India's injecting drug problem may be worse than thought, a new survey of the country's breadbasket region shows, worrying health experts and activists who say it could fuel the spread of HIV and AIDS.
The UNAIDS-backed survey by the Society for Promotion of Youth and Masses (SPYM) - a group fighting drug abuse - showed that nearly 60 percent of 3,300 drug users in 10 cities and towns in Punjab and Haryana shared needles and syringes.
The prosperous region - home to around 50 million people - was not known for injecting drug users (IDUs), and the survey is the first large-scale mapping in the area.
"This shows the problem of IDUs has been underestimated in mainland India, as most of the problem was thought to be in the northeast," Denis Broun, the India head of UNAIDS, the United Nations AIDS agency, told Reuters.
Official estimates say there are about 200,000 IDUs in India, a figure activists say is a huge underestimate. The problem is seen as most acute in the remote northeast, which borders Myanmar and the opium-producing Golden Triangle.
India has the world's largest number of people living with HIV with 5.7 million people thought to be infected, although findings of a new population-based national survey have indicated that the actual figure could be lower.
In other parts of Asia, injecting drug use has fuelled the HIV epidemic. But India's state-run National AIDS Control Organisation (NACO) says drug users are responsible for just 2.2 percent of HIV transmissions.
UNAIDS says this number may now need to be looked at again.
"This survey points out that the IDU transmission figure is likely to be higher than 2.2 percent," Broun said. "The percentage for IDU transmissions may be relatively small but if there are more IDUs than thought, it could be a major transmission route in the future."
Many drug users in India are married or visit sex workers, presenting an HIV risk to their partners, Broun added.
"WAKE UP CALL"
In Jind, a small town of 135,000 people in Haryana, nestled amid wheat and rice fields, ignorance about HIV seems common among drug users.
"HIV? AIDS? What's that?" asked 23-year-old Jasvinder, who can barely move his right arm because of his injecting habit, at the sole drug rehabilitation centre in the town, 130 km northwest of New Delhi.
"This is a wake up call for the country which, till now, has focused on the northeast and big cities," said Atul Ambekar, a drug rehabilitation expert who is analysing the survey data.
Official data shows that more than 10 percent of intravenous drug users have HIV, a higher prevalence than among prostitutes, while the overall national average is about 0.9 percent for those aged between 15 and 49.
While efforts to combat the spread of HIV among drug addicts have concentrated on the northeast and in big cities, the SPYM survey reveals India's rural heartland is no longer immune from the threat.
In Ludhiana, an industrial city in Punjab, official data shows 21 percent of injecting drug users are HIV-positive. Yet many are unaware of the risks of injecting.
"I know AIDS is a disease that can cause death but I never dreamed it can come through a needle," said 23-year-old Jagdev Singh, a farmer who regularly shoots morphine into his veins with the same needle his friends use.
In Jind, the rehab centre's director, Dilbag Duhan, said he was struggling to deal with the number of addicts coming for help. "This is becoming a huge headache," he said.
On the other hand, a crackdown on narcotics has pushed people to inject legal painkillers like morphine and sedatives, which are available without a prescription, further fuelling injecting drug use, said Rajesh Kumar, the head of SPYM.
NACO chief Sujatha Rao said the government planned to step up efforts to stop HIV transmission through drug use in Haryana and Punjab by promoting oral drug substitutes and by setting up more testing, drug counselling and rehab centres.
"We have to watch this trend very carefully ... as cheap pharmaceuticals are available over the counter, people have money and little to do, and there is peer pressure," she said.