HIV FOLLOWS HEROIN TRAFFICKING ROUTES
Julie Stachowiak, MIA, MPH and Chris Beyrer, MD, MPH
Johns Hopkins Bloomberg School of Public Health

I was asked to give a short presentation explaining how the HIV virus has been documented to follow drug trafficking routes, as well as the intersection between HIV in this setting and human rights issues. <Slide #1>

Introduction: Lessons learned from Southeast Asia
Based on research done in Southeast Asia, Chris Beyrer predicted the outbreak of HIV which exploded in Almaty in 2000. <Slide #2>

The study that preceded that prediction was designed to examine the link between drug trafficking routes in Asia and outbreaks of HIV. The team used molecular subtyping of HIV to track different strains of HIV in infected people living on four drug trafficking routes out of Burma and Laos. Subtyping involves isolating the HIV virus from the blood of infected people and sequencing the DNA of the virus. By mapping out where the subtypes are found geographically as well as the risk factors of those infected with the specific subtypes, it is possible to create an accurate picture of where HIV has entered a population and how it is moving.

For example, in Urumchi, the capital of Xinjiang province in China, the virus is very close genetically to the virus in infected individuals in Yunnan. Heroin trafficking routes lead out of Burma into Yunnan, then go east to Nanning or Hong Kong, or north to Urumchi. Dr. Beyrer and his team looked at the map of trafficking routes which continued further north from Urumchi on into the destination market of Russia. Almaty was directly on one of these routes, which led to the prediction that there would soon be an HIV explosion in that city, which is otherwise remote from the epidemics that were occurring in neighboring countries. Likewise, Irkutsk was the overland terminal point for another route, and currently has the second highest prevalence of HIV in the Russian Federation.

Mechanism of HIV spread
<Slide #3> The spread of HIV along heroin trafficking routes begins with uptake of heroin use, leading to injecting drug use outbreaks, followed by explosive HIV outbreaks. It is quite significant that Central Asia is a trafficking route, as there are distinct differences in heroin use and subsequent HIV epidemics along the heroin supply continuum, which begins in production zones, follows trafficking routes and ends in destination markets.

<Slide #4> In cultivation and production zones, such as Afghanistan, there is an abundance of opium, making it accessible and inexpensive. Most users in these areas smoke the opium, with a minority snorting it. Neither of these methods presents a direct risk for HIV.

<Slide #5> However, as one progresses along drug trafficking routes, opium is less abundant. It is much easier to transport refined heroin than opium, as 10 kilograms of opium are concentrated to 1 kilo of heroin. Also, the further away from the source one goes, the more expensive pure heroin becomes, as handlers along the way add on their fees. Many people begin by smoking the heroin, then transition to injection. Once addicted, the economic drive to injection is overwhelming, as it is far cheaper to inject drugs for a more effective high.

<Slide #6> Once the heroin reaches the destination markets, users almost immediately begin injecting, as smoking is neither economical or effective to become high, as the drug has been cut so much that it must be injected for the desired effect.

Along the trafficking route, there are several factors that come together to lead to effective person-to-person transmission of HIV. It appears from experience in many diverse settings across the world, that regardless of culture, religion or other societal factors, when heroin is present, a certain percentage of people will try it and become addicts. Many traders and traffickers self-test heroin by injecting themselves. It has been seen in SE Asia that due to repressive drug laws, traffickers do not carry their own injection equipment, rather they share with those with whom they trade with or stay overnight with along the route. Drug laws are similarly repressive in Central Asia. The amount of heroin which legally constitutes a "very large amount," thus labeling the owner a dealer or trafficker, is 7/1000 gram, resulting in imprisonment of seven or more years.

<Slide #7> The speed with which HIV moves through an injecting population is incredible, as can be seen in this slide, which shows how HIV prevalence among IDUs jumps in just one year in various settings. In Central Asia, the cities of Timertau, Kazakstan; Yangi Yul, Uzbekistan; and Osh, Kyrgistan, have some of the highest documented rates of HIV in the region and all lie directly on drug trafficking routes.

Central Asia: what we don't know
<Slide #8> While numbers of people documented as being infected with HIV are certainly growing, we do not yet have a clear idea of the true prevalence of HIV in the region. Case-finding surveillance is still used in Central Asia, testing those that are arrested for drug possession or otherwise "registered" as drug users. In addition, there is a shortage of assays and adequate facilities to perform the tests.

<Slide #9> Central Asia also remains a mystery in terms of HIV subtypes. The region is surrounded on all sides by different subtypes, A in Russia, C in Pakistan and India, and B/C recombinant form in China. Discovering which subtypes are present will tell us much about trafficking patterns and risk behavior in the region.

Central Asia: what we do know
Despite our precise lack of knowledge about HIV prevalence and subtypes, much is known about drug trafficking and other factors which make the Central Asian region vulnerable to HIV. Illicit drug trafficking, while a serious problem in many countries, takes place most efficiently in settings where there the following conditions exist: 1) proximity to production zone; 2) porous borders; and 3) poverty and corruption, where revenues act as "tax" for protection.

We know that Central Asia is a critical drug trafficking route, the corridor through which much of the world's hard drug trade from Afghanistan, Pakistan and Central Asia itself, is conducted. The quantities of raw poppy seeds that have been seized in the past year indicates that heroin production laboratories may now exist in Tajikistan. The Open Society Institute estimates that 10 percent of the drugs being produced and trafficked are consumed in-country. The region is estimated to contain approximately 500,000 drug users.

<Slide #10> The government of Tajikistan has acknowledged that security forces are corrupt, and that most citizens keep silent rather than risk retaliation from the police. In the southern regions of the country, many border guards are involved in the drug trade and the local population has made numerous complaints of harassment and abuses committed by them. Traffickers include individuals who rose to positions of power and wealth as field commanders during the Tajik civil war, the so-called "warlords."

One striking piece of evidence of CAR drug trafficking success is the explosion of HIV among IDUs in Russia, Ukraine and Belorus, which are both destination markets and transit routes as drugs continue on to Western Europe.

We also have ample data on the economics leading to and supporting trafficking. For instance, one report on Tajikistan found that 30 percent of the population is economically dependent on the illicit drug business. In an OSI study, it was shown that economic factors were also responsible for many people initiating drug use, due to stress, boredom and unemployment.

One rarely mentioned phenomenon facilitating HIV spread along drug trafficking routes is the linkage between trafficking of women into sex work and trafficking of narcotics. Many of the same people are involved, both within the government and official structures, as well as members of organized crime groups. For instance, over 1000 women were trafficked from Tajikistan in 2000. Many times, these women are used to transport drugs as they themselves are being trafficked into sex work, either out of the country or being forced to service men moving along the trafficking routes. Many of them become users themselves, exponentially increasing their risk of HIV and that of their clients.

Urgently needed measures to counteract HIV
<Slide #11> The vast majority of measures directed at the region have involved reduction of drug supply through seizures and passing laws that levy harsh penalties upon people possessing even tiny amounts of illicit drugs.

In order to slow the spread of HIV in this region, the problem must be confronted openly and honestly. Repressive drug laws do not stop people from using drugs, they simply drive addicts further underground, making them harder to reach and resulting in riskier behavior.

Two measures are urgently needed in Central Asia. The first is access to drug treatment. Methadone maintenance therapy has been shown to reduce HIV risk behaviors, particularly needle use, giving us strong evidence that methadone prevents HIV among IDUs.

The second measure which could limit the spread of HIV in Central Asia is an effective system of needle exchange programs, which would reduce the practice of needle sharing. OSI has established or sponsored many needle exchange points in this region, as well as in the destination markets of Russia, Ukraine and Belorus. However, adequate coverage will not be reached if the most vulnerable addicts are afraid to access their services, due to repressive drug laws.

Thus, the intersection of heroin trafficking, HIV spread and human rights issues forces individuals and governments to consider the needs of the heroin user along trafficking routes. It is only by respecting his or her rights to information, to adequate medical treatment and to dignity that we can hope to slow the spread of HIV in the Central Asian region.