The results indicate that a significant proportion of injecting drug users in both the states of Manipur and Nagaland engage in high risk sexual behaviors. Further, IDUs who share needles were more likely to have multiple sexual partners. However, state level differences in the association between injecting and sexual risk behaviors were also evident, and the observed differences could be, at least in part, due to the different types of drugs used in each of the states. In Manipur, heroin users were less likely to have two or more partners in the last 12 months as compared to non heroin users. Further, sex with a paid partner in the last 12 months was not associated with any injecting behavior of IDUs. This is consistent with literature that documents a negative association between the use of heroin and sexual risk behavior as heroin use tends to suppress sexual desire[23, 30]. In Nagaland, Spasmoproxyvon was used more widely and our results demonstrate that riskier injecting behavior was associated with riskier sexual behavior in this state. Although regular injectors in Nagaland were more likely to have two or more partners in the last 12 months and have sex with paid partners, those who accessed NGO services were significantly less likely to be inconsistent condom users. Hence NGO services have been effective in increasing condom use among those IDUs who actually access them, as documented by a previous study conducted in these two states. These findings persisted even after adjusting for socio-demographic characteristics known to be strong confounders of both injecting and sexual behaviors. Our finding that IDUs practicing high risk injecting behaviors are more likely to practice high risk sexual behaviors is consistent with findings from previous studies conducted in the USA and South Africa[19–21, 23].
The present study findings should be considered in light of the following limitation. As the data for each district was collected independently and an unweighted analysis conducted at the state level by combining districts, we could not use RDSAT for our regression analysis. Further, since there is no consensus among statisticians as to whether data gathered through RDS can be appropriately weighted for multivariate analysis, it is important to interpret these regression findings with some caution.
Despite this limitation, the findings highlight the double jeopardy faced by high risk IDUs who engage in both risky injecting and risky sexual practices, amplifying not only their own risks of HIV infection but also the likelihood of HIV transmission to their injecting and sexual partners. This underscores the importance of interventions that focus on safer sexual practices, especially among high risk IDUs, in the ongoing HIV prevention programs in Northeast India.
This is especially the case in Nagaland where the link between unsafe injecting and unsafe sex was strongest. The importance of preventing sexual transmission of HIV in Nagaland is being increasingly recognized. In 2008, the HIV prevalence among IDUs in Nagaland was only 3.2% (compared with 9.2% among IDUs nationally), while among FSWs it was 14.1% (compared with 4.9% among FSWs nationally). Based on prevention of parent to child transmission (PPTCT) testing data, Nagaland has the highest HIV prevalence among pregnant women in the country (0.89% compared with 0.19% nationally). These data point towards a shift away from an HIV epidemic driven by unsafe injecting, to one driven by unsafe sexual behaviors. The overlap between unsafe injecting and unsafe sexual behaviors among a high-risk sub-set of IDUs, as identified in this study, has the potential to amplify HIV transmission in this state.
Typically, programs targeted towards IDUs focus primarily on distribution of needles and syringes; however, as documented in previous literature, it is essential that these efforts are strongly complemented with sexual risk reduction programs. Also, given that condom use is more consistent among IDUs who access NGO services, extending the coverage of the targeted HIV prevention interventions so they reach a greater proportion of IDUs is recommended.