy. Currently, more than other problems facing drug users. Some IDUs 600 PLWHAs have been receiving antiretroviral may be more accessible to their peers than to therapy from the government with support representatives of public health and medical and collaboration from many communities xvi organizations, since other current and former and agencies. IDUs have personal insight into this situation. In 2004, China started eight methadone Friends and family members may also be maintenance treatment (MMT) programmes important resources. By going through with government support. More than 2,000 community channels, HIV programme managers drug users were recruited into the MMT clinics have the opportunity to utilize peer networks in four provinces. These clinics are linked with to advance HIV prevention, treatment, care and other health and social services, including support initiatives. outreach services and NSEP to recruit more IDUs when appropriate. Another 26 MMT clinics were approved in November 2004, and it was anticipated that some 20,000 drug users would be treated by the end of 2005. xvii A community-based methadone maintenance programme integrated with HIV/AIDS prevention and care services for Akha hilltribes in northern Thailand has been providing both drug dependence treatment/rehabilitation services and HIV prevention and care services to Akha drug users and their families in selected villages. The project has been a collaboration of Akha communities, Hill Area Development Foundation (a local NGO), and Mae Chan District Hospital of Thailand Ministry of Public Health.

14 Drug Injection and HIV/AIDS in Asia The Map Reports 2005 4. Protecting IDUs and other n Provide HIV/AIDS care and treatment, community members from HIV/AIDS including medical and social support, for IDUs living with HIV/AIDS and for their families. by engaging them in prevention and Special attention must be given to HIV-positive care efforts IDUs in the provision of antiretrovirals due to the associated complications of different drug regimes, particularly related to liver function. Responding to drug use-related HIV/AIDS epidemics is one of the most important strategies n Strengthen collaborations among commu- for containing HIV/AIDS in Asia. If Asian countries nities, health workers, law enforcement are to implement evidence-based HIV/AIDS workers, decision makers and drug users. interventions, they must consider drug use-related All stakeholders should be encouraged to HIV/AIDS as a top priority because of the roles recognize that drug use-related HIV/AIDS is a IDUs play in transmitting HIV to other IDUs and global challenge requiring everyone to work to non-IDUs. Both IDUs and their families need together on the same goal—reducing the support in order for interventions to be effective. impact of the HIV/AIDS epidemic on society. Key strategies should include the following. There is nothing inevitable about the spread of HIV, the right prevention, care, support and n Try to keep people off drugs in the ﬁrst place. treatment services for the right people, n Reduce HIV transmission among and from immediately delivered on a large enough scale, IDUs, which means, among other things, can change the course of HIV epidemics and their reducing unsafe injection practices and unsafe impact in Asia. Time is running out to implement sexual practices, as well as dissuading people and scale up effective intervention plans in from making the transition from non-injecting response to drug use-related HIV/AIDS in Asia. to injecting drug use. These intervention Political and community leaders in Asia must activities should be available at many sites, take decisive action now, basing their plans on including prisons and drug treatment/ the available evidence, to protect people from rehabilitation centers in the community. becoming infected and affected by HIV. n Provide drug dependence treatment, rehabilitation and relapse prevention services/ support. Services should be effective, accessible and affordable for drug users and their families, as well as communities and government agencies. n Provide HIV prevention and support programmes, with attention to the availability, accessibility and quality of conﬁdential voluntary HIV counselling and testing services. Correct and consistent condom use with all sex partners should be emphasized and condoms should be made available, as should services to promote the early diagnosis and treatment of sexually transmitted infections. Leadership from HIV-positive drug users is important for the success of these programmes.

The Map Reports 2005 Drug Injection and HIV/AIDS in Asia 15 Appendix 1: Members of the Monitoring the AIDS Pandemic Network

The members of the MAP Network are listed below. Special thanks to those who appear in bold for their active participation in the preparation of this report.

Roy Anderson Osamah Hamouda D Stephen Reddy Chris Archibald Catherine Hankins Deborah Rugg Anabella Arredondo Nguyen Tran Hien Tobi Saidel Emil Asamoah-Odei Rokiah Ismail Swarup Sarkar Tasnim Azim Manoj Jain Bernhard Schwartlander Timoteo Badoy John Kaldor Mohammed Shaukat Seth Berkley Mitsuhiro Kamakura Qu Shuquan Stefano Bertozzi Claudes Kamenga Weerasit Sittitrai Stephen Blount Masahiro Kihara Karen Stanecki Tim Brown Ann Marie Kimball Robert Stein Hor Bun Leng Irena Klavs Rand Stoneburner Anne Buve Maria Laga Steffanie Strathdee Carlos F. Caceres Peter Lamptey Donald Sutherland Ricardo Calderon Stefano Lazzari Daniel Tarantola Bilali Camara Sophie Le Coeur George Tembo Michel Carael Susu Liao Kumnuan Ungchusak Manuel Carballo Conky Lim-Quizon Johannes Van Dam Jordi Casabona Isaac Babila Macauley Eric Van Praag Pedro Chequer Ricardo Mateo Jr Maria Wawer A Chung Thierry Mertens Peter Way Tom Coates Steve Mills Alan Whiteside Jim Chin Rob Moodie Stefan Wiktor Paloma Cuchi Rosemary Musonda Fernando Zacarias Gina Dallabetta Jai Narain Myint Zaw Quang Vinh Dao Ibra Ndoye Xiwen Zheng Karl-Lorenz Dehne Angus Nicoll Debrework Zwedie Kevin de Cock Mary O’Grady Paul De Lay Mead Over Carlos Del Rio Tia Phalla Helene Gayle Chansy Phimphachanh Peter Ghys Peter Piot Ron Gray Elizabeth Pisani Soﬁa Gruskin Gilles Poumerol Francoise Hamers Abdool Karim Quairrasha

16 Drug Injection and HIV/AIDS in Asia The Map Reports 2005 Appendix 2: Sources used in this Futures Group Europe. 2001 Baseline Behavioural report Surveillance Study in Yunnan and Sichuan Province: Sex Worker Report. Surveillance Data India The majority of the data in this publication is National AIDS Control Organization, Ministry of taken from national surveillance systems. This Health & Family Welfare, Government of India publication is based on the best available data. Its National Baseline General Population behavioural authors have, as far as possible, ascertained that Surveillance Survey – 2001 the data used were collected following reliable National AIDS Control Organization. National protocols and standard procedures. The MAP Baseline High Risk and Bridge Population Network wishes fully to acknowledge the sources Behavioural Surveillance Survey-2001 Part -I (FSW for all of the data used. However because the and their clients) report refers to data with very great frequency, the sourcing of each individual data point cited National AIDS Control Organization. National would be impractical. For that reason, the sources Baseline High Risk and Bridge Population for surveillance data are consolidated in this list. Behavioural Surveillance Survey -2002 Part- II (MSM and IDUs) Any data point that is not individually sourced, or that is sourced to “national surveillance records” National AIDS Control Organization. HIV Sentinel or “behavioural surveillance”, comes from the Surveillance Report Population – and sentinel site sources on this list. Unless otherwise stated, a – wise report 1998-2002. cited data point refers to the most recent year for AIDS Prevention and Control Project and which data are available, as stated on this list. Note Voluntary Health Services. HIV Risk Behaviour that this list refers to the year of data collection, Surveillance Survey in Tamil Nadu Wave I – VII not the year of publication. Data from stand-alone (1996-2002) studies rather than from repeated surveillance efforts are individually referenced using endnotes. Indonesia (See the next section of this Appendix.) Directorate of Communicable Disease Control Bangladesh and Environmental Health, Ministry of Health. HIV sentinel surveillance (1989-2003) National AIDS/STD programme, Directorate General of Health Services, Ministry of Health Directorate of Communicable Disease Control and Family Welfare Government of the People’s and Environmental Health, Ministry of Health Republic of Bangladesh. National HIV and and Central Bureau of Statistics. Behavioural Behavioural Surveillance. (1999-2003) surveillance (1996-2004) Cambodia Kazakhstan National Center for HIV/AIDS, Dermatology and National AIDS Control Programme and Ministry STDs. HIV Sentinel Surveillance (1997-2003) of Health, Center of Public Opinion Investigation, UNAIDS. Behavioral surveillance among injecting National Center for HIV/AIDS, Dermatology and drug users in nine cities of Kazakhstan (Almaty, STDs. BSS I-VI (1997-2004). Pavlodar, Shymkent, Karaganda, Temirtau, Astana, National Center for HIV/AIDS, Dermatology and Petropavlovsk, Uralsk, Ust-Kamenogorsk) 2002 STDs. STI Prevalence Survey (1996 and 2001) National AIDS Control Programme and Ministry China of Health, Report on sentinel epidemiological HIV Prevalence among STD patients and CSWs in surveillance over HIV prevalence in the Republic Guangxi (1995-1999) Provided by China Centre for of Kazakhstan in 2002, Almaty 2002 Disease Control Nepal China-UK HIV/AIDS Prevention and Care Project, New ERA and FHI. Behavioural Surveillance Survey Behavioural Surveillance Survey of HIV/AIDS in in The Eastern to Western Highway Route of Nepal: Sichuan and Yunnan provinces. (2003) Round No.1-5 (1998-2002)

The Map Reports 2005 Drug Injection and HIV/AIDS in Asia 17 New ERA and FHI. Behavioural Surveillance Survey AIDS Control Division, Health Department, Bangkok with FSWs in Kathmandu Valley: Round 1 (2002) Metropolitan Administration. The Behavioural Surveillance Survey of 7 Target Groups in Bangkok New ERA and FHI. Behavioural Surveillance Survey (2000-2003) with FSWs in The Western to Far-western Highway Route of Nepal: Round No.1 (2002) Vietnam New ERA/SACTS and FHI. Behavioural and Sero National AIDS Committee, HIV sentinel surveillance Prevalence Survey Among IDUs in Kathmandu (1994-2003) (2002) National AIDS Standing Bureau and National New ERA/SACTS and FHI. Behavioural and Sero Institute of Hygiene and Epidemiology, HIV/AIDS Prevalence Survey Among IDUs in Pokhara (2003) Behavioural Surveillance Vietnam (2000) New ERA/SACTS and FHI. Behavioural and Sero Prevalence Survey Among IDUs in Eastern Terai Endnotes Districts (Jhapa, Morang and Sunsari) (2003) iChina National Center for AIDS/STD Control New ERA/SACTS and FHI. HIV/STD Prevalence and and Prevention (2003). Questionnaire survey of Risk Factors among Migrant and Non-Migrant injection drug users in a copulsory detoxification Males of Kailali District in Far-Western Nepal centre and non-treatment locations in Beijing. (2002) Beijing, World Health Organization. New ERA/SACTS and FHI. HIV/STD Prevalence and iiChina National Center for AIDS/STD Control and Risk Factors among Migrant and Non-Migrant Prevention (2004). A needle social marketing Males of Achham District in Far-Western Nepal intervention program in Guangdong and Guangxi (2002) provice, China Center for Disease Control. New ERA/SACTS and FHI. STD and HIV Prevalence iiiNavaratnam, V., B. Vicknasingham, et al. (2003). Survey Among Female Sex Workers and Truckers Survey of drug users in Penang and the Northern on Highway Routes in the Terai, Nepal – round 1 Province Wellesley district. Penang, Universiti Sains (1999) Malaysia. Center for Research on Environment Health and ivIsman Ramadi, West Kalimantan Health Population Activities (CREHPA) and FHI, Injecting Department, personal communication. and Sexual Behaviours of Injecting Drug User in vHu, D. J., S. Subbarao, et al. (2002). “Higher viral Birathagar, Nepal (2003) loads and other risk factors associated with HIV-1 CREHPA and FHI. Injecting and Sexual Behaviours seroconversion during a period of high incidence of Injecting Drug Users in Dharan, Nepal (2002) among injection drug users in Bangkok.” J Acquir Immune Defic Syndr 30(2): 240-7. CREHPA and FHI. Injecting and Sexual Behaviours of Injecting Drug Users in Pokhara, Nepal (2002) viHu, D. J., S. Subbarao, et al. (2002). “Higher viral loads and other risk factors associated with HIV-1 CREHPA and FHI. Injecting and Sexual Behaviours seroconversion during a period of high incidence of Injecting Drug Users in Jhapa District, Nepal among injection drug users in Bangkok.” J Acquir (2002) Immune Defic Syndr 30(2): 240-7. Philippines viiVietnam Ministry of Labour Invalids and Social Republic of the Philippines, Department of Health. Affairs (2001). Report results of the survey on high The 2002 Technical report of the National HIV/ risk factors of drug abuse among groups of female AIDS Sentinel Surveillance System. (1997-2002) prostitutes in Vietnam, UNDCP. Thailand viiiVietnam National AIDS Standing Bureau and National Institute of Hygiene and Epidemiology Ministry of Public Health, Bureau of Epidemiology, (2001). HIV/AIDS Behavioural Surveillance. Hanoi, HIV Serosurveillance in Thailand (1989-2003) Vietnam, Family Health International. Ministry of Public Health, Bureau of Epidemiology, Behavioural Surveillance Surveys (1995-2003)

18 Drug Injection and HIV/AIDS in Asia The Map Reports 2005 ixGirault, P., T. Saidel, et al. (2004). “HIV, STIs, and Sources for ﬁgures sexual behaviors among men who have sex with Figure 1: National surveillance reports. (See men in Phnom Penh, Cambodia.” AIDS Educ Prev “Surveillance data” earlier in this appendix.) 16(1): 31-44. Figure 2: Elizabeth Pisani, using Asian Epidemic xBeyrer C, Sripaipan T, Tovanabutra S, et al. MSM- Model IDU in Northern Thailand: High HIV, HCV and sexual risk and rates among dual risk men seeking Figure 3: New ERA and STD/AIDS Counselling drug treatment, 1999-2002. 16th International and Training Service (2002). Behavioural and sero Conference on the Reduction of Drug Related prevalence survey among IDUs in Kathmandu. Harm, Belfast, Northern Ireland, March 2005 Kathmandu, Family Health International. [abstract 644]. Figure 4: Behavioural surveillance data. (See xiBuavirat, A., K. Page-Shafer, et al. (2003). “Risk “Surveillance data” earlier in this appendix.) of prevalent HIV infection associated with Figure 5: Bangladesh National AIDS/STD incarceration among injecting drug users in programme (2003). HIV in Bangladesh: is time Bangkok, Thailand: case-control study.” BMJ running out? Background document for the 326(7384): 308. dissemination of the fourth round (2002) of xiiCenter for Research on Environment Health national HIV and behavioural surveillance. Dhaka, and Population Activities (2002). A situational Ministry of Health and Family Welfare. assessment of injecting drug users in Kathmandu xviiiKamarulzaman, A., K. Petoumenos, et al. (2003). Valley: a focus ethnographic study. Final Report. Antiretroviral Therapy in HIV-infected Patients Kathmandu, Family Health International. in Kuala Lumpur, Malaysia. University Malaya xiiiChina National Center for AIDS/STD Control Medical Centre, Kuala Lumpur. and Prevention (2004). A needle social marketing intervention program in Guangdong and Guangxi provice, China Center for Disease Control. xiv(Reference: National HIV Serological and Behavioral Surveillance 2003-2004, National AIDS/STD Programme, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh). xvNavaratnam, V., B. Vicknasingham, et al. (2003). Survey of drug users in Penang and the Northern Province Wellesley district. Penang, Universiti Sains Malaysia. xviSocial Awareness Organization (2000). “Comprehensive services for IDUs and their sexual partners in Imphal.” xviiPresentation of Dr. Wu Zunyou at the 16th International Conference on the Reduction of Drug Related Harm, Belfast, 2005.

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MAP Report 2005

Drug Injection and HIV/AIDS in Asia