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AIDS:
doi: 10.1097/01.aids.0000343764.62455.9e
Article

Injecting and sexual risk behaviours, sexually transmitted infections and HIV prevalence in injecting drug users in three states in India

Mahanta, Jagadisha; Medhi, Gajendra Kumara; Paranjape, Ramesh Sb; Roy, Nandanc; Kohli, Anjaleec; Akoijam S, Brogend; Dzuvichu, Bernicee; Das, Hiranya Kumara; Goswami, Prabuddhagopalc; Thongamba, Gayc; for the IBBA study team

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Author Information

aRegional Medical Research Centre (RMRC), Dibrugarh, India

bNational AIDS Research Institute (NARI), Pune, India

cFamily Health International (FHI), New Delhi, India

dRegional Institute of Medical Science (RIMS), Imphal, India

eKripa Foundation, Kohima, India.

* Members of the IBBA study team are listed at the end of the paper.

Correspondence to Jagadish Mahanta, Regional Medical Research Centre (RMRC), NE Region, (Indian Council of Medical Research), Post Box No. 105, Dibrugarh 786 001, Assam, India. E-mail: mahantaj@icmr.org.in; icmrrcdi@hub.nic.in

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Abstract

Objective: To describe and compare sexual and injecting risk behaviours and sexually transmitted infections (STI), hepatitis C virus (HCV) and HIV prevalence in injecting drug users (IDU) in six districts in three states of India: Manipur, Nagaland, and Maharashtra.

Method: The respondent-driven sample consisted of 2075 IDU. Consenting participants were administered a structured questionnaire and samples of blood and urine were collected to test for HIV and STI. Data were analysed using RDSAT.

Results: In two districts in Manipur, 77 and 98% of IDU injected heroin, whereas the main injecting drug in Nagaland was dextropropoxyphene (99%). In Mumbai/Thane, Maharashtra, the majority of respondents reported using chlorpheniramine (87%) and heroin (99%). In all districts, almost half of IDU reported generally sharing needles and syringes; consistent condom use with non-paid female partners was also low. Approximately one-quarter of IDU in Mumbai/Thane visited a paid partner in the past year. IDU with reactive syphilis serology were higher in Nagaland (7 and 19%) than in Manipur and Maharashtra. HIV in two districts of Manipur (23%, 32%) and Mumbai/Thane (16%) was greater than Nagaland (<2%). HCV prevalence was more than 50% in Mumbai/Thane and Manipur.

Conclusion: Irrespective of regional differences, high-risk behaviour of needle sharing and low condom use makes IDU a critical subpopulation for HIV prevention interventions. Interventions need to address the differing drug use patterns in the regions and transmission prevention among non-paid regular and casual female partners of IDU in the northeast districts and paid female partners in Mumbai/Thane.

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Introduction

Injecting drug use has received increased attention because of the risk of HIV transmission and, more recently, hepatitis B virus (HBV) and hepatitis C virus (HCV). Clinical management of injecting drug users (IDU) is a cause for concern in the field of substance use prevention and treatment and has implications for the human resource development initiatives of many Asian countries including India [1]. Epidemics of HIV among IDU can spread rapidly, and in some places, including Bangkok, cities in the United States and Manipur state in India, the prevalence has reached between 50 and 90% in less than 6 months [2–4]. Prevention and control of HIV among IDU, through decreasing injecting drug use, reducing sharing of injecting equipment and promoting safe sex, are essential transmission control strategies for IDU and should minimize the transmission of HIV into the general population [5–7].

Harm reduction strategies and programmes carried out since the early 1990s, including ensuring a supply of clean needles, syringes and condoms, detoxification, substitution therapy, healthcare and peer-led outreach services, have been shown to reduce the risk of HIV [2,8,9]. Addressing environmental issues, such as stigma and discrimination including police harassment, can support interventions and result in positive behaviour change for participants in such programmes [10]. With the advent of the National AIDS Control Programme Phase II (1999–2006), the Government of India, with non-governmental organizations and donor agencies, strengthened the ongoing needle and syringe exchange programmes (NSEP) and several outreach and condom promotion programmes in northeast India and selected cities with high concentrations of IDU [5,11].

IDU in India, with the exception of the northeastern states, are predominantly urban, with varying levels of HIV prevalence. Studies in India and elsewhere have shown linkages between IDU and the general population through sexual contact with regular partners, selling sex and purchase of sex [12–14]. Since 2003, Manipur and Nagaland, two states in northeast India, have witnessed a growing HIV prevalence in pregnant women that reached 1.25 and 0.93%, respectively, in 2006. The HIV epidemic in Manipur is older than in Nagaland. Data from the facility-based targeted intervention surveillance system in India documented an HIV prevalence among IDU in Manipur of over 20% since 2003; whereas in Nagaland it ranged from 8% in 2003 to 2% in 2006 [15–17]. In Mumbai, the 2006 surveillance data indicated an HIV prevalence of 20% among IDU compared with 20% for female sex workers (FSW) and 16% for men who have sex with men [5].

We report here on data from the Integrated Behavioural and Biological Assessment (IBBA) obtained through a district-wide sample of IDU that was carried out as part of the overall evaluation strategy of Avahan's India AIDS Initiative, a large-scale HIV prevention programme in six states [18]. These data provide an opportunity to understand IDU characteristics and behaviours between the rural/periurban and remote districts in Nagaland and Manipur and the highly urbanized and connected Thane and Mumbai districts of Maharashtra.

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Methodology

The methods for the IBBA are described in another paper in this supplement [18]. Briefly, six districts were purposely selected because of their diverse sociocultural backgrounds and size of the IDU population from among districts where Avahan was intervening. The districts selected were Churachandpur and Bishnupur in Manipur, Phek and Wokha in Nagaland, and Mumbai and Thane in Maharashtra. In all three states, differences in geography, economy, culture and sociopolitical scenario exist, although these differences are most notable between the northeastern states and Maharashtra.

IDU from these six districts were recruited for a cross-sectional survey on HIV risk behaviours and HIV and STI biological markers. Interviewees had to meet the following criteria: be a man, 18 years or older, who injected addictive substances/drugs for non-medical purposes at least once in the past 6 months. A sample size of 400 was estimated for each survey district (a combined sample size of 400 was used for Mumbai and Thane (termed ‘Mumbai/Thane’). As a result of the clandestine nature of IDU, respondent-driven sampling (RDS), a social network-based sampling technique [19], was used.

RDS is a variant of chain-referral sampling; it relies on drawing recruits from the personal networks of initial and subsequent respondents. It employs a dual system of structured compensation: one for being interviewed and another for recruiting peers to be interviewed.

By limiting the number of recruits for each respondent and applying network analysis using RDSAT (an RDS analysis tool), the data represent a probability sample producing weighted results [20,21].

After written consent, participants were interviewed with a pre-coded, closed-ended questionnaire that assessed the following information: (1) demographic profile; (2) injection practices; (3) sexual behaviour; (4) self-reporting of STI; (5) knowledge of HIV-related services; (6) perception of HIV risk; and (7) exposure to interventions.

Dried blood spots (venous blood in Mumbai/Thane) were collected and tested for HIV, hepatitis B (HBV), HCV, syphilis, and herpes simplex virus type 2 (HSV-2) (on a 10% random sample). Urine specimens were collected and tested for Neisseria gonorrhoeae and Chlamydia trachomatis.

Study protocols were approved by the Health Ministry Screening Committee of the Government of India and ethical review bodies of the participating institutions (Family Health International, Regional Medical Research Centre and National AIDS Research Institute). Double entered, cleaned data were used for statistical analysis in RDSAT (version 5.6). All results presented in this article are weighted univariate measures with 95% confidence intervals.

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Results

Sociodemographic profile

More than one-third of respondents in the northeast were in the 21–25 year age group (Table 1). In Phek and Wokha, an additional 43 and 23% of respondents, respectively, were 18–20 years old. In Mumbai/Thane, approximately half of respondents were 31 years or older; only 4% were 20 years or younger. Approximately one-third of respondents in Mumbai/Thane were illiterate and nearly 60% had more than 11 years of schooling. In the northeast, less than 15% of IDU were illiterate. In Mumbai/Thane, 22% of the respondents were unemployed, whereas approximately 40% of IDU in both districts of Manipur, 48% in Phek and 65% in Wokha, were unemployed. In Bishnupur and Churachandpur, 27 and 23%, respectively, of IDU were currently married. In Phek and Wokha, 10 and 24%, respectively, were currently married. In Mumbai/Thane, 31% were married.

Table 1
Table 1
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Knowledge of HIV

Approximately 90% of respondents in both districts of Manipur, at least 42% in the two districts of Nagaland and 23% in Mumbai/Thane reported knowing that HIV could be prevented by not sharing injecting equipment and by using condoms consistently (Table 2). Knowing someone with HIV was highest in both districts of Manipur, approximately 75%, followed by Mumbai/Thane (41%), Wokha (13%) and Phek (8%). In Bishnupur and Churachandpur, approximately 40% of respondents felt at risk of contracting HIV, whereas in Phek, Wokha and Mumbai/Thane, fewer than 22% felt the same. In all districts, less than 26% of respondents had undergone voluntary HIV testing.

Table 2
Table 2
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Drug injecting profile

In Bishnupur, Churachandpur and Mumbai/Thane, approximately two out of five respondents started using drugs by the age of 18 years (Table 3). Close to two-thirds of IDU in Phek and Wokha reported using drugs for the first time by the age of 18 years, with most of these reporting first time drug use before the age of 16 years. Half of IDU in Phek started injecting at the age of 18 years or younger, and between 10 and 30% of IDU in the remaining districts started injecting by 18 years. Respondents reporting injecting for less than one year were captured more frequently in Phek (42%), followed by Bishnupur (27%) and Mumbai/Thane (21%).

Table 3
Table 3
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In both districts of Manipur, heroin (diacetylmorphine hydrochloride) was the drug most commonly injected, followed by spasmoproxyvon (dextropropoxyphene). IDU in both districts of Nagaland injected dextropropoxyphene more frequently (99%) and only a small proportion (<10%) reported injecting heroin. In Mumbai/Thane, heroin (99%) and avil (chlorpheniramine maleate) (87%) were the two main drugs injected. Over three-quarters of the IDU in the northeast reported that drug use was done indoors. In contrast, the majority of IDU in Mumbai/Thane reported injecting drugs in public places (such as parks and alleys).

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Injecting drug use

In Bishnupur and Phek, 30 and 22%, respectively, injected less than monthly (‘rarely’), or at least once a month but not weekly (‘intermittently’); 30% in both districts (Table 4). In Mumbai/Thane and Churachandpur, 62 and 77%, respectively, injected daily (‘most frequently’). More than 80% injected most frequently or ‘frequently’ (at least once a week) in Wokha.

Table 4
Table 4
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Among those who reported injecting drugs in the previous month, 63% of respondents in Bishnupur, 55% in Mumbai/Thane and approximately 40% in the remaining three districts reported not sharing a needle/syringe. Among those who shared needles/syringes, most shared with one to three injecting partners in the past one month.

With the exception of Bishnupur, at least 60% of respondents in the northeast reported, in general, receptive sharing (using injecting equipment previously used by another IDU). In Mumbai/Thane and Bishnupur, 47% reported receptive sharing. More than half of IDU in all districts (except Bishnupur, 41%) injected from a common drug container during their last injection. Approximately 60% of respondents in Churachandpur, and more than 35% in the other districts, reported sharing injecting paraphernalia other than the drug container during last injection. Although many IDU reported cleaning injecting equipment, they did this with water, which will not sanitize injecting equipment.

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Sexual partnerships and condom use

In Phek and Wokha, 72 and 82%, respectively, of respondents had at least one female sexual partner in the past year, whereas 59% in Mumbai/Thane, 56% in Churachandpur, and 40% in Bishnupur reported the same (Table 4). Approximately half of IDU in Phek and Wokha had multiple sexual partners. In Mumbai/Thane, Churachandpur and Bishnupur, 35, 27 and 16%, respectively, had multiple sex partners.

Although a small proportion of IDU in the northeast, 14% in Bishnupur and less than 6% in the other districts had sex with a paid female partner, 27% in Mumbai/Thane reported paying for sex. Condom usage at the last sex with a paid female partner was reported by 37% in Mumbai/Thane and over 80% in Bishnupur.

In Bishnupur, Churachandpur and Mumbai/Thane, 35, 32 and 30% of IDU, respectively, reported having a steady sexual partner (wife or girlfriend); 57 and 73% in Phek and Wokha reported the same. Reported condom use at last sex with steady sexual partners was between 30 and 40% in the four northeastern districts and 17% in Mumbai/Thane.

Approximately 50% of IDU in Phek and Wokha, 34% in Churachandpur and 5% in both Mumbai/Thane and Bishnupur reported having non-paid, casual female partners in the past year. In Phek, Wokha and Churachandpur, 67, 55 and 34%, respectively, reported using a condom during last sex with this partner.

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Blood-borne and sexually transmitted infections

HIV prevalence among IDU was 32% in Churachandpur, 23% in Bishnupur, 17% in Mumbai/Thane, 1% in Phek, and 2% in Wokha (Table 5). The proportion testing positive for HCV was 56% in Bishnupur, 78% in Churachandpur, and 53% in Mumbai/Thane. HCV prevalence was 17% in Wokha and 5% in Phek. HBV prevalence was highest in Mumbai/Thane (11%) and less than 7% in the other districts. Reactive syphilis serology prevalence was 20% in Wokha and less than 7% in the remaining districts. Chlamydia prevalence was 11% in both districts of Nagaland and less than 2% in the other districts. Gonorrhoea prevalence was less than 2% in all the districts. HSV-2 prevalence was 24% in Mumbai/Thane, 21% in both Churachandpur and Wokha, 14% in Phek and 2% in Bishnupur.

Table 5
Table 5
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Discussion

In the IBBA, along with the most frequently injecting IDU, the study definition included IDU injecting at least once in the past 6 months. The proportion of rare injectors was higher in Bishnupur (30%) and Phek (22%). Responses from these injectors may have influenced survey estimates on various injecting practices. Furthermore, RDSAT does not allow for bivariate analysis and thus restricts subgroup analysis.

Overall, IDU in Manipur were better informed about HIV. Levels of awareness were substantially lower in Nagaland followed by Mumbai/Thane, including awareness that not sharing injecting equipment and consistent condom use can prevent HIV. This may reflect both the age and type of interventions in different states. Interventions in Nagaland and Manipur started in the 1990s with an emphasis on harm reduction, whereas in Mumbai/Thane they were initiated in the 1990s among FSW and later with IDU. Furthemore, interventions in Manipur were spread throughout the district, and had greater emphasis and coverage [10]. Both Nagaland and Manipur are ethnically diverse although the former is a geographically more challenging terrain, which may have posed challenges for interventions. A higher prevalence of HIV in IDU and the general population make it more likely that an IDU in Manipur will know an HIV-positive person and, possibly, feel more at risk of HIV.

Nevertheless, studies have shown a disconnection between increased knowledge and reduced risky behaviour [22]. Wood et al. [23] illustrated that, with the likelihood of underreporting of risk behaviours as a result of social desirability bias, programmes should focus on those with increased self-perceived risk of HIV as this was associated with increased HIV seroconversion. Whether this is true in India should be explored, including how knowledge of HIV and knowing an HIV-positive person may affect perceived risk.

IDU in the northeast generally start their drug habit with injection drug use [10]. IDU from Nagaland reported experimenting with drug use and injection drug use before 18 years, whereas in Manipur this happened across the age groups. IDU in Phek and Bishnupur, followed by Wokha, had higher proportions of newer IDU (one year or less). Most IDU in Mumbai/Thane reported first injection drug use at older ages than in the northeast, with one-third being newer injectors.

Studies have shown a link between HIV seroconversion with both young age and recent onset of injection drug use [24–28] indicating the importance of focusing services on youth and those who have recently started injecting drugs. This vulnerability may be explained by the inability of IDU to inject themselves, peer influence to try injection, variation in quality or availability of drugs, unemployment, borrowing needles/syringes from older IDU, not paying for first drug use as well as structural factors such as police harassment [10,24,29]. With a large proportion of new injectors, the risk of the further spread of HIV remains high.

IDU in the northeast mostly inject indoors; therefore, identifying and providing services to these individuals may be a challenge. A restrictive political environment with military and underground militant groups active in the state impact the consistency of services and safety of non-governmental organization staff and IDU [30]. Earlier research [30–33] in Manipur showed that societal and systemic factors such as stigma against buying needles, size of networks, quality and content of interpersonal communication within injection networks, inclusion of larger community in prevention strategies and the cultural appropriateness of interventions have influenced the outcomes of IDU interventions such as NSEP and opioid substitution therapy. Community and religious groups are more influential in the northeast and IDU tend to live with their families. These support structures, financial, emotional and residential, are an advantage for interventions as they may provide an opportunity for prevention messages, reducing stigma and innovation in providing harm-reduction services.

Although IDU in Mumbai/Thane inject in public places, the location of these sites may change with the availability of drugs and increasing police harassment. With seemingly fewer hidden groups, interventions face the challenge of providing services to IDU that visit different sites for injecting drugs and those IDU who are homeless. IDU with unstable housing environments may be at an increased risk of HIV as a result of the risky behaviours in their environments [34].

IDU in Mumbai/Thane and Manipur injected heroin more often followed by chlorpheniramine or dextropropoxyphene, respectively, whereas in Nagaland, IDU used dextropropoxyphene. Dextropropoxyphene increases the risk of abscesses, non-healing ulcers and amputation [10]. Increased use of over-the-counter medications may be due to accessibility and low cost, increased tolerance with higher cost drugs such as heroin and increased police enforcement on drug trafficking [10]. One study in Mizoram, a state in northeast India, found that the injection of pharmaceutical drugs increases damage to veins leading to more frequent switching from injecting to non-injecting drug use [10]. This may reduce the risk of HIV by reducing the size of the IDU population and the frequency of injection behaviour at any one time [10]. It may also increase the chance of injecting in more critical veins posing larger health risks for IDU.

IDU in Churachandpur, Mumbai/Thane and Wokha injected most often. This may be related to the duration of drug use, in which more than 65% of IDU in the same districts reported injecting drugs for more than one year. Sharing behaviour was widespread among all IDU who had injected in the past month. In spite of knowledge about HIV, sharing behaviour was as high as 63% in Churachandpur. Furthermore, nearly half of IDU in most districts reported using shared containers and other injecting equipment.

A study among IDU showed that not only are young IDU at increased risk of HIV, but also that those who use drugs in shooting galleries, or places where they interact with other and older IDU, were more likely to initiate injecting drug use early and were at increased risk of HIV and hepatitis as a result of a higher prevalence among the older subgroup [28]. In Mumbai/Thane, it is easier for IDU to travel and, as a result, they may be likely to encounter a wider variety of social networks. High levels of reported sharing behaviour across districts may be related to the place of injection (e.g. dealers' house, friends' house, public places) as these are places where other IDU are likely to inject drugs. Furthermore, IDU in the northeast have reported in other surveys that they cannot carry syringes because of police and political activity that threatens their personal safety [10].

A study by Costenbader et al. [35] found an association between changing personal networks and risk behaviour. Involving peer leaders in programmes to provide services and targeting influential IDU with large networks may impact sharing behaviours by creating positive role models. For interventions, this presents the need to apply innovative methods for NSEP so that syringes are available when IDU need them most [36], perhaps through peer educators or mobile NSEP in addition to programmes based out of drop-in centres. Providing regular, accessible and an adequate number of clean needles and syringes should be supplemented with information on the risk associated with sharing injecting equipment. Although most IDU cleaned injecting equipment, they used water, which will not sanitize the equipment or prevent the transmission of blood-borne diseases. Willingness to clean equipment may be an opportunity for interventions to promote appropriate cleaning behaviour as a strategy to reduce risk [37].

IDU in Nagaland were more sexually active than in Manipur and Mumbai/Thane, with more than half reporting more than one female sexual partner in the past year. In Bishnupur and Mumbai/Thane, sexual behaviour was characterized by sex with paid and regular female partners and low condom use. The remaining districts were characterized by regular and casual female partners and low condom use. Condom use was higher in Nagaland with casual female partners than in Manipur.

In Manipur, many FSW inject drugs. Levels of HIV have increased among FSW [17] as well as wives of IDU (45% prevalence) [10]. Churachandpur is already experiencing a dual epidemic, with HIV driven through drug use and sexual behaviour [10]. Nagaland may follow this same pattern as a result of low condom use, multiple sex partners and IDU-related risk behaviour. Emphasizing information and services for safe sex with different types of partners along with harm reduction strategies is essential to decrease the risk of HIV transmission in Nagaland. Similar strategies should be followed in Mumbai/Thane because of sex with FSW and regular partners.

Similar to earlier findings [6,38–40], the HIV risk behaviours including sharing injecting equipment and unprotected sex, risk of contamination from sharing practices and non-sanitized usage of injecting equipment are present in considerable proportions, albeit in varying degrees.

Earlier research indicates that these practices have resulted in a high prevalence of HCV (92%), HBV (100%) and HIV among IDU followed by a high prevalence of HIV with their non-injecting sexual partners and their children in Manipur [31,40–43].

In our study, higher rates of STI were seen in Nagaland, which correlated with the increased sexual activity, multiple partners and low condom use. Furthermore, high rates of STI increase the risk of transmitting and acquiring HIV. HIV and HCV prevalence was highest in Manipur followed by Mumbai/Thane and then Nagaland. Variation in HIV prevalence may be explained by the duration of injecting drug use posing an increased risk of exposure, the size of the HIV-positive IDU population in the district, which increases the likelihood of transmission, places of injection that may expose IDU to higher risk behaviours, and frequency of injection. Furthermore, restrictive political environments may reduce the possibility of carrying needles forcing IDU to be more secretive, leading to riskier behaviours.

HIV sentinel surveillance data (published by the National AIDS Control Organization) suggest that HIV seropositivity has been decreasing among IDU in Manipur and Nagaland [5]. Overall, this gives an impression that the HIV prevention interventions among IDU have been successful. Data from the upcoming second round in conjunction with IBBA round one are expected to generate more specific insights on the levels of impact of intervention in the study districts. Operations research on appropriate and successful interventions in these types of environments is important to improve programmes and reduce the risk of HIV transmission.

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IBBA study team

IBBA team: National AIDS Research Institute (NARI), Pune: Abhijit Deshpande, Amey S., Amol Salagare, Arun Risbud, Bhagyashri, Deepak More, Dilip Pardeshi, Geetanjali Mehetre, Jagnnath Navale, Jayesh Dale, Kishore Kumar, Mandar Mainkar, Milind Pore, Narayan Panchal, Rahul Gupta, Raman Gangakhedkar, Sachin Kale, Sachin P., Shailaja Aralkar, Shashikant Vetal, Shirin Kazi, Shradha Gaikwad, Shradha Jadhav, Sucheta Deshpande, Sujata Zankar, Tanuja Khatavkar, Trupti Joshi, Uma Mahajan.

National Institute of Nutrition (NIN) Hyderabad: B. Narayana Goud, B. Sesikeran, Ch. Hanumatha Reddy, G. Krishna Reddy, G.N.V. Brahmam, K. Venkaiah, L.A. Rama Raju, M. Chandra Sekhara Rao, M. Shamsuddin, R. Harikumar, R. Hemalatha, S.P.V. Prasad, V.V. Annapurna.

National Institute of Epidemiology (NIE), Chennai: M.D. Gupte, V. Selvaraj, V. Joshua, A.K. Mathai, A. Bhubneswari, A. Manjula, A. Pauline Priscilla, A. Sivaraman, Beena Thomas, C. Femina, C. Kalpana Devi, C. Selvendran, C.P. Girish Kumar, D. Prabhu, J. Rajkumar, Jagan Jeyasingh, Joseph David, K. Boopathi, K.J. Dhananjeyan, K.J. Kalyanam, L. Palani, M. Amulu, M. Stabri Dhanabakyam, Michael Muniraja, Paul Tambi, R. Muthu, S. Karthikeyan, S. Periasamy, S. Tilakvathi, S. Velan, Stephen Raja, T. Karunakaran, T. Rabinson, T. Venkata Rao.

National Institute of Medical Statistics (NIMS), New Delhi: Arvind Pandey, B.S. Sharma, D. Sahu, D.K. Joshi, G.P. Jena, M. Thomas, Nandini Roy, P. Mahato, R.P. Sharma, R.S. Chadha, S.K. Benara, U. Sengupta.

Regional Medical Research Council (RMRC), Dibrugarh: Ashim Das, Basumati Apum, D. Borasaikia, Dulon Chetia, Gajendra Singh, Golap Ch. Barua, Gunavi Sonowal, Jogeswar Barman, Manas Barman, Mintu Gogoi, Nabajyoti Laskar, Purnima Barua, R. Gogoi, S.Z. Hussain, T. Rahman, Utpal Saikia, Wahid Bora.

Family Health International (FHI): Rajatashuvra Adhikary, Ajay Prakash, Bitra George, Kathleen Kay, Tobi Saidel, Lakshmi Ramakrishnan, Motiur Rahman, Sharad Malhotra, Srinivasan Kallam, Umesh Chawla.

Sponsorship: Support for this study was funded by the Bill and Melinda Gates Foundation.

The views expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Bill and Melinda Gates Foundation.

Conflicts of interest: None.

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Keywords:

HIV; India; injecting drug user; Maharashtra; Manipur; Nagaland; respondent-driven sample

© 2008 Lippincott Williams & Wilkins, Inc.

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