The Northeastern region is experiencing the highest IDU-related HIV transmission in India and this study has revealed the extent of the injecting drug use problem as well as some of the key characteristics of IDUs in 5 states. In contrast to the popular belief that the injecting drug use problem was mainly concentrated in urban areas, this study identified many rural locations of IDUs. In the worst hit state, Manipur, >70% of sites were identified in rural and remote areas. Therefore, the challenge of harm-reduction programs is to reach IDUs in these locations with difficult geographical terrains overcoming the socio-environmental barriers [9
]. As expected, the study demonstrates that the injecting drug use problem was more extensive in 3 of the states (Manipur, Nagaland and Mizoram) bordering Myanmar. National Aids Control Organization (2006) of India estimated that Manipur was the worst hit state with IDU problem, followed by Nagaland in the whole country. Mizoram had the third highest numbers of IDUs among northeastern states of India [5
Majority of the IDU locations were residential homes in the states of Manipur and Nagaland. Subsequent studies carried out in these states reconfirmed our findings [9
]. In such settings, identification and providing services to IDUs presents a major challenge [9
]. Homes may be safer place for IDUs because of the social unacceptability and clandestine nature of drug use. However, in Assam and Meghalaya, injecting drug use is still sporadic and IDUs mostly inject outdoors and in isolated places, such as graveyards. People usually avoid frequent visits to these places and perhaps for this reason they were chosen for such clandestine activities. The presence of shooting galleries in some states is of great concern because these are considered not only high risk environment for individual users, but may also act as repositories of contaminating pathogens. Use of contaminated equipment spread pathogens from an infected individual to uninfected users [14
Earlier studies showed that younger IDUs who injected with older subgroups or with those who have injected for longer duration were at increased risk of blood-borne infection because of the higher prevalence among the older subgroups [15
]. In many sites across the states, younger and new users were found to be injecting with older IDUs, making themselves more vulnerable to the blood-borne infections from older sub-groups. Data regarding the duration of drug use was not collected in this study. Nevertheless, findings of a cross-sectional study involving several districts in this region suggest that older IDUs usually have longer drug using "careers" [9
]. In Manipur, prevalence of HIV among the IDU population is ~20% and about three quarter of IDUs is also infected with HCV [8
]. Hence, in such settings, new IDUs are certainly at greater risk of contracting blood-borne infections from older IDUs through sharing injection equipment. Interventional efforts should therefore focus more on young IDUs before they get infected with blood-borne infectious agents [9
Injecting drug use is perceived predominantly as a male problem in India. However, this study highlighted significant presence of female IDUs in all the 5 northeastern states. Further, evidence of sex work in some locations added a new facet in the transmission dynamics of HIV infection. Female IDUs may often sell sex for drugs and for their livelihood in the region [19
]. It appears that the dual risks of sexual and drug injecting practices put female IDUs in this region at greater risk of the acquisition and transmission of HIV infections. An earlier study in Manipur reported a high prevalence of HIV (57%) among female IDUs [18
]. Female IDUs also acting as sex workers in the region may facilitate transmission of HIV infections to a wider general population through their non-IDU sexual partners.
Sizes of injecting networks, and their density and connectivity are key determinants of transmission of blood-borne infection among IDUs [19
]. The larger size of injecting network may have contributed to the rapid spread of HIV in some parts of Pakistan [20
]. Moreover, a higher level of personal network density and larger drug network size are positively associated with needle sharing [25
]. During interviews in the present study, many IDUs disclosed having bigger personal network (11-20 or more). Many of them also reported sharing needles and syringes with non-regular injecting partners and strangers. Recent studies have reconfirmed that the IDU population in Manipur, Nagaland and Mizoram have higher levels of shared injecting equipment use [9
]. In the present study, many IDUs reported obtaining their needles and syringes from sources other than government or non-government organization run NSEPs, which might have contributed to sharing. In the worst hit states, Manipur and Nagaland, obtaining needles and syringes from NSEPs was lower despite the existence of interventional programs. The pharmacy was an important source of acquiring needles and syringes among IDUs. However, our findings suggest that the inability to afford to purchase sterile syringes regularly forced many IDUs to share or re-use syringes. Also, in a setting where drug use is not a socially acceptable behaviour, IDUs may not like openly to purchase syringes from pharmacies. Although pharmacies can be added sources of sterile needles and syringes, and provide benefit in addition to those derived from NSEP [26
], cost and visibility often prevent many IDUs from procuring needles and syringes from pharmacies in this region.
Continued risky injecting practices among IDUs, despite the presence of NSEPs, may be attributable to a number of factors, including environmental barriers. The socio-political environment in states such as Manipur and Nagaland affects the consistency of services and safety of NGO staffs and IDUs [9
]. Program workers may often fail to reach IDUs to distribute sterile injecting equipments for safe drug injection due to disturbing situations. On many occasions, distribution of sterile injecting equipment to IDUs is also hampered by regular police harassment of outreach workers if they were found with needles and syringes [9
]. Many IDUs in our study also revealed that the IDUs did not have any other alternative than re-using old needles and syringes or sharing them with other IDUs due to the inconsistencies of interventional programs.
The discriminatory and negative attitude of the community in general towards IDUs is also a major barrier in implementing interventions in this region [13
]. Therefore, to reduce the negative attitudes of the community towards IDUs, there needs to be an enhancement of community mobilization effort. Environmental barriers encountered in implementing outreach programs can be minimized through mobilizing the community at large before targeting the IDU population [13
]. However, more research is needed to understand the causes of continued high-risk injecting behaviour of IDUs in the region [9
This study has certain limitations that need to be mentioned. Despite our best efforts, we could not cover some remote difficult-to-reach areas in the states. Hence, the problem in the rural and remote areas may be bigger than we have actually found in this study. Secondly, many IDUs may not often congregate at identifiable and accessible locations because of the clandestine nature of IDUs' behaviour. Thus many groups in hard-to-reach locations remained relatively unexplored. Therefore, the findings of the assessment may not reflect the true magnitude of the injecting drug use problem in different states. However, the findings of this assessment may indicate adequately the severity of the problem in different states that is consistent with other assessments [5
]. Thirdly, recruitment of IDUs for the interview was purposive; hence the findings of the study may be affected by the bias inherent in purposive sampling. Fourthly, except for Meghalaya and Mizoram, no female IDUs were interviewed in the other 3 states. Therefore, findings of structured and semi-structured interviews may not be generalized to all female IDUs.