Bangladesh has 20,000 - 40,000 injecting drug users (NASP working group on size estimation of HIV infection in Bangladesh, March 22, 2004; final estimate recommended by the same group in Nov 28, 2004). Risky injection and sexual practices among IDUs, including needle and syringe sharing, multiple sexual partners and unprotected sex, have been identified as factors underlying the rapid spread of HIV/AIDS among IDUs and their partners
[2]. HIV prevalence among IDUs has seen a steep rise; infection rate among intravenous drug users escalated from 1.7% in 2001 to 4% within a year
[3]. To deal effectively with HIV in Bangladesh, International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B) has recommended among several steps that "Oral drug substitution treatment needs to be introduced urgently".
India
Rapid Situation Assessments conducted in two rounds found a rising proportion of IDUs in 14 cities
[4]. A small proportion of women and prisoners injected drugs. About 14.3% of those seeking treatment reported having ever injected drugs
[5]. Data from the National Household Survey reports that about 0.1% of the sample population had ever injected drugs. Among drug users on the street, about 43% were injecting drugs
[6]. Sharing of injection equipment including needles, syringes, water, cotton, use of contaminated needles and incorrect cleaning practices has been observed at sites across the country. In addition to risky injection practices, unsafe sexual activity is also reported among IDUs
[7]. At the same time, IDUs did not perceive themselves to be at risk of HIV transmission and only a small proportion has reportedly undergone HIV testing
[8]. The risk of HIV infection to wives/sexual partners of IDUs on account of low condom use has been viewed as a serious public health concern
[4]. HIV prevalence among IDUs varies widely across cities. While seropositivity among injectors was found to be as high as 80.7% in Imphal, in Kolkata only 2% of IDUs were HIV positive
[9]. In some of the north-eastern states, the spread of HIV/AIDS to the general population has been attributed to HIV infection among IDUs
[4]. According to NACP-III, national epidemiological data attributed 2.24% of total HIV infections to injecting drug use
[10]. Moreover the expert group which carried out size estimations of the core groups at risk in 2006, was of the opinion that the future of India's HIV epidemic depends on the scope and effectiveness of programmes for three high risk groups, including the sex workers, men having sex with men (MSM) and IDUs.
Maldives
The first HIV positive case in the Maldives was reported in 1991. Till mid-2006, a total of 13 HIV positive cases had been reported among Maldivians and 168 cases among expatriates. According to the report on 'The HIV/AIDS situation in the Republic of the Maldives in 2006'
[11], drug use is on the rise and injecting drug use is becoming more common. NNCB estimates that there are around 3000 drug users in Maldives, but unofficial estimates by the NGO Journey put the number at around 8000 drug users. Injecting drug use was indicated to be practiced by 8% of drug users in 2004, and research in 2006 indicated that this could be as high as 20%. However, in Male it was estimated that nearly 25% of drug users were injecting. Other high-risk behaviour like needle sharing is known to occur frequently. The report also mentions the link between sex work and drug use. Given this scenario, the report says that "rising prevalence of injecting drug use, combined with needle/syringe sharing, is the most likely entry point for the HIV epidemic in the Maldives". The report on the 'HIV/AIDS situation in the Republic of the Maldives in 2006' recommends that "of critical importance is introducing harm reduction interventions at an early stage to prevent introduction of HIV into this community (of drug users)". Specifically, the report recommends two pilot programmes for drug users - one on Needle Syringe Programmes and a program to use methadone. Further the final draft of the National Strategic Plan on HIV/AIDS, Republic of Maldives, 2007-11
[12] proposes that: "Drug users and their sexual partners will receive prevention services with the priority on drug users who inject drugs. They will receive comprehensive prevention and support services both in the community and closed or custodial settings."
Nepal
The first HIV positive case was identified in Nepal in 1988. With consistently increasing prevalence of more than 5% in certain groups (injecting drug users, migrants), years after years, the country has remained at a critical juncture of concentrated epidemic
[13]. Recent integrated bio- behavioral surveys (IBBS) indicate that HIV prevalence among IDUs to be 51.6% in Kathmandu, 31.7% in eastern Tarai districts and 21.7% in Pokhara
[14]. The estimated number of IDUs in Nepal is 19, 850 and it is estimated that approximately 1707(8.6%) of the IDUs are covered by various harm reduction interventions
[15]. At present, adequate provision of oral substitution treatment (OST) as a core element in the package of harm reduction services for HIV prevention intervention among IDUs remains a critical gap in Nepal. The Methadone Maintenance Treatment (MMT) is the most acknowledged and extensively researched programme in Nepal. MMT was implemented successfully during 1994-2002 by the Patan Mental Hospital in Kathmandu Valley for 400 clients and proved to be an effective intervention. However this programme was discontinued in 2002. This programme also influenced the development of the National policy guidelines for oral substitution therapy in Nepal in 2002. Recently there was an immediate discontinuation of the MMT programme in the country in May 2007, thereby endangering the lives of IDUs who were clients of the private practitioners. At the same time, there is a high level of commitment on the part of the civil society and the government to roll out MMT in the country. UNODC as one of the cosponsor for UNAIDS, is the lead agency within the UN system for providing on going technical guidance and policy advice to the government of Nepal on HIV/AIDS prevention, care, treatment and support for Injecting drug users (IDU). As a result of the reports in the international media, UNODC stepped in to conduct a needs assessment of the situation and developed a three phased response in consultation with the government, UN, donors, and the civil society. UNODC was given a go-ahead by Ministry of Home Affairs (MoHA), Ministry of Health & Population (MOHP), National AIDS Centre, civil society, UN, donors, Narcotic Control Board etc. - to immediately start the emergency response (Methadone) for IDUs. Both MoH and MOHP have agreed to fast track the approval process and remove all bureaucratic bottle necks.
Pakistan
According to the National Drug Abuse Assessment Study conducted by the government, in association with UNODC in 2000/01, there are an alarming 500,000 chronic heroin users, including drug injectors (15% or 60,000) in Pakistan
[16]. IDU is reported to be an urban phenomenon and on the rise. 60,000 drug users are reported to inject
[17]. Of these, 64% are reported to share injection equipment indicating an imminent threat of exploding HIV/AIDS and Hepatitis C epidemics. 2.19% cases of HIV/AIDS have been attributed to injecting drug use.
