Rise in needle sharing among injection drug users in Pakistan during the Afghanistan war
Introduction
Many parts of Asia have witnessed burgeoning HIV epidemics associated with injection drug use (Crofts et al., 1998, Stimson, 1994, Reid et al., 2002). In Manipur, a state in northeast India, HIV prevalence among injection drug users (IDUs) and their non-injecting wives was 80 and 45%, respectively, indicating the potential for secondary transmission of HIV infection through heterosexual contact (Panda et al., 2000). In contrast, HIV prevalence among IDUs in Pakistan has been low, typically ranging from 0–2% (Baqi et al., 1998, United Nations Office for Drug Control and Crime Prevention and UNAIDS, 1999, Khawaja et al., 1997). HIV infection rates also appear low among other high risk populations in Pakistan including sex workers, hijras (i.e. eunuchs), prisoners, truck drivers and persons seeking treatment for sexually transmitted diseases (Baqi et al., 1999, National AIDS Programme, Islamabad, 1996). While the lack of high quality surveillance data has likely underestimated the scope of the HIV/AIDS epidemic in Pakistan, available data suggests that a major HIV epidemic has yet to occur (Khan and Hyder, 1997).
The window of opportunity to prevent a major HIV epidemic among IDUs in Pakistan may be closing rapidly. Most recent estimates suggest that there are approximately 0.5 million heroin addicts in Pakistan (United Nations Office for Drug Control and Crime Prevention, 2002), which has been attributed in part to Pakistan's proximity to Afghanistan. Afghanistan became the world's largest producer of heroin under the Taliban rule, contributing to an estimated 75% of the world's heroin supply by 2000 (Lubin et al., 2002, Reid et al., 2002). Until recently, Pakistan was a major conduit for opium grown in Afghanistan, which led to the emergence of local consumption markets.
Widespread availability of high quality powder heroin in Pakistan and neighboring regions led to a phenomenon called ‘chasing the dragon’, a practice whereby heroin is burned on a foil and the fumes are inhaled.
Since the late 1990's—during periods when the purity or availability of heroin has decreased—a growing number of drug users in Asia shifted from chasing the dragon to injecting combinations of pharmaceuticals that are readily available from pharmacies at a low price without a prescription (Reid et al., 2002, United Nations Office for Drug Control and Crime Prevention and UNAIDS, 1999, Zafar and ul Hasan, 2002, Dorabjee and Samson, 1999). In India, IDUs inject ‘cocktails’ of buprenorphine, antihistamines and tranquilizers (Dorabjee and Samson, 1999).
Recent events in Afghanistan may have had direct or indirect effects on the heroin supply and on drug user's behaviors in Pakistan. In early 2001, the Taliban regime started enforcing a ban on opium production in Afghanistan. Although some reports claimed that heroin production in Afghanistan fell 91% (United Nations Office for Drug Control and Crime Prevention, 2002), others countered that opium cultivation increased in some regions of the country and large stockpiles of heroin existed (Lubin et al., 2002). Nevertheless, since the Afghanistan war began, reports surfaced of intermittent availability, reduced purity and increased price of heroin (Reid et al., 2002, Zafar and ul Hasan, 2002, Pugh, 2001). In October 2001, the price of opium increased 10-fold in Taliban controlled areas in Afghanistan (Reid et al., 2002). Contributing factors may have included changes in regional drug trafficking patterns prompted by the war (Lubin et al., 2002), or increased military pressure on the Afghan–Pakistan border interrupting the flow of heroin into Pakistan. Concerns have been raised that this situation may have inadvertently facilitated transitions to injection drug use among heroin users in Pakistan (Zafar and ul Hasan, 2002, Pugh, 2001), but this hypothesis has not been empirically studied.
Circumstances surrounding the war may have also caused indirect effects on drug users’ behaviors in Pakistan. Following the US bombing campaign in Afghanistan, antiwar and religious protests turned violent in many cities (Washington Post, November 4, 2001, Washington Post, November 10, 2001). Reports of rallies, church bombings and attacks on Western tourists were met with increased police and military presence. Since fear of arrest has been associated with covert injection behaviors and increased needle sharing in other settings (Koester, 1994, Harvey et al., 1998, Rhodes et al., 2002), we hypothesized that increased police pressure following the beginning of the war may have inadvertently facilitated needle sharing among urban Pakistani IDUs.
We studied drug use behaviors and factors associated with needle sharing among heroin users registering for services at a non-profit service organization catering to drug users in Lahore, Pakistan. Specifically, we examined whether drug use, needle sharing behaviors and needle exchange program coverage differed in the period immediately preceding and following the bombing campaign in Afghanistan. Such information is critical to inform program planning to prevent transmission of blood borne diseases in countries influenced by war and other complex emergencies, and may assist Pakistan and other countries in Central Asia to avoid explosive IDU-associated HIV epidemics experienced by neighboring countries.
Section snippets
Study population
Situated in the Punjab province, Lahore is the second largest city in Pakistan with approximately three million inhabitants. In July 2000, a drop-in centre was established by a non-profit organization (Nai Zindagi, or ‘New Life’) in a location near Ali Park in Lahore where several hundred drug users are known to congregate and sleep on the streets. At a street-based drop-in center located within two blocks of Ali Park, drug users are offered various services, including food, tea, bathing
Results
A total of 244 drug users registered for services between August and October 2001, of whom 125 (51.2%) were current IDUs. As seen in Table 1, the sample was predominantly male (99.6%). Median age was 35 years (interquartile range (IQR): 27–40). All were of Pakistani origin, with the majority being Punjabi (85.7%). High proportions were uneducated (48.6%) and unemployed (78.9%). Over half were homeless (54.6%); however, 39.7% were married. Among heroin users, the median age at first use was 38
Discussion
In our study of drug users in Lahore, Pakistan, we observed a significant increase in needle sharing coinciding with the initiation of the bombing campaign in Afghanistan. In the period immediately preceding the war, 58% of IDUs reported sharing needles, whereas in the immediate post-war period over three quarters reported sharing needles. After adjusting for other factors associated with needle sharing, the odds of needle sharing was more than threefold higher among IDUs registering in the
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