Interface between drug use and sex work in Manipur.

BACKGROUND: In India, drug use is seen predominantly as a problem among men. This study attempts to address the interface between drug use and sex work among women drug users in Manipur and the prevalence of HIV, hepatitis B and other sexually transmitted infections in them. METHODS: This cross-sectional survey was conducted between April and October 1997 at the time of an ethnic clash in imphal, the capital of Manipur. Sixty-nine women drug users were interviewed through street-based outreach workers; 38 women (55%) were injecting drug users. Data were generated with the help of a semi-structured questionnaire on sociodemography, drug use practice and health issues after obtaining informed consent from the participants. Subsequently, consent was also obtained from 60 respondents for collecting blood for unlinked anonymous tests for HIV and hepatitis B surface antigen. Clinical examination for reproductive tract infections, offered to all the study participants, generated data on sexually transmitted diseases. RESULTS: The prevalence of HIV infection in injecting drug users was 57% (20/35) compared to 20% (5/25) among non-injecting drug users (p = 0.001), although the prevalence of hepatitis B surface antigen was similar in the two groups, 48% v. 56%, respectively. Eighty per cent of the respondents, many of whom migrated following the ethnic clash, reported having sex with non-regular partners, two-thirds reported sex in exchange for money or drugs. Eighty-one per cent (29/36) of women who agreed to have a clinical examination had abnormal vaginal discharge, of which 10 had endocervical discharge. The presence of infection was confirmed in only 24% of those with vaginal discharge--4 had bacterial vaginosis and 3 trichomoniasis. CONCLUSION: Environmental interventions to reduce civil unrest and forced migration have an important role to play in HIV containment. The high rate of HIV infection, and the probability of a high rate of sexually transmitted infections in women drug users suggests that a targeted intervention in this population group is a public health need. An innovative outreach strategy should be designed for effective implementation of interventions among women injecting drug users and non-injecting drug users who operate from the streets as sex workers to support their drug habit as well as livelihood.

Lessons from home based care for persons affecting with HIV and AIDS.

PIP: In India, clinicians conducted a cross sectional analysis of 104 HIV-positive intravenous (IV) drug users registered at the ICMR Unit for Research on AIDS in northeastern states of India to examine home-based care of these individuals living in Imphal, Manipur. 10% required referral to a hospital, mainly due to meningitis. 26% were asymptomatic. Tuberculosis (TB) was the most common opportunistic infection (12.5% for pulmonary TB and 6.7% for extrapulmonary TB). Other frequent signs and symptoms were oropharyngeal candidiasis (9.6%), hepatic involvement (9.6%), diarrhea (9.6%), and non-tubercular chest infection (8.7%). Among all 340 IV drug users registered at the unit, 17.1% were referred to either a hospital or an institution. Only 37.9% of those referred were satisfied with institutionalized care. The family extended support in 99.1% of all 340 cases. 25% of the families received counseling support. These findings suggest that families could care for most of the patients in their homes. Since the burden of caring for AIDS patients on the health care delivery system is expected to increase, a home-based care model and an improved referral network are needed.^ieng

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.