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Moving beyond detoxification

By Eldred Tellis

The prevalence of HIV amongst injecting drug users in India could be more than 5%. But the only government intervention for these hidden, marginalised people is detoxification. Those who cannot obtain treatment and continue to inject drugs, or those who relapse, need other methods for reducing the risk of HIV transmission, including community outreach, the provision of new needles and syringes, condom provision and drug substitution therapy

According to the World Health Organisation, the sharing of HIV-contaminated injecting equipment accounts for 5-10% of all adult HIV infections worldwide and is a major driving force of the HIV and hepatitis C epidemics in some developing countries. As much as 30% of all new HIV infections are attributed to injecting in countries outside sub-Saharan Africa.

Ever since the first report of HIV infection amongst Injecting Drug Users (IDUs) in northeast India in 1989, there has been a diffusion of HIV among IDUs in different parts of the country. In the national sentinel surveillance for 2005, HIV prevalence among IDUs was more than 5% in nine states. Hepatitis C prevalence among IDUs is alarmingly high in many places in the country: Chennai -- 93%; Imphal (Manipur) -- 90%; Kolkata -- 80%; Mumbai -- 79% (sentinel surveillance figures for 2003) and Darjeeling district of West Bengal -- 48%.

Injecting drug use is a major driver of the epidemic in the northeastern states. Recent size estimation data shows that injecting drug users could constitute 1.9-2.7% of the adult population in Manipur and Nagaland. The risk of HIV transmission to sexual partners and wives of injecting drug users has been documented across India. In a sample of injecting drug users in the northeast, 75% were HIV-positive, most were under the age of 19, two-thirds were sexually active, and only 3% reported using condoms. Injecting drug users are also found in most of the major cities of India outside the northeast. The prevalence of HIV ranges between 2% and 44% in these groups. Little is known about the overlap of injecting drug users and other risk groups in states outside the northeast.

Prevention programmes gain effectiveness and sustainability when implemented in the context of a strong public health system and linkages to other programmes. Government services for STDs and basic HIV care require more resources for training and sensitisation of personnel to meet the needs of all high-risk groups which include female sex workers, men who have sex with men, injecting drug users, and people living with HIV/AIDS.

Drug treatment and HIV prevention

Drug treatment has historically been seen as abstinence, which is the most effective way of preventing HIV transmission among IDUs. Programmes based on abstinence range from detoxification to rehabilitation and from primary care to after-care. These are residential programmes and require 24-hour professional inputs which are not always possible with the available budgets. Also as drug abuse becomes more common among the poor, residential programmes which charge high fees are out of reach for marginalised drug users.

Further, efforts at abstinence have not been very successful. While programmes promoting voluntary abstinence should be encouraged, it may not be a realistic or achievable goal for all. Relapse after detoxification is common, with relapse rates often reaching up to 90% in the Asian region.

The Ministry of Social Justice and Empowerment provides grants to 400 ‘de-addiction centres’ all over the country, providing one to two months of treatment. However, this is neither here nor there: detoxification usually needs not more than two weeks whereas rehabilitation requires about six months.

Detoxification is only the initiation into treatment and not a complete treatment for addiction. Those who cannot obtain treatment and continue to inject drugs, or those who relapse, need other methods for reducing the risk of HIV and other blood-borne virus (BBV) transmission. This is known as the harm reduction approach and incorporates activities such as community outreach, provision of new needles and syringes, condom provision accompanied with information on safer sexual practices, provision of effective drug treatment including substitution therapy such as methadone or buprenorphine, voluntary counselling and testing, and life skill programmes.

The need for needle and syringe programmes
 
The risk factor for HIV and other BBV transmission is not in the injecting of drugs itself, but the sharing of injecting equipment with an HIV-infected person, or the reuse of contaminated needles and syringes. For those individuals who continue to inject drugs, the provision of needles and syringes through needle and syringe programmes (NSP) reduces the need for IDUs to share injecting equipment.

A study in 2002 from 103 cities in 24 countries showed that HIV infection rates declined by an average of 18.6% annually in 36 cities with needle and syringe programmes, while it increased by an average of 8.1% annually in 67 cities that did not have NSPs.

Research from around the world has established that NSPs are effective in the prevention of HIV. They do not increase drug use, they do not recruit new IDUs or lower the age of first injecting, they do not increase the number of needles discarded in the community, and they are cost-effective.

Advocates of needle and syringe programmes highlight that most injecting drug users are not in treatment. NSPs attract injecting drug users who are out of treatment to risk-reduction services, increase referrals to treatment and reduce the transmission of HIV. Thus, it is crucial to reach IDUs and provide them with risk-reduction materials and services if one is to reduce the risk of HIV to them, their sexual partners, their families and their community.

However, needle and syringe programmes need support from law enforcement officers who sometimes round up drug users who may be receiving services for prevention of HIV and force them into prisons where they may be even more vulnerable.

Opioid substitution treatment: Concept and objectives

Substitution pharmacotherapy, sometimes called ‘maintenance treatment’, is replacing the drug being taken with another drug or a similar drug (for example, methadone for heroin users). It may also mean using the same drug but taking it in a different way, for example, sublingual buprenorphine to replace the injecting of buprenorphine. The length of treatment can vary from six months to several years. Among the aims of drug substitution are lessening the risk of contracting or transmitting HIV/AIDS by switching from an injected to non-injected substance; to switch users from illicit drugs of indeterminate quality, purity and potency to legal drugs of known purity and potency. Opioid substitution treatment is an efficacious, safe and cost-effective modality for the management of opioid dependence and the prevention of HIV among IDUs. Provision of substitution maintenance therapy should be integrated with other HIV prevention interventions and services, as well as with those for treatment and care of people living with HIV/AIDS. A recent Cochrane review recommended that the provision of substitution treatment should be supported for opioid dependence in countries with emerging HIV and injecting drug use problems as well as in countries with established populations of injecting drug users.

In India, the experience with sublingual buprenorphine indicates that the treatment is attractive to drug users, families as well as communities. Further, the treatment has the potential to retain clients in treatment as well as link them with other services including treatment for conventional drug use. The post-marketing surveillance of sublingual buprenorphine from 10 centres across India indicated fewer adverse effects, and no deaths have been reported.

We need to develop appropriate, strategic and pragmatic long-term approaches to reduce HIV transmission among drug-using populations and their sexual partners. Needle and syringe programmes and opioid substitution can have a considerable impact on HIV transmission but they need to be implemented to scale in India. We need a clear-cut policy to create an enabling environment for services to reach these hidden, marginalised populations.

(Eldred Tellis is Director of the Sankalp Rehabilitation Trust, Mumbai, and a member of NACO’s Technical Resource Group for programmes related to injecting drug users. He has worked extensively in various parts of India and Asia developing and replicating programmes for IDUs)

InfoChange News & Features, January 2008