Participant Manual
Module 1
Drug Use and HIV in Asia Treatment and Care for HIV-Positive Injecting Drug Users
Regional Office for South-East Asia
Family Health International
Module 1
Drug use and HIV in Asia Participant Manual
2007
The Association of Southeast Asian Nations (ASEAN) was established on 8 August 1967. The Member States of theAssociation are Brunei Darussalam, Cambodia, Indonesia, Lao PDR, Malaysia, Myanmar, Philippines, Singapore, Thailand and Viet Nam. The ASEAN Secretariat is based in Jakarta, Indonesia. For inquiries, contact The Public Affairs Office, The ASEAN Secretariat, 70A Jalan Sisingamangaraja, Jakarta 12110, Indonesia, Phone: (62 21) 724-3372, 726-2991, Fax: (62 21) 739-8234, 724-3504. E-mail: public@aseansec.org. General information on ASEAN appears on-line at the ASEAN Website: www.aseansec.org. Catalogue-in-Publication Data Treatment and Care for HIV-Positive Injecting Drug Users Jakarta: ASEAN Secretariat, December 2007 616.9792 1. ASEAN – USAID 2. HIV – Drugs – Modules ISBN 978-979-3496-63-4 (NLM classification: 503.6)
This publication is available on the internet at www.aseansec.org, www.fhi.org and www.searo.who.int/hiv-aids publications. Copies may be requested from: The ASEAN Secretariat, 70A, Jl. Sisingamangaraja, Jakarta 12110, Indonesia. e-mail: public@aseansec.org and Family Health International, Asia/Pacific Regional Office, 19th Floor, Tower 3, Sindhorn Building, 130–132 Wireless Road, Lumpini, Phatumwan, Bangkok 10330, Thailand, e-mail: sunee@fhibkk.org and HIV Unit, Department of Communicable Diseases, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi-110 002, India, e-mail: hiv@searo.who.int Module 2: Comprehensive services for injecting drug users – participant manual Module 3: Initial patient assessment – participant manual Module 4: Managing opioid dependence – participant manual Module 5: Managing non-opioid drug dependence – participant manual Module 6: Managing ART in injecting drug users – participant manual Module 7: Adherence counselling for injecting drug users – participant manual Module 8: Drug interactions – participant manual Module 9: Management of coinfections in HIV-positive injecting drug users – participant manual Module 10: Managing pain in HIV-infected injecting drug users – participant manual Module 11: Psychiatric illness, psychosocial care and sexual health – participant manual Module 12: Continuing medical education – participant manual Trainer manual: Treatment and care for HIV-positive injecting drug users © ASEAN Secretariat 2007
All rights reserved. The text of this publication may be freely quoted or reprinted with proper acknowledgment.
Typesetting and Design: Macro Graphics Pvt. Ltd. Printed in India
Acknowledgements This training package was prepared for the USAID Cooperation with the Association of Southeast Asian Nations (ASEAN) by Family Health International (FHI) and the World Health Organization, Regional Office for Southeast Asia. Oversight and supervision on behalf of ASEAN in the preparation of the curriculum were provided by: Ms Moe Thuzar, former Assistant Director of the ASEAN Secretariat; Dr Bounpheng Philavong, ASEAN Secretariat; and the following representatives of the ASEAN Coordinating Country Malaysia: Dato Dr Haji Ramlee bin Haji Rahmat; Dr Hjh Rohani bte Ali; Dato Dr Faisal bin Haji Ibrahim; Dr Mohd Nazlee bin Abdullah. We would like to thank the ASEAN Task Force on AIDS for their comments in particular Lao PDR (Chair of ATFOA 2005-2007), Cambodia (Past Chair of ATFOA 2003-2005), Malaysia (Coordinating Country) and the ASEAN Secretariat for their review and kind comments on the modules during their meeting in May 2007 in Bangkok, Thailand. FHI and WHO express their sincere gratitude to the curriculum writing team: Kelwyn Brown, Indonesia HIV Prevention and Care Project; Rachel Burdon, FHI Viet Nam; Kathleen Casey, FHI Asia Pacific Regional Office, Thailand; Donn Colby, Viet Nam CDC Harvard Medical School AIDS Partnership, Viet Nam; Erik Fleischman, consultant, Thailand; David Jacka, former staff of WHO Indonesia; Lu Gougan, consultant, China; Bradley Mathers, National Drug and Alcohol Research Centre, Sydney, Australia; Michael McDonough, consultant, Australia; Anne Mijch, Royal Prince Alfred Hospital, Melbourne, Australia; Penny Miller, FHI Asia Pacific Regional Office, Thailand; Emanuele Pontali, consultant, Italy; Mukta Sharma, former staff of FHI Bangladesh; Nick Walsh, Turning Point Alcohol and Drug Centre, Melbourne, Australia. We thank the following contributors who reviewed the curriculum: Dr Chansy Phimphachanh, Chairperson ASEAN Task Force on AIDS; Dr Hjh Rohani bte Ali, Ministry of Health Malaysia; Dr Salmiah Sharif, Klinik Kesihatan Batu, Selangor, Malaysia; Palani Narayanan, consultant, Malaysia; Tuti Parwati, Rumah Sakit Sanglah, Bali, Indonesia; Emanuele Pontali, consultant, Italy; Michael McDonough, former consultant, Australia; Dr M. Suresh Kumar, consultant, Chennai, India; Gray Sattler and Michel Tailhades, former staff of WHO Regional Office for the Western Pacific. Sincere thanks also to Mukta Sharma for her management support in the final phase, Chris Parker, Bandana Malhotra and Graham Neilsen for editing the final draft, Annie Malcolm for her contribution and to Chunjira Wichai, Chutima Chomsookprakit and Sunee Sarif for their administrative support. Curriculum development coordinators: Penny Miller, FHI Asia Pacific Regional Office; Ying-Ru Lo, WHO Regional Office for South-East Asia. The development of this curriculum was funded by USAID under the Implementing AIDS Prevention and Care (IMPACT) Project, which is managed by FHI under Cooperative Agreement HRN-A-00-97-00017-00.
Contents Foreword.............................................................................................................................................................................vi A Message from the Secretary-General of ASEAN ............................................................................................ vii Abbreviations and acronyms.................................................................................................................................... viii How to use this curriculum...........................................................................................................................................ix Module 1: Drug use and HIV in Asia............................................................................................................................1 Overview................................................................................................................................................................................ 1 What are drugs?................................................................................................................................................................... 2 Global drug use................................................................................................................................................................... 2 Drug use in Asia................................................................................................................................................................... 3 Drug production and trafficking in Asia..................................................................................................................... 3 How people take drugs.................................................................................................................................................... 3 Drugs that are commonly injected in Asia................................................................................................................ 5 References and recommended reading..................................................................................................................... 6
Annex 1: PowerPoint presentation 1: Drug use and HIV in Asia.......................................................................8
Foreword There is a high risk of widespread transmission of HIV in Asia, not only because of the large size of the population and the high burden of sexually transmitted infections but also due to the prevailing risk behaviours and vulnerabilities. The use of heroin and opium as well as cannabis and hashish are quite common throughout Asia. Heroin is most commonly used in various countries of the Mekong Basin region, and the favoured method of administration is by injecting. The proportion of those injecting heroin does, however, vary from place to place and in different cultural and social settings. Data suggest that about 50% of heroin users take to injecting once they get over the initial phase of consumption through smoking or inhalation. In the late 1990s, amphetamine-type stimulants had increasingly become a drug of choice in Cambodia, China, Indonesia, Japan, Lao PDR, Myanmar, the Philippines, the Republic of Korea and Thailand. HIV spreads most rapidly among injecting drug users (IDUs) when injecting equipment is shared between many people – a widespread practice in many countries. In places with a drug culture where IDUs gather at one place to inject, the sharing of one needle between three to even 50 participants can be common. It is not the drug use or even the actual injecting of the drug that causes HIV infection; it is the sharing of contaminated injecting equipment that transmits the virus. In Asia, studies have shown an overlap between sex work and injecting drug use with a substantial proportion of male IDUs buying sex, male and female IDUs selling sex, and sex workers injecting drugs. HIV transmission through injecting drug use has kickstarted the epidemic in many countries of Asia. Half the number of all IDUs in Asia today are infected with HIV and in need of care, support and antiretroviral therapy programmes. However, health-care providers, carers and families often have limited knowledge and skills in managing the health problems of IDUs and, in particular, of those who are already HIV-infected. Therefore, the ASEAN Task Force on AIDS, in collaboration with Family Health International and the World Health Organization Regional Office for South-East Asia developed this set of training modules for clinicians who provide treatment and care, including antiretroviral therapy, for HIV-positive IDUs. I am confident that physicians in Member countries will find this set of training modules both relevant and useful.
Samlee Plianbangchang, MD, Dr PH Regional Director
A Message from the Secretary-General of asean ASEAN is committed to preventing the further transmission of HIV and mitigating the impact of HIV and AIDS, by improving regional responses and enhancing Member Countries’ development of people-centred programmes. An important focus of ASEAN’s efforts has been in increasing access to treatment and care for HIV-positive injecting drug users (IDUs), who by far are the group most at risk in the transmission of HIV. As part of this initiative, the ASEAN Task Force on AIDS (ATFOA) has been working closely with the US Government under the ASEAN-USAID HIV and AIDS Cooperation Framework to develop a curriculum to train doctors and health givers in dealing with health problems experienced by HIV-positive IDUs such as hepatitis B, hepatitis C and tuberculosis. Overall, the curriculum identifies critical skills that will be needed by health givers and clinicians in ensuring that HIV-positive IDUs are provided with high-quality treatment. I would like to congratulate the ATFOA, USAID and all those who had contributed to this outstanding endeavour. This collaboration has put in place a milestone document which will enable ASEAN to carry out its task of preventing HIV and AIDS more effectively. I thank all involved for helping ASEAN forge a caring and sharing community.
Ong Keng Yong Secretary-General of ASEAN
Abbreviations and acronyms AIDS ART ARV acquired immunodeficiency syndrome antiretroviral therapy antiretroviral
ASEAN Association of Southeast Asian Nations ATS CDC DALY FHI HIV IDU LSD amphetamine-type stimulants Centers for Disease Control and Prevention (US Government) disability-adjusted life year Family Health International human immunodeficiency virus injecting drug user lysergic acid diethylamide
MDMA methylenedioxymethamphetamine MSM OTC men who have sex with men over the counter
PLWHA people living with HIV and AIDS SP sw spasmoproxyvon sex worker
UNODC United Nations Office on Drugs and Crime USAID WHO United States Agency for International Development World Health Organization
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How to use this curriculum What you should know before the course This course is designed for clinicians who provide care and treatment, including ART, for HIVpositive IDUs. As a participant, you should have clinical experience in providing ART before taking the course. It is expected that you will provide care and treatment to HIV-positive IDUs once you have completed this course.
Module structure The training course consists of 12 participant modules with PowerPoint presentations, a trainer manual and one CD-ROM which contains key references. Most modules are divided into submodules. The modules are structured in such a way that they can be used as individual blocks for a single training session and can be combined as needed for training requirements. This curriculum is not recommended for self-study but for training by trainers.
Training methodology The overall training approach used in these modules is based on adult learning theory and is a combination of lectures, discussions, small group work, interactive practical exercises and roleplays. It is recommended that this curriculum be delivered by trainers with extensive experience in the content of each specific module. It is acknowledged that this will limit the number of trainers able to deliver individual sessions.
Adaptation by countries and adoption as a national curriculum Technical writers from across Asia contributed to the curriculum. Countries should seriously consider adopting the curriculum for use in country-level training programmes. Countries are also encouraged to undertake any adaptation they feel is required for in-country use.
Additions, corrections, suggestions Do you want to suggest changes to this module? Is there additional information you would like us to include? Please write or e-mail us. We will collect your letters and e-mails, and consider your comments in the next update to this module.
Contact: Family Health International Asia/Pacific Regional Office 19th Floor, Tower 3, Sindhorn Building 130-132 Wireless Road, Lumpini, Phatumwan Bangkok 10330, Thailand Phone: +662 263 2300 E-mail: sunee@fhibkk.org www.fhi.org or World Health Organization Regional Office for South-East Asia Department of Communicable Diseases HIV/AIDS Unit World Health House Mahatama Gandhi Marg Indraprastha Estate New Delhi 110 002, India Phone: +91 11 233 70804 E-mail: hiv@searo.who.int www.searo.who.int or Asean ASEAN Secretariat 70 A, Jalan Sisingamangaraja Jakarta 12110, Indonesia Phone: +62 21 724 3372, 726 2991 E-mail: public@aseansec.org
Module
1 OVERVIEW
Drug use and HIV in Asia
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Objectives: By the end of the session participants will be able: To understand which drugs are used globally and their contribution to mortality and morbidity To understand the distinction between licit and illicit drug use To be familiar with the patterns of drug use in Asia To understand the connection between a change in the pattern of drug use and HIV transmission To be familiar with the regional epidemiology of drug use and HIV. Time to complete session: 1 hour Session content: What are drugs? Global drug use Drug use in asia Drug production and trafficking in asia How people take drugs Drugs that are commonly injected in asia Training materials: PowerPoint presentation 1: Drug use and HIV in Asia Evaluation form
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Drug use and HIV in Asia
What are drugs? It is important to know what is meant by the word “drugs.” People often have a different understanding of what drugs are and how they are classified. According to the Lexicon of alcohol and drug terms published by the World Health Organization: Drug: A term of varied usage. In medicine, it refers to any substance with the potential to prevent or cure disease or enhance physical or mental welfare, and in pharmacology to any chemical agent that alters the biochemical physiological processes of tissues or organisms. Hence, a drug is a substance that is, or could be, listed in a pharmacopoeia. In common usage, the term often refers specifically to psychoactive drugs, and often, even more specifically, to illicit drugs, of which there is non-medical use in addition to any medical use. Psychoactive drug or substance: A substance that, when ingested, affects mental processes, e.g. cognition or affect. This term and its equivalent, psychotropic drug, are the most neutral and descriptive terms for the whole class of substances, licit and illicit, of interest to drug policy. “Psychoactive” does not necessarily imply dependence-producing and, in common parlance, the term is often left unstated, as in “drug use” or “substance use” . Common usage distinguishes between licit and illicit drugs: (1) Legal (licit) drugs such as medications, tobacco, alcohol and coffee/tea (2) Illegal (illicit) drugs such as opium, heroin, cocaine, amphetamine-type stimulants (ATS), and cannabis (note: cannabis is an illicit drug in most countries in Asia but is a licit [legal] drug in countries such as Italy, Luxembourg, Portugal and Spain where personal cannabis use has been decriminalized).
Mortality related to illicit drug use Estimating the contribution of alcohol, tobacco and illicit substance use to the global burden of disease is gaining attention. Based on a standard of measurement known as disability-adjusted life years (DALYs), estimates of the burden imposed on society due to premature death and years lived with disability have been assessed. The global burden of disease findings by WHO show that tobacco and alcohol are major causes of mortality and disability worldwide, with the impact of tobacco expected to increase in many parts of the world. There is ample evidence to show that the burden of ill-health from the use of psychoactive substances, taken together, is substantial.
Global drug use It is estimated that 2 billion people globally use alcohol; approximately 1.3 billion smoke tobacco; and approximately 200 million people (5% of the adult population) use illicit drugs (2005). Cannabis is the most widely used illicit drug in the world with 158.8 million users (3.8% of the adult population), followed by ATS with 24.9 million using amphetamines and 8.6 million using ecstasy. Cocaine is reportedly used by 14.3 million (0.3% of the adult population), whereas opiates are used by 15.6 million (0.4% of the adult population) of whom 11.1 million (0.3% of the adult population) use heroin.
The content of this handout has been drawn largely from Module 2: Drug use and HIV/AIDS: Global and regional perspective, in: Reid G and Dorabjee J. Resource modules for trainers: Basic principles and practices of drug use related HIV/ AIDS prevention and care in the Mekong region. Melbourne, Centre for Harm Reduction, 2005.
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Drug use and HIV in Asia
Drug use in Asia Heroin and opium use as well as cannabis and hashish use have been common throughout Asia. In the late 1990s, ATS have increasingly become a drug of choice in Thailand, South Korea, the Philippines, Taiwan, China, Japan, Cambodia, Lao PDR and Indonesia. Ecstasy (methylenedioxymethamphetamine [MDMA]), a type of ATS, is commonly used in the Asian dance party scene. Buprenorphine, a type of drug that provides sedative effects, is reportedly used in India, Pakistan, Bangladesh, Nepal, Iran and China (to a leaser extent). Dextropropoxyphene (known as spasmoproxyvon) is widely used in the north-eastern Indian states. Most countries in Asia reported using mixed pharmaceuticals such as analgesics and tranquillizers. Solvents and glues are used by youth in India, Lao PDR, Indonesia, Mongolia, Viet Nam, the Philippines and Thailand (Reid and Costigan, 2002).
Drug production and trafficking in Asia The main drug-producing areas in Asia are known as the Golden Crescent (covering Afghanistan, Iran, Turkey and Pakistan) and the Golden Triangle (covering Myanmar, Thailand and Lao PDR). Many countries in the Region are criss-crossed by trafficking and transiting routes linking drugproduction zones to lucrative consumer markets. Iran is a major bridge for opium and heroin en route to the Persian Gulf, Turkey, Russia and Europe, and it is estimated that 32% of heroin seized in India has its origins in Afghanistan or Pakistan. Myanmar is the main producer of opium, heroin and ATS in the South-East Asia Region. While its production of opium has diminished in recent years, it remains the second-largest producer globally, surpassed only by Afghanistan (UNODC, 2006). Most heroin produced in Myanmar is now trafficked through China, rather than through Thailand; China is now the most important transhipment route for the international market (National Narcotic Control Commission China, 2004). Many nations in the Mekong Region have borders that are porous, remote, inaccessible, mountainous, some with extensive waterways and coastlines, and often undermanned and with inadequate customs services to monitor the heavy volume of people crossing certain land boundaries. China has recently become a major producer of methamphetamines for domestic use and has an established record of supplying to international markets, primarily Japan, South Korea, the Philippines and Taiwan. The production of methamphetamines in China appears to have accelerated with 1608 kg of the drug seized in 1999, increasing to 20000 kg by 2000. India still remains a transit route for heroin, hashish and morphine-base from Afghanistan, Pakistan, Myanmar and, to a smaller extent, Nepal. HIV infection has been shown to follow drug trafficking routes. In South-East Asia, HIV epidemics among injecting drug users (IDUs) started or spread rapidly on drug trafficking routes through Myanmar, China, Viet Nam, India, Thailand and Malaysia.
How people take drugs Drugs can be taken by smoking, snorting, ingesting (eating, drinking) or injecting. Not all drugs can be taken by all routes. Drugs that are commonly smoked or inhaled include tobacco, marijuana, opium, heroin, ATS and glue. Drugs that are commonly ingested or swallowed (as in drinking) include alcohol, opium, marijuana, sedatives (e.g. diazepam), buprenorphine and heroin (rarely). Drugs that are commonly injected include heroin, sedatives, ATS and buprenorphine. Cocaine is commonly snorted (inhaling into the nostril).
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Drug use and HIV in Asia
It is important to know that some people switch from one way of taking drugs to another (e.g. from smoking to injecting heroin). Some people also take a number of different drugs by different routes over a period of time (e.g. drinking alcohol, smoking tobacco, swallowing Ecstasy, or injecting heroin).
Chasing the dragon Chasing the dragon is a way of smoking heroin. The drug user puts powdered heroin on a piece of foil and heats it from below with a flame. The heroin turns to a sticky liquid and wriggles around like a Chinese dragon. Fumes are given off and are inhaled through a tube, or a rolled-up newspaper or magazine.
Injecting HIV spreads most rapidly among IDUs when equipment is shared between many people – a widespread practice in many countries. In places with a drug culture where IDUs gather to inject, the sharing of one needle between 3 and 50 participants can be common. It is not the drug use that causes HIV infection; it is not even drug injecting; it is the sharing of contaminated injecting equipment that transmits HIV infection. Pooling of money to purchase drugs and sharing of needles is common in Asia (Reid, 2002; Bezziccheri, 2004). There has been a marked increase in poly-drug use, for several reasons. When particular commonly used drugs are more difficult to access (often because drug seizures result in price increases), it is common for drug users to seek and use a range of alternatives to achieve the desired effect. Professional injectors (those who receive payment for injecting a client with an illicit drug) operate in Myanmar, Pakistan, India, Bangladesh, Nepal, Viet Nam and Malaysia (UNODC, 2006). Professional injectors rarely employ hygienic practices, and consequently HIV transmission among IDUs is inevitable. In Bangladesh, it has been shown that a professional injector will often use the same needle for 20–50 people with a needle changed only when blunt.
Profile of drug users Historically, opium smoking was a male phenomenon; this is still the case and the majority of drug users throughout South and South-East Asia are male. There has, however, been a rise in the number of female drug users in countries in recent years. This increase has particularly been recognized in association with female sex work in parts of China and Viet Nam. Cambodia, Lao PDR and Viet Nam all have substantial populations of street children who increasingly consume drugs, living precariously with little or no family support or guardians. A substantial proportion of illicit drug users are unemployed or underemployed and, while educational standards vary, large proportions have achieved a lower secondary education at best. Women injecting drug users Drug use among women in Asia is often considered a minor problem largely because the number of women classified as IDUs is estimated at 10% or less (Reid, 2002). It has been suggested, however, that this figure will increase and that monitoring of the situation needs to improve. In the developed world, such as the United States of America, United Kingdom and Australia, the proportion of IDUs who are women is often as high as 25%. In China, most drug users are men but the number of women using drugs is increasing. In Yunnan and Guangxi provinces women make up 16–25% of all drug users in treatment and tend to be younger than male drug users. Other countries in Asia where there are significant numbers of women IDUs include Nepal, India, Pakistan, Bangladesh, Indonesia, Viet Nam, Thailand, Sri Lanka, the Philippines, Taiwan, Japan and Malaysia.
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Drug use and HIV in Asia
In general: Women drug users are likely to have a male sexual partner who injects drugs. Women tend to be introduced to drugs by a husband/boyfriend or male member of their family. Access to drugs usually occurs through the male sexual partner. Women are more likely to share needles and to be injected by someone else. Women experience difficulty in avoiding drug use/abstaining/accessing drug treatment if the male partner is an active drug user. Female sex workers and injecting drug use In Asia studies have shown an overlap between sex work and injecting drug use with approximately half of female IDUs estimated to be sex workers (MAP, 2005; Tuan et al. 2004). In Guangxi province in China, 80% of female drug users are sex workers. Female IDUs may become involved in sex work to pay for their drugs. Female sex workers may use drugs. In some situations, brothel owners introduce sex workers to drugs. Also, women who are coerced or sold into sex work may resort to drug use.
Drugs that are commonly injected in Asia Heroin Where heroin is the drug of choice in various countries of the Mekong Region, the favoured method of administration is injecting. The rate of heroin injecting does, however, vary from place to place and in different cultural and social settings: once the initial phase of smoking and inhalation of heroin has generally passed, data suggest that around 50–60% of heroin users inject (Reid, 2002; Garten et al. 2004; Hammett et al. 2005; Mith Samlanh, 2002).
Buprenorphine Injecting buprenorphine is common in South Asia. Buprenorphine is produced in India and diverted to the illicit drug market. A study of drug sharing and injecting networks in Bangladesh found that most IDUs in Bangladesh inject buprenorphine, with sharing of equipment and drugs. Poorer users tended to report larger, more open drug-sharing networks (Rahman et al. 2004).
Amphetamine-type stimulants (ATS) Amphetamine-type stimulants (ATS) are generally ingested or smoked, but injecting of ATS, albeit in smaller numbers, has been identified in Thailand, China, Lao PDR and Cambodia (Lewis, 2003; Liu, 2002). As a street drug, amphetamines are usually sold as a powder that contains amphetamine mixed with other powders or drugs.
Dextropropoxyphene/Proxyvon These are synthetic opiates that are produced legally and sold over the counter. Spasmoproxyvon (SP) is the trade name for dextroproxyphene. It costs approximately one tenth of the price of heroin and is therefore used as a substitute. Proxyvon is commonly used by IDUs in north-east India (Mizoram, Manipur and Nagaland).
Midazolam tablets Midazolam, a fast-acting benzodiazepine, is increasingly used as a drug of injection in Bangkok. Midazolam tablets are crushed, dissolved in water, filtered and injected. Sharing of equipment is common. Abscesses, gangrene and vein degradation are common (Kiatying-Angsulee et al. 2004).
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References and recommended reading Aceijas C, Stimson GV, Hickman M, Rhodes T. Global overview of injecting drug use and HIV infection among injecting drug users. AIDS, 2004, 18:2295–2303. AIDS Project Management Group. Is there anyone left in the general population? Report prepared for the Open Society Institute. Sydney, Australia, 2005. http://www.afronets.org/files/APMG-OSIConcentrated-Epidemics-Report.pdf Beyrer C et al. Overland heroin trafficking routes and HIV-1 spread in South and South-East Asia. AIDS, 2000, 14:75–83. Bezziccheri S, Bazant W. Drugs and HIV/AIDS in South East Asia: a review of critical geographic areas of HIV/AIDS infection among injecting drug users and of National programme responses in Cambodia, China, Lao PDR, Myanmar, Thailand and Viet Nam. Bangkok: United Nations Office on Drugs and Crime, 2004. Brown T. What next? Epidemic dynamics in the Asian context. In: Pisani E, Marais H, eds. AIDS in Asia: face the facts. A comprehensive analysis of the AIDS epidemics in Asia. Bangkok, Monitoring the AIDS Pandemic (MAP) Network, 2004. Centre for Harm Reduction. Manual for reducing drug related harm in Asia. Melbourne, The Centre for Harm Reduction, Macfarlane Burnet Centre for Medical Research and Asia Harm Reduction Network, 2003. Garten R et al. Rapid transmission of hepatitis C virus among young injecting heroin users in Southern China. International Journal of Epidemiology, 2004, 33:182–188. Hammett M et al. Correlates of HIV status among injecting drug users in a border region of southern China and northern Viet Nam. Journal of Acquired Immune Deficiency Syndromes, 2005, 38:228–235. Kiatying-Angsulee N et al. Midazolam tablet injection in Bangkok: pattern of use and HIV risk behaviour. Poster for XV International AIDS Conference, 11–16 July 2004 (http://gateway.nlm.nih. gov/MeetingAbstracts/102283974.html. last accessed 18 June 2007). Kulsudjarit K. Drug problem in Southeast and Southwest Asia. Annals of the New York Academy of Sciences, 2004, 1025:446–457. Lewis DR. The long trip down the mountain: social and economic impacts of illicit drugs in Thailand. Bangkok, UNODC, 2003 (UNODC Publication No. 12/2004). Liu T, Hao W. WHO multi-site project in amphetamine-type stimulants evaluation report from China. Geneva, World Health Organization, 2002. Mith Samlanh-Friends. Drug use and HIV vulnerability. Phnom Penh, International HIV/AIDS Alliance, 2002. Monitoring the AIDS Pandemic (MAP) Network. MAP Report 2005: drug injection and HIV/AIDS in Asia. Bangkok, MAP Network, 2005:9. National Narcotic Control Commission China. Report of drug abuse surveillance 2003. Beijing, National Narcotic Control Commission China, 2004. Population Services International. HIV/AIDS risk behavior among female sex workers and injecting drug users in Yunnan Province, People’s Republic of China: results of behavioral surveillance survey. Kurming, China, Population Services International, 2004. Rahman Z et al. Drug sharing and injecting networks in Bangladesh: implications for HIV transmission. XV International AIDS Conference, 11–16 July 2004 (abstract no. C12531). Razzaghi EM et al. Profiles of risk: a qualitative study of injecting drug users in Tehran, Iran. Harm Reduction Journal, 2006, 3:12
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Reid G, Costigan G. Revisiting the “hidden epidemic”: a situation assessment of drug use in Asia in the context of HIV/AIDS. Melbourne, Australia, Centre for Harm Reduction, Burnet Institute, 2002. Sarkar S. UNAIDS Regional Support Team Asia Pacific. Why IDU intervention? Why scaling up NOW? Presentation at the ASEAN Regional Dialogue on HIV and Drug Use, Kuala Lumpur, 6 December 2005. The AIDS situation in Asia: planning and implementing appropriate and timely responses. Presentation by Brown T, Walker N. World Bank, Washington, DC, 28 July 2005. siteresources.worldbank.org/INTSAREGTOPHIVAIDS/Resources/BrownWalkerAIDSinAsia.pdf Tuan NA et al. Intravenous drug use among street-based sex workers: a high-risk behavior for HIV transmission. Sexually Transmitted Diseases, 2004, 31:15–19. United Nations Office on Drugs and Crime. World drug report 2007. Vienna, Austria, 2007 www. unodc.org/pdf/research/wdr07/WDR_2007.pdf UNODC Regional Office for East Asia and the Pacific. Major ATS trafficking routes. APAIC: Asia and Pacific Amphetamine-Type Stimulants Information Centre, 2005. www.apaic.org/TRENDS/ recentatstrendsnew.htm World Health Organization. Lexicon of alcohol and drug terms. Geneva, WHO, (http://www.who. int/substance_abuse/terminology/who_lexicon/en/index.html).
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Annex 1
presentation 1: Drug use and HIV in Asia Session objectives
Drug use and HIV in Asia
Understand what drugs are used globally and their contribution to mortality and morbidity Understand the distinction between licit and illicit drug use Be familiar with patterns of drug use in Asia Understand the connection between a change in pattern of drug use and HIV transmission Be familiar with the regional epidemiology of drug use and HIV
What are drugs? Definition: WHO In pharmacology: any chemical agent that alters the biochemical physiological processes of tissues or organisms http://www.who.int/substanceabuse/terminology/who_lexicon/en/index.html
How much of a global problem is illicit drug use? 200 million illicit drug users Source: UNODC 2005
Illicit drugs Alcohol Tobacco
2 billion alcohol users Source: WHO 2002
Legal = Licit
Medications, tobacco, alcohol, coffee/tea Opium, heroin, cocaine, ATS, cannabis
Illegal = Illicit
1.3 billion smokers Source: WHO 2002
Source: www.who.int/substance_abuse/facts/global_burden/en/index.html www.unodc.org/pdf/research/wdr07/WDR_2007.pdf
Of the 200 million people who use illicit drugs … People (millions) % Global pop. All illicit drugs Cannabis ATS Amphetamine Ecstasy Cocaine Opiate Heroin 200.0 158.8 24.9 8.6 14.3 15.6 11.1 5.0% 3.8% 0.6% 0.2% 0.3% 0.4% 0.3%
Drugs and their effects – 1
Stimulants – coffee, nicotine, cocaine, ketamine, amphetamines, ecstasy
Physiological arousal Exhilaration Anxiety Feeling of well-being Decreased hunger, weight loss Indifference to pain and fatigue Unpredictability: Irritability / restlessness / panic /paranoia Decreased / increased concentration Enlarged pupils Sexual arousal / affectionate Feelings of strength / prowess / violence Myocardial infarction / cardiac arrest / stroke
Source: www.unodc.org/pdf/research/wdr07/WDR_2007.pdf
Photo: Centre for Harm Reduction.
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Drugs and their effects – 2
Drugs and their effects – 3
Sedatives – alcohol, benzodiazepines, inhalants (and opioids)
Euphoria, disinhibition Calm, feeling of well-being Reduced anxiety / stress / pain Decreased concentration, coordination Sedation / drowsiness, respiratory suppression Variably: Pupils big / small Diminished appetite / nausea Decreased motivation Paranoia / aggressiveness / hallucinations Drug-induced psychosis
Hallucinogens – LSD, magic mushrooms, cannabis
Intense sensory experiences Mixing of senses Distorted time and space Visual hallucinations Rapid pulse, dilated pupils, nausea, ↑blood pressure Variably: Relaxation / well-being Paranoia / confusion / anxiety / psychosis Loss of appetite
Drugs used in Asia
How do people take drugs?
Heroin and opium use throughout Asia Cannabis (marijuana, hashish) common throughout Asia ATS/methamphetamine ↑ drug of choice:
Smoke / inhale: tobacco, cannabis, opium, heroin, ATS, glue Chase or chasing the dragon: heroin Ingest: alcohol, opium, cannabis, sedatives Inject: heroin, cocaine, sedatives, ATS, buprenorphine Snort: cocaine, heroin Suppositories: Ecstasy Some people transition from one route to another (from smoking to injecting heroin). Some use multiple drugs and multiple routes (e.g. drink alcohol, smoke tobacco and inject heroin).
Thailand, S. Korea, Philippines, Taiwan, China, Japan, Cambodia, Lao PDR, Indonesia growth in Asia dance party scene India, Pakistan, Bangladesh, Nepal, Iran, China
Ecstasy (MDMA) use:
Buprenorphine:
Dextropropoxyphene: NE India Mixed pharmaceuticals: analgesics/tranquillizers Solvents and glue:
India, Lao PDR, Indonesia, Mongolia, Viet Nam, Philippines, Thailand, Cambodia
Source: Basic principles and practices of drug use related HIV/AIDS prevention and care in the Mekong Region. Melbourne, Burnet Institute Centre for Harm Reduction, 2005.
How people take drugs is important Injecting carries a high risk of HIV transmission if there is sharing and reusing of injecting equipment. Smoking, snorting, inhaling or swallowing drugs does not carry a direct risk of HIV transmission but is often associated with increased risk behaviour. Source: SubstanceAbusePrevention.org
IDUs in Asia 13 million estimated IDUs in the world 43% in Asia-Pacific
South and South-East Asia: 3.3 million East Asia and the Pacific: 2.3 million
Globally, 5–10% of total HIV infections result from injecting drug use 50–70% of HIV infections in some Asian countries are due to injecting drug use
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Drug use and HIV in Asia
Diffusion of opioid injecting in selected countries in the Asian region Thailand 1960 1970 Heroin smoking 1980 1990 Heroin injecting Myanmar Manipur Heroin smoking Heroin injecting Heroin smoking Heroin injecting Viet Nam Indonesia Opium and heroin injecting Heroin injecting
Diffusion of injecting drug use
Photo: Jimmy Dorabjee
Typically (but not always) starts with richer groups and shifts to poorer sectors Associated with mobility and drug transit routes Associated with rapid social and economic change
Photo: Peter Higgs
Source: Centre for Research on Drugs and Health Behaviour, 2000.
Beyond the stereotype: diverse life situations Population groups that include drug users:
Profile of an injecting drug user
Circumstantial drug users – transport workers (truck and taxi drivers), students Occupational groups – fishermen and miners Street children Middle-class drug users Recreational drug users
Male (but women increasing) Education level variable Often jobless or underemployed – does odd jobs to support habit Poor Criminalized, stigmatized, discriminated Will beg, borrow or steal to get drugs Homeless / lives on the streets This often results in:
Low self-esteem Low awareness of treatment availability and of bloodborne viruses Low concern for personal health Low trust level
Source: Basic principles and practices of drug use related HIV/AIDS prevention and care in the Mekong Region. Burnet Institute Centre for Harm Reduction, 2005.
Factors that increase HIV transmission associated with injecting drug use
Professional injectors and shooting galleries Professional injectors: those selling drugs also do the injecting, using one needle and syringe for many drug users Shooting galleries: communal places used by IDUs for injecting Professional injectors and shooting galleries are found in Viet Nam, Indonesia, Myanmar, Malaysia, Pakistan, Nepal and Bangladesh
Sharing of injecting equipment Frequency of injection Professional injectors Shooting galleries Sexual behaviour of IDUs
Selling sex to buy drugs Women IDUs selling sex to buy drugs Male IDUs selling male – male sex to buy drugs Drug injectors buying sex
Incarceration
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Drug use and HIV in Asia
11
Incarceration IDUs and sex Throughout Asia drug injectors buy sex, Except for Thailand, most of it is uprotected. Hanoi, Virtnam Bangkok, Thailand** Katmandhu Valley, Nepal Surabaya, Indonesia Delhi, India Sidhuan, China* Central Bangladesh 0 10 20 30 40 50 Percent 60 70 80 90 100 Unprotected commercial sex Bought sex with a condom
IDUs have high rates of incarceration
Thailand: 27% of IDUs had been in prison
Some IDUs are HIV – positive when they are incarcerated Others are infected while incarcerated Extremely high rates of sharing among IDUs during incarceration
Percentage of male IDUs buying sex in various cities, by consistent condom use in commercial sex *Sichuan: condom use at last commercial sex **Bangkok includes non-injecting drug users
Source: MAP Report 2005
Women injecting
Women injecting
Are more likely to have a male sexual partner who injects drugs Tend to be introduced to drugs by husband/ boyfriend or male member of their family Access to drugs usually occurs through male sexual partner Photos: Korsang (anticopyright)
More likely to share needles More likely to use needle after IDU partner More likely to be injected by someone else If male partner is active drug user, woman IDU experiences difficulty in avoiding drug use/ abstaining/ accessing drug treatment
Photos: AHRN Picture Gallery. Photo by A. Backer Photo: Korsang (anticopyright)
Sex workers (SWs) who inject Ho Chi Minh City, Viet Nam
Main drugs injected in Asia
Heroin ATS – South Korea, Japan, Thailand, Lao PDR Buprenorphine – India, Pakistan and Bangladesh Dextropropoxyphere – NE India
50% of SWs who inject are HIV positive 19% of SWs who use drugs but do not inject are HIV positive SWs who use drugs are 50% less as likely to use condoms Photo: A. Backer Photos: Jimmy Dorabjee
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Drug use and HIV in Asia
Heroin
Injecting buprenorphine
Smoking Chasing the dragon Injecting
Synthetic injectable opioid produced legally (India) Widely available over the counter in Asia, also smuggled Used by IDUs in Iran, Pakistan, India, Bangladesh, Nepal, Sri Lanka and China
Photos: SubstanceAbusePrevention.org
Photo: AHRN Picture Gallery. Photo by A. Backer
Injecting Proxyvon
Amphetamines in Asia Instrumental use: Second World War – particularly legal in Japan Long-haul drivers and labourers across the Region Thai and Cambodian fishermen Japan 1945–1957, 1970 onwards associated with organized crime Industrialization associated with growth of middleclass users in Republic of Korea and Thailand, including students and young people Also perhaps driven by strong work ethic, demanding industries and long work hours – entertainers, sex workers, businessmen Philippines methamphetamine use reported more than that of cannabis
Epidemic of use:
Dextropropoxyphene = Proxyvon = Spasmoproxyvon = SP One tenth the price of heroin Legally produced Over-the-counter drug Injected in NE India – Mizoram, Manipur, Nagaland Photo: Jimmy Dorabjee
Amphetamine-type stimulants (ATS) Amphetamine
Powder – snorted, mixed in a drink or injected Base – swallowed Powder – snorted Crystals (ice) – smoked Tablets – swallowed Source: www.apaic.org/TRENDS/recentatstrendsnew.htm
Methamphetamine
Photo: SubstanceAbusePrevention.org
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Drug use and HIV in Asia
13
Injecting ATS
Injecting midazolam tablets Short-acting benzodiazepine Health risks – swelling of injection areas, abscesses, gangrene, venous degradation
Injecting ATS – same risks of HIV, hepatitis, etc. as other forms of injecting drug use ATS products often contain substances that do not easily dissolve in water and block small blood vessels, resulting in tissue injury in the kidneys, lungs and possibly the brain
Photo: Klatying-Angsulee N et al.
Photo: Weerakit. ART in Injecting Drug Users and HIV/AIDS
HIV prevalence among IDUs (1998/2005) Estimated number of injecting drug users (IDUs) and HIV prevalence among IDUs Up to 66.5
35 countries and territories with at least one report of HIV prevalence of 20% or more in at least one study Eastern Europe and Central Asia : Azerbaijan, Belarus, Estonia, Georgia, Kazakhstan, Latvia, Moldova, Poland, Russia, Ukraine and Uzbekistan
(mid-point estimates) Up to 73.7 Western Europe 1.2m East. Eur ope & Central Asia 3.2m 2.3m Sou th & S.East Asia 3.3 m Up to 90.1 Aust ralia& New Zealand 200,00 0
Up to 42.0
North Americ a 1.5 m Caribbean 13,80 0
Up to 84.0
South and South-East Asia : Cambodia, India, Indonesia, Iran, Malaysia, Myanmar, Nepal, Thailand and Viet Nam East Asia and Pacific : China North Africa and the Middle-East : Libya Sub-Saharan Africa : Kenya Latin America : Argentina, Brazil and Uruguay Caribbean : Puerto Rico
NorthAfrica & MiddleEast 400,00 0
Up to 55.2
Latin America 1m Up to 80.0
Sub-Saharan Africa 900,00 0
Up to 1.23
Up to 2.0
North America : Canada and USA Western Europe : France, Italy, Netherlands, Norway, Portugal and Spain 19 had at least one site with an HIV prevalence among IDUs of >50% (7 of these in South and South-East Asia) © R e fe r e n c e G r o u p o n H IV /A ID S p r e v e n ti o n a n d c a r e a m o n g I D U w w w . i d n r e f g r o u p . org
Up to 59.4
Source: Aceijas C, Stimson GV, Hickman M, Rhodes T. AIDS, 2004.
IRAN: 206,000 0.5%
SOUTH & SOUTH-EAST ASIA Estimated number of injecting drug users (IDUs) HIV prevalence among IDUs AFGHANISTAN: (mid-point estimates1998/2005) 34,08 0 unknown PAKISTAN: 462,00 0 unknown INDIA: 1,294,000 68.4% MYANM AR: 195,00 0 Up to 79.5% BANGLADESH: 98,00 0 2.6% THAILAND: 57,00 0 54% LAOPDR: 8,000 unknown NEPAL: 41,000 Up to 60% BHUTAN: unknown
HIV among IDUs remains high and new IDU epidemics are emerging… 80 70 60 50 40 30 Rangoon, Burma Guangxi, China Bangkok, Thailand Hanoi, Viet Nam Jakarta, Indonesia
VIET NAM:128,0 00 64%
20 10 0
MALDIVES unknown SRILANKA: 28,241 unknown MALAYS IA:19,500 35.5%
88
92
94
96
98
90
10
1% SINGAP ORE: 15,000 1.7%
INDONES IA:580,000 47%
Source: Aceijas C, Stimson GV, Hickman M, Rhodes T. AIDS, 2004.
Source: Brown T. AIDS in Asia: face the facts. A comprehensive analysis of the AIDS epidemics in Asia. Bangkok, MAP Network, 2004.
10
PHI LIPPINES:17,000
0
2
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Drug use and HIV in Asia
Sharing of needles Percent age of male injectors reporting sharing needles and syringes in recent injections 100 90 80 70 60 50 40 30 20 10 0 Sichuan, China Kazakhstan(9cities) Katmandu Valley, Nepal Hanoi, Viet Nam 42 33 14 46 Percent HIV-positive 100 90 80 70 60 50 40 30 20 10 0
High prevalence among new injectors and increase with duration of injection 81 68 Percent infected with HIV by duration of injection and by sex, Kathmandu valley, Nepal, 2003 HIV prevalence is high even among people who have just started injecting
One year or loss 2–5 years More than 5 year
50 37 24 11
Male Injectors (N-303)
Female Injectors (N-57)
(Source: New Era and STD/ AIDS Counselling and Training Service 2002)
Source: Drug injection and HIV/AIDS in Asia. MAP, 2005.
Sex and drugs
IDUs sell sex to buy drugs Male IDUs buy sex Sex workers who inject IDUs who have sex with men
Percentage of street-based sex workers who inject drugs, who have sex with injectors who report buying sex, three cities, Viet Nam 2000 Sex worker injects drug herself Sex worker reports sex with male drug injector Male injector report buying sex from sex worker
Ho Chi Minh City
Halphong
Hanoi
0
20
40 %
60
80
Source: UNAIDS/WHO AIDS Epidemic Update, Dec 2005.
Sex workers injecting
IDUs and sex with men Indonesia – higher rates of injecting among male sex workers than other groups Cambodia – 3% of MSM injected in preceding 12 months (2000) Tehran – 1/3 of male IDUs reported sex with men
Viet Nam
Haiphong – nearly 40% (2000) Manipur – 20% (2001) Sichuan province – 2.5% 5% among street-based SWs <4% SWs injecting
India
China
Bangladesh
Source: MAP report 2005.
Participant Manual
Drug use and HIV in Asia
15
Asian epidemics ignited by injecting drug use
IDU ‘kick-starts‘ the HIV epidemic in Indonesia Most sexual infections in Jakarta would never have occurred if there had not been a "seed" infection transmitted through drug injection
Pakistan, NE India, Nepal, Bangladesh, Indonesia, Viet Nam, parts of China IDU kick-starts sexual transmission, amplifying epidemic potential
Cumulative number of HIV infections
120000 100000 80000 60000 40000 20000 0 19
HIV infections if nothing changes HIV infections if there were no IDU epidemic HIV infections in IDUs if nothing changes Sexual infections resulting from a chain of infection originating with a needle
110,000
36,000 2,000 85 986 987 988 989 990 991 992 993 994 995 996 997 998 999 000 001 002 003 004 005 006 007 008 009 010 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2
Figure 2 HIV prevalence in Jakarta, Indonesia, with and without IDUs. Actual data to 2003, and projections with behaviour unchanged from 2003 levels
Source: MAP report 2005.
Delaying IDU epidemics buys time to prevent sex work epidemics Percent age of adults living with HIV
Iran . . . early, taking off
Early concentrated epidemic
Long history of opium smoking Recent rise in heroin injecting Injecting accounts for 67% of HIV infections 200 000 IDUs HIV prevalence 0 – 65% Sharing 30 – 100%
5 202
0
5
0
5
0
5
5
0
Start year of IDU epidemic Source: Brown T, Walker N. 2005
—1985 —1995 —2005 —Never
203
202
200
200
201
201
198
199
199
0
Source: Brown T, Walker N. 2005
Nepal
Myanmar
Ongoing conflict Early concentrated epidemic driven by:
One of the most serious epidemics in Asia which has spread to lower-risk populations Largely fuelled by injecting drug use 90 000–300 000 IDUs Two third sharing Prevalence of HIV among IDUs 45 – 80% HIV prevalence among SWs 31% in 2003
Migration Injecting drug use Sex work
Estimated 30 000 IDUs* - 40 – 68% HIV Sharing common High prevalence among new injectors Drugs–sex overlap:
15% male IDUs buy sex. Half use condoms Small sample 300 FSW, 5% injecting
Source: AIDS Project Management Group, 2005 www.afronets.org/files/APMG-OSI-Concentrated-Epidemics-Report.pdf
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Drug use and HIV in Asia
HIV and AIDS in Thailand 60
direct CSW 50
indirect CSW
Male STD
IDU
40
30
20
10
0
Jun- Dec- Jun- Dec- Jun- Dec- Jun- Dec- Jun- Dec- Jun- Dec- Jun- Jun- Jun- Jun- Jun- Jun- 'Jun 'Jun 'Jun 'Jun 89 89 90 90 91 91 92 92 93 93 94 94 95 96 97 98 99 00 01 02 03 04
Source: UNAIDS.
Source: Sarkar S, 2005. (Data from MOPH Thailand, 2005)
Participant Manual
Treatment and Care for HIV-Positive Injecting Drug Users The “Treatment and Care for HIV-Positive Injecting Drug Users” training curriculum is designed for clinicians who provide treatment and care, including ART, for HIV-positive injecting drug users. The training curriculum consists of a trainer manual, 12 participant manuals, and a CD-ROM with PowerPoint presentations and reference articles. Topics covered in the curriculum include: Module 1: Drug use and HIV in Asia Module 2: Comprehensive services for injecting drug users Module 3: Initial patient assessment Module 4: Managing opioid dependence Module 5: Managing non-opioid drug dependence Module 6: Managing ART in injecting drug users Module 7: Adherence counselling for injecting drug users Module 8: Drug interactions Module 9: Management of coinfections in HIV-positive injecting drug users Module 10: Managing pain in HIV-infected injecting drug users Module 11: Psychiatric illness, psychosocial care and sexual health Module 12: Continuing medical education Trainer manual
The ASEAN Secretariat 70A, Jl. Sisingamangaraja Jakarta 12110 Indonesia Phone: +62 21 724 3372, 726 2991 E-mail: public@aseansec.org
World Health Organization Regional Office for South-East Asia Mahatma Gandhi Marg Indraprastha Estate, New Delhi - 110002 India Phone: +91 11 233 70804 E-mail: hiv@searo.who.int www.searo.who.int
Family Health International Asia/Pacific Regional Office 19th Floor, Tower 3, Sindhorn Building 130-132 Wireless Road, Lumpini, Phatumwan Bangkok 10330, Thailand Phone: +662 263 2300 E-mail: sunee@fhibkk.org www.fhi.org
ISBN 978 979 3496 63 4
978 979 3496 63 4