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Country Profiles
State of the HIV Epidemic: Afghanistan, Bangladesh, India, Myanmar, Nepal, Pakistan (Source:Concept Note/IDU Consultation/World Bank/April 2007)
Afghanistan
Afghanistan is in an early stage of the HIV epidemic, but with high potential for rapid spread. Action is urgently needed to break transmission, especially among IDUs and their partners, and among other vulnerable groups at high risk. The absence of a robust and reliable surveillance system makes it difficult to determine the size of the problem with any precision although there are an estimated 920,000 drug users in Afghanistan, of whom 19,000 are IDUs. A recent survey found that 3% of IDUs in Kabul are HIV positive and behavioral surveys point to a high risk behavioral environment.
A critical contributor to the high risk and vulnerability for HIV is the recent increase in opium production, Afghanistan being the world's largest producer. In addition, prolonged war and insecurity, poverty and cross border migration have led to increased drug use and vulnerability to HIV infection. A survey conducted by UNODC and the Ministry of Counter Narcotics estimated in 2005 that the number of opium and heroin users in Kabul increased by 220% and 235% respectively between 2003 and 2005. Furthermore, returnees account for nearly one third of heroin users and opium users in Afghanistan.
HIV prevention to date has been very weak, although a few NGOs are reaching out to high-risk populations on a small scale with harm reduction programs, including needle exchange programs. Initial efforts are also under way to integrate HIV/AIDS services in the government's basic package of health services, aiming to cover 90% percent of the population.
Bangladesh
Bangladesh has low HIV prevalence but significant risk behaviors. Data from Bangladesh's second generation HIV surveillance system indicate that HIV prevalence among the most vulnerable groups has remained relatively low with the highest prevalence in IDUs with an average of 4%. Behavioral sentinel surveillance among high risk groups showed low levels of risk perception, high rates of risk behavior, low condom use, and high levels of symptoms associated with STIs. WHO and UNAIDS estimated the number of people with HIV in Bangladesh at about 13,000 at the end of 2003.
CARE/Bangladesh started a needle/syringe exchange program (NEP) in Dhaka in 1998 covering approximately 880 IDU. By 2004, IDU in 19 districts of Bangladesh were reached and the number of IDU in Dhaka being reached had increased to approximately 4,400. CARE/Bangladesh's intervention program for IDU also has an advocacy component. Advocacy is done with members of the community, law enforcing agencies, policy makers from the government, general community leaders, NGOs, and Development Partners. Special local level advocacy meetings are held at the community level when problems are faced in the field.
India
India's HIV epidemic is highly heterogeneous and poses risks and challenge in the form of many local concentrated epidemics. Mapping studies provide some evidence of substantial pockets of high-risk networks including injecting drug user networks that are primarily concentrated in the northeastern states (Manipur, Mizoram, and Nagaland), where they have ignited major epidemics. With the rapid expansion of the HIV epidemic among IDUs in northeastern states, a growing number of women, many of them widows of men who have died from AIDS related illness, engage in sex work. This emerging pattern will likely amplify the epidemic and require a more comprehensive prevention strategy.
Targeted intervention programs for high-risk groups - including IDUs - have been a cornerstone of the National AIDS Control Organization's response to HIV, however the pace and approach of scaling up these high-impact interventions require adjustment to interrupt the expansion of concentrated epidemics across India. NGOs and CBOs implement most targeted interventions, but the content and quality of interventions vary and critical gaps exist: few targeted interventions focus on IDU (outside of the northeast), and NGOs face challenges in project design and implementation. A concerted effort is required to develop strategies involving peer education and implementation capabilities for rapid expansion of interventions targeting IDUs.
Myanmar
By 1989, HIV prevalence among IDU in Yangon had reached 73%, and since then, HIV prevalence among IDU tested in Yangon and Mandalay has ranged from over 50% to 85%. In 2002, consensus was achieved on an operational plan for scaling up effective interventions for reducing HIV among IDU. Current activities are thought to cover 85% of the drug dependent population. The ministries of Health and Home Affairs have worked with UN agencies and NGOs to establish pilot programs with a focus on NSP, outreach, methadone substitution therapy and advocacy.
Nepal
Surveillance of HIV, STIs, and behavior in Nepal has been neither systematic nor continuous, and a coherent, comprehensive perspective of the epidemic across the country is difficult to ascertain. However, it is certain that Nepal has the potential for a substantial HIV epidemic, especially among high risk groups including IDUs where HIV prevalence is estimated at 45%. Injecting drug use occurs across the country and significantly overlaps with commercial sex. As with other South Asian countries, injecting drug use, as well as female and male sex work, is likely to continue to drive the HIV epidemic in Nepal, particularly in light of the nexus between injecting drug use and sex work. There is, therefore, an urgent need to increase targeted interventions for female SWs, MSM, and IDUs.
Pakistan
According to UNAIDS estimates, about 85,000 people, or 0.1 percent of the adult population in Pakistan, are infected with HIV. Although overall HIV prevalence is low, there is growing evidence of substantial high risk groups which could contribute to local concentrated epidemics.
The number of drug dependent people in Pakistan is estimated to be about 500,000, of whom an estimated 60,000 inject drugs (12%). In 2005, 8% of IDUs in Larkana were HIV-positive, as were at least 6% in Faisalabad, Lahore, Sargodha and Sialkot. The majority of these IDUs were either married or sexually active. In Karachi, 26% of IDUs participating in a 2005 study were HIV-positive. The common risk factor for the majority of infected drug users was that they shared nonsterile injecting equipment. Awareness among IDUs on HIV transmission routes is relatively low and about half of the IDUs in the Karachi study said they had used non-sterile injecting equipment in the previous month.
Pakistan's NACP plans to reach 27,000 IDUs through service packages. The services are already established in Karachi, Lahore, Rawalpindi, Peshawar, Faisalabad, Sialkot, Sargodha and Quetta. Two projects working with IDUs under the national program report that that 28.4% of IDUs were reached and received some kind of harm reduction intervention during 2004-05.
