International Journal of Collaborative Research on Internal Medicine & Public Health

editor@imedpub.com Submit a Manuscript

Prevalence of HIV and the risk behaviours among injecting drug users in Myanmar

Lin Aung Swe, Abdul Rashid

Lin Aung Swe1*, Abdul Rashid2
  1. Beneficial Partner Group, Yangon. Myanmar
  2. Department of Public Health Medicine, Penang Medical College, Malaysia
Corresponding Author: Lin Aung Swe
Related article at Pubmed, Scholar Google

Abstract

Background: Myanmar has one of the largest HIV positive populations in Asia and injecting drug use represents one of the major causes of HIV transmission.

Aim: the aim of the study was to determine the prevalence of HIV and the risk behaviours among injecting drug users in Myanmar.

Methods: A cross sectional study was designed to collect the data among injecting drug users enlisted in the state harm reduction programme in selected regions.

Results: Of the 590 participants, 152 (25.8%) were HIV positive. Female (OR 5.96. 95% CI 1.31;30.45), using ‘used syringes’ (OR 1.81. 95% CI 1.23;2.68) and sharing syringe when first used drugs (OR 2.98. 95% CI 2.00;4.44) and injecting drugs past six months (OR 3.36. 95% CI 1.50;6.15) were significant risk factors. Age (p=<0.001) and frequency of drug use per day (p=0.022) were also statistically significant. HIV positive IDUs were more likely to use disposable syringes (OR 3.0. 95% CI 1.50;6.15) and were less likely to share syringes (OR 3.41. 95% CI 1.71;6.96) during their last drug use. HIV positive IDUs were also more likely to check for VDRL (OR 1.89. 95% CI 1.26;2.84) and more likely to be VDRL positive (OR 1.90. 95% CI 1.11;3.26).

Conclusion: HIV positive respondents used disposable syringes and few shared syringes the last time they injected drugs. This could probably be due to the education they received in the needle exchange programme centres.

Keywords
Injecting drug use, HIV, risk behaviours, Myanmar

Introduction
Myanmar has one of the largest HIV positive populations in Asia. It is estimated that around 238,000 people are living with HIV and an estimated 17,000 people died of AIDS-related illness in Myanmar in 2009 [1].
The HIV epidemic in Myanmar is mostly due to transmission of the virus among the high risk groups. These high risk groups include sex workers and their clients, men who have sex with men and the sexual partners of these sub-populations. In addition to this, drug users who share non-sterile injecting equipment are also at a higher risk. The documented mode of transmission among the reported AIDS cases in 2008 included 73% due to unsafe sex, 3% due to injecting drug use (IDU), 3% from mother-to-child and 2% due to blood transfusion [2].
Myanmar is the second largest opium poppy growing country after Afghanistan, contributing 20% of the opium poppy cultivation of the world in 2008 [3]. Heroin use is widespread and is the primary drug of choice among people who inject drugs. However due to the poppy eradication effort and crop substitution programs, opium and heroin availability has reduced leading to the decline in the use of heroin and opium in recent years [4]. The use of methamphetamine has been found to be increasing among the young people residing in major cities such as Yangon and Mandalay since 2003. The use of so called ‘crazy medicine’, Amphetamine Type Stimulants (ATS) can influence high risk sexual behaviours which can lead to significant risk of HIV infection. Injecting of amphetamine type stimulants has also been reported to occur, as well as injection of a mixture of opiates and pharmaceutical drugs. According to Myanmar Behaviour Surveillance Survey 2008, among the IDU’s in Mandalay, Lashio, and Myitkyina more than a third of the respondents reported having sex while under the influence of amphetamines [5].
Injection drug use represents one of the major causes of HIV transmission in Myanmar. According to the HIV Sentinel-sero Surveillance Survey, in 2008 the prevalence of HIV among the IDU population was 37.5% [6]. The drug user population in Myanmar is estimated to be between 60,000 [7] and 300,000 [8]. In Myanmar, drug users are mandated to register with a government identified facility for treatment [9] and possession of needle and syringe is considered illegal [10]. According to the Central Committee for Drug Abuse Control, there were 63,149 registered drug users in Myanmar in 2002 and the number rose to 69,547 in June 2008 as reported by major drug treatment centres around the country [11]. Depending on certain published reports, the estimated injecting drug user population varies from 90,000 [7] to 150,000- 250,000 [12] and 90,000 to 300,000 [13]. The population prevalence of injecting drug use among 15-64 year-olds was 0.23%, which is the fourth highest population based prevalence of injecting drug use after China, Malaysia, Thailand and Vietnam in the Asia region [14].
IDUs make up a population group with a high prevalence of blood-borne infections, mainly HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) [15]. In Myanmar, it has been estimated that 12% of the general population carry HBV [16]. A study conducted among the IDUs along the China Myanmar border reported the prevalence of HIV/HBV coinfection and HBV infection among the Myanmar IDUs as 11.3% and 43.1% respectively [17]. According to HIV Sentinelsurveillance Survey 2008, the prevalence of syphilis among the IDUs was 2.9%, HIV/Syphilis (VDRL+) co-infection among the IDU was 3.3% and syphilis (VDRL+) among the HIV negative IDUs was 2.7% [6].
The objective of the study was to determine the prevalence of HIV infection and risk behaviours among injecting drugs users in Myanmar.

Methods and Materials
Setting: The study was conducted in several regions in Myanmar namely in Shan State, Mandalay Division, Yangon Division and Kachin State. These locations were chosen due to the high prevalence of injecting drug users in these locations.
Study design: A descriptive cross sectional study was chosen as the study design. The study was conducted from Dec 2009 to Oct 2010.
Sampling: All current injecting drug users enlisted in the state harm reduction programmes in the regions mentioned above were eligible. The inclusion criteria included those aged 15 years and above who consented and were able to communicate effectively. Respondents who were injecting drugs in the last six months of the study for any nonmedical purposes were designated as "current IDUs".
Tools: A quantitative questionnaire was developed and field tested prior to the actual study. The questionnaire had two sections. Besides the questions on socio demography, the first section had multiple response questions on the respondent’s first drug use experience and the last drug use experience as well as their awareness of HIV. The second section included questions on risk factors associated with HIV. This section had questions on past and latest drug use history, detoxification history and co morbidity. Interviews were conducted by trained research assistants who were able to communicate in the local languages. The interviewers were trained for three days and an additional two days of field practice. The interviews were conducted in privacy in various locations such as private rooms of tea shops, at the drug user’s homes, special rooms in restaurants etc. The blood test reports done by the laboratories of the National AIDS Programme STI/AIDS Teams were requested from the participants.
Ethics: This study was ethically conducted. An informed verbal consent was taken before commencing the interview and reviewing the blood test report. The confidentiality of the participants is assured.
Research Analysis: Data analysis was done using SPSS version 15.0. Results were tabulated and cross tabulated. Chi square test was used to compare the variables. Odds ratio was used to estimate the risk of HIV.

Results
A total of 590 IDUs participated in the study, 152 (25.8%) were HIV positive and 438 (74.2%) HIV negative. Most of the respondents were males, aged between 22 to 30, Myanmar’s, Buddhist, unmarried, employed and with a highest level of education up to middle school.
Table one show the participants’ first drug use experience. Irrespective of being HIV positive or negative the most common type of drug used for the first time was heroin followed by opium and the most common method of drug use was by inhalation. The most common body part of injection was the forearm and friends were the most common people the syringe was shared with.
Table two show the participants’ last drug experience. Irrespective of being HIV positive or negative the most common drug last used was heroin and IV injection into the forearm was the most common route of administration. Considerably fewer participants shared the syringes and friends were the most common people syringes were shared with. Most respondents received their syringes from harm reduction programmes in their local areas. Majority returned the used syringes to the program centres, however considerable users disposed the syringes recklessly. As shown in this table most of the respondents had poor awareness of how HIV is spread.
As shown is table three among the IDU’s females were almost six folds at higher risk of being HIV positive compared to males (OR 5.96. CI 1.31;30.45). More unemployed and employed participants were HIV positive as compared to students (p=0.017) and there were more HIV positive respondents in the age group 31 to 40 followed by those within the ages 22 to 30 (p<0.001). The differences in race, religion, education and marital status were not found to be statistically significant.
As shown in table four, respondents who used ‘used syringes’ for the first time (OR 1,81. CI 1.23;2.68) and respondents who shared syringes during the first use (OR 2.98. CI 2.00;4.44) were at higher risk of being HIV positive. Differences in the age first used drugs were found to be statistically significant.
Table five shows the risk behaviours with the last drug use. Respondents who used drugs by injection in the last six months were more likely to be HIV positive (OR 3.36. CI 1.63;7.09). However HIV positive respondents were more likely to use disposable syringes (OR 3.00. CI 1.50;6.15) and not to share syringes (OR 3.71. CI 1.71;6.96) now. Difference in the frequency of drug use was also found to be statistically significant (p=0.022).
As shown in table six, HIV respondents are more likely to have tested for VDRL (OR 1.89. CI 1.26;2.84). Respondents who were VDRL positive were more likely to be HIV positive as well (OR 1.90. CI 1.11;3.26).

Discussion
Recent updated global reviews shows that 148 [7] countries have reported injecting drug use compare to only 129 countries in 1998 [18] and the prevalence of HIV infection among injecting drug users was reported to be zero in only eight of 148 countries [7]. This suggests an increase in injecting drug use over time.
One study estimates that one in five IDUs globally may be infected with HIV [7]. Once HIV infection penetrates a network of injecting drug users who share needles there is a possibility that 50% of the network of drug users will get infected within a few months. The prevalence of HIV infection among the IDUs in this study is lower than the prevalence rate of 37.5% reported in the HIV Sentinal Sero-survellance Survey 2008 [6]. It is also lower than the prevalence reported in another study conducted among Chinese IDUs along Myanmar China border (33.7%) [17] and in a study among IDU’s attending detoxification clinics throughout Thailand (30 to 40%) [19]. However it is higher than the 18.4% reported in northern Vietnam [20].
In this study the risk of HIV infection was found to be higher in females, those in the age group between 31 and 40, among the unemployed and those who started injecting at a younger age. In 2009 it was estimated that 33.3 million adults worldwide were living with HIV and AIDS and half were women [21]. Female IDUs are at a higher risk of contracting HIV not only due to their practice but also from male IDU partners [22]. Females were more likely to engage in high risk behaviours such as sharing syringes, injecting with sex partners, less likely to use condom, more likely to be stigmatized and more likely to engage in sex work [23]. All these risk behaviours could possibly contribute to higher risk of protracting HIV than male IDUs. Similar to the finding of this study, results of the Sentinel-surveillance Survey conducted by the Myanmar National AIDS Programme in 2008 indicated that the highest numbers of the HIV positive IDUs were seen among the population in the ages between 30 and 34 [6]. Similarly Celentano et al. also showed that there were more HIV positive IDUs in the age groups 30 to 39 in his study conducted in Northern Thailand [24]. Older adults have been shown to have less knowledge about HIV risk behaviours compared to their younger counterpart [25]. This poses a serious problem as they may be unknowingly infecting others and may fail to receive appropriate medical care.
Drugs can be taken in a variety of ways including drinking, smoking, snorting etc. but injecting carries the highest risk of HIV transmission. Depending on the location and the population the most commonly used drugs like heroin and opiates, cocaine and amphetamine are injected. Drugs are injected for a variety of reasons, including availability and because injecting drug is cheaper and is more rapid acting. In Mexico [26], Russia [27] and India [28] because sterile needles are unavailable or due to the laws which make it an offence to distribute or possess syringes for non-medical purposes, most IDUs for fear of confrontation with authorities do not use new needles for injecting drugs. In Canada due to police actions during drug busts, needle exchange programme noted a drop by a third [29] leading to receptive or distributive type of sharing. Azim et al had shown in his study that IDUs with either receptive sharing or distributive sharing were at a higher risk of transmitting HIV [30].
Many studies have shown that frequency of injections had significant association with HIV infection. The IDUs with higher frequency of injecting has higher risk of contracting HIV. Jia et al. has shown in his study that higher frequency of injection was an independent risk factor for HIV infection among the IDUs in Yunnan [31]. Lack of awareness and education about the risk of injecting drugs can also lead to needle sharing. In Afghanistan less than half of those who were aware of HIV knew that using a new needle for injecting drugs reduced the risk of transmission [32].
There is evidence that the needle exchange programme have reduced HIV transmission rates among injecting drug users and there was no evidence to suggest that it encouraged drug use [33]. Only 82 countries worldwide have needle exchange programmes. Even in these countries IDUs do not have adequate access to the services. This could be due to the lack of resources, public or political opposition as well as laws [34]. Needle exchange programmes in Myanmar provide syringes and needles including spirit swab, distilled water and all injecting paraphernalia. In addition to providing drug injecting paraphernalia this program also plays an important part in educating the users on safe injection practices, proper disposal, safe sex practices and it provides an access to other prevention services including substitution services. In the present study it can be seen that more HIV positive respondents use disposable syringes and fewer shared syringes the last time they injected drugs. This could probably be due to the education they received in this centres.

Conclusions
Female injectors are at a higher risk of being HIV positive. Health intervention programmes should focus on this vulnerable group with the emphasis on the harmful effects of sharing needles. Extensive education programmes to increase the awareness among IDU’s for prevention of HIV/AIDS among them and their partners can help reduce the prevalence of HIV in this group of people.

Limitations
Due to monetary constraints the total number participants in this study was less than optimal however the findings of this study may spur more detailed studies.

Acknowledgements
The authors would like to thank the government counterparts, staffs of the NGOs and Peers for organizing the data collection and other non-governmental organizations for their continuous efforts and support in our efforts to advance IDU research.

Conflict of interest
None to declare
image
image
image
image
image
image
image

References

  1. National AIDS Programme. Department of Health. Ministry of Health Myanmar. UNGASS Country Progress Report Myanmar 2010. https://www.unaids.org/en/dataanalysis/mon itoringcountryprogress/2010progressreports submittedbycountries/myanmar_2010_cou ntry_progress_report_en.pdf. Accessed 24/08/11
  2. WHO. 2008. National AIDS Programme, Myanmar. HIV Estimates and Projections, Myanmar 2008-2015. UNAIDS. WHO country office for Myanmar. https://www.burmalibrary.org/docs09/mm_e stimates_and_projections_2008_to_2015.p df. Accessed 24/08/2011.
  3. UNODC. 2000. World Drug Report 2009. United Nations Office on Drugs and Crime. Vienna. https://www.unodc.org/documents/data-andanalysis/ WDR2011/World_Drug_Report_2 011_ebook.pdf. Accessed 24/8/2011
  4. UNODC. 2009. Patterns and Trends of Amphetamine-Type Stimulants and Drugs in East and South-East Asia (and neighbouring regions). United Nations Office on Drugs and Crime. Vienna. https://www.scribd.com/doc/23236458/2009 -Patterns-and-Trends-of-Amphetamine- Type-Stimulants-and-Other-Drugs-in-Eastand- South-East-Asia. Accessed 24/08/2011
  5. The National AIDS Programme. Department of Health. Ministry of Health. National Behavioural Surveillance Survey 2007-08 Report Myanmar On Injecting Drug Users and Female Sex Workers. Myanmar.https://www.plri.org/sites/plri.org/ files/Myanmar_BSS_2008_HIVAIDS_IDU _and_FSW.pdf. Accessed 24.10.2011
  6. The National AIDS Programme. Department of Health. Ministry of Health. HIV Sentinel Sero-surveillance Survey 2008.Myanmar. https://aidsdatahub.org/dmdocuments/HSS_ Survey_Myanmar_2009.pdf. Accessed 24.10.2011
  7. Mathers B, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee S, Wodak A, Panda S, Tyndall M, Toufik A, Mattick RP. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. The Lancet 2008; 372(9651): 1733-45.
  8. UNODC. Myanmar Country Profile 2005. https://www.unodc.org/pdf/myanmar/myan mar_country_profile_2005.pdf. Accessed 24.10.2011
  9. Narcotic Drugs and Psychotropic Substances Law: Myanmar Law (1993) Chapter 5. Section 9 & 10: Chapter 8, Section 15 & 16) https://www.blc burma.org/html/Myanmar%20Law/lr_e_ml 93_01.html. Accessed 6.10.2011
  10. The Burma Excise Act 1917. Chapter IV Section 13 and Section 33: 7,12 https://www.blcburma. org/PDF/Law/BC/vol3/THE%20BU RMA%20EXCISE%20ACT.pdf. Accessed 6.10.2011
  11. UNODC. Drugs and HIV/AIDS. Country Programme. Myanmar. (2009- 2010).https://www.burmalibrary.org/docs09 /unodc_myanmar_country_programme- 2009-10-red.pdf. Accessed 24.10.2011
  12. Centre for Harm Reduction, Burnett Institute. Revisiting. The Hidden Epidemic. A Situation Assessment of Drug Use in Asia in the context of HIV/AIDS. 2002.
  13. Aceijas C, Stimson GV, Hickman M, Rhodes T. United Nations Reference Group on HIV/AIDS Prevention and Care among IDU in Developing and Transitional Countries. Global overview of injecting drug use and HIV infection among injecting drug users. AIDS 2004;18(17):2295-303.
  14. Bergenstrom A, Ye Swe Htoon YS, Sharma M, Garg R, Macdonald V, Awng H, Buhler M, Gang S. Myanmar Country Advocacy Brief: Injecting Drug Use and HIV. United Nations Regional Task Force on Injecting Drug Use and HIV/AIDS for Asia and the Pacific. 2010.
  15. Sulkowski MS. Viral hepatitis and HIV co infection. J Hepatol. 2008;48:353- 367. Available at:
  16. Khin M. Regional Health Forum. Communicable diseases. Control of Hepatitis B Virus Infection in Myanmar: Public Health Issues WHO South-East Asia Region (Volume 6, Number 2).
  17. Zhou YH, Liu FL, Yao ZH, Duo L, Li H, Sun Y, Zheng YT. Comparison of HIV-, HBV-, HCV- and Co-Infection Prevalence between Chinese and Burmese Intravenous Drug Users of the China-Myanmar Border Region. PLoS One 2011;6(1):16349.
  18. Ball AL, Rana S, Dehne KL. HIV prevention among injecting drug users: responses in developing and transitional countries. Public Health Rep. 1998 June; 113(Suppl 1): 170–181.
  19. UNGASS Country Progreess Report. Thailand. 2010. https://www.tncathai.org/data/data13.pdf Accessed 24.10.2011
  20. UNGASS Country Progreess Report. Vietnam. 2010. https://www.unaids.org/en/dataanalysis/mon itoringcountryprogress/2010progressreports submittedbycountries/vietnam_2010_count ry_progress_report_en.pdf. Accessed 24.10.2011
  21. UNAIDS. Report on the Global AIDS Epidemic, 2010. https://www.unaids.org/documents/2010112 3_GlobalReport_em.pdf. Accessed 24.10.2011
  22. UNAIDS. A strategic approach: HIV & AIDS and education. https://www.unaids.org/en/Resources/Press Centre/Featurestories/2009/June/20090615 UNESCO/. Accessed 8/10/2011
  23. Cleveland CM, Jarlais DC, Perlis TE, Stimson G, Poznyak V, and the WHO Phase II Drug Injection Collaborative Study Group. HIV risk behaviours among female IDUs in developing and transitional countries. BMC Public Health 2007;7:271.
  24. Celentano DD, Hodge MJ, Razak MH, Beyrer C, Kawichai S, Cegielski PJ, Nelson KE, Jittiwutikarn J. HIV -1Incidence among Opiate Users in Northern Thailand. Am J Epidemiol 1999;149:558- 64.
  25. Mack KA, Ory MG. AIDS and older Americans at the end of the twentieth century. J Acquir Immune Defc Synd 2003;33:68-75.
  26. Pollini RA, Brouwer KC, Lozada RM, Ramos R, Cruz MF, Magis-Rodriguez C, Case P, Burris S, Pu M, Simon D, Frost W, Palinkas LA, Miller C, Strathdee SA. Syringe possession arrests are associated with receptive syringe sharing in two Mexico-US border cities. Addiction. 2008;103(1):101-108.
  27. Rhodes T, Judd A, Mikhailova L, Sarang A, Khutorskoy M, Platt L, Lowndes C, Renton A. Injecting Equipment Sharing Among Injecting Drug Users in Togliatti City, Russian Federation: Maximizing the Protective Effects of Syringe Distribution. JAIDS. 2004; 35: 293-300.
  28. Chakrapani V, Kumar Kh.J. 'Drug Control Policies and HIV Prevention Among Injection Drug Users in Imphal, India', from International Harm Reduction Development Program, Open Society Institute (2009, March), 'At What Cost?: HIV and Rights Consequences of the Global War on Drugs'.
  29. Human Rights Watch. Abusing the User: Police Misconduct, Harm Reduction and HIV/AIDS in Vancouver. 2003.: https://www.unhcr.org/refworld/country,,H RW,,CAN,,3f4f594fd,0.html. Accessed 24/08/2011
  30. Azim T, Chowdhury EI, Reza M, Faruque, MO, Ahmed G, Khan R, Rahman M, Pervez MM, Jana S, Strathdee SA. Prevalence of Infections, HIV Risk Behaviours and Factors Associated with HIV Infection Among Male Injecting Drug Users Attending a Needle/Syringe Exchange Program in Dhaka, Bangladesh. Subst Use Misuse 2008;43(14):2124-44.
  31. Jia Y, Lu F, Zeng G, Sun X, Xiao Y, Lu L, Liu W, Ni M, Qu S, Li C, Liu J, Wu P, Vermund SG. Predictors of HIV infection and prevalence for syphilis infection among injection drug users in China: Community-based surveys along major drug trafficking routes. Harm Reduct J. 2008;5:29.
  32. Todd CS, Abed AMS, Strathdee SA, Scott PT, Botros BA, Safi N, Earhart KC. Association between expatriation and HIV awareness and knowledge among injecting drug users in Kabul, Afghanistan: A crosssectional comparison of former refugees to those remaining during conflict. Conflict and Health 2007;1:5.
  33. Wodak, A. and Cooney, A. Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS among Injecting Drug Users. World Health Organization 2004.: https://www.who.int/hiv/pub/prev_care/effe ctivenesssterileneedle.pdf. Accessed on 24/08/2011
  34. Cook C. Global State of Harm Reduction. IHRA London. 2010: https://www.ihra.net/contents/535. Accessed 20/09/2011
open access journals, open access scientific research publisher, open access publisher
Select your language of interest to view the total content in your interested language

Viewing options

Flyer image

Open Access Journals

Share This Article

paper.io

agar io

wowcappadocia.com
cappadocia-hotels.com
caruscappadocia.com
brothersballoon.com
balloon-rides.net

wormax io