Injections for health-related reasons amongst injecting drug users in New Delhi and Imphal, India

Summary

Objectives

In many parts of the world where unsafe injection practices in health settings are common, the prevalence of blood-borne viruses (BBVs) is high amongst injecting drug users (IDUs). If IDUs in these settings are receiving injections for health-related reasons, the possibility of amplification of BBV transmission via medical injections exists. The aim of this study is to describe the nature and extent of injections received for health-related reasons amongst IDUs in two Indian cities, New Delhi and Imphal.

Methods

A cross-sectional survey of 200 IDUs was conducted in late 2004. Trained peer outreach workers asked participants about health problems experienced, consultations with healthcare providers and health-related injections received in the preceding 4 weeks.

Results

Most participants (99.5%) were male, the average age was 29 years, and the average time since first injection of illicit drugs was 6 years. A total of 133 injections were received for health-related reasons during the preceding 4 weeks by 15% of the participants. The average number of injections was 8.6/participant/year.

Conclusion

Injections for health-related reasons were commonplace amongst these IDUs. Therefore, amplification of BBV transmission within communities due to unsafe injections is possible and warrants further investigation.

Introduction

Injections are one of the most common medical procedures in the world, with more than 16 billion given annually.¹ The World Health Organization (WHO) estimates that 39% of injections in developing and transitional countries are unsafe, and the proportion is estimated to be as high as 75% in parts of the WHO South-east Asian region (which includes India).² Globally, the proportion of blood-borne viral (BBV) infections attributable to unsafe injections is estimated to be 32% for hepatitis B virus, 40% for hepatitis C virus and 5% for human immunodeficiency virus (HIV) infections.¹

The problem of unsafe injection practices is influenced by a range of structural, economic and sociocultural factors, including overvaluing of injections by patients and overprescribing by providers. In some places, injections are judged to be a more efficacious form of treatment due to the belief that they are faster acting, stronger and more direct than oral medications.3, 4, 5 Healthcare providers frequently believe that patients want injections, and if injections are not provided during a consultation, they will seek health care elsewhere.⁴ Additionally, there can be financial incentives that encourage healthcare providers to give injections in place of oral medication, such as extra payment for injection administration. A comprehensive review of injection practices found that between 25% and 96% of outpatients visits in developing countries resulted in at least one injection, and 70–90% of injections were judged to be therapeutically unnecessary or inappropriate, and may even have been causing harm.⁶

In developing countries, it is possible to conceptualize the administration of injections as occurring in four sectors, as follows:

• The formal sector, given by biomedically trained, allopathic healthcare providers who operate in both the government and private spheres, and include doctors, nurses and other healthcare workers who are trained to administer injections and who are authorized by the state to do so.⁴

• The informal sector, given by traditional healers who may or may not be recognized by the state through associations, and who are often trained by apprenticeship to other healers, as well as untrained providers whose practices are not institutionalized and who are not authorized by the state to give injections (sometimes referred to as ‘injectionists’, ‘injection doctors’, ‘compounders’ or ‘quacks’).⁴

• The illicit drug injecting sector by injecting drug users (IDUs).

• The domestic sector by relatives, friends or self administration.

It is probable that these sectors of injection activity intersect, i.e. many patients attending biomedical healthcare services also consult traditional and other providers. Similarly, IDUs are likely to experience a high burden of illness related to unsterile injecting practices, BBV infections, undernourishment and drug overdose, and, therefore, possibly consult both biomedical and traditional providers.

Current theories of HIV transmission identify heterosexual sex as the main route for HIV spread from IDU to non-IDU communities. However, in many parts of the world where unsafe injection practices are common, the prevalence of BBV infections amongst IDUs is high, so if IDUs are receiving injections for health reasons in the context of unsafe injection practices, the opportunity for amplification of BBV transmission via medical injections is great, i.e. the intersections between the IDU sector and the formal and informal healthcare sectors may be making an important contribution to the spread of BBVs in some communities. If this is the case, a change in the current emphasis of HIV prevention strategies may be warranted.

However, little is actually known about the health-seeking behaviours of IDUs in developing countries or the injections they receive for reasons other than illicit drug use. The aim of this study is to describe the extent of injections received for health-related reasons and the source of these injections amongst IDUs in two Indian cities, New Delhi and Imphal.

New Delhi is the capital of India and is located in the north of the country with a population of 13.8 million.⁷ There are an estimated 25,000–30,000 IDUs in New Delhi and the drug most commonly injected is Tidigesic (buprenorphine).8, 9 Imphal is the capital of Manipur, a north-eastern state that borders with Burma, which has a relatively small population of 2.2 million.⁷ Manipur is characterized by a recent history of substantial civil unrest (armed insurgency and intertribal violence) and a large military presence. There are an estimated 15,000–20,000 IDUs in Manipur, and heroin and Spasmo-Proxyvon (dicyclomine+dextropropoxyphene) are the most common drugs used for illicit injection.8, 9

People in India seek health care and receive injections from formal biomedical and informal traditional healthcare providers.10, 11, 12 Biomedical healthcare services are provided in the private and public spheres, while traditional services are almost exclusively private and generally have to be paid for out of pocket. Many traditional providers such as ayurvedic and homeopathic practitioners also inject a range of allopathic medicines including antibiotics, antimalarials, steroids and vitamins, although they are not qualified to do so. Several studies have described unsafe injection practices in both public and private spheres of health care in India.13, 14, 15 Recently, a large World-Bank-funded study, undertaken by the India CLEN Programme Evaluation Network, estimated that the average number of injections/person/year was 5.8, and that 32% of injections have the potential to transmit BBV infections. Public and private healthcare facilities performed equally poorly with respect to injection safety.¹⁶ Other Indian studies have linked infection with BBVs to unsafe injection practices.17, 18, 19

Illicit injecting drug use occurs throughout India but is perceived to be a serious problem in large cities such as Delhi, and in the north-eastern states bordering Burma. The prevalence of BBVs in this group is very high. Overall, about 4% of IDUs are HIV infected, but the levels are far higher in some places, e.g. Manipur (81%), Delhi (45%) and Chennai (31%).8, 9 The prevalence of HCV infection amongst Indian IDUs is extremely high, e.g. 98% in Manipur.²⁰