December Issue 2005

“I am carrying the huge burden of hiding my HIV positive status from my wife,” says forty-something Saadi, a former injecting drug user(IDU). He cannot decide which is worse: the fear that his wife will contract the deadly virus or her discovering that he is HIV positive. Saadi has just recently found out that he has AIDS.

And the trauma is taking its toll. “I want to use a condom to prevent my wife from contracting AIDS, but when I do my wife asks me if I don’t want to have children with her, or if I don’t love her anymore,” says Saadi. Unable to tell her the truth, Saadi has started to spend less time with her using a myriad excuses to avoid going home from work. Contrary to the expected wasted appearance of a drug addict, Saadi sports well-manicured nails and a trimmed beard. He’s a handsome man, one you couldn’t imagine living on the streets. Saadi holds a diploma in civil engineering and belongs to a fairly well-off family.

During the Taliban rule in Afghanistan, stringent measures to curb heroin production by the Drug Enforcement Agency in Pakistan resulted in temporary disruptions, and consequently heroin became more expensive. “The dealers also gave us a lot of trouble in terms of delivery, quality, quantity and price. That is when I switched to injecting other drugs, and life became much simpler,” recounts a former drug addict. “These drugs were available at any pharmacy and since most chemists knew what we wanted, they would sell us ready-made packs with vials and a disposable syringe at the same price. My biggest anxiety was over,” he continues. “As the drugs were readily available. I could buy them at any time, even on credit.”

And what exactly is this concoction of drugs? “A normal drug cocktail includes doses of Pentazocine (a benzomorphan derivative), Diazapam (a benzodiazepine) and Avil (an antihistamine), costing around Rs 35-40,” says Saadi. “Alternatively, drugs like Temgesic or Bupron are also injected but because of the high cost — almost Rs. 100, very few can afford them.”

“The instant kick that injected drugs provide, combined with the over-the-counter availability of psychotropic drugs without prescription, are some of the factors contributing to this changeover,” says Dr Nadeemur-Rehman, programme coordinator, of the UN Office for Drug Control and Crime Prevention (UNODC). Dr Muhammad Tariq, a programme officer at the Family Health International’s Institute of HIV/AIDS in Pakistan, acknowledges that the practice of injecting drugs is more satisfying. “It is also a “market-dependent phenomenon,” says Tariq. “The pattern is set by availability and market dynamics.”

Dr Syed Abdul Mujeeb, head of the department of Blood Transfusion Service at the AIDS Surveillance Centre, JPMC, asserts that the needle sharing phenomenon mainly occurs “because the sharing of drugs is a cost-effective approach and also establishes a sense of companionship.”

Some drug users become what are known as ‘street doctors’, helping others to inject. Salahuddin Shah is one such doctor who has been injecting drugs into others for almost 25 years now. “I help about a hundred IDUs every day on an average. I can find veins even in the most delicate of areas — even in the neck. In return the users give me money or some let me share their drugs. I determine how much a person needs and inject the correct amount accordingly. At times I divide the cocktail I’ve made between two people.” Shah is completely oblivious to the risks he’s subjecting his ‘patients’ to.

According to recent studies, 26 per cent out of the total number of drug users in Karachi have tested HIV positive. Karachi also has the highest number of IDUs and HIV positive injectors in Pakistan. According to Dr Saleem Azam, injecting drugs is a recent phenomenon. “The 1993 National Survey showed that unreported injectors made up only 1.8 per cent of the total heroin-using group and the majority belonged to Karachi. Of all drug users interviewed, 80 per cent did not use new needles each time they injected.”

According to Dr. Azam, another fairly recent occurrence which may have contributed towards the increased use of injections, is a drug called sufaid maal. “Not really heroin, it has been circulating for the last few years and its availability is restricted to the Burns Road and Chanesar Goth areas. Sufaid maal is an extremely potent drug and can only be injected,” says Dr. Azam.

Dr Rehman, agrees with Dr Azam: “The 1993 National Survey showed that IDUs existed only in Karachi,” he says. However, the 2000 National Assessment Study on Drug Abuse, conducted by UNODC and the government of Pakistan, shows that out of the 500,000 “chronic” heroin abusers in the country, 60,000 (or a little over 20 per cent) are IDUs. With this increase in injecting drugs, and the resulting syringe-sharing, there has been a corresponding rise in HIV cases. “Some countries have experienced very rapid increases in HIV prevalence among IDUs in a short period of time — in some cases, going from zero per cent to 50 per cent in a six month period.”

Although an educated man, Saadi confesses that he was not fully aware of the deadly consequences of sharing needles when he resorted to injecting drugs. “Well, there was a nagging doubt at the back of my mind that this was not a healthy habit, but I had no idea that I would contract HIV.” According to the Monitoring of AIDS Pandemic Network’s 2005 report, “HIV is easiest to transmit to others when high levels of the virus are present in a person’s blood — a state known as viraemia.” Viraemia develops shortly after a person is initially infected when he shows no signs of the virus, or when he develops full blown AIDS. In the first phase, when the person has no knowledge of his HIV positive status and his risk behaviour (sharing needles, continuing with unprotected sex and donating blood), continues as normal, there is a strong likelihood that he will infect a number of other people. Dr. Azam warns: “If the problem of IDUs is not contained as soon as possible, we will experience an HIV/AIDS epidemic in the next ten years.”

Those who have worked with IDUs, maintain that even when users are fully aware of the consequences, it does not always translate into safer behaviour. Dr. Rehman adds: “When we started interventions in Karachi in our pre-intervention survey, only 15 per cent of IDUs were aware of HIV as well as its means of transmission and 80 per cent shared needles. A post-intervention survey two years later, revealed that more than 60 per cent were now aware of the HIV virus and its transmission, and yet 70 per cent continued to share needles.”

Dr. Zafar blames this apathetic attitude upon “insufficient public information.” He emphasises that the message has to be consistent, “IDUs continue to be under the impression that HIV is not an issue in Pakistan as they have not been exposed to HIV related deaths in the media. Drug users also have no value for life and often see death as a release from misery and consequently take unnecessary and uninhibited risks,” says Dr. Zafar.

Dr. Saleem Azam adds that drug users also indulge in very risky sexual behaviour. “Those who’ve just begun to take drugs are initially sexually very active so HIV is spread rapidly during this time.” According to Saadi, drug users on the streets indulge in all sorts of sexual activity. “Sometimes if they can’t get female sex workers, they have sex with men, and even with street kids. At times they provide sexual services in return for drugs.” So be it buying or selling sex, the HIV virus is being transmitted. “And when they are completely intoxicated,” Saadi says, “They are not concerned about using condoms. They don’t fear contracting or transmitting HIV/AIDS, even if they are aware of the risks.”

So, what kind of action is required to minimise drug injecting and consequently prevent an the HIV/AIDS epidemic? “Survey the IDUs themselves and ask them for solutions,” suggests Dr. Zafar, who has been campaigning for this more interactive approach. He should know as he himself was a former drug user. Dr. Zafar warns that donor-driven or ready-made models are bound to fail if drug users are not researched on a personal level.

After years of apathy, the government has finally begun to realise that messages like ‘say no to drugs’ or calling for ‘a drug-free world’ are ineffective, and that there is a clear and present danger of an HIV/AIDS epidemic. Finally, there is an understanding in government circles that this ‘silent tsunami’ cannot be contained by pretending it doesn’t exist. Government officials can now often be heard using words and phrases such as “condom use”, “sexually transmitted infections”, “needle exchange and promotion of safe injection practices,” without blushing or wiping the sweat off their foreheads.

They have also realised that there are various harm reduction — as opposed to eradication — programs in place, supported by scientific evidence, which indicate that measures such as providing substitutes for injecting drugs and increasing access to clean needles and syringes reduce the probability of transmitting HIV to uninfected injectors. Such programs are being implemented in Islamic countries such as Iran and, more recently, in Malayisa.

As a first step, the government of Pakistan has negotiated a grant of US$ 9.28 million and loan of US$27.83 million with the World Bank for its Enhanced HIV/AIDS Control Program, which has been in effect in Punjab since 2003. In Sindh which hosts the highest number of IDUs in Pakistan, intervention could not begin because of vested interests of some Sindh government officials, says informed sources. This delay will lead to disaster as 23 per cent of IDUs in Karachi are HIV positive.

In Pakistan there are no substitution programs. Substitution programs provide IDUs with an oral drug that gives the same high. The IDU can get his dose at a clinic on a daily basis. Over a period of time the dose can be gradually tapered off, at the discretion of the IDU and his counselor. The first methadone maintenance treatment (MMT) clinic in Iran was set up in 2002, since then 15 clinics have been established in medical universities, two in drop-in-centres and five in prisons across Iran.

There have been some very basic intermittent interventions in the Central Prison in Peshawar, while several needle-sharing and distribution programs have been initiated by the government in Lahore, Karachi and Larkana, Hyderabad, Peshawar and Quetta. “New programs are being launched under the enhanced program for HIV/AIDS and will be implemented in more cities soon,” says Dr. Emmanuel. However, Dr. Rehman feels the current interventions are superficial and warns that, “If drug treatment and rehabilitation services remain weak, and if outreach work and follow-up is not increased, the epidemic will engulf us all.” Dr. Zafar agrees. “If coverage is limited, the program will not be effective. It has to be implemented all over Pakistan simultaneously.” According to Dr. Tariq, “Right now programs and projects lack vision and are vertically oriented. Unfortunately a very local approach is in place which neglects national needs and ignores coordination with other cities and the public sector.” Dr. Emmanuel feels that,”A more comprehensive strategy needs to be devised for countries like Pakistan, where IDUs use synthetic drugs.” We need to consider the cost of these drugs (which is very affordable), as well as hold pharmacies accountable for selling drugs without prescription.”

“Continuum of care,” is Tariq Zafar’s mantra. This means “reaching out to IDUs and providing education, access to information, health care, access to clean syringes, availability of oral substitutes, access to drug treatment, and rehabilitation.” Dr. Azam emphasises the need to counsel families of HIV sufferers. “They need to be aware that without the family, support and love, no amount of medicines and rehabilitation from outsiders will help them recover fully. And most important of all, we need to remove the stigma attached to HIV.”

Another expert says he does not subscribe to the “very western concept of voluntary counselling and testing. “It can’t work in our cultural context. For HIV/AIDS testing over here, we need to strengthen our family network. People don’t want to go to strangers for counselling. We have a strong family institution and should utilise it.”

Both Dr. Azam and Tariq Zafar are staunch believers in the strategy of harm reduction. “This is the first step to a continuum of care. The ultimate goal is abstinence and a functional life, but this is a process which will take time. Harm reduction is about minimising the effects of drug addiction, like HIV, Hepatitis C, crime, etc. even though the use of drugs continues.” says Dr. Zafar. Such programs exist in four cities in Punjab, as well as Karachi and Larkana, but currently reach less than five per cent of the IDU population. “Coverage means being able to reach out to all IDUs regularly (at least 3-4 times a week) and provide them access to certain services. If the coverage is below 60 per cent it will not stop a potential HIV epidemic.

If urgent steps are not taken there is every possibility that Pakistan will face an AIDS epidemic sooner rather than later.