Danielle Slaughter 1MSGH 417Research PaperFriday December 5, 2014

Addressing the dual public health challenge of drug abuse and HIVthrough Opioid substitution therapy in Manipur and Nagaland in

Northeast India: past, present, and future challenges

Introduction While there is much documented evidence surrounding the

importance and success of opioid substitution therapies (OST) in high

and middle-income countries, there has been little research

surrounding the importance and viability of similar programs in low-

income countries like India. While OST for the treatment of heroin

dependence is widely supported by the Joint United Nations Program on

HIV/AIDS, the World Health Organization, and the United Nations Office

on Drugs and Crime, there continues to be apprehension about

implementing OST programs in developing countries(1). Fear and doubts

about the ethics of providing opiate substitutions to drug users have

helped erect barriers to scaling up interventions(2). India, however,

represents a resource-limited country that has had relative success in

integrating the OST into public health programming. Following two

major longitudinal studies on community-based opioid substitution

therapy programs in Manipur and Nagaland, the public health system

identified OST as a necessary component of their 5 year plan to reduce

illicit opiate use, curb HIV risk behaviors, and lessen deaths from

overdose and criminal activity(3, 4). This paper will provide a review

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of recent studies and literature surrounding the efficacy of OST in

India as well as barriers to scaling-up(5). In reviewing the

introduction of heroin into the northeastern states, this paper will

demonstrate the complex social, religious, economic, and governmental

influences on opioid dependence and the dual epidemic of HIV. Through

focusing on an operational research study and the subsequent follow-up

studies, this paper will identify community-based approaches to

responding to heroin dependency as well as the collaboration between

NGOs, government healthcare facilities, and various ministries and

departments within India(6).

Background/ContextIndia has a population of over 1.2 billion with 28 hugely diverse

states and seven territories. Although the prevalence of HIV in India

is around 0.3%, the prevalence is much higher among commercial sex

workers (CSW) and their clients, individuals with sexually transmitted

infections, men who have sex with men (MSM), hijras (transgenders), and

people who inject drugs (PWID)(7). Following the introduction of

heroin in the early 1980s, the number of people injecting drugs

rapidly increased. As of 2014, there are between 106, 518 and 223, 121

individuals who inject drugs(8). Approximately 10% of HIV infections

worldwide are attributable to injecting drug use, usually an opiate

such as heroin. Needle sharing, unsafe sex practices, the increased

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risk for blood borne viruses, and criminal activity all significantly

increase the risk of acquiring HIV in PWID populations. PWID are also

at higher risk for blood borne viruses like HCV, with a prevalence

ranging from 36% to 90%(9).

While in India, sexual transmission is the main route of HIV

transmission, accounting for 90% of the total prevalence, injection

drug use remains the primary transmission mode in the northeastern

states(7). The prevalence of HIV among PWID in India is 9.2% as of

20012, primarily through the injection of opioids like heroine (2).

HIV prevalence is not uniform throughout the large country, rather the

epidemic seems to have affected the northeastern states and southern

states most drastically with HIV seropositivity reaching up to 29% of

the PWID in 2008(9). Recent estimations from centennial data show that

between 1.9 and 2.7% of the adult populations in Manipur and Nagaland

injects drugs—both heroin and other pharmaceutical drugs(10).

Consequently, the northeastern states of Manipur and Nagaland are the

two highest HIV-prevalence states in India. Both of these states are

geographically isolated form the rest of India and struggle with

poverty rates rounding 30%(11).

The Socio-cultural Contexts of Manipur and NagalandManipur and Nagaland have a long history of insurgent movements,

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which have aided in isolating the states from the mainland Indians

even further. In addition to tensions from insurgent groups and the

Indian military, conflicts between tribes and fighting between rival

insurgent groups have all structured the societal order. This form of

structural violence is deleterious to the progression of public health

programs like the expansion of OST. These insurgent groups act as de

facto governments in the northeastern sites where extortion of funds

from government, NGOs, and private citizens funds their activity(11).

In Kermode et al’s study of the health, culture, and religion in

Manipur and Nagaland, the authors noted that the underground groups,

primarily Christians, exert powerful control over moral and social

behaviors (11). The hill tribes converted to Christianity following

American and British missions, in part an act of cultural defiance to

separate themselves from the rest of India. 90% of people in Nagaland

and 40% in Manipur are Christian, and their beliefs as well as the

conservatism of the tribes contribute to the attitudes surrounding

public health interventions for at risk populations(11).

The physical and ideological separation from the formal Indian

government has allowed the underground insurgent groups to gain

significant control over the states—exerting harsh social and moral

control over the populations. Kermode et al highlighted specific

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instances of this control in their characterization of common

punishments inflicted on PWID and sex workers in the area: “Injecting

drug users have been chained and caged as punishment for drug use, and

in some cases shot. Sex workers have been tonsured and had their names

and faces published in newspapers to humiliate them and their

families” (11, pp. 49-50). A lack of government presence in Manipur

and Nagaland has prevented HIV prevention interventions from scaling

up appropriately to address the needs of PWID.

Opioid Substitution Therapy

Opioid substitution therapy is an evidence based intervention for

opioid dependence that replaces the illicit drug use with medically

prescribed opiates such as buprenorphine and methadone (4). Oral

opioid agonists mimic the effects of heroin by binding to receptors in

the brain, thereby preventing withdrawal, lessening cravings, and

reducing illicit drug injection and related activity to improve the

overall wellbeing of the recipient. In 2009, the World Health

Organization (WHO) created guidelines recommending two opioid

agonists, methadone and buprenorphine, as leading pharmaceuticals for

the treatment opioid substance abuse (12).

Methadone is the most commonly approved and utilized oral agonist

for OST. Methadone is a full opioid agonist that produces cross-

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tolerance and blocks the effects of injected opioids. It has a

prolonged duration of action that lessens withdrawal symptoms up to

nearly two days, with an elimination half life between 15-40

hours(12). An additional benefit of methadone is that the full binding

to receptors in the brain allows it to accumulate in the brain tissue

with repeated administration. Although clinical guidelines suggest

dosages between 60-120 mg/daily, the average dosage in the South East

Asia Region (SEAR) is between 20-40 mg/daily(12, 13). Methadone is not

currently available in India, but its use in the prison setting is

currently being tested through a pilot study in the State of

Punjab(14). Buprenorphine is a partial opioid agonist, with less

potent activity in brain receptors. It ameliorates withdrawal symptoms

while mimicking the painlessness and euphoria of heroin. Action of the

drug reaches its peak within two hours and is metabolized in 27

hours(12). One of the downsides of buprenorphine is the “ceiling

effect” of treatment—after a period of time, increased dosage will not

prevent withdrawal symptoms. Additionally, buprenorphine is a

sublingual tablet that easily dissolves in water, making it easy to

inject and abuse.

OST as HIV PreventionOpioid substitution therapy (OST) as a method for HIV prevention is

a multimodal intervention that seeks to minimize the risk of

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contracting HIV and other infectious diseases as well as prevent the

transmission of HIV through sexual contact and needle sharing. Through

providing OST in a clinical setting, the patient encounters the health

care system and has broader access to treatments for any underlying

conditions or future maladies. While OST is widely supported and

endorsed by UNAIDS, UNODC, and WHO as one of the nine core

interventions to prevent the spread of HIV through intravenous drug

use, developing nations have been slow to adopt the treatment(1).

Although resources are scarce in developing countries, an update on

the international HIV epidemic from 2005, reported that opioid

substitutions cost significantly less than many widely used medical

therapies to decrease HIV transmission(15). Subsequent studies

demonstrated that OST programs are cost effective in regions where the

main driver of HIV transmission is through injected drug use (9). The

cost-effectiveness of methadone maintenance therapy was demonstrated

to decrease HIV expenditures for PWID and the general population,

criminal activity, mortality, and overall health care costs (15).

Methadone maintenance therapy (MMT) is cost-effective when it is used

with or without other HIV prevention efforts, demonstrating the

importance of OST as both a primary and secondary means of

prevention(15). There are limited studies on the cost effectiveness

of buprenorphine in developing countries, yet it has proven to be

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similarly successful in improving health outcomes and reducing HIV

transmission.

OST in Developing CountriesIn the South Eastern Asian Region (SEAR), one of the primary

routes of transmission for HIV is through intravenous drug use—

creating a dual epidemic of HIV and drug use. Almost 2/3 of PWID have

been infected with HIV and almost all with HCV within the first two

years of beginning of inject (16). Unsafe sexual practices have also

resulted in heterosexual transmission, reported as an increasing in

HIV prevalence among pregnant women in Manipur (16). Many infected

with HIV are becoming increasingly viremic and symptomatic, making

transmission more likely and imposing greater demands on resource

limited health sectors. Late presentation of HIV continues to be a

problem throughout developing countries, especially in more rural

regions. People presenting with CD4 counts less than 350 cells/µL or

presenting with an AIDS-defining event are diagnosed as late

presenters(17). In developing countries, it has been estimated that

between 40% and 50% of individuals present with CD4 counts lower than

200 cells/µL, indicating an increased need for individuals to enter

the healthcare system earlier and get the appropriate treatment to

prevent transmission(17).

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Many injecting drug users who would otherwise have no contact with

any health services are attracted by the community aspect in OST

centers and are more likely to uptake services when supported by

families and their religious communities. In developing countries,

many men and women live in extended family structures with

cohabitating relatives who all play an important role in treatment

retention. According to Viswanath et al., in the Indian context,

family members are effectively involved in treatment, thereby

minimizing the risk of diversion/abuse (12). The treatment programs

can then act as gateways to the broader healthcare system(18).

Subsequent primary care services like HIV testing, antiretroviral

therapy and treatment for tuberculosis, hepatitis C and sexually

transmitted infections amplify the effects of OST on curtailing the

spread of HIV. One study on the use of methadone maintenance therapy

as a tool for HIV prevention found that Patients are less likely to

initiate ARVs when opioid abuse/dependence is not addressed(13). When

OST is provided, patients are more likely to initiate ARVs and have

improved adherence to treatment (13).

The relationship with NGOs is significant because of their

‘targeted’ scope. Social workers, counselors, peer educators, and

former drug users help to manage the provision of care and support for

OST patients in a supportive environment. Their main asset to the

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success of OST is the ability of the NGO team to understand the

community and mobilize support from key leaders in the area. In

Manipur and Nagaland, where conservative Christian views dictate the

moral and social acceptance of behavior, it would be necessary to

generate support from church pastors. NGOS have the advantage of

understanding the family dynamics that play a critical role in

determining successful completion of treatment. Family structure and

relationships are social determinants that can greatly affect health

behaviors and outcomes.

Ahavan and Project OrchidHeroin became the drug of choice in northeast India as early as

the 1980s. Sharing a border with the golden triangle introduced

northeast India to the injection of heroin, and its use and abuse

quickly escalated. . The advent of the HIV epidemic was congruent with

the heroin boom in the northeastern states, inevitably leading to an

outbreak among PWID. Between 1989 and 1990, the estimated HIV

seroprevalence among 15,000 drug users rose from 0 to 50%,

demonstrating how fast the epidemic infiltrated the community(19).

The proximity has allowed heroin to be trafficked across the Myanmar

border through Manipur into Nagaland and throughout India(11).

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Initial community responses to the HIV epidemic in the PWID

populations were based on the principle of abstinence. The government

echoed this principle, which then lead public security to arrest and

detain drug users. Drug users were massively incarcerated in state

prisons, where abstinence was forced upon the 90% of inmates in

Manipur who were drug users. The criminalization of drug use in no way

prevented the use of drugs or the transmission of HIV. Drug users were

commonly sent to the detoxification camps, without trial or due

process—often, by word from a family/community member or a police

officer(8). This practice led drug users to engage in even riskier

behaviors like sharing contaminated and led to a huge increase in

opioid overdose. The government-sponsored drug detoxification ‘camps,’

were unsuccessful in drug detoxification as relapse rates were greater

than 80%.(11) The criminalization of drug use as well as the

abstinence method of treatment led to increases in criminal activity

and in the number of drug users engaging in commercial sex work.

Following the relative failure of the government and the church to

address the dual public health challenge, the communities of Nagaland

and Manipur grew frustrated and rallied support for the introduction

of harm reduction.

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Community based outreach programs have been established since the

early 1990s, largely funded by international NGOs. In 1994, the Indian

Christian NGO, the Emmanuel Hospital Association (EHA) developed a

comprehensive community based intervention that introduced the first

needle and syringe exchange program in northeast India(11). Although

church and community leaders initially challenged the ethics and

legality of this intervention, the failure of the abstinence model

prompted them to modestly support alternative approaches. Within 2

years of this intervention, the State AIDS Policy in India and the

Manipur State AIDS Society adopted the programs into the National AIDS

control Program. Yet increases in the prevalence of HIV between 1996

and 2002, stirred debate surrounding the interventions’ role in

promoting drug use and commercial sex work. In 2002, the HIV

prevalence among PWID was estimated to be 39% in Manipur and 10% in

Nagaland(10). In response to dwindling church and governmental

support, the former drug users in both states mobilized to create

organizations that would continue to provide harm reduction

interventions. Their work along with support from local NGOs grabbed

the attention of the State AIDS Control Society (SACS), which expanded

their program to provide clean needles, distribute condoms, and

provide voluntary testing and counseling for HIV.

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In 2004, the Ahavan program, funded by the Bill and Melinda Gates

Foundation, responded to the growing epidemic among PWID and

established a program in six Indians states where PWID was the main

route of HIV transmission—Manipur, Nagaland, Andhra Pradesh,

Karmataka, Maharashtra, and Tamil Nadu(11). This program build upon

existing infrastructure to scale-up harm reduction projects in achieve

widespread coverage. In Manipur and Nagaland, Project ORCHID, a joint

initiative of the EHA and the Nossal Institute for Global health,

implemented the project with help from SACS. SACS, a well-established

community organization, was able to mobilize extensive support through

peer networks of former PWID. Project Orchid was able to help more

than 20 NGOs in capacity building so that they would have the

necessary infrastructure to coordinate the provision of harm reduction

interventions(11). Program components varied between sites because of

a lack of national guidelines, monitoring and evaluation systems, as

well as inadequate training.

Despite these efforts, the dual epidemics of drug use and HIV

transmission persisted. The communities once again mobilized to

discuss what their population base needed out of an intervention. When

assessing and HIV prevention intervention for PWID, three

considerations must be reviewed(12):

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1) the ability to reduce HIV related risk behaviors2) the role of broadening access and adherence to HIV

treatment for PWID3) the ability to reduce or stop the use of illicit

opioid drugs.

In recognition of the programming’s inability to address these needs,

the community based organizations sought additional funding for the

implementation of Opioid Substitution Therapy in Manipur and Nagaland.

In 2006, Project ORCHID received funding from the UK’s Department for

International Development to initiate a sublingual buprenorphine-based

OST program in 11 of the 20 NGOs(4). Due to a lack of adequate health

infrastructure in these regions, the community-based programs began to

operate out of drop-in centers. Introduction of OST became the most

attractive option for PWID, their family and the broader community.

Rather than receiving pushback from the church, the program actually

garnered their support. The reduction in drug-related, ‘sinful’

activities as well as the recognition of OST as an evidence based

medical approach pleased the conservative Christian community.

Subsequent funding from the EHA and the National Aids Control

Organization allowed for routine program monitoring and analysis of

OST in a resource limited setting in a developing country.

During the DFID-funded period, between May 2006 and December

2007, data was routinely and prospectively collected from clients

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enrolled in an OST program (n= 2569, 1853 in Manipur and 716 in

Nagaland)(4). Working within and operational research framework,

Armstrong et al sought to assess the effectiveness of the intervention

in a less controlled setting. Self reported information collected

during interviews with NGO outreach workers or nurses allowed the

researchers to examine many client characteristics that could impact

the success of treatment. Interviews conducted at intake and the three

month follow-up built a socio demographic profile for each client,

detailing their drug use, HIV risk behaviors, and quality of life (4).

At cessation of treatment, the questionnaires reported the reason for

cessation, family involvement during treatment, and adherence to

treatment. The inclusion of family involvement as a metric signaled

the researchers’ intent to capture the dynamic picture of drug use in

northeastern India. When completion of treatment did not occur, either

due to relapse or an unknown reason, researchers drew relevant

information from the client file.

Following the one year period, Armstrong et al.(4) found

significant support for the efficacy of OST as an intervention in

resource poor settings. Within 3 months, researchers were able to see

improvement in HIV risk behaviors as well as quality of life, which

rose by 50% (4). Substantial reductions in HIV risk behaviors were

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seen in all clients, even those who relapsed or were detained. Within

three months, needle sharing decreased from 25% to 2%, unprotected sex

decreased from 16% to 8%, and jail/detention decreased from 12% to 1%.

OST participation reduced the risk for HIV transmission for the PWID

as well as their partners. Additional social benefits were observed

through a decrease in criminal activity and an increase in employment

for the clients.

Treatment duration significantly impacted the success of

treatment. The retention in OST in Manipur and Nagaland (63% after 6

months) was comparable to the WHO collaborative study (70% after six

months) demonstrating the ability to reproduce the success of OST in

resource limited settings. These findings are complicated by the data

collected after treatment completion. More than half of the clients

who ceased OST relapsed to their previous opiate drug use(4). Family

involvement in OST treatment in addition to longer duration of

treatment was strong protective factors against relapse.

Armstrong et al, also provided important data regarding the type

of drug and the use practices among PWID. While heroine was the

predominant drug of choice in Manipur, the choice in Nagaland was

split between heroin and a synthetic opioid analgesic called SP(4).

Naga clients also reported higher rates of additional drug use

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including alcohol (50.9%), Repilen (20.3%; a combination drug similar

to SP), and Nitrosun (26.4%). These may help tailor future

interventions according the drug use behavior. For example, in

settings where heroin is not the primary drug of choice, or is one of

many, a full opioid agonist like Methadone, may be more effective in

eliminating the drug dependence.

While the research conducted by Armstrong et al, demonstrated the

ability of OST to act as an HIV prevention method in complex, limited

resource setting, the intervention was unable to significantly impact

the HIV prevalence in the two regions. Despite this, the NACO adopted

OST as part of their HIV prevention program in 2008. This adoption

lead the NACO to rapidly expand the number of sites offering OST from

20 to 45. 23 of these 45 sites are located in the northeastern states,

demonstrating the powerful effects of Armstrong’s research in

providing policy makers with the local evidence needed to expand

interventions. The additional support allowed Kermode et al. to

follow-up with the clients to determine long-term outcomes. A random

sample of 10% of the 1853 clients in Manipur enrolled in OST during

the DFID funded period was obtained in December 2009. The follow-up

involved collaboration between 8 different NGOs, outreach workers, and

peer educators. Contrary to previous findings of treatment failure for

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more than half of clients, Kermode et al. determined that nearly 60%

of clients were either abstinent from drug use or were enrolled in OST

treatment(3). Further challenges to previous estimates, found that

approximately two-thirds of those who had relapsed by December 2007

had either resumed OST treatment or were abstinent by 2009. And of the

26.1% of individuals who relapsed after completion in 2007, half

remained abstinent as of 2009. The incongruent findings between these

two studies demonstrate the cycle between OST, relapse, and abstinence

that most PWID face. This cycle supports the advocacy of OST as a

long-term maintenance treatment for chronic opioid dependence. In

general, the follow-up studies resounded the success of Project

ORCHID, but it is important to note that 13% of the sample Kermode et

al. intended to study had died by 2009(3).

SuccessesThe successes can be viewed among the PWID enrolled in OST, whose

prevalence of HIV has dramatically declined. Rates of sharing

equipment at the last injection were cut in half between 2001 and 2006

and HIV prevalence declined from 52% in 2002 to just over 15% in

2009(8). Since Avahan’s presence in the northeastern states, the NACO

has estimated that between 36% and 68% of new HIV infections were

averted as of 2010 (14). The success of Project Orchid is most

substantially measured by their influence on the public health care

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system in India. Through local research and subsequent follow-up, the

Ministry of Health and Family Welfare created an entire department

dedicated to the prevention of HIV transmission. Although no

countrywide legislation has included harm reduction strategies, the

involvement of the national government via the NACO is essential to

scale up OST programming throughout India. The relative success of

Project Orchid in Manipur and Nagaland serves as the basis for

preventing HIV among PWID in other states, specifically those that are

experiencing new growth of HIV (the south and northwestern states).

LimitationsDespite decreasing the transmission of HIV, Project orchid was

unable to scale-up appropriately to meet the needs of the growing

population. In India, there has been no significant decline in the

prevalence of HIV since 2007. Despite the decline in HIV prevalence

among PWID in Manipur and Nagaland, the northeastern states have

actually experienced an increase in overall HIV prevalence. According

to a progress report on HIV/AIDS in the South-East Asia Region

published in 2011, HIV prevalence in Manipur rose from 26% in 2003 to

29% in 2008 (9). The relative stability of the epidemic sheds light on

both the successes and failures of previous interventions to curtail

the spread of HIV. The northeastern states of India have experienced a

decline in risk behaviors and a parallel decline in HIV prevalence,

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but their success is countered by the rapid emergence of new epidemics

in the northern and southern states. Asia’s epidemic has historically

been concentrated in certain populations, specifically PWID, CSWs, and

MSMs; however, following 2008, the epidemic steadily began to reach

the lower-risk populations. The inability to scale-up appropriately

has allowed the PWID epidemic to reach into populations and regions

that were previously untouched. More women are presenting with HIV and

neighboring states are now experiencing the dual epidemic of drug

abuse and HIV infection.

In Manipur, the sexual transmission of HIV from PWID has lead to an

increased HIV infections among pregnant spouses (14). To prevent the

HIV epidemic from entering a new period of growth, it is necessary to

expand HIV prevention efforts for targeted groups, namely PWID. A

recent meta-analysis conducted in Viet Nam found that low-risk women

have a considerable risk of HIV infection because of the high-risk

sexual partners and their intravenous drug use behaviors(20). These

findings are supported by data from the NACO, which found that the

proportion of women living with HIV rose from 19% in 2000 to 35% in

2008(20). The potential for sexual transmission of HIV from PWID to

their non-injecting female partners has been identified as a new

challenge to current HIV programming. Previous studies found that less

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than 22% of females with injecting partners reported used a condom the

last time they had sex (20). In the northeastern states in India, the

prevalence of antenatal HIV is greater than 3%, demonstrating how

outbreaks in the PWID population can lead to wider sexual epidemics(8,

10). New pockets of high HIV transmission through PWID in the northern

states have emerged though the expansion of heroin trafficking—between

20% and 56% are infected with HIV(20). Currently only 1.5% of PWID in

India have access to OST, demonstrating a lack of congruence between

the new epidemics and the availability of appropriately scaled-up

treatment(8).

Scaling-Up: Opportunities and ChallengesThe AVAHAN India AIDS Initiative is in the process of transitioning

ownership to the national government. Through complementary programing

with Project ORCHID and community-based organizations, the NACO hopes

to open 300 OST sites, broadening coverage of OST to 20% of the PWID

population(14). In order to achieve the intended scale-up in the

developing context, both standardization of services and flexibility

are necessary. In India, programs are often scaled up by the national

government. In order to ensure that harm reduction strategies are

implemented, it is necessary for research and subsequent publications

to reach the policy makers who develop national initiatives—and just

as importantly, fund the programs. The NACO is currently working on a

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collaborative model of OST delivery through a pilot study in

Punjab(14). The model hopes to integrate government facilities and the

local NGOs implementing targeted interventions for IDS to expand OST

across 32 states. The NACO report detailed the progressive plan that

would utilize the strengths of government hospitals as well as local

NGOs. Each government hospital or clinic would be linked with a nearby

NGO that targets PWID. The client would receive their prescription

from the clinic and would be linked with a local NGO for counseling,

support, and service utilization. The NGO would facilitate the service

uptake at government facilities by motivating clients in their area

and referring them to treatment. Outreach workers at the local

agencies would also generate support for the program and follow-up

with dropouts to ensure that comprehensive data is collected.

Barriers to project implementation and uptake can be overcome

through structured advocacy by community me members and community

leaders(21). Community mobilization was central to the success of

Project ORCHID. The PWID community developed innovative solutions that

met the individual needs of their patient base. For example, the Naga

community of former drug users created a community crisis response

team to help deal with violence as well as an overdose management

system to prevent death by opioid overdose of new OST patients(21).

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Committees organized by the NGOs have also helped prevent overlapping

services from leading to unnecessary expenditure of limited funding.

In the process of scaling up, the NACO has the opportunity to

address many of the shortcomings of Project Orchid. The project was

not able to address the co-infection with HCV. The cost of diagnosis

and treatment was too high for the project to include and the lack of

a national strategy prevented its inclusion at hospitals and clinics.

The NACO also has the responsibility to determine the best opioid

agonist for use in OST. Methadone, a full opioid agonist, is more

effective in treatment of clients who abuse multiple drugs and is more

efficient at blocking the effects of the synthetic opioids which are

gaining popularity in the northwest. Methadone has also proven to be

cost effective in other SEAR countries relative to buprenorphine.

Regardless of the drug(s) chosen for OST scale-up, it is necessary for

the NACO to develop national guidelines for optimal dosage of the

treatment.

Although convincing policy-makers with local public health

evidence on the effectiveness of OST is a critical component to

scaling up, increased acceptance of the approach by public security is

essential in increasing utilization and support. PWID continue to be

detained, violating their right to due process as well as their human

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right to appropriate care. Prisons continue to have HIV prevalence

greater than 10%, which is 30-40 times greater than the overall

prevalence in India. Incarcerating a PWID can lead to unsafe injection

practices in prisons or can interrupt treatment at OST centers.

Although there is limited data about HIV and intravenous drug use in

Indian prisons, studies in Nepal and Thailand found that 75% and 97%

of drug users in prison ‘always shared needles.’ One of the metrics

prisons provided in 2003 suggests a similar situation in Indian

prisons, where HIV prevalence was between 5-10% upon entry and then

rose to 20% upon release(8).

RecommendationsUntreated opioid dependence in developing countries leads to HIV

transmission, on an international level. The independent Commission on

AIDS in Asia estimated that 80% of the new HIV infections could be

averted if financial resources were allocated to “low-cost,” but

“high-impact” interventions that target PWID, among other at-risk

populations(22). Without the adoption of low cost, high impact harm

reduction activities, the HIV prevalence among PWID may rise to 40%

within 1 to 2 years after the virus is introduced in their

communities. The emerging pockets of HIV in the northern,

northwestern, and southern states require rapid scale up of OST

programing in order to prevent escalation of the epidemic to that

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proportion. In India, the philosophy surrounding OST has been to wait

to use methadone until the patient demonstrates a “need” for it. Often

in meeting the need, the patient has encountered the justice system,

acquired a BBV, overdosed, or engaged in risky behaviors like

commercial sex work to support their illicit acquisition of

heroin(13). Within impoverished populations in developing countries,

the lack of formal employment often caused by a separation or

isolation from ‘mainstream society’ exacerbates the pleasure seeking

behavior that can lead to drug abuse. Rather than being regarded as a

secondary prevention strategy for HIV, MMT should be regarded as an

effective primary strategy. Waiting for adverse health outcomes to

develop is irresponsible and the risks of delaying OST far exceed the

cost of providing treatment.

Future research of OST in India should focus on determining the

behaviors association with injection of each drug and thereby the

nature of association between the particular drug and degree of HIV

risk. Further profiling differences in drug use and sexual practices

between age groups would allow NGOs to target at risk groups and

reduce the transmission of HIV. The pilot study in Punjab will be

instrumental in shaping the national guidelines for the provision of

OST. Research surrounding the comparative effectiveness of OST in

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clinical settings versus community settings would help guide

implementation in India and other developing nations. As demonstrated,

the socio cultural context of the developing regions is supremely

important in developing public health interventions. Further

epidemiologic and ethnographic studies should be conducted in the

states with emerging HIV epidemics to determine what social or

historical factors may lead to successful completion of treatment.

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