BMJ  2004;329:697-698 (25 September), doi:10.1136/bmj.329.7468.697

Editorial

HIV in injecting drug users in Asian countries

Available effective interventions need to be implemented

Discussions of HIV control in developing countries usually pay insufficient attention to injecting drug use. Yet half the population of the world now lives in developing countries within a few hours' flight from Bangkok, in a region where HIV infection is dominated by the sharing of injecting equipment. The number of people infected with HIV in India and China alone is estimated to increase from 6-10 million at present to 30-40 million by 2010.¹ By 2010 The Joint United Nations Programme on HIV/AIDS (UNAIDS) expects that Asia will outstrip sub-Saharan Africa in absolute numbers of HIV carriers.¹ In seven of the 10 UNAIDS regions—accounting for 90% of the global population—injecting drug users are considered among the most important risk groups for HIV.²

Fortunately, strategies to prevent the spread of HIV infection among and from injecting drug users can be effective and cost effective interventions. In addition, the effectiveness and safety of these prevention strategies have been known for almost two decades. Moreover, we now have extensive international experience to draw on, as these measures have long been put to good effect in many countries of the European Union and Australasia.^{3 4}

How can national authorities be persuaded effectively to adopt these prevention strategies early enough in the development of an HIV epidemic? How can such authorities quickly scale up the size of the response in order to slow the rate of HIV spread among injecting drug users? The major obstacle remains an entrenched commitment to an unbalanced drug policy that is heavily reliant on control of supply. A common but unwarranted fear exists that expansion of drug policies to include pragmatic harm reduction strategies will conflict with efforts to control the supply of and demand for illicit drugs. Harm reduction recognises the reality of drug use and promotes pragmatic policies and programmes that are intended to minimise the adverse health, social, and economic consequences of continuing drug use in the individual and the community. Successful strategies include the provision of needle exchange, drug substitution treatment for heroin addiction, and distribution of condoms.

Many countries are of the view that harm reduction interventions contravene the major international drug treaties of 1961, 1971, and 1988, but the legal section of the United Nations International Drug Control Programme has recently confirmed that the interventions used to prevent the spread of HIV among and from injecting drug users are not inconsistent with the international treaties.⁵ As in many other areas countries often look to the United States for leadership. Regrettably, the timing and scale of implementation of HIV prevention measures for injecting drug users in the United States has been anything but impressive.⁶ At least 36% of new cases of AIDS in the United States are still directly or indirectly associated with injecting drug use.⁷

The evidence for action for several major HIV prevention measures has been recently reviewed by WHO.⁸ Needle and syringe programmes and oral substitution maintenance by drugs such as methadone and buprenorphine are supported by strong evidence of effectiveness.

A high prevalence of HIV is now found among injecting drug users in many Asian countries including Myanmar, Vietnam, China, Thailand, Malaysia, Indonesia, Nepal, and Iran.⁴ In several of these countries authorities are now reporting that more than 60% of injecting drug users who have been tested are HIV positive.⁹ China alone is now estimated to have almost 900 000 injecting drug users.⁴ Disturbingly large pockets of HIV infected injecting drug users exist in other populous Asian countries such as India and Pakistan.⁸ Fuelled by economic, social, and political constraints, injecting drug use continues to proliferate in this region as it does in many other parts of the world.

In some countries, such as Thailand and Myanmar, HIV initially spread among injecting drug users before generalised heterosexual epidemics developed.⁹ Commercial sex workers who also inject drugs seem to be a critical bridge between injecting drug users and the broader heterosexual population. Fortunately generalised heterosexual epidemics have not always occurred in countries after injecting drug users became infected. Predictive factors for rapid spread to the general population from injecting drug users are yet to be fully identified.

Encouragingly pragmatic approaches to HIV infection among injecting drug users are being adopted. For example, Indonesia, Vietnam, Myanmar, and China have recently shown promising signs of increasing interest in developing outreach, syringe exchange, and drug substitution interventions. But the frightening fact remains that HIV continues to spread among and from injecting drug users much more rapidly than such harm reduction interventions are adapted and expanded.

HIV/AIDS is probably the most serious global health problem since the Great Plague more than half a millennium ago. Awareness of the AIDS epidemic is still less than a quarter century old and is likely to continue for at least several generations to come. For the next few decades, the health and wellbeing of the most populous region of the world will depend a lot on the speed with which Asian countries adopt, adapt, and fully implement harm reduction interventions especially needle and syringe and drug substitution programmes for injecting drug users.

St Vincent's Hospital, Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia (awodak{at}stvincents.com.au)

University of Adelaide (robert.ali{at}adelaide.edu.au)

Addictions Resource Centre, London SE5 8RS (m.farrell{at}iop.kcl.ac.uk)

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Competing interests: None declared.

References

1. National Intelligence Council. The next wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China. ICA 2002-04 D. September 2002. www.fas.org/irp/nic/hiv-aids.html (accessed 28 Jun 2004).
2. Joint United Nations Programme on HIV/AIDS (UNAIDS), World Health Organization. AIDS epidemic update: December 2002. Geneva: UNAIDS, 2002. www.who.int/hiv/facts/en/epiupdate2002_en.doc (accessed 9 Jul 2004).
3. Commonwealth Department of Health and Ageing, Drummond M. Return on investment in needle and syringe programs in Australia. Canberra: Health Outcomes International, National Centre for HIV Epidemiology and Clinical Research, 2002. www.drugpolicy.org/docUploads/ROIfinal.pdf (accessed 30 Jun 2004).
4. World Health Organization, Department of Mental Health and Substance Dependence. The practices and context of pharmacotherapy of opioid dependence in South-East Asia and western Pacific regions. Geneva:WHO, 2002.
5. Legal Affairs Section, United Nations Drug Control Programme. Flexibility of treaty provisions as regards harm reduction approaches. United Nations International Narcotics Control Board. 30 September. E/INCB/2002/W.13/SS.5.Vienna, 2002.
6. Centers for Disease Control and Prevention. 1996. AIDS associated with injecting-drug use—United States. Morb Mortal Wkly Rep MMWR 1995;45: 392-8.
7. Lurie P, Drucker E. An opportunity lost: HIV infections associated with the lack of a national needle exchange programme in the US. Lancet 1997;349: 604-8.[CrossRef][ISI][Medline]
8. Cooney A, Wodak A. Effectiveness of sterile needle and syringe programmes. Int J Drug Policy (in press).
9. Reid G, Costigan G. Revisiting the hidden epidemic. Melbourne: Centre for Harm Reduction, Burnet Institute, 2002.

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