International Journal of Drug Policy 14 (2003) 407–415

Five years of needle syringe exchange in Manipur, India:

programme and contextual issues
Mukta Sharma a,∗ , Samiran Panda b , Umesh Sharma c , Haobam Nanao Singh c ,
Charanjit Sharma d , Rajkumar Raju Singh d
a London School of Economics and Political Science, London WC2A2AE, UK
b HIV/AIDS (SPARSHA), AE-35, Rabindra Polly, Kestopur, Kolkata-101, India
c Asian Harm Reduction Network, Chiang Mai, Thailand
d Khwai Lalumbung Makhong, RIMS Road, Imphal, Manipur, India

Received 1 December 2002; received in revised form 15 March 2003; accepted 8 July 2003

Abstract

This paper reviews the performance of the syringe exchange programmes (SEPs) in Manipur, northeast India, with the objective of identifying
good practice, and areas that require improvement. The paper also examines contextual and structural factors in Manipur that inhibit optimal
functioning of SEPs and hinder behaviour change, and argues that these factors need to be addressed as part of any endeavour aimed at
improving services and programme coverage in the future.
© 2003 Elsevier B.V. All rights reserved.

Keywords: HIV; Manipur; Needle syringe exchange programmes; Sharing of injecting equipment; Environmental factors

Introduction unique cultural and linguistic identity. Among them are

Manipur (formerly known as Kanglaipak) in the northeast
of India is inhabited by people of Tibeto-Mongoloid ances-
try. Imphal is the capital city of this state. It is bordered on
the east by Myanmar (Burma), on the north by Nagaland, on
the west by Assam and on the south by Mizoram. Its proxim-
ity to Myanmar and the Golden Triangle has made it one of
the chief transit routes for drug smuggling, both out of and
into Burma. The National Highway-39 starting in the border
town of Moreh on the Burmese border, runs through Ma-
nipur into Nagaland (see Figs. 1 and 2). The state has an area
of 22,327 km2 and is one of the smallest of India’s states.
Manipur is geographically and culturally divided into
valley and hill regions. The Vaishnavite Hindu Meitie com-
munity dominates the valley, and comprises more than 60%
of the state’s population. The hills are dominated by vari-
ous tribal groups, among whom animism (i.e. the worship
of nature deities and other spirits) is the dominant faith—
although many have converted to Christianity. There are
approximately 29 such tribal groups—each with their own
the Kukis, Paite, Tanghkuls, Lushai, Chin, Langte, Thadou,
Vaiphei and the Zoe tribes.
The region is prone to very high levels of political un-
rest. The immediate manifestation of this is an abundance of
various militant organisations claiming to represent ethnic
and cultural aspirations. The fiercest of these conflicts ex-
ists between the Kukis and the Naga groups. Ethnic cleans-
ing is a common feature of such conflict, and hundreds of
lives are lost each year. These militant groups seek not just
economic control of resources, but also social control of
those they claim to represent. They have been known to pass
extra-judicial sentences (often manifested in fatal shootings)
on individuals whose behaviour or stance they deem as un-
acceptable. Hence, violence is aimed not only at government
structures and members of other tribes and organisations,
but also against drug users, peddlers and in some cases those
who have been diagnosed as HIV positive. This serves to
drive injecting drug use underground.
HIV/AIDS and injecting drug use in Manipur

∗Corresponding author. Tel.: +44-208-5421-269. The HIV/AIDS epidemic in Manipur is over a decade old
E-mail address: M.Sharma@lse.ac.uk (M. Sharma). and still continues to evolve. The disease is rapidly becom-

0955-3959/$ – see front matter © 2003 Elsevier B.V. All rights reserved.
doi:10.1016/S0955-3959(03)00142-7
408 M. Sharma et al. / International Journal of Drug Policy 14 (2003) 407–415
Fig. 1. Map of Manipur.
ing the main cause of death among young adults (Manipur
AIDS Control Society [henceforth referred to as MACS],
1999). As of October 2002, 14,097 HIV positive cases and
1532 AIDS cases have been reported; of these 69% are from
Imphal (MACS, 2002)—the capital city of Manipur. HIV
Fig. 2. Map of India. (Source: http://www.cia.gov/cia/publications/
factbook/geos/in.html.)
gained a foothold in Manipur among injecting drug users
(IDUs) in 1989; seroprevalence in IDUs at the end of 2002
was reported to be nearly 60% (Sentinel Surveillance Data,
MACS, 2002) (Table 1). However, the role of sexual and
mother to child transmission, particularly to the partners and
children of IDUs, has become increasingly significant. In
a study by Panda et al. (2000) that looked into the deter-
minants of the spread of HIV from IDUs to their wives,
45% of the non-injecting wives of IDUs were found to be
infected with HIV; only 2% of the wives recruited in this
study reported having sex outside marriage. HIV seropreva-
lence among STD clinic attendees had also increased to
more than 11% in 2002 (Sentinel Surveillance Data, MACS,
2002). Further, nearly 3.2% of antenatal clinic attendees
were HIV positive, bearing testimony to the generalised na-
ture of the epidemic (Sentinel Surveillance Data, MACS,
2002).
Injecting drug use is a widespread phenomenon in Ma-
nipur. It is estimated that at least 1% of the urban popu-
lation injects drugs (Sarkar, Panda, Das, & Sarkar, 1997).
According to a Rapid Situation Assessment conducted in
2000 in Imphal (n = 306), there were approximately 12,667
IDUs in Imphal (Hijam & Sharma, 2000). Heroin (locally
known as ‘white sugar’ or No. 4) remains the drug of choice,
even though there is an increasing trend towards the use of
pharmaceutical drugs, such as pheniramine maleate, dextro-
propoxyphene, pentazocine, benzodiazepines and Buprenor-
phine. Of those injecting, 93% primarily injected heroin,
 M. Sharma et al. / International Journal of Drug Policy 14 (2003) 407–415
Table 1
HIV seroprevalence among IDUs in Manipur (1994–2001)
Year
1994 1995 1996 1997
Point prevalence (%) 55.7 54.2 64.1 76.9
Source: Sentinel Surveillance Data, 1994–2001 (MACS, 2002).
Note. Sentinel surveillance among IDUs is based upon a sample size of n = 250.
while the remaining 7% used Spasmo-Proxyvon or Lobain
(Hijam & Sharma, 2000).
Methodology
The review of the syringe exchange programme (SEP) in
Manipur was undertaken as part of a wider exploratory as-
sessment of HIV/AIDS prevention strategies (including both
policies and programmes) among IDUs in India. A case
study approach was used and SEPs in two sites, including
Manipur, were studied. The methodology used was ‘Situa-
tional Analysis’ (Miller et al., 1997). Given the inadequacy
of injecting drug use and HIV/AIDS data in India, both qual-
itative and quantitative data were collected and triangulated.
The review in Manipur was carried out over a period of 3
months between June and August 2000. It was based upon
service statistics and observational visits to eight needle sy-
ringe exchange sites; behavioural data collected among 201
IDUs through a semi-structured interview (of these 97 used a
SEP while 104 [street sample] procured their injecting equip-
ment from other sources); in-depth interviews and interviews
with service providers. The behavioural survey question-
naire was based upon Knowledge Attitude Behaviour Prac-
tice (KAPB) surveys and the Injecting Risk Questionnaire
(IRQ) developed by Stimson, Jones, Chalmers, and Sullivan
(1998). A purposive quota sampling strategy was used in
order to cover geographical areas and the eight needle sy-
ringe exchange sites. Quantitative data were analysed using
SPSS 10.0 and qualitative data were analysed using simple
content analysis techniques. Due to space constraints, qual-
itative data are not presented here.
Client confidentiality was protected during the study. In-
terviewees were not asked their names and addresses and
hence these were not recorded. SEPs routinely collect only
demographic and behavioural information at intake from
clients and do not collect names and addresses. Clients are
provided with a code number that allows them to access ser-
vices.
Overview of the response
The severity and duration of the HIV epidemic has meant
that HIV/AIDS prevention and care services in Manipur tend
409
1998 1998 1999 2000 2001
(February– (August– (August– (August– (August–
March) September) October) October) November)
67.6 72.8 58.8 69.6 56.3
to be fairly well established. For instance, SEP has been in
existence since 1994. In 1996, Manipur was the first state
in India to formulate a State AIDS Policy (SAP), which ex-
plicitly included a ‘harm reduction’ approach to HIV/AIDS
prevention among IDUs. Knowledge of HIV/AIDS is al-
most universal in the general population as well as among
IDUs. According to the National Family and Health Survey
1998–1999 (Round II) nearly 93% of women aged 15–49
had ever heard of HIV/AIDS. According to Sarkar et al.
(1995), more than 90% of IDUs were aware of HIV/AIDS
in Manipur.
Since late 1998, MACS has implemented the Rapid Inter-
vention and Care (RIAC) programme in partnership with 10
non-governmental organisations. RIAC is a comprehensive
strategy to prevent HIV/AIDS and provide care for those af-
fected in Manipur. Its components are SEP, condom promo-
tion and provision, referral for HIV testing, STD treatment,
home-based care, and counselling. In 2001, the programme
was implemented in 10 sites in Imphal and 2 sites in Chu-
rachandpur.
Even though the programme has limited geographical
coverage within Manipur, it is one of the largest harm re-
duction efforts in Asia. At the time of fieldwork (2000), the
RIAC programme was intended to cover 6000 IDUs and
their sexual partners. In this context, it is worth mentioning
that a 50% coverage target through non-SEPs in a location
with a high baseline HIV infection rate and a large number
of injectors, such as Imphal (which has a little over 12,500
IDUs and currently 60% HIV prevalence in them), with a
presumable plan for phased expansion later, will be inad-
equate in averting new HIV infections in the target popu-
lation. It is beyond the scope of this paper to focus on all
aspects of the RIAC. Instead, we focus specifically on the
syringe exchange component.
The syringe exchange programme
The SEP component of the RIAC programme is delivered
either through drop-in centres (DICs) or through outreach
workers (OWs). As many IDUs feel uncomfortable being
seen entering a DIC, OWs are crucial to bringing services
to those who need them.
Programme statistics collected from the seven RIAC part-
ners between October 1998 and June 2000 reveal that a total
410 M. Sharma et al. / International Journal of Drug Policy 14 (2003) 407–415

Table 2
Summary programme statistics from needle syringe exchange in Manipur
Name of NGO Total

KRIPA SASO (2 DICs) IAC IWCDC LRRC MVHA ISD

Target 500 700 500 500 300 500 500 3500

Estimated number of IDUs in 637 1204 1067 700 988 809 931 6336
wardsa
Actual number recruited 310 403 375 375 221 335 368 2387
Percent of target recruited 62 58 75 75 74 67 74 70b
Percent (and n) among 31.6 (98) 31.5 (127) 100 (375) 76.3 (286) 43.4 (96) 60.1 (203) 100 (368) 48.6c
recruited who receive
needles/syringes regularly
Numbers of needles/syringes 5773 5861 3474 5251 8446 1767 3825 34397
distributed
Numbers of needles/syringes 4614 3779 1931 3315 6872 1210 2694 24415
returned
Return rate of needles/syringes 79.9 64.5 55.6 63.1 81.0 68.0 70.0 70.98
Source and Notes: Compiled from service statistics (1 October 1998 to 30 June 2000) collected from individual RIAC partners during fieldwork. These
should be treated as coarse estimates. KRIPA: KRIPA Society; IAC: International AIDS Consortium; IWCDC: Integrated Women and Child Development
Centre; ISD: Institute for Social Disease; MVHA: Manipur Voluntary Health Association; SASO: Social Awareness Service Organisation; LRRC: Lamka
Rehabilitation and Research Centre.
a Estimated by MACS.
b The figure of 69.7% is an average figure.
c This is an average figure excluding IAC and ISD—the two organisations having a definition of ‘regular clients’ that had a wide margin of flexibility

and contrasted sharply with that of the other partners of RIAC.

of 2387 clients had enrolled in the SEP either through OWs
or via DICs. This figure represented nearly 70% of 3500—
which is the target set by RIAC (see Table 2) for these seven
partner NGOs (a total of 10 NGO partners implement the
RIAC programme in Manipur—the other NGOs who are
RIAC partners were either unable to, or did not wish to
provide data for this study). All of them are located in Im-
phal except the Lamka Rehabilitation and Research Centre
(LRRC) which is located in Churachandpur.
Programme coverage
A relatively small proportion (less than 37%) of the es-
timated ‘risk’ group population is being serviced through
the intervention (2387 out of 6336 IDUs who are estimated
by MACS to live in areas assigned to the partner NGOs).
In this context it should be noted that it is possible that
less than 2387 people were injecting over the 21-month pe-
riod. This is because Social Awareness Service Organisation
(SASO) operated a Buprenorphine substitution programme
from November 1999. A total of 418 clients were enrolled
in the programme. However, only 124 clients were still en-
rolled 3 months later and this figure would not significantly
change the status of low coverage discussed in the main
body of text of the present article. Given that the sexual
partners of these IDUs also constitute a vulnerable group,
it is evident that the proportions being reached are smaller
still.
Of the 2387 IDUs recruited, less than half were able to
gain access to the service on a ‘regular’ basis: even though
the definition of ‘regular user’ varied between one partner
of RIAC to another. Only 48.6% of those recruited received
needles/syringes ‘regularly’. However, the authors were not
able to determine from MACS or from NGOs what is con-
sidered ‘regular’. It appears that a subjective definition is
used by various NGOs in determining what was ‘regular’.
While calculating this proportion, the numbers that did not
corroborate with the records of the RIAC partners as well
as observation by the field researchers were excluded.
The total number of needles/syringes distributed over the
entire project period (i.e. October 1998 to June 2000) was
34,397. If 2387 IDUs are serviced by the programme and on
average they inject 3 times a day, then they need: 2387×3×
30 = 214,830 needles/syringes each month (if international
parameters of the daily needs of each IDU are accepted and
each injection occurs with sterile equipment). Over the entire
project period of 21 months this figure becomes 214,830 ×
21 = 4,511,430 needles/syringes.
However, in resource-constrained settings, the interna-
tional parameters used for establishing the daily needs of
IDUs may not be feasible. While there are no clearly estab-
lished local parameters for Manipur, it was found that even
if an injector were to use the same needle/syringe continu-
ously for 3 days (which is a maximally stretched use of two
needles and one syringe acquired by one IDU during one
contact with the SEP), then 1,002,540 needles and 501,270
syringes are required for the project period. Hence, a sub-
stantial shortfall of needles and syringes still exists in the
ongoing SEP in Manipur. Given the poor economic status
of the IDUs in Manipur, and the specific context of drug
user poverty, it may be assumed that IDUs are not procur-
ing sterile injecting equipment on a consistent basis from
 M. Sharma et al. / International Journal of Drug Policy 14 (2003) 407–415
pharmacies. In Manipur, the price of one needle and syringe
is between 5 and 6 INR (roughly 10–15 US cents). Over a
1-month period this translates into 150–180 INR. For many
drug users, this is not affordable.
There is wide variation in the return rate between service
providers. Table 2 shows that International AIDS Consor-
tium (IAC) reports a 55% return rate, while KRIPA Society
(KRIPA) and LRRC report approximately 80%. The causes
behind this variability need to be examined. Clearly, fac-
tors such as ‘quality of care’ or environmental issues (such
as law enforcement activity, insurgent activity, programme
funding or general strikes), have a considerable impact on
return rates.
Service delivery at the individual level
There appears to be a slight preference among IDUs for
outreach-based services. Among those IDUs who use SEPs,
over half reported getting their needles and syringes from
OWs. However, the numbers of needles/syringes disbursed
and the frequency of disbursal were not always satisfactory.
Nearly two thirds of these (64.8%) said that their OW visited
them once a week or even less frequently. The remainder
reported that their OW visited them between 2 and 4 times
per week. Nearly 38% service users said that they could
only get between 1 and 2 needles and syringes per visit.
The remainder reported that they could obtain between 3
and 5 needles and syringes per visit. Thus, there are clear
limitations on the numbers of needles and syringes that a
service user was able to obtain from an OW in a single visit.
Moreover, 8% reported that their OW did not visit them
regularly, or as scheduled.
Of the 44% (n = 43) that went to the DIC to collect their
needles and syringes, only 30% (n = 13) reported visiting
the DIC daily. Another 53% (n = 23) reported visiting the
DIC, 2–4 times a week. Nearly 91% reported that they could
get 1–2 needles/syringes in each visit. One fifth of DIC users
reported that the hours of the DIC were not suitable for them.
These findings clearly indicate that the numbers of nee-
dles/syringes provided by the DICs and OWs to IDUs are
insufficient. Programme coverage both in terms of numbers
covered and the ‘dosage’ of sterile equipment delivery, is in-
adequate. Given the wide variation in performance between
the different NGO partners, there seems to be considerable
room for improvement in the way services are delivered by
the RIAC partners, and monitored by the programme man-
agers.
Quality of service delivery
The concept of ‘quality of care’ was applied by Bruce to
family planning and reproductive health programmes in or-
der to assess supply side factors, and the impact they have on
uptake and demand for services. Quality is a client-centred
concept. Six key factors were identified: staff–client interac-
tion; technical competence of staff; appropriate constellation
411
of services; choice of methods available; amount and qual-
ity of information provided to clients and continuity mecha-
nisms (Bruce, 1989, 1990). We adapted this framework and
applied it to HIV prevention among IDUs. Key indicators of
quality services, in addition to those proposed by Bruce are:
access, confidentiality, gender sensitivity of services, ade-
quate coverage and linkages/referral to other services within
a continuum of prevention and care. We discuss some of
these indicators below.
Staff–client interaction
As evidenced from visits, the general atmosphere in the
observed DICs was quite good. Clients and staff were usu-
ally social equals. Staff treated clients politely and profes-
sionally. As some staff had been drug users in the past, staff
commitment and motivation levels were quite high and this
was reflected in their interaction with clients.
However, most staff were abstinent drug users, who fol-
low strictly the Narcotics Anonymous (NA) 12 Step Pro-
gramme. For them, harm reduction is a short-term strategy,
whose eventual aim is complete abstinence. This can have
the unintended effect of reducing psychological access to
services for current injectors. The authors argue that access
to services would benefit tremendously from engaging more
current users in peer outreach activities. While the authors
acknowledge that employing current drug users can give
rise to some problems, these have been overcome in other
projects successfully—examples being the Indian Council
of Medical Research (ICMR)-WHO project in Churachand-
pur, Manipur, during 1994–1996 and the ongoing SHAKTI
project of CARE-Bangladesh in Dhaka.
Confidentiality
Given the high levels of stigma and discrimination asso-
ciated with HIV in Manipur, breached confidentiality can
lead not only to social ostracisation, but physical harm. Drug
users and individuals with HIV are frequently assaulted
and ill-treated. While the levels of confidentiality and steps
taken to maintain it are reasonable, they can vary quite a
lot between individual organisations and the staff within
them. Files with client names and information are relatively
easy to access. In conversations with staff, the research
team was sometimes informed if a client was HIV posi-
tive, without any solicitation. Thus, stringent measures for
ensuring confidentiality need to be implemented and made
evident in everyday operations in order to increase client
confidence.
Access
Most services in Imphal district are concentrated in the
west. In the eastern part of Imphal services were very
limited. Only two NGOs offered services in areas of East
Imphal, like Checkon or New Lambulane. These areas are
considered to have a high prevalence of drug use, even
within Imphal. The inhabitants are often tribal and usually
poorer than those in West Imphal. For those who cannot
412 M. Sharma et al. / International Journal of Drug Policy 14 (2003) 407–415

or do not want to access services through these NGOs,
choices are limited. Therefore, urgent consideration needs
to be given to increasing coverage of services in East
Imphal.
A related issue of access to services is of the opening hours
of DICs, or the times of OW visits. The normal working
hours of NGOs in Imphal are from 10:00 a.m. to 4:00 p.m.
Only one NGO attempted to experiment with more flexible
working hours. Thus, if drug users cannot access services
between these hours they must find alternatives. Most drug
users need a fix as soon as they wake, and also late in the
evenings. For service provision to be meaningful, they must
be able to respond to the lifestyles of the clients.
Gender sensitivity of services
Based on treatment records and key informants, women
comprise approximately 7–10% of IDUs in Imphal. Further,
as sexual partners of male IDUs, they constitute a substantial
proportion of those who need to access services, such as
condoms, prevention of mother to child HIV transmission
and STD treatment. Given the conservative environment,
many of them are unable to access services. Women also
find it difficult to psychologically access services delivered
by men. RIAC partner NGOs are largely male organisations.
The managers, counsellors, peer educators, OWs, etc., are
overwhelmingly male. Hence, RIAC needs to urgently invest
in ways of reaching out to female IDUs and sexual partners
of IDUs in their homes. One way could be to develop a
core of female OWs who can bring services to the home
or provide referral services to primary and tertiary health
providers.
Coverage
The findings show that programme coverage is highly
inadequate. Of Imphal’s estimated 12,667 IDUs, only 2387
were currently being served (i.e. 18.8%). This figure needs to
expand considerably and quickly if any impact is to be made
on HIV incidence. Further, the nature of service delivery
needs to be reassessed extensively in order to provide an
effective service for those who are particularly vulnerable,
such as new and intermittent injectors.
Impact on behaviour change
In the absence of baseline data, it is not possible to
comment with certainty on the impact of current service
provision on risk behaviours. However, the results of the
behavioural survey among IDUs (n = 201) indicate that
levels of HIV/AIDS knowledge in both groups are strikingly
high, with almost universal awareness of at least one trans-
mission method. More than 90% of SEP users are able to
cite more than one correct method of transmission. Among
non-service users this proportion is slightly lower at just over

Table 3
Comparative injecting and sharing behaviour among service and non-service users in 4 weeks prior to survey (Imphal, 2000)
Non-service Service users, P value (all Chi-square
users, N = 104 N = 97 except where shown)
Mean number of people shared with in the last 4 weeks 3.5 4.0 0.326a
Ever lent used needles/syringes 76 (73) 69 (71)
Frequently 7 (6.7) 5 (5.2) 0.131
Sometimes 57 (54.8) 61 (62.9)
Rarely 12 (11.5) 3 (3.1)
Never 28 (26.9) 28 (28.9)
Ever borrowed used needles/syringes 69 (66.3) 52 (53.6)
Frequently 4 (3.8) 2 (2.1) 0.050b
Sometimes 42 (40.4) 41 (42.3)
Rarely 23 (22.1) 9 (9.3)
Never 35 (33.7) 45 (46.4)
Ever drawn up from same container as someone else 90 (86.5) 83 (85.6)
Frequently 42 (40.4) 53 (54.6) 0.055b
Sometimes 41 (39.4) 29 (29.9)
Rarely 7 (6.7) 1 (1.0)
Never 14 (13.5) 14 (14.4)
Ever shared any injecting equipment 87 (83.6) 84 (86.6)
Frequently 35 (33.7) 33 (34.0) 0.211
Sometimes 52 (50.0) 51 (52.6)
Rarely 7 (6.7) 1 (1.0)
Never 10 (9.6) 12 (12.4)
Percentages in brackets and rounded to one decimal point.
a Independent sample t-test. Equal variances not assumed.
b Significance lost when cross-tabulations were done by ‘frequently + sometimes’ and ‘rarely + never’ (i.e. 2 × 2).
 M. Sharma et al. / International Journal of Drug Policy 14 (2003) 407–415
86%. Non-service users also contain a higher proportion
citing incorrect or vague transmission reasons than service
users. Moreover, they also have a much larger proportion of
respondents who cite incorrect or vague prevention meth-
ods in comparison to service users. In spite of the high
levels of HIV/AIDS awareness, levels of risk behaviour,
even among service users appear to be extremely high
(Table 3).
A modestly significant difference between service users
and non-service users was found for ‘how frequently have
you borrowed a needle and syringe in the last 4 weeks’ (P =
0.05), and the variable corresponding to ‘how frequently
have you drawn up from the same container as someone
else in the last 4 weeks’ (P = 0.055). However, other vari-
ables such as ‘how frequently have you shared any injecting
equipment in the last 4 weeks’ or ‘how frequently have you
lent injecting equipment in the past 4 weeks’ did not yield
significant differences. Further, there was no significant dif-
ference between the mean numbers shared with in the last 4
weeks. Over 44% of those surveyed reported ‘frequently’ or
‘sometimes’ borrowing a needle/syringe in the last 4 weeks.
The proportion that lent injecting equipment ‘frequently’ or
‘sometimes’ is higher at 65%. Nearly two-thirds reported
‘sharing’ injecting equipment with more than three people
in the last 4 weeks.
The levels of sharing of containers or using the same wa-
ter for flushing purposes are also very high with more than
80% reporting that they had ‘frequently’ or ‘sometimes’
shared these. Nearly 53% of SEP users had shared a nee-
dle and syringe as part of the process of dividing drugs.
Moreover, cleaning practices seldom involved any use of
disinfectants or boiling. It was noteworthy that the levels
of risk practices on some counts, such as ‘frequently’ or
‘sometimes’ lending used syringes/needles, within the last
4 weeks, or injecting with the same needle as someone else
in the last 4 weeks, or indirect sharing (by using the same
bottle, syringe or vial) while dividing drugs, were slightly
higher among users of SEP, compared to those who did
not use it, indicating a need for enhanced education about
the potential spread of blood borne viruses through indirect
sharing.
Discussion
In summary, two major points can be made. First, it
can be stated that the levels of unsafe injecting practice
among IDUs in Imphal are very high. This reiterates that
high levels of HIV/AIDS awareness alone, does not ensure
safer behaviour unless the means for change and an en-
vironment conducive to practice safer behaviour are also
ensured. Second, and perhaps a little surprisingly, levels
of risk behaviour are equal to or higher on some counts
among SEP users than among non-SEP users. This is dif-
ficult to explain given that SEP users displayed a slightly
better understanding of HIV transmission methods than
413
non-SEP users. An analysis of the socio-demographic
profile of the two groups showed no major difference be-
tween the two groups, including frequency of injecting,
income and education levels. However, the median age of
SEP users (26 years) was lower than non-SEP users (29
years). This may explain the slightly higher levels of risk
behaviour among SEP users, if it is assumed that younger
drug users engage in higher risk behaviours than older
users.
The issue that needs consideration in this context is the
‘selection effect’. Are service providers being successful in
targeting ‘harder’ cases? In a study of IDUs (n = 1093) re-
cruited from methadone maintenance and out-patient drug
detoxification programmes, Hahn, Vranizan, and Moss
(1997) found that those who were frequent injectors, home-
less and aware of their serostatus were more likely to use
SEPs. They concluded that SEPs ‘attracted a very high risk
subgroup of injectors’. In Manipur, homelessness among
IDUs has not been documented and there is no difference
in the mean frequency of injecting between SEP users and
non-SEP users. However, only 2.9% of non-SEP users re-
port themselves to be infected with the HIV virus, while
10.5% do so among the SEP users.
As such there is no specific policy among service
providers for targeting and enrolling more vulnerable or
marginalised IDUs. Another possible explanation could be
related to reporting bias. Service users may be more likely
to report sharing behaviour due to increased confidence or
less fear of repercussions. However, overall it is more likely
that both SEP and non-SEP users under reported injecting
risk practices in the survey.
The authors surmise that part of the explanation for high
levels of residual risk behaviours among SEP users must
be sought in the nature of service provision. As previously
pointed out, the numbers of needles and syringes in circula-
tion is very low. Injectors are simply not being provided with
enough injecting equipment to make it easier for them to
stop sharing. A little under half of all service users use 4 or
less needles/syringes over a week. Thus, one needle/syringe
is used for more than five injections, if used by the user
alone. A little over 11% of all service users admitted that
they had given their last needle and syringe to someone else
after they had used it.
While there are constraints imposed on behavioural
change by service delivery and supply factors, there are
non-programmatic constraints as well. These are linked to
wider contextual, structural, environmental, developmen-
tal, political and economic considerations (see Rhodes,
Stimson, et al., 1999b; Rhodes, Ball, et al., 1999a). These
factors impair the normal functioning of service provision
dramatically, while at the same time serving to drive ‘risky’
behaviour further underground.
The political situation in Manipur has been particularly
volatile for the past two decades. Killings, armed insur-
gency and large-scale paramilitary and military activity are
the norms. In addition, the state is bankrupt and good gov-
414 M. Sharma et al. / International Journal of Drug Policy 14 (2003) 407–415
ernance a distant dream. For example, ethnic cleansing in
Churchandpur in 1997 led to a mass exodus of single wid-
owed and orphaned women who were forced to engage in
sex work and drug peddling in Imphal (Panda et al., 2001).
Some of them practiced injection drug use. Panda et al. high-
lighted the impact of political environment on the spread of
HIV in their study, where of the 80% who reported hav-
ing sex with non-regular partners; well over two-thirds had
migrated following ethnic clashes. Two-thirds reported hav-
ing sex in exchange for money or drugs. Over 57% of the
female sex workers who also injected drugs were HIV pos-
itive, compared to 20% in non-injection drug using female
sex workers.
In addition, insurgent groups regularly target drug users
for physical humiliation. Drug users may be shot, beaten
up or have their heads shaved and have their pictures dis-
played on the front page of the local daily newspaper. In
spite of a favourable policy environment for harm reduction,
as evidenced by the SAP (3 October 1996), law enforcement
agencies continue to penalise injectors—by using injecting
paraphernalia as proof of illegal drug use. In an environment
like this, it is natural that IDUs do not want to be identified,
or risk carrying injecting equipment on their person. This
is reflected in the limited numbers who utilise DIC-based
services. Moreover, regular curfews and bandhs (complete
closure of the city as a form of protest) do not allow for
continuity in service delivery.
There are three key recommendations that can be
based upon Manipur’s experience with SEP to have an
impact on behaviour change and population level HIV
prevention.
First, SEP must provide adequate coverage and ‘dosage’
of interventions—meaning that the number of needles
and syringes available to injectors needs to be adequate,
and the proportion of injectors covered by the SEPs,
needs to be increased. The dosage and type of nee-
dles/syringes distributed needs to correspond to inject-
ing patterns. In developing country settings, it may not
be feasible or cost effective to provide a new needle
and syringe for each injection. However, given an in-
jecting frequency of 2–3 times a day, an injector should
have 7–10 needles and syringes available per week as a
minimum.
Second, access to SEPs must be increased. The focus of
the service must be the client and his/her need; opening
hours need to be longer, and responsive to the lifestyles of
injectors. Further, DIC-based services are less likely to be
fully utilised given the levels of discrimination and stigma
associated with HIV and drug use in many parts of Asia.
Therefore, outreach-based services are likely to be a better
option in terms of increasing coverage of SEPs. A related
issue in increasing access to SEPs is the employment of
current drug users as OWs. Experience in the field has shown
that current users are much more effective in taking services
to wider drug using populations. Further, SEPs should invest
in training female OWs, as women injectors are increasingly
becoming visible in different parts of Asia, such as China
(Wu, 2001).
Third, given the frequent dissonance between drug pol-
icy and health policy in Asian countries, SEPs must adopt
a strategic and tailored approach to increasing access and
coverage. Advocacy with the local community and with law
enforcement agencies is a crucial aspect.
Acknowledgements
The authors would like to thank the Manipur AIDS Con-
trol Society and its partner agencies for extending their
co-operation for this study. In particular, we would like to
thank Mr. Dineshwar Hijam (KRIPA Society), Dr. Jayanta
Kumar (Institute of Social Disease) and Dr. Khomdon
Singh, Project Director, MACS, for facilitating data collec-
tion. Our special appreciation goes to the IDUs of Manipur
who helped us in understanding the different issues of
risk behaviour and vulnerability, and suggested ways of
improving the services.
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