There are an estimated 15.9 million injecting drug users (IDU) in the world, of whom approximately 3 million are infected with HIV according to The Lancet(1).

Estimates place the number of injecting drug users in Bangladesh between 20,000 and 40,000, with the highest concentration in the capital Dhaka (approximately 7400). The National HIV Serological Surveillance suggests a HIV prevalence of 7% in this population (2).

The sharing of contaminated needles/syringe is the main cause of transmission of HIV and other blood-borne infections, such as hepatitis C, among drug users. Epidemiological data also shows that sexual transmission is taking place from HIV-positive people who inject drugs to their sexual partners, and subsequently to their children(3).

Harm reduction services are evidence-based public health interventions trying to prevent or reduce the negative health consequences associated with the sharing of contaminated injecting equipment, and improve the health and social status of those at greater risk of acquiring HIV/AIDS. Harm reduction programmes mainly offer the following services to injecting drug users:

* distribution of sterile needles and syringe * distribution of condoms * behaviour change communication * abscess and STI management.

Another key harm reduction strategy employed in many countries for people dependent on opiate drugs is substitution therapy - using synthetically manufactured substances as a substitute for heroin and other opiates. Under medical supervision care is offered to injecting drug users based on a similar or identical substance to the drugs they normally use.

Methadone is one such substance, used in oral substitution treatment (OST). Benefits of methadone treatment for opioid dependence include loss of cravings, allowing the individual to cease their compulsive drug use and its associated risks and harms, and focus on normal life events. Worldwide, approximately 82 countries employ oral substitution therapy for opioid users, of which 48 use methadone treatment, servicing about 1 million individuals(4).

The effects of methadone are much longer lasting than heroin, a single dose being effective for approximately 24 hours. In a treatment program, methadone is usually given out in syrup form and drunk with a flavoured drink or fruit juice.

As OST requires the use of narcotic (opiate-based) drugs, to date it has been considered illegal in Bangladesh. However, following extensive advocacy by UNODC and ICDDR,B with policy makers of different departments and government ministries as well as civil society, the Government of Bangladesh finally approved a pilot study on oral substitution treatment with methadone in August 2008.

This study will be funded with technical support by UNODC as part of their regional project Prevention of Transmission of HIV among Drug Users in SAARC countries, and will be conducted by ICDDR,B with around 200 injecting drug users in three sites in Dhaka. ICDDR,B has already been involved with the project since 2004 as a mentor and the national learning centre.

Two of the sites will be located in the area identified with a current concentrated epidemic, and the third will be the Central Drug Treatment Centre operated by the Department of Narcotics Control (Ministry of Home Affairs).

The pilot study will hopefully highlight ways to enhance the health and social status of injecting drug users in Bangladesh, and greatly contribute to containing the HIV/AIDS epidemic in Bangladesh.

On World AIDS Day 2008, we recognize and appreciate the National Narcotics Control Board and the Government of Bangladesh for this well-timed decision, in what is a great achievement for all stakeholders working with HIV/AIDS issues in Bangladesh.

For further information on the oral substitution treatment trial study contact Ezazul Islam Chowdhury.

References: 1. Mathers et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review, The Lancet early online publication, 24 September 2008. 2. Government of Bangladesh (2007). National HIV Serological Surveillance, 7th Round Technical Report, 2006 Bangladesh. Dhaka, National AIDS/STD Programme, Directorate General of Health Services, Ministry of Health and Family Welfare, Govt. of Bangladesh. 3. Biregional Strategy for Harm Reduction 2005-2009, WHO, 2005. 4. Dr Alex Wodak, "Controlling HIV among injecting drug users: current status of harm reduction", paper presented at International AIDS Conference, Toronto, 15 August 2006.