Reaching out beyond the hills: HIV prevention among injecting drug users in Manipur, India.

Outreach interventions using ex-IDUs to inform and educate their peers about HIV/AIDS prevention measures have been found to be effective in the United States and other developed countries. While HIV/AIDS prevention programmes targeting IDUs have also been implemented in a number of developing countries, very little information is available on the process of implementation of these programmes. This paper attempts to document some of this knowledge by describing the implementation process of an outreach intervention targeting IDUs in a small town--Churachandpur--with high injection drug use and high HIV infection rates, in the north-eastern state of Manipur. The paper describes the barriers encountered in implementing the outreach and how these barriers were minimized. In conclusion, the paper makes the case for targeting outreach to the larger community before targeting the IDUs.

PIP: In the small town of Churanchandpur, Manipur, India, heroin injection began in the early 1980s. Over 80% of the injecting drug users (IDUs) in the state of Manipur are estimated to be HIV-positive. The implementation of an outreach intervention targeting IDUs is detailed. An advisory committee sought to create a supporting environment for the outreach by minimizing police harassment of IDUs. Church leaders were also provided information about the HIV/AIDS problem as were families of IDUs and the community. Outreach workers were recruited from the community and trained regarding HIV/AIDS epidemiology, prevention, antibody testing, and referral. The IDUs were approached in pairs by the outreach workers who delivered prevention messages: not to use drugs and injecting equipment; cleaning syringes with bleach; avoiding multiple sex partners; and using condoms. Within 1 year, 750 of the estimated 800 IDUs were reached and 3930 bleach kits and 4734 condoms were distributed. Referrals were made for medical problems (thrombophlebitis, abscess, and infections) to a team doctor or drop-in centers. Later, active IDUs were also recruited to help reach new IDUs. Dealers' homes were also visited to distribute risk reduction information and bleach kits. At the six drug treatment centers regular weekly visits were paid to provide prevention information. Weekly visits were made to the jail with a similar bid. A drug users' organization was formed which discussed health concerns faced by IDUs on a weekly basis. Two drop-in centers were also set up, where an average of 10-15 IDUs could come daily and discuss any problem with the field staff. Constraints on the outreach implementation included illegal drug use, low morale among the outreach workers, lack of understanding of the community and church, the cumbersome bureaucracy, the deteriorating political situation, no facilities for voluntary HIV testing and counseling, and the relapse of outreach workers into drug use.

Injection drug use in Calcutta: a potential focus for an explosive HIV epidemic.

Our objective was to assess HIV risk perceptions, risk behaviours and factors that may facilitate an increase in injection drug use in Calcutta. Focus group discussions and in-depth interviews were conducted with a selected group of drug users to delineate drug use patterns, languages used to express addictive and related experiences and acceptance of harm minimization messages. Results from these were used to develop a semi-structured interview instrument which was used to interview 111 drug users (76 IDUs and 35 non-IDUs) recruited from jails and detoxification centres. Secondary data of narcotic seizures for the last 5 years were collected from the Calcutta police department. Data on percentage of IDUs admitted to large detox facility in the city was also collected. Findings show that HIV/AIDS knowledge and risk perceptions were low; sharing of injection equipment was reported by 66% of the injectors; and condom use was insignificant. Non-availability, rising cost and increasing tolerance to heroin were cited as factors contributing to switch to injection. Ecological association was found between intensified police activity and an increase in: the amount of smokable heroin seized; increased injection of buprenorphine; and admission to detoxification centres. In addition to HIV, IDUs were also found to be prone to hepatitis B and C. The findings suggest an urgent need for developing and implementing community-based HIV prevention interventions targeting drug users in Calcutta.

Epidemiology of Vibrio cholerae O139 with special reference to intrafamilial transmission in Calcutta.

A total of 27 families of hospitalised patients (index case families) suffering from acute watery diarrhoea caused by Vibrio cholerae O139, and 14 neighbourhood families were bacteriologically screened for 4 consecutive days to determine the extent of V. cholerae O139 infection amongst healthy contacts and other suspected vehicles of transmission at the intrafamilial level. V. cholerae O139 was isolated from faeces of 14.6% of healthy contacts in index case families as compared to none in neighbourhood families (P = 0.002). The organism could be recovered from 3.7% of handwashings of contacts of index cases and also from stored drinking water (8.0%), open well water (28.6%), flies (3.8%) and pond water (25.0%) used by the index case families and none from neighbourhood families. The large number of asymptomatic infected persons indicate an epidemiological similarity to that of eltor cholera. The organisms may be carried on hands and may act as a potential source of infection to other inmates through contamination of stored drinking water, open wells etc. The results will be useful in formulating strategies for intervention of transmission of V. cholerae O139 at the community level.

HIV-2 strikes injecting drug users (IDUs) in India.

Manipur, a north-eastern state of India bordering Myanmar, observed introduction of HIV-1 among fairly large number of IDUs in October 1989, followed by rapid spread within the next 6 months. HIV-2 in injectors was not present until recently, though it was detected from other parts of India in 1991. This communication reports for the first time presence of HIV-2 among young injectors of Manipur. All the HIV-2 infected IDUs were also found to be infected with HIV-1. HIV-2 has affected a large number of people in Africa through heterosexual transmission. It remains to be seen whether HIV-2 spreads rapidly also among the drug-injecting population of Manipur. Observation of the disease progression among HIV-2 infected IDUs will also be of interest.

PIP: HIV-1 was first detected in India in 1986. HIV-2 was first detected in the country in 1991 when paid blood donors and STD clinic attenders in north India tested seropositive for the virus. HIV-2 was later detected in Bombay and Goa. HIV-2 was also introduced in Madras and followed by an exponential increase in 1992 where heterosexual transmission was found to be responsible for the spread of the virus. 433 blood samples were collected and screened during the second quarter of 1994 from blood donors, injecting drug users (IDUs), and clinically suspected HIV disease cases admitted to the Regional Medical College (RMC) Hospital or treated at the outpatient department. 60.5% of IDUs tested positive for HIV-1, 6.6% were infected with both HIV-1 and HIV-2, and none were found to be infected exclusively with HIV-2. HIV-infected IDUs were aged 15-35 years and exclusively male. Most clinically suspected cases were young males attending the various departments of RMC with a history of long continued diarrhea, herpes zoster, extreme weight loss, miliary pulmonary tuberculosis, extrapulmonary tuberculosis, or pericardial effusion. Their histories suggested that many were IDUs, while a few only gave histories of unprotected sex with commercial sex workers. The report of a possible link between IDUs of Manipur and Madras suggests that HIV-2 may have come from Madras. The study of dual infection with both HIV-1 and HIV-2 among the IDUs may help in understanding the factors responsible for the efficient transmission of the two viruses. An extensive literature search found that HIV-2 among IDUs has previously been reported only from Spain approximately two years earlier.

A cross-sectional study on factors including HIV testing and counselling determining unsafe injecting practices among injecting drug users of Manipur.

In India, a steep increase in the prevalence of HIV (0% to 50% within six months) among the IDUs has been reported in Manipur, a north eastern state in 1990. In spite of large scale intervention program like educational campaign and widespread voluntary HIV testing in this state, the infection has quickly spread to the heterosexual population at large. The determinants of risk taking behaviors like sharing of unclean needle among the IDU population has been explored in this paper. A cross sectional study has been carried out among all of the 488 IDUs who attended any detoxification centers and prison during last two years at Imphal, the capital city of this state. Self reported behaviors based on the pre-scheduled interview were recorded and participation rate was satisfactory. The data was compared to a similar survey carried out by us in 1990. Although there has been decline in risk behavior among the IDUs, a logistic regression analysis reveals that unsafe needle sharing behavior is not influenced by the knowledge on HIV transmission, educational status or history of HIV testing or serostatus of the individual. The limitation of cross sectional nature of the study, bias due to collection of data in prison, self reported behavior, possible differences with street samples of the addict are discussed.

PIP: During August 1991 to July 1993, in Manipur State, India, social workers interviewed 488 intravenous drug users (IDUs) who were drug-free for at least 7 days and who had been institutionalized within the previous 6 months in 1 of 9 detoxification centers (the largest being the Manipur Central Jail) in Imphal city. They aimed to examine the extent of risky injecting behavior, determinants of safer injecting behavior, and any change in risky behavior since 1990. The research team provided HIV counseling after the interview. This counseling was in addition to routine counseling provided by the centers. Almost all (99%) subjects were male. The median age was 26 years. IDUs in this study were less likely to currently share needles than in 1990 (70% vs. 96%; p 0.01). IDUs in 1993 were less likely to report never cleaning needles than in 1990 (10% vs. 62%; p 0.01). Nevertheless, only 69% knew specifically the protective role of any type of cleaning. No IDU knew about the use of bleach to clean needles. The HIV prevalence rate among IDUs has increased from 56% to 80%. IDUs in 1993 were more likely to know that HIV is transmitted via sexual intercourse and by needle sharing than in 1990 (95% vs. 70% and 93% vs. 75%, respectively; p 0.01). About 70% of all IDUs in 1993 had undergone HIV testing. Knowing one's HIV status did not influence needle sharing (69.4% vs. 71% for not knowing). Knowledge of HIV transmission, educational status, or history of HIV testing or HIV status influenced unsafe needle sharing practices. When the researchers controlled for education, ethnicity, duration of drug use, and awareness about their HIV test result, only age less than 30 years was associated with sharing of unclean needles (83.4% vs. 16.6% for 30-44 year olds; odds ratio = 2.2; p = 0.0016). These findings suggest urgent and appropriate intervention in this high-risk group.

Clinical features of HIV infection in drug users of Manipur.

BACKGROUND: The human immunodeficiency virus was first detected in young intravenous drug users in Manipur in 1989 and it quickly reached a high prevalence in this group. Diagnostic facilities are scarce and it is thus important to suspect the presence of the infection by its clinical features. METHODS: We did a cross-sectional survey for 13 months among residents of different detoxification centres of Imphal, Manipur, to study the sensitivity, specificity and positive predictive values of different signs and symptoms occurring at the early phase of the infection. RESULTS: Most of the young injectors in this survey were found to be in the early phases (stage I 43%; stage II 32%; stage III 15% and stage IV 9.9%) of the World Health Organization clinical staging of human immunodeficiency virus infection and disease. Herpes zoster, oral candidiasis, pruritic papular eruptions, jaundice and lymphadenopathy had positive predictive values of 100%, 100%, 93%, 93% and 88% respectively. Cryptosporidial diarrhoea and tuberculosis (pulmonary and extrapulmonary) were also encountered. CONCLUSION: Intravenous drug users in Manipur who have human immunodeficiency virus infection suffer from different opportunistic infections which give rise to clinical features that are easily recognizable. It is important to be aware of these in areas which lack diagnostic facilities for confirming the infection.

PIP: A cross-sectional study conducted among intravenous drug users in India's Manipur State suggests that certain clinical signs and symptoms can be used to detect human immunodeficiency virus (HIV) in areas with scarce diagnostic resources. From May 1992 to April 1993, 154 intravenous drug users recruited from drug detoxification centers in the capital city of Imphal were monitored for clinical manifestations of disease. 131 subjects were HIV-positive, but examining clinicians were not given data on HIV status. All subjects had started injecting within the last seven years, so the majority were in the early phases of HIV. The distribution, by clinical stage, was as follows: I, 43%, II, 32%, III, 15%, and IV, 9.9%). Clinical features most frequently encountered included herpes zoster (27 men), oral thrush (7), pruritic papular eruptions (15), lymphadenopathy (33), and jaundice (14). The positive predictive values of these signs were 100%, 100%, 93%, 88%, and 93%, respectively. Similar studies in other areas are urged to provide information on the sensitivity and specificity of major signs for defining clinical cases of HIV infection.

Production and cross-reactivity patterns of a panel of high affinity monoclonal antibodies to Vibrio cholerae O139 Bengal.

A series of monoclonal antibodies of different isotypes specific for Vibrio cholerae O139, the new pandemic strain of cholera, was produced. These mAbs reacted only with the reference strain (MO45) representing serovar O139 but did not react with any of the other reference strains representing serovars O1 to O140. Significantly, the mAbs did not agglutinate the R-cultures of V. cholerae (CA385, 20-93) which demonstrated the exceptional specificity of these mAbs and indicated that the mAbs recognized antigenic determinants unique for the O139 serovar. There was heterogeneity in the intensity of reactivity of the mAbs with strains of V. cholerae O139 isolated from diverse sources. Apart from 4H6, the other mAbs agglutinated all the O139 strains examined. 2D12 and 2F8 were the best mAbs based on the intensity of agglutination with all the O139 strains. Evaluation of 3A10 in comparison with a polyclonal anti-O139 antibody raised in rabbit using the slide agglutination format revealed that 3A10 fared as well as the polyclonal antibody for the laboratory identification of the O139 serovar. The acquisition of these mAbs provide reagents which would be very useful in the development of simple immunodiagnostic assays for the diagnosis of V. cholerae O139 infections.

Spread of Vibrio cholerae O139 Bengal in India.

Vibrio cholerae serogroup O139 Bengal, a novel strain with epidemic potential, completely displaced V. cholerae serogroup 01 in Calcutta in January 1993, which was followed by an epidemic caused by V. cholerae O139 in March-May 1993. From November 1992 to July 1993, 95.6% of 916 V. cholerae isolates submitted to the National Institute of Cholera and Enteric Diseases from 28 locations in India were confirmed as serogroup O139. As of July 1993, V. cholerae O139 had been isolated from 13 Indian states and a union territory, and large outbreaks of cholera caused by the O139 serogroup had occurred in several cities. The extent of spread of V. cholerae O139 Bengal in India and its ability to swiftly disseminate leaves little doubt that this is the beginning of the eighth pandemic of cholera.

Implementation of ORT: some problems encountered in training of health workers during an operational research programme.

During an operational research study on implementation of oral rehydration therapy in a block of West Bengal, India, amongst a population of 2, 16,805, a total of 171 Community Health Guides and 152 Anganwadi Workers were initially trained for one working day by lectures and slides about diarrhoea case management at the community level. The training was evaluated after two months and found to be inadequate. The workers were then retrained with modern approach using a module (prepared in local language) as suggested by World Health Organisation. The level of retention of the imparted knowledge of Health Workers for different items 2-3 months after training with lectures and slides ranged between 5-25% except preparation of ORS which was 80%. With the use of modules, 47-98% of health workers could retain the same knowledge 3 months after the training. The knowledge thus acquired were sustained even after 12 months of training to a level which was still much better than that retained 2 months after training with slides and lectures. However some of the items like indication of use of Home Available Fluids, dosage of ORS and when to refer a diarrhoea case to health facility were more difficult to recall after one year. This possibly indicates need for in-service training of grassroot level health workers at suiTable interval.

PIP: In India, the National Institute of Cholera and Enteric Diseases implemented an operations research project on oral rehydration therapy in the rural block of Polba of Hooghly district in West Bengal. Its physicians used lectures and slides to train grassroot level health workers about dehydration signs, management of diarrhea, referral of patients with diarrhea to the Primary Health Center, and how to educate mothers in the community about early management of diarrhea. Each health worker received a reference booklet, prepackaged oral rehydration salts (ORS), and a 1-liter standard plastic container. Two months after the initial training, their knowledge was reevaluated and they underwent retraining. A module in Bengali was used for the retraining. It consisted of individual readings, examples and exercises of simulated conditions, discussions, role playing, and demonstration of ORS preparation. The workers were reevaluated at 3 months and 1 year post-retraining. Other than preparation of ORS (80%), few grassroot workers retained the messages delivered via the lecture and slides approach (5-25%). For example, only 5% could correctly identify the signs of dehydration. On the other hand, many more health workers retained the messages delivered via the modular approach 3 months after retraining (47-98%). At 12 months post-retraining, dosage of ORS, referral, and use of home fluids were more difficult to recall than were signs of dehydration, indication of ORS, and preparation of ORS (18-29% vs. 48-87%). These results show that periodic refresher training increases knowledge to a sustained level. The researchers concluded that simple booklets in local scripts facilitate efficient training of health workers in diarrheal treatment services. Each worker should have his/her own personal copy.

Herpes zoster in an HIV-positive 14-month-old baby.

BACKGROUND: In Manipur, a state in northeast India bordering Myanmar, within one year of reports of a high human immunodeficiency virus (HIV) seroprevalence among young injecting drug users, there has been a rapid spread of HIV infection in the general population. METHODS: Since 1990 our unit, together with the Medical Directorate, Government of Manipur, has studied different aspects of this epidemic, especially the natural history of HIV in this setting. RESULTS: Here we report the first case of herpes zoster in a 14-month-old HIV-positive baby (diagnosed by the polymerase chain reaction). The case was referred to our clinic by one of our patients residing in the same locality as the child and presently working as a counsellor in a drug detoxification-cum-rehabilitation centre at Imphal, Manipur. Dual infection of HIV and herpes zoster was also found in several other members of the same family. CONCLUSION: This report of perinatally acquired HIV infection in an environment of injecting drug users in India might help in understanding the course of paediatric HIV infection here.

Epidemic of herpes zoster following HIV epidemic in Manipur, India.

Since 1989, injecting drug use (IDU) related HIV infection has affected thousands of young adults in Manipur, a north eastern state of India bordering Myanmar following a similar kind of epidemic in adjoining countries like Thailand and Myanmar. During a clinical surveillance of a group of HIV positive IDUs for a natural history study at Manipur, herpes zoster (HZ) emerged as the most specific early HIV related illness (positive predictive value of 100%) in patients belonging to the age group of 12-45 years. Data collected from the dermatology departments of the two main hospitals of the state revealed that there had been an epidemic of HZ since 1990 (rate of 1990 being 11.3/1000 compared to 6.5/1000 in 1989, P value < 0.0001) among males of 12-45 years. The epidemic of HZ has been attributed to the preceding epidemic of IDU related HIV in the same age and gender group occurring 1 year earlier. HZ should be recognised as a marker condition similar to tuberculosis indicating the necessity of screening for HIV in regions where the dual problem of IDU and HIV exist in young adults.

An outbreak of acute diarrhoeal disease amongst tribal population in Tripura.

A massive outbreak of acute diarrhoeal diseases occurred during March-April, 1992 in the north district of Tripura. Investigation of the outbreak revealed Vibrio cholerae 01 biotype ElT or as the main etiologic agent in 50 per cent of patients. The outbreak which started amongst the tribal population might have spread due to prevailing illiteracy, poverty, low personal and domestic hygiene and vulnerable water sources (chhara water).

Prevalence of diarrhoeal diseases amongst tribals of Car Nicobar Island, India.

In a cross sectional study of total 14514 tribal Nicobarese people of Car Nicobar Island, an union territory of India, situated in Bay of Bengal, morbidity, mortality and treatment practices of diarrhoeal diseases of under-five children were surveyed. The incidence of diarrhoea (0.2 episode/ch.year), Crude death rate (3.6/1000) and IMR (31/1000 live births) were exceedingly low as compared to SouthEast Asian Countries including mainland of India. ORS utilisation rate was high (41%) as compared to the National figure (12.0%). This is the first study of it's kind carried out in this island and amongst the Nicobarese tribe in India. A preliminary study carried out among the mothers of the hospitalised children indicated that protective behaviours like breast feeding, hand washing, use of chlorinated water and proper disposal of stool were regularly being practiced by the community traditionally. An in-depth study on risk factors of diarrhoea in this island can yield useful clue for describing the same.