Demographic information and current life situation
The mean age of participants was 24.5 years (range 19–28, SD 2.17). The majority identified ethnically as Naga (45.5%) or Meitei (39.5%). More than half were Christian (57.0%) and 40.0% were Hindu (Table ). Due to oversight the question about marital status was only asked in Nagaland where 66% were single and 34% were or had been married. Slightly more than half had either not attended or not finished school (52.0%), and 11.0% had graduate or post-graduate qualifications (Table ).
Demographic information by state
Only 17.9% of participants were employed. The mean monthly income was Rs3662 (~USD 84) (range 200–20000, median 3000, SD 31.3). Participants were asked the source of their income other than through employment and most received money from their family (83.8%). State differences in all of these variables were observed (Table ).
The majority of participants (70.5%) lived in their family home and 72.9% were sharing their living space with their parents. Only 14.6% lived with a partner/wife/husband, 12.6% with other relatives, 6.5% with friends, 4% with others such as parents-in-law, and 1.5% lived alone (multiple responses allowed). One quarter (25.1%) had children of their own. The average number of children was 1.5 (range 1–3, SD 0.7), and 78.6% of those with children were currently living with them. In terms of mobility, all participants were born in north-east India, but 38% were currently residing in a district that was not their birthplace.
Description of initiation into injecting drug use
The mean age of the first injection of illicit drugs was 20.1 years (range 13–26, median 19, SD 2.4). There was no difference in age of first injection by state or by drug injected. For their first injection, 65.5% of participants injected SP and 30.5% injected heroin. Two-thirds (66.7%) had used the drug previously. In 53.5% of cases the needle used for the first injection belonged to someone else (Table ).
Circumstances of first injection of illicit drugs by state
Participants were asked whose idea it was to inject, whether or not the event was planned or spontaneous, who paid for the drug, who obtained it and where the first injection took place. The idea to inject was most often someone else's (58.0%). For the majority (79.0%), the first injection was remembered as happening spontaneously. Almost half of the participants paid for the drug themselves (48.5%) or shared the cost with another (13.1%). The drug was most often obtained by someone other than the participant (63.3%). The most common places for the first injection were a friend's house (43.5%) or the participant's own house (17.5%). Only 2.5% were initiated at the drug dealer's place. More than half of the participants (53.3%) had other drugs in their system at the time of the first injection (Table ).
Initiation into injecting drug use was a companionable event. The mean number of other people present (not counting the participant) was 2.7 (range 0 – 25, median 2, SD 2.2), and most of those present also injected. Only 2.0% of participants were alone when they injected for the first time and 95.0% had up to five other people present. More than four-fifths (85.5%) had at least one friend present, 14% had at least one relative, 13.0% had at least one acquaintance/stranger, 3.5% had a drug dealer (known as 'peddlers' in north-east India), and 1.5% had a partner/wife/husband present the first time they injected (multiple responses allowed).
Most participants (94.5%) were injected by another person the first time, most commonly a friend (84.1%), followed by a relative (9%), an acquaintance/stranger (4.7%), a partner/wife/husband (1.6%) or a drug dealer (0.5%). They had known this person for an average of 7.0 years (range 2 hours – 21 years, SD 5.8 years). A very small proportion (2.9%) had known the person who initiated them for one month or less; 14.9% had known the person for between one month and one year; 18.3% had known them for between one and three years; and close to two-thirds (64.1%) had known the person who initiated them for more than three years. In 87.3% of cases the participant asked the other person to inject them. Another person prepared the drug 93.3% of the time, taught the participant how to inject 69.8% of the time, and told the participant about the need to use new injecting equipment 36.5% of the time.
All eleven participants who injected themselves the first time were shown how to inject by either friends or relatives. The participants had known this person for an average of 6.4 years (range 6 months – 20 years). In six cases the participant asked the other person to show them how to inject, in eight cases the participant prepared the drug, having been taught by another person in six of those cases, and in three cases the other person mentioned the need to use new injecting equipment.
A number of state differences in the circumstances of first injection were observed (Table ). Those from Nagaland were more likely to have: injected SP; used the drug previously; used someone else's needle; planned the injection; and paid for and obtained the drug themselves.
Reasons for injecting
Participants were asked an open-ended question about their reasons for injecting at that point in time. The reasons were coded as: curiosity about the high/pleasure seeking (46.7%); the influence of others (34.7%); economic reasons (10.1%); and other reasons (8.5%), which were mainly a reaction to a negative situation in their life, or not knowing that the drug could be used in any other way. The influence of others was expressed in two different ways. Firstly, there was a desire on the part of some participants to be the same as their friends who injected, and secondly some participants were urged by their friends to try injecting. The economic imperative to inject was due to a shortage of money or drugs and therefore a need to use the available drug more efficiently by injecting rather than chasing/smoking or taking it orally.
Life situation at the time of initiation
Participants were asked a series of questions about their life situation at the time of initiation into injecting drug use. One-third of participants (35.5%) were either unemployed or had dropped out of school (Table ). Most participants were living with their parents (80.0%) or other relatives (13%) at that time (Table ).
Life situation at the time of initiation into injecting drug use by state
Almost all participants (91.0%) knew other IDUs prior to their initiation into injecting (Table ). The mean number of IDUs known was 7.5 (range 0 – 50, SD 6.5). About one-tenth (9.2%) knew no other IDUs at the time of initiation; 74.9% knew between 1–10 IDUs; 13.8% knew 11–20 IDUs; and 2.0% knew more than 20 IDUs. The majority (83.3%) had at least one injecting friend, 55.7% knew of people in their neighbourhood who injected, 20.3% knew of relatives (other than immediate family), 16.7% had a brother who injected and 1.0% a partner.
Almost one-quarter of participants (23.2%) had previously been in trouble with the police prior to their first injection, on an average of two occasions (range 1 – 7, SD 1.5). Of those who had been in trouble with the police, 48.9% had been in prison (11.0% of the entire sample); on average 1.4 times (range 1–6, SD 1.1).
State differences in life situation at the time of initiation into injecting drug use were noted (Table ). Participants from Nagaland were more likely to be out of school or unemployed and to have experienced a period of incarceration.
Drug use history
Around the time of initiation into injecting drug use (as opposed to on the occasion of initiation outlined above) and during the last six months and the last week prior to the survey, use of multiple other drugs was commonplace (Table ).
Information about injecting drug use during the last six months and the last week was collected. During the preceding six months 46.7% had injected only SP, 18.1% had injected only heroin, 23.1% had injected both, and 12.1% had injected neither. As some survey participants were recruited from drug substitution programs, their injecting drug use during the last week was atypical. Excluding the 56 (28.3%) participants who had not injected any drug in the last week, 67.6% injected SP and 43.0% injected heroin. Of those participants who had injected in the last week, the average number of injections was 16.9 (range 1 – 70, SD 10.66). They spent an average of Rs149 per day (~USD 3.4) on injecting drugs (range 10 – 1000, median 95, SD 132.4).
Participants were asked about injecting risk behaviours. The majority (81.2%) said they rarely or never used a needle used by someone else, but 12.5% did use a needle used by someone else at least weekly. Among those who have on occasions used a needle or syringe used by someone else, 77.7% always cleaned it before use, most commonly with water and/or saliva.
A number of state differences in drug use history were observed (Table ). Participants from Nagaland were consistently less likely than those from Manipur to report use of most drugs including alcohol, marijuana, heroin and cigarettes, but they were more likely to report use of SP.
Knowledge of blood-borne pathogen transmission prior to initiation
Prior to initiation into injecting, almost three-quarters of participants (72.4%) had heard of HIV and AIDS, 27.0% had heard of hepatitis B and 18.6% hepatitis C, but only 67.5% knew that diseases could be spread by unsafe injecting practices. The majority (87.5%) said they knew where to obtain new needles and syringes at that time. Most participants (68.5%) said that they were not worried about HIV infection the first time they injected. The most common reasons for not being worried were: lack of knowledge about HIV (41.6%); a new needle/syringe was used (37.2%); the focus was exclusively on obtaining the drug and getting high (9.5%); feeling confident that their friend was not HIV infected (5.1%); and the injecting equipment was cleaned prior to use (2.9%).
Participation in HIV and HCV testing
Overall, 48.7% reported having been tested for HIV and only 5.2% for HCV infection. Of the 91 participants who had been HIV tested, 79 shared the result with the interviewer, and 19.0% of these were positive. Of the ten participants who had been tested for HCV, four were negative, three were positive, and three chose not to share this information. Only 10.0% of participants reported that they were vaccinated against hepatitis B.
Initiation of others
The majority of participants (69.3%) had helped someone else inject for the first time. This was unrelated to state, age, drug initially injected or length of time since first injection, but was associated with sex. Males were more likely to initiate others than females (73.5% cf 35.0%, p < 0.01). The average number of people initiated was 5.0 (range 1 – 20, median 3, SD 3.76). This means that 138 study participants went on to initiate 690 others into injecting drug use. Logistic regression modelling was used to identify variables independently associated with being an initiator of others (Table ). Initiators were more likely to: be male and unemployed; have had IDU friends and been an alcohol user around the time of their own initiation; and to have been taught how to inject and not paid for the drug at the time of their own initiation.
Odds ratios (unadjusted and adjusted) for variables that predict initiating others into injecting drug use
Although the number of females in the study is too small to draw any meaningful conclusions about them, a number of sex differences were observed that are briefly described here. Compared with males, the females in this study were more likely to be married (90.0% cf 27.8%, p < 0.01), have children (64.7% cf 20.7%, p < 0.01), and to have either never attended or dropped out of schooling (80.0% cf 48.9%, p < 0.01). They were less likely to be living with their parents (20.0% cf 78.8%, p < 0.01), had a higher monthly income (p < 0.01), and were more likely to be obtaining money from partners (35.0% cf 6.2%, p < 0.01) and sex work (60.0% cf 0.0%, p < 0.01). Consistent with anecdotal reports, females were more likely than males to have injected heroin the first time (60.0% cf 27.2%, p < 0.01), and to have reported heroin use in the last six months (100.0% cf 52.2%, p < 0.01), and the last week (80.0% cf 40.8%, p < 0.01).