Public Health Response to HIV Epidemics among Injecting Drug Users in South Asia: A Systematic Review

BACKGROUND: World Health Organization (WHO) has defined harm reduction (HR) programs specifically in relation to injection drug users (IDUs) which states that the comprehensive intervention included in HR package aims to prevent the propagation of blood borne infections including HIV that occurs through sharing of contaminated injecting equipment and drug preparations. In the present systematic review, we aim to describe HR programs targeted towards IDUs in South Asia (SA) and to explore the trend of HIV infection and risk behaviors among IDUs in these countries. METHODS: Online search was done using electronic databases including PubMed (Medline), Psychinfo, SCIRUS Studies (Elsevier and Google Scholar). Studies that described HR program, HIV infection and risk behaviors among IDUs were included in the review. The authors selected the original articles in English language, extracted the data and performed narrative analyses based on WHO's comprehensive intervention criteria evaluating the prevention and treatment of HIV among IDUs. RESULTS: Search resulted in 76 peer reviewed and 78 grey literature manuscripts from 1991 to 2010. HIV among IDUs has been reported in all countries of SA except in Bhutan and Maldives. The problem is concentrated (>5%) in India, Nepal and Pakistan. HR interventions are implemented in all countries where HIV among IDUs exists, but the coverage is low. The access of IDUs to the HR program ranged from 17% in Afghanistan to 50% in India. None of the countries had all elements of the WHO's comprehensive intervention package. Considerable decline in HIV prevalence and risk behaviors among IDUs is observed in Nepal and India (north-eastern states). The initiation of HR program in Bangladesh has maintained low HIV prevalence among IDUs, but HIV prevalence in Pakistan and other areas of India continues to increase. CONCLUSION: Decrease in risk behaviors and HIV prevalence among IDUs have been found in areas with good coverage of HR program. Hence, the SA countries should continue HR interventions with emphasis on increasing the comprehensive coverage. However, the inconsistent results from the region and the lack of effectiveness studies makes it difficult to reach a general conclusion about the role of HR program in reducing HIV infection and risk behaviors among IDUs in SA. Therefore, there is a need for effectiveness studies of available HR programs in SA.