Preventing Blood-borne Infections among Injection Drug Users: A Comprehensive
Approach takes a different tack, one that many in the prevention arena recognize and are
acting on. No one provider or approach can do it all. To help IDUs reduce their sexual
and drug-use risks of transmission, communities and organizations must embrace a broad
approach that incorporates a variety of pragmatic strategies addressing IDUs ’differing
life circumstances, cultures and languages, behaviors, and readiness to change.
Services and interventions for IDUs don’t take place in a vacuum, however. They are
carried out within a complex, often contentious social, political, and legal environment.
Potential partners in the effort to reduce infection among IDUs may not agree on
everything, but they do need to find ways to work together so that a critical mass of IDUs
can obtain sufficient, high-quality services. A Comprehensive Approach discusses this
environment and lays out some principles that can help community groups, agencies, and
providers begin —or continue —to collaborate.
The challenges are substantial, but so are the rewards, for reducing infections among
IDUs will translate into a substantial public health benefit for the whole community. We
hope this document will help move the field in that direction by providing new ways of
thinking about this problem and about IDUs and by encouraging dialogue, collaboration,
and constructive action.
Transmission of HIV among IDUs occurs primarily through behaviors like needle/syringe
exchange /sharing and practice of unsafe sex. Behaviors that increase the likelihood,
frequency and magnitude of exposure to infected blood increase the risk of infection. The
frequency of needle sharing, the number of partners with whom needles are shared, the
probability that those partners are HIV- infected and the manner in which sharing occurs,
all influence HIV risk.
In addition to sharing needles, the unsafe sexual practice is another important area that
contributes to their vulnerability to HIV infection. Drug users tend to be sexually active
during their initial phase and studies have shown that their condom use practice is often
low. The IDUs and their partners are often acted as a bridge to transmit HIV to other
general populations.
The dynamics of the HIV/AIDS epidemic is predicted to follow a pattern like: Rapid
increase in most vulnerable groups (e.g. IDUs, FSWs) Spread in “bridge population
10
“(their partners) and to general population
Respect for human rights is fundamental for good public health. A range of ethical,
human rights and legal barriers are making drug users especially vulnerable to the HIV
epidemic. Drug users also experience marginalization and exclusion from the very
processes and services that should protect them from HIV. Current anti-drug and anti-
paraphernalia laws drive drug users underground and precipitate risky drug injecting and
needle sharing behavior, and thus facilitate the spread of HIV through IDU. Yet there is
little recognition of either the importance of legal, ethical or human rights issues in
proliferating HIV transmission among IDUs or the need to investigate possible solutions.
Studies show that in most drug users total abstinence from psychoactive substance all at
once is not a feasible option. However, more than twenty years of findings from research
and field reports in implementing interventions for IDUs indicate that HIV transmission
among IDUs can be prevented, slowed or even stopped. These findings have generated
guidelines and principles for designing and implementing feasible, sustainable and
effective interventions. Intervening early before HIV prevalence among IDUs reaches 5%
can prevent the epidemic spread and its consequences. Intervening as early as possible
even after prevalence has increased substantially can also prevent the further spread of
HIV in IDUs and transmission into other population.
Technical resource network (TRN) is essential for the implementation of risk reduction
activities. The Asian Harm Reduction Network, supported by UNAIDS and other
agencies, has become an important mechanism for promoting approaches to the
prevention of drug use and HIV/AIDS in Asia.
The abuse of drugs is an international problem, which affects almost every country in the
world, both developed and developing countries. The problem of drug abuse involves not
only illicit but also licit and prescribed substances. Current evidence from around the
world reveals a continuing upward trend in the misuse of psychoactive drugs
2
.
Drug may be defined as substances, which act on a person's nervous system to produce
changes in sensations, mood and perceptions
3
. There are many different kinds of drugs;
some like tobacco are legal other like Ecstasy and cannabis are not. Different drugs have
2
Gossop M. and Grant M., Preventing and Controlling drug abuse. WHO, Geneva, 1990
11
different effects on people; some of these effects are more dangerous than others.
Injecting drugs is more dangerous than sniffing or smoking them
4
.
Many health problems and even deaths associated with such abuse are the result of a
complex interaction between the drug (and its pharmaceutical and toxicological
properties), the individual (his or her personality and health status), and the setting in
which the drug is taken. There is no doubt that every country in the world incurs
substantial costs as result of the direct and indirect damage caused by drugs and alcohol
5
.
Societies in all parts of the world have used substances that suppress pain and sorrow and
also provide pleasurable sensations when consumed
6
. People take drugs in different ways
from different societies. Drug users frequently abuse several different types of
substances
7
.
Nepal also is not untouchable from this phenomenon. Now heroin (brown sugar, smack),
codeine, morphine and numbers of other natural and synthetic mind altering drugs or
psychotropic substances are found to be in common use among both young and adult
Nepalese people
8
. Peer pressure, curiosity, frustration /to forget problems, and sub
cultural acceptances etc. are social reasons for drug abuse among Nepali youth
9
.
It is believed that Ganja (Cannabis), Bhang (seeds of cannabis) and Charesh (Hashish are
found in religious usage in Nepalese society.
People have been using these since very beginning. It has been clearly mentioned in the
Hindu's religious books that the God Shiva used to smoke such drugs for the meditation.
3
Dr. Shrestha, M.P., Sociological Aspects of Drug Dependence. SOVENIR: a first national; seminar & workshop on drug
abuse and addiction. HMG/Nepal and WHO, 1981
4
Drugs: A Parent's Guide, 1992
5
Gossop M. and Grant M., Preventing and Controlling drug abuse. WHO, Geneva, 1990
6
Gossop M. and Grant M., Preventing and Controlling drug abuse. WHO, Geneva, 1990
7
King, Michael B., AIDS and Mental Health. Illicit Drug Use and HIV infection. Cambridge University Press, UK, 1993
8
Ejam, Dilli Ram, Social cost of drug abuse: a study from Kathmandu, thesis submitted to TU Nepal, 1996
9
Fr. Gafney, T.E., Socio-cultural and economic aspects of drug abuse in Nepali society. SOVENIR: a first national; seminar &
workshop on drug abuse and addiction, HMG/Nepal and WHO, 1981
12
There are different types of drugs, which have different influential effects. The drugs
affect the central nervous system of human body when consumed. The drugs either they
are illicit and licit or prescribed; they belong to narcotic or psychotropic. Drug users
administrate the drugs through smoking, smelling, inhaling, swallowing, chasing and
injecting. The drug users who administrate the drug habitually through injecting are
known as Injecting Drug Users (IDUs)
10
.
This study was emerged for the fulfillment of Master's degree in Rural Development
combining only those drug users who administrate the drug habitually through injecting
as study population.
I.2. STATEMENT OF PROBLEM
Injecting drug use (IDUs), is a major component of HIV/AIDS epidemic throughout the
world. IDUs are found in more than 130 countries in the world. The drastic change in the
number of drug users and the pattern of drug use – a shift from non-injecting to injecting,
in South East Asia, including Nepal has aggravated the risk for HIV/AIDS among drug
users.
In Nepal more than double in comparison to the beginning of 1990s has increased the
number of drug users and among the drug users three quarters are IDUs.
The National Center AIDS and STD Control estimates that there may be between 40,000-
50,000 drug users from a population of about 20.9 million people in Nepal
11
. Out of them
20,000 are estimated to be Injecting Drug Users.
Kathmandu holds the largest urban conglomeration in Nepal and like the other big cities,
“a big city effect”, where the chance for illicit or quasi-licit activity is greater than in
other parts of the country, it is estimated that the number of IDUs is 15,000 or more here.
10
Dhital, Shambhu. Trends of drug use in Nepal: a presentation paper. LALS, Kathmandu, 1999
11
UNAIDS and UNDCP. 2000. Drug Use and HIV Vulnerability: Policy research study in Asia. Bangkok. UNAIDS and
UNDCP.
13
A rapid assessment in 1999 showed that HIV prevalence among IDUs nationwide is 40%
and in Kathmandu 50 %
12
. Out of IDUs tested in 1991, 1.6% was HIV positive
13
. In 1997,
out of total IDUs tested in Kathmandu, 50% were HIV positive
14
.
A recent survey has revealed that the prevalence rate for HIV/AIDS has risen to 68%
among IDUs in Kathmandu
15
. New epidemiological data suggest that HIV may be
increasing more rapidly than estimated. Nepal has entered into the stage of a
“concentrated epidemic “i.e. the HIV/AIDS prevalence consistently exceeds 5% in sub –
groups like IDUs, FSWs nationwide. IDUs are at risk to HIV/AIDS infection. This may
be due to their needle sharing behavior and/or unsafe sexual practice.
The cause for sharing needle might be- lack of knowledge about routes of transmission of
HIV/AIDS, unavailability of uninfected/new syringe when required, lack of money to buy
new syringe, social pressure or lack of environment to buy and store new syringe. Unsafe
sexual practice among IDUs might also be due to these same reasons.
This study aims at finding out the cause of the above mentioned “at risk “behavior. Drug
users also function as a “bridging group” i.e. a bridge for HIV transmission between a
core HIV risk group and the general population. Also, from the studies done in past
most of the drug users in Katmandu are of productive age group (72%) IDUs 20-30 years
in Kathmandu,
16
which is a threat to the country and usually mobile group who can
transmit HIV/AIDS to other parts of country.
Drugs are taken for the relief of pain, for the treatment of disease, to change mood to
soporific euphoria or to hyperactive exuberance, to find or to loose identity, to escape, to
forget and to explore
17
. The body and sometimes the mind can so crave these sensations
that their absence becomes intolerable and drives some users to extremes in order to
assuage the desire more (ibid). Some times drug is used without medical purpose, which
increases the physical and psychic dependence of users.
12
National Center for AIDS and STD Control (NCASC), Nepal
13
Karki B.B. 1999. RAR survey among drug users in Nepal. Paper prepared for the “The Harm Reduction
14
UNAIDS 2000, Oelrichs et al.2000, Furber et al 2001, Burrows et. al.2001
15
New Era. & FHI, 2003
16
Report for the Center for Harm Reduction, Jan 2001
17
World Drug Report, UNDCP, 1997:p9
14
In fact, the abuse of licit or illicit substance is rooted deeply in every society in the world.
The consequences of drug abuse have advanced the society in crucial situation. It has
created many critical problems in the society and adverse consequences in public health
as well as in social system of the society.
Some drugs have varied medical properties while most have doubtful medical values. But
the effects it imparts on an individual, especially after addiction, with behavioral,
psychosomatic, physical and nutritional changes, stress on economic and social wellbeing
and other consequences may pose serious health and social problems.
18
Beyond the economic poverty, and as consequence of it, drug users have suffered from
being deprived of normal balanced family life
19
.
Use of illicit drugs continues to expand in many countries, propelled by a powerful,
economic underworld
20
. Countries in all regions of the world have experienced rapid
increases in drug use, drug injecting and subsequent HIV epidemic, which began among
IDUs and moved to their sexual partners and onwards to the general community
21
.
In fact the world in the twenty-first century has been threatened by the epidemic of
HIV/AIDS. It has become clear that there are two major modes of HIV transmission:
First, through penetrative sexual contact, anal, vaginal, and possibly oral; and Second,
through the sharing of infected injecting equipment by intravenous drug users
22
.
Therefore, it is also clear that drug use has an intimate connection with HIV. The
connection occurs when drugs are injected, using contaminated equipment
23
.
Illicit drug use, in particular injecting drug use, is major component of the AIDS epidemic
throughout the world
24
.
18
Dr. Shrestha, M.P., Sociological Aspects of Drug Dependence. SOVENIR: a first national; seminar & workshop on drug
abuse and addiction. HMG/Nepal and WHO, 1981
19
Fr. Gafney, T.E., Socio-cultural and economic aspects of drug abuse in Nepali society. SOVENIR: a first national; seminar
& workshop on drug abuse and addiction, HMG/Nepal and WHO, 1981
20
King, Michael B., AIDS and Mental Health. Illicit Drug Use and HIV infection. Cambridge University Press, UK, 1993
21
Costigan, Genevieve, Manual for reducing drug related harm in Asia, Harm Reduction Center, Australia, 1999
22
Martin A. Plant, AIDS, drug and prostitution. Published by Routledge London, 1990
23
Cowal, Sally, Preventing the spread of HIV through Drug Injecting. Paper for the panel on Drug abuse and HIV/AIDS,
presented at UN's General assembly special session on drugs, New York, June 1998
24
Rana, Sujata, Harm Reduction in Asia. Report of Harm reduction workshop AHRN, Thailand, 1996 P.15
15
Injecting drug has played a critical role in the global diffusion of HIV-1 injection. There
is also increasing concern throughout the world about the complications such as Hepatitis
B and C, Syphilis, and other complications such as overdose among the IDUs
25
.
There are at least five and half million and possibly up to 10 million injecting drug users
in the world today ranging across 128 countries and territories up from around 80 years
ago
26
. By the end of 1996, injection of illicit drugs had been reported in over 121
countries in all regions of the world, with HIV transmission associated with injection
reported in at least 84 of these countries. This is substantial increase over the 52 countries
known to have HIV-1 infection among IDUs
27
. Therefore, it can be assumed that
phenomenon of injecting drugs as well as HIV diffusion among and from IDUs'
communities is spreading out all over the world rapidly like diffusion of new fashion in
the market.
Nepal is not also untouchable from this phenomenon. It has been facing the problem of
drug trafficking and drug abuse since the beginning of 1970s
28
. The consumption of
opium and its derivatives has been found to be decreasing among the drug users but the
use of pharmaceutical drugs is increasing in an alarming proportion in Nepal. Increased
use of psychotropic drugs is due to the easy availability and low price. Psychoactive
drugs are smuggled into Nepal from India. Codeine based cough syrup, Burpernorphine,
Diazepam, Nitrazepam, etc. are the common psychotropic drugs, which are sold and
consumed locally. The quantity of psychotropic substances seized by the law enforcement
agencies is increasing every year. The problems of drug abuse are localized especially in
the urban and semi urban areas. However, there have been few instances of drug abuse in
rural parts as well (ibid).
Though people have been using Cannabis and Hashish since very beginning, people
started to look the drug use as problem from the 60's when Hippies entered in Nepal with
drug abuse culture. At mid of 70's, there were only 50 drug users in Nepal
29
, whereas at
the present time, it is estimated that there are about 50,000 drug addicts in Nepal out of
25
Rapid Assessment and Response Guide. WHO, Geneva, 1994
26
Cowal, Sally, Preventing the spread of HIV through Drug Injecting. Paper for the panel on Drug abuse and HIV/AIDS,
presented at UN's General assembly special session on drugs, New York, June 1998
27
Rapid Assessment and Response Guide. WHO, Geneva, 1994
28
Narcotic Control Bulletin. Year 9 No. 1 (Jan-Dec. 1999)
29
Dr. Bhandari, Bishnu, Status of Drub abuse and its prevention: from United Nations to nepal. Drug Abuse in Nepal:
Prevalence, Prevention, Treatment and Rehabilitation. Drug Abuse Prevention Nepal (DAPAN), Kathmandu, 1988b
16
which 20,000 use injection and possibly about 50% of them are already HIV positive
30
.
At the beginning of 90s the prevalence of HIV injection in IDUs' population was only
1%
31
, whereas in 1999, the prevalence of HIV infection in IDUs' population was about
40%
32
.
As of February 29, 2000 the HIV infection report was 1468, out of which 1018 were male
and 450 female. 325 cases (215 male and 110 female) were identified at full-blown stage
of AIDS, and 140 persons have died. The heterosexual transmission was found prominent
among the total reported cases whereas injection drug use was another cause of infection.
The report shows that 174(173 male and 1 female) injecting drug users (IDUs) were
infected with HIV. Available data show that HIV has attacked those people who are at the
age of economically active age in life.
As of July 31, 2005 the HIV infection report was 5,201, out of which 3,790 are male and
1,411 are female. 901 cases (649 male and 252 female) were identified at full-blown stage
of AIDS, and 257 persons have died. The report shows that 1017 (1002 male and 15
female) injecting drug users (IDUs) were infected with HIV
33
.
There are different and various modes of drug use such as: sniffing, smoking, swallowing,
drinking, chasing and injecting. The use of drugs is injurious to health and harmful in the
way of social, moral, legal and financial, but the use of drugs through injecting is more
vulnerable to HIV and other blood-borne viral infections.
The available events show the increasing trends of drug users' population, and most of
drug users are changing their drug use modes from smoking, inhaling and chasing to
injecting because of easily available and cheap price of Tidigesic (a kind of injecting drug
which belongs with Buprenorphine). On the other hand, the diffusion of HIV is spreading
out rapidly among and from IDUs' community.
Government and other international/national NGOs have taken the initiation to implement
and support harm reduction program for the prevention of AIDS epidemic and other
blood borne viral infections among and from IDUs' communities. Harm reduction began
as a strategy to directly intervene into IDUs' communities and allow drug users to adopt
30
Dr. Karki, BB, Rapid Assessment and Response survey among Drug users in Nepal, NCASC, Kathmandu, Nepal 1999
31
Costigan, Genevieve, Manual for reducing drug related harm in Asia, Harm Reduction Center, Australia, 1999
32
Dr. Karki, BB, Rapid Assessment and Response survey among Drug users in Nepal, NCASC, Kathmandu, Nepal 1999
17
risk reduction practices that would prevent the spread of HIV
34
. Harm reduction was
introduced in Nepal by Lifesaving and Lifegiving Society (LALS), a Kathmandu based
NGO, at the beginning of 90s.
In fact, intravenous drug users (IVDU) which are known today as injecting drug users
(IDUs), however, are much less well organized socially or politically to seek appropriate
treatment and resist prejudice than are other groups. Despite increasingly positive
approaches o the management of drug use; they remain a singularly unpopular minority.
Prevention of HIV infection on IDUs may vary widely, even between adjacent
geographical areas, and depends on local patterns of needle and syringe sharing and on
the mobility of users. Nevertheless, they comprise the fastest growing group of people
with AIDS
35
.
However, the community of injecting drug users (IDUs) is in crucial stage at the present
time. There is no any effective intervention for IDUs. There is no proper account and
study of IDUs. Although very few organization s are working with them, their initiations
are not extensive and effective. IDUs are underground in the community. They are
isolated from the civil society regretting their own mistakes and accepting the prejudice
from society. In the result the population of IDUs as well as diffusion of HIV is
increasing rapidly.
Many scholars have done their studies on drug abuse problem selecting all modes of drug
uses as respondents of the study. There are not more specific and proper studies and
information to analyze IDUs with their knowledge and risk behavior and drug use
patterns. In fact, there is very limit academic research study on this population.
I.3. RATIONALE
Abuse of drug is a crucial phenomenon in Nepali society, which has advanced the society
towards critical situation. Available evidence and data show the increasing trend of
population of IDUs in the country. On the other hand, HIV and other viral infections are
spreading out rapidly among and from the IDUs' population.
Though very few initiations have been executed for the prevention of drug abuse, they are
33
National Center for AIDS and STD Control (NCASC), Cumulative HIV/AIDS Situation in Nepal since 1988 as of July 31,
2005 (www.ncasc.gov.np)
34
Rana, Sujata, Harm Reduction in Asia. Report of Harm reduction workshop AHRN, Thailand, 1996
18
not enough and effective to draw the attention of people against drug abuse. Law
enforcement has executed effective legal provision, but the supply of drugs has fulfilled
the demand of drug users as required. Some national and international NGOs have
launched the harm reduction program for the reduction of drug related harm as well as for
the prevention of HIV and other viral infection among and from IDUs' communities.
Although Harm Reduction program is essential and successful intervention for the
prevention of drug related harm and HIV transmission among and from IDUs population,
it is considered as a conflict approach. Because harm reduction allows IDUs to adopt risk
reduction practices, which looks like illegal activities in the legal and social context.
However, IDUs are those who administrate drug through injecting, and the population of
IDUs is considered as a more vulnerable population of HIV and other viral infection.
There are limited proper and specific studies on IDUs' population.
Although the study was emerged to fulfill the requirement of Master's degree in Rural
Development, the findings of the study can be useful for program managers and
organizations for the implementation of HIV/AIDS prevention program among and from
IDUs in Nepal. Because of the study gives clear illustration on knowledge and risk
behavior of IDUs.
1. This study aims at finding the risk behavior among IDUs; therefore, it will make
significant contribution to the following:
2. Give the picture of the socio- economic, demographic characteristics of IDUs
that might work as guideline to those working for/with IDUs.
3. The study will reflect the risk behavior and knowledge regarding HIV/AIDS, STI
and Hepatitis of IDUs served by Siddhi Memorial Foundation (SMF), Bhaktapur,
thus facilitating the organization to evaluate program effectiveness.
4. Most of the research done in this area is concentrated in general IDUs. This
research will try to find out risk behavior of drug user served by SMF so that new
program can be designed according to the findings of the study.
I.4. EXPECTED OUTCOME OF THE RESEARCH
This research will study the demographic characteristics of the IDUs .It will identify the
existing awareness of IDUs on HIV/AIDS and their practice of the “at risk behavior. It
35
King, Michael B., AIDS and Mental Health. Illicit Drug Use and HIV infection. Cambridge University Press, UK, 1993
19
will help to explore the common causes of why IDUs practice “at risk” behavior. It could
be helpful to other researchers to further research in this topic and assist to carry out
similar research in similar areas. The results of the study will be useful to the concerned
institution, local community, the DPHO, NGOs/INGOs working for the IDUs and the
central level to plan and conduct activities effectively now and in the future.
I.5. UTILIZATION OF THE REASEARCH FINDINGS
Organization working on Harm Reduction among IDUs can prioritize and strengthen their
further activities on the basis of need and gaps supplemented by the research. Findings
will be useful to the further researcher in the related topic Findings can be used by the
social workers, DPHO and any health agencies planners, policymakers working in the
related field.
I.6. OBJECTIVES OF THE RESEARCH
I.6.1. General Objective
To investigate the knowledge and behavior in relation to the risk of HIV/AIDS among
Injecting Drug Users (IDUs) of Bhaktapur district.
I.6.2. Specific Objectives
1. To study the socio-demographic background of the injecting drug users;
2. To investigate drug using behavior of IDUs;
3. To assess knowledge of HIV/AIDS, STI and Hepatitis among IDUs;
4. To explore the "at risk" behavior among injecting drug users “At risk” behavior –
a. needle/syringe exchange/sharing and b. unprotected sex (sex without condom
use).
I.7. Limitation of the Study
The study was limited to Injecting Drug Users (IDUs) served by Siddhi Memorial
Foundation, Bhaktapur. Information collected were base on only interview with clients,
observation and publications of the Siddhi Memorial Foundation, Bhaktapur.
20
The study has tried to assess knowledge and risk behavior of IDUs in the present time.
The study is sociological; and the analysis of data has been consisted within broader of
social parameters.
The study may not reflect the health pattern of IDUs in depth except the drug use
behavior, sexual behavior and knowledge about HIV/AIDS, Hepatitis and STI in general.
The study has comprised only those drug users who administrate drug habitually through
injecting.
I.8. Structure of the Study
The study has been structured into seven chapters. The first chapter includes background
of the study, statement of problem, rational, expected outcome of the research, utilization
of research findings, objectives of the research, limitation of the study, structure of the
study.
The second chapter accounts a review of existing literature. The third chapter outlines the
details of methodology applied for the study. Findings have been presented in the fourth
chapter, whereas general discussions have been made in the fifth chapter.
The chapter six presented the summary, conclusion and recommendations and
Questionnaire is inserted in the seventh chapter - Annexure. The lists of reference
materials, books, reports, are included under Bibliography section in eighth chapter.
21
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