Intravenous drug use (IDU) is emerging as a significant driver for the “second wave” of the international HIV/AIDS pandemic, according to Dr. Chris Beyrer, a leading authority on the disease.
This wave is driven, in part, by record world levels of opium production, particularly in Afghanistan, and is compounded by the virtual absence of effective HIV/AIDS treatment programs in public health systems.
Beyrer, a leading epidemiologist at Johns Hopkins Bloomberg School of Public Health, presented his findings to a group of ethnic media journalists who were co-hosted by New America Media and the Open Society Institute’s Washington, D.C. office.
The “good news,” Beyrer said, is that “there is evidence of the slowing and decline of new infection rates” in sub-Saharan Africa and South America. However, Iran, Nepal, Indonesia, Central Asia, Vietnam, North Korea, Russia and the Ukraine are among those countries that are almost certain to experience an epidemic that will overwhelm their current capacity to adequately cope or contain the disease.
Beyrer noted that, while HIV/AIDS is most often associated in the American public’s mind with sexual activity, intravenous drug use adds another unique set of challenges to public health systems, particularly where those systems are relatively fragile or, as in some developing countries, virtually non-existent.
Data gathered in 2004 on Russia, for instance, showed that 87 percent of registered HIV cases were the result of intravenous drug use. Nine countries within the former Soviet Union’s orbit typically showed well over 50 percent of registered cases attributable to IV drug use.
Beyrer pointed out that well known drug trafficking land routes correlate with projected second wave epidemics, but countries in the path of drug shipping are also at risk. Thus, in West Africa, Ghana and Nigeria are potential “second wave” countries, while the island of Mauritius off of Africa’s east coast is suffering an alarming increase in IV drug use-driven HIV cases as smuggled drugs head toward Tanzania and Kenya, two countries that also made the list as emerging epicenters.
Quite simply, the flood of heroin through a country—whether it is the eventual destination or not—tends to increase the number of users there who quickly determine that needle injection is the best method to derive the desired effects of the drug. Beyrer also emphasized that, in some countries, the spread of HIV/AIDS is accelerated by needle sharing among prison populations. Iran is a prime example.
Beyrer cited 2005 data that showed only 10,000 cases of HIV/AIDS being reported to the Iranian ministry while the estimated drug user population ranged between two to four million people. Yet, there was a 15.2 percent prevalence of HIV “among male intravenous drug users attending drug treatment in Tehran in 2005” and the disease was “strongly associated with a history of shared drug use injection in prison rather than sharing outside of prison.”
Additional evidence showed that IV drug use was responsible for 85 percent HIV/AIDS transmission among drug users in Iran.
Regardless of religion or culture, drug use appears to take root when there is a sizeable flow of drugs through a society. The Uighurs, a people of Turkic origin, are facing an increase in IV drug use despite their adherence to Islam. Their homeland, China’s Xinjiang province, lies along a major drug trafficking route. Similarly, Iran, regardless of its religious traditions, is likely to remain at risk given its proximity to Afghanistan.
Yet, Beyrer says Iran is among the countries making important steps to confront its IV drug use patterns. Iran has legalized sterile needle exchange programs, a practical approach to limiting the infectious spread of the disease that the United States still refuses to fund through its international and even domestic HIV/AIDS prevention programs. Iran has also legalized the use of methadone as a treatment methodology.
Beyrer explained that heroin, a derivative of opium from the processing of poppy, is treatable with an “opioid analogue therapy.” Methadone is probably the best known drug used in this therapy. Countries that ban methadone remove a useful tool in their public health arsenal. Beyrer also noted that Iranian public health officials are leveraging their cultural strengths to confront IV drug use. Having identified the mother in the Iranian family as a central actor in running the household, Iranian health officials are engaging mothers in monitoring their children’s adherence to drug treatment regimens. Collectively, Iranian actions indicate the growing consciousness that intravenous drug use is a public health concern rather than simply a criminal offense.
It is difficult for individuals to admit their addiction in societies that champion criminal detention and prosecution as the mainstay of their anti-drug strategy, Beyrer explained. Criminal charges can lead not only to social alienation, but to termination of legal rights. Stripped of their dignity, imprisoned users thus become among the most marginalized members of a society, with no effective treatment available as they face the prospect of contracting HIV/AIDS through shared needle use.
Breyer called for countries to begin building their public health capacities by using “evidence-based” strategies to curtail IV drug use-driven HIV/AIDS. But he was somewhat somber in the face of the record bumper crop of opium harvested in Afghanistan in 2006.
When Afghanistan was under Soviet occupation, through the eras of the warlords, the Taliban, and now under President Karzai, no Afghan government has been able to eliminate opium production, according to data collected since 1980. The most successful effort was in 2001, the last year of Taliban rule, due to compliance with a government “fatwa,” or religious edict, calling for a ban on opium production. Since 2002, however, production has risen.
Beyrer said the country’s 6,100 tons of opium produced in 2006 was the highest on record by far. The volume would have yielded approximately 610 tons of heroin, “more than all the drug users [in the world] can use.”
Beyrer said that the staggering volume of heroin available and the amount of profit that can be derived from drug sales makes confronting IV drug use-transmitted HIV/AIDS daunting. Unless countries put a health infrastructure in place now, he said, the world will be seeing a fourth and fifth wave of HIV/AIDS in the decade ahead.
“The window of opportunity to control these epidemics is narrow and closing,” Beyrer said.