Drug use among the urban poor in Kolkata: behaviour and environment correlates of low HIV infection.
BACKGROUND
HIV infection in injecting drug users (IDUs) has worked as a driving force for further spread of the virus in other population groups. Major metropolitan cities such as Mumbai, Kolkota, Chennai and Delhi have seen a diffusion of injecting drug use within the last decade. The prevalence of HIV infection among injectors ranges from 2% to 30%. Identifying effective interventional elements that have kept the prevalence of HIV low for the past 7 years among IDUs of Kolkata is thus of public health importance.


METHODS
A purposive sample of opioid/opiate users was studied. Primary and secondary data on drug users, law-enforcement environment, records at drug treatment centres, jail admission data related to the 'Narcotic Drug and Psychotropic Substance Act' and interventions in other risk groups were collected. Laboratory tests for HIV, hepatitis B surface antigen and syphilis were done on consenting IDUs (n=129) and non-IDUs (n=120). For univariate and multivariate analysis, IDUs were taken as cases and non-IDUs as controls.


RESULTS
Of the IDUs, 2% were positive for HIV. No non-IDU was HIV-positive. Significantly more non-IDUs (10% v. 4%, p=0.05) were positive for syphilis. Sharing injection equipment within the past 6 months was reported by 71% of IDUs; sharing partners were stable and ranged from 1 to 3. More IDUs compared to non-IDUs reported being in touch with intervention programmes. The police has been tolerant to needle-syringe exchange and oral sublingual buprenorphine substitution conducted in Kolkata. Unlike in the early 1990s, non-IDUs did not switch to injecting during non-availability of brown sugar in the latter half of the 1990s and instead sought tratment. The availability of high quality heroin (>20%-50%) was low and the proportion of moderate quality heroin (>10%-20%) went up during these times due to increased police seizures. No intervention exists in jails despite the fact that a large number of drug users spend time in jail.


CONCLUSIONS
Stable and few injection equipment-sharing partners of IDUs, launching of early targeted interventions among IDUs and sex workers in the city, police tolerance to harm reduction activities and preference of non-IDUs for detoxification during heroin draught periods have kept HIV prevalence at a low level among drug users of Kolkata for the past 7 years. immediate launching of interventions for drug users in jails seems necessary. Similar multi-pronged strategies with targeted and environmental intervention could work in other settings as well.
Panda
S
S
West Bengal Narcotic Research Laboratory, Kolkata, India.
Saha
U
U
Pahari
S
S
Nathan
M
M
Poddar
S
S
Neogi
D
D
Sarkar
M
M
Pal
N K
NK
Mahalanabis
D
D
D000293:Adolescent; D000328:Adult; D002648:Child; D015658:HIV Infections / Q000150:complications*; D006801:Humans; D007194:India; D008875:Middle Aged; D009293:Opioid-Related Disorders / Q000150:complications; D011204:Poverty Areas; D012725:Sexual Behavior; D012959:Socioeconomic Factors; D015819:Substance Abuse, Intravenous / Q000150:complications*