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March 24, 2003

Pakistani and Afghani Drug Users at High HIV Risk

HIV/AIDS Interventions Especially Needed among Afghan Refugees

The majority of Pakistani and Afghani male drug injectors lack basic knowledge of HIV and the risk factors that lead to infection, according to a study conducted by the Johns Hopkins Bloomberg School of Public Health. The researchers found that only 16 percent of the study participants were aware of the existence of HIV or AIDS. In addition, they said many study participants admitted taking part in high-risk behaviors such as needle sharing and unprotected sex. Very little is known about HIV prevalence and its risk factors in Afghanistan. The study, “HIV Knowledge and Risk Behaviors among Pakistani and Afghani Drug Users in Quetta, Pakistan,” is among the first to report the HIV risk behaviors among drug users from Afghanistan and will appear in the April 1, 2003, issue of the Journal of Acquired Immune Deficiency Syndromes.

Steffanie Strathdee, PhD, senior author of the study and associate professor of epidemiology in the School of Public Health, said, “Although Pakistan has thus far averted a major HIV epidemic, this could soon change since large-scale prevention programs are lacking. Our study clearly shows that there is no room for complacency; high-risk needle sharing and sexual behaviors are rife. The fact that none of the Afghani drug users we studied had ever used a condom underscores the vulnerability of this population, which was likely exacerbated under the Taliban rule.”

Between July 2001 and November 2001, the researchers examined HIV knowledge and risk behavior of 956 Pakistani and Afghani drug users at a drop-in treatment center in Quetta, situated on the Pakistan-Afghan border. All of the research participants were male, over half had received no formal education, and the majority used heroin. The participants were questioned about their current and past drug use and sexual behaviors.

Researchers found that only 16 percent of all participants had heard of HIV/AIDS. Of the 125 participants who reported using injection drugs, only 20 percent cleaned the needles before using them. Condom use was reported by only 4.3 percent of the participants, all of whom were Pakistani. Of the 120 Afghanis who had sex, none had ever used a condom.

Significantly higher proportions of Afghani drug users had no formal education, were homeless, unemployed, and had a lower income when compared to the Pakistani research participants. Afghanis were also more likely to have used an opiate as their first illicit drug, to have other drug users in their family, and were more likely to inject drugs or share needles. The Afghani study participants were also less likely to know that sharing needles could spread disease.

The number of people addicted to heroin in Pakistan has increased in recent years as its neighbor, Afghanistan, is one of the largest producers of heroin in the world. A growing number of heroin addicts have started injecting combinations of pharmaceuticals available from pharmacies without a prescription, thus increasing their vulnerability to HIV and viral hepatitis from sharing needles and other injection paraphernalia. Over five million Afghan refugees have also entered Pakistan, further straining a health care system in which HIV prevention is a low priority.

The researchers explained in their report that an intervention to prevent transitions to injection drug use, as well as to institute needle exchange programs and drug treatment, is urgently required to prevent blood-borne infections, especially among Afghani refugees who are in desperate situations. Dr. Strathdee said, “Efforts are urgently needed to step up interventions to prevent HIV and sexually transmitted diseases among Afghan refugees, and in Pakistan overall.”

Additional authors were Heena Brahmbhatt, MPH, PhD, an assistant scientist in the Department of Population and Family Health Sciences at the Johns Hopkins Bloomberg School of Public Health. Tariq Zafar, BBS, Ghazanfar Imam, and Salmann ul Hassan, BSc, all with Nai Zindagi, in Islamabad, Pakistan, were also co-authors.

Public Affairs Media Contacts for the Johns Hopkins Bloomberg School of Public Health: Kenna Brigham or Tim Parsons at 410-955-6878 or

Photographs of Steffanie Strathdee and Heena Brahmbhatt are available upon request.