India’s injecting epidemic – a problem for young people

HIV incidence is much higher among young people who inject drugs compared to their older peers. A new study published in JIAS shows younger people are far less likely to access harm reduction services and more likely to take risks making them vulnerable to HIV.

The study includes a cross-sectional analysis of 14,381 people who use drugs across 15 cities in two regions considered the epicentre of India’s injecting drug use epidemic – Northeast and North/Central India. The investigators aimed to compare substance use and psychosocial risk behaviours, harm reduction service use, and HIV incidence among younger and older people who inject drugs.

They also wanted to identify factors associated with recent injection and sexual risk behaviours to evaluate whether these factors vary among different age groups.

Participants completed an interviewer-administered electronic survey that included modules on socio-demographic and substance use characteristics, HIV testing experience, sexual and injection risk behaviours, psychosocial risks and use of harm reduction services. After completing the survey, they were then counselled and tested for HIV.

Recruitment used well-connected individuals in each of the cities (“seeds”) to recruit three people using a voucher system who were then also asked to recruit three of their peers. The process continued until sample size criteria of 1,000 people per city (except for one) was met.

Participants were divided into three groups: ‘emerging adults’ aged 18 to 25; ‘young adults’ aged 25 to 30; and ‘older people who inject drugs’ aged over 30. Emerging adults formed a separate group as previous studies have shown higher risk injecting behaviours to be particularly common among this age group. These years are a distinct developmental time period associated with exploration and increased risk-taking behaviour. It has also been hypothesised that interventions at this stage in life have the greatest impact on future adult behaviour.

More than a quarter (26%) of all the recruits were under the age of 25, while 30% were under 30 and 44% of the sample were over 30. Age of first inject was median 21 years, but 12.6% and 16% of 'emerging adults' in the Northeast and North/Central regions respectively had initiated injection drug use before the age of 16.

Among emerging adults, HIV prevalence was already 16.8% in the North/Central region, significantly higher than the, still high, 9.8% reported in the Northeastern region. HIV prevalence was similar between regions among young adults, while among older people, HIV prevalence was much higher among those in the Northeast (35.6%) compared to the North/Central region (18.2%).

Needle sharing was high across age groups, but recent needle-sharing was significantly higher in the North/Central region (35.6%) compared to the Northeast (21.9%). HIV testing was also significantly lower in the North/Central region, at 35.9% compared to 55.1% in the Northeast. In both regions, the majority of people had never received an HIV test, and use of needle and syringe exchange programmes (NSP) and opioid substitution therapy (OST) varied across age groups and regions – but was still weak across the board.

Among young people, HIV epidemics have the potential to accelerate rapidly given difficulties engaging them in services. Previous studies have indicated that people injecting drugs in India were largely under the age of 30. However, little information is available in India about young people who inject drugs, which makes creating policies and interventions to reach this vulnerable population more difficult.

Furthermore, while India has recognised the potential of harm reduction services, including NSPs and OST, their reach varies across the country. India’s traditional epidemic epicentre is in the Northeast of the country, due to their geographic and social isolation and proximity to the ‘Golden Triangle’ region of heroin production. Here, harm reduction programmes have been in place since the 1990s and are well distributed, while in the rest of India, injecting drug use is a relatively new epidemic which has yet to be properly responded to through services.

The investigators remarked, “These findings highlight the importance of shifting HIV prevention initiatives 'downwards’ to prevent injection initiation in the first place, as well as to intervene in the youngest users early in their injection careers, including in adolescence.”

“There is an urgent need to address these younger PWID separately and specifically in policies and through development of targeted interventions and services.”

In their conclusions, the authors called for policies to go beyond ‘youth-friendly services’: “An agenda for addressing the needs of young PWID in India should involve identifying and ameliorating the structural, demographic and psycho-social drivers of injection initiation and engagement in high-risk behaviours; conducting a rapid assessment to obtain reliable size estimates of adolescent PWID; revising consent laws for HIV testing and OST receipt among adolescent PWID; establishing ambitious targets for participation in harm reduction services by young PWID; and addressing barriers unique to young PWID for participation in such services.”