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July 10, 2003

Rise in Needle Sharing Among Pakistani Injection Drug Users

Afghanistan War May Have Adversely Influenced HIV Risk Behaviors

Needle sharing among Pakistani injection drug users increased more than three-fold after the start of the U.S.-led war in Afghanistan in 2001, according to researchers from the Johns Hopkins Bloomberg School of Public Health. The study, “Rise in Needle Sharing Among Injection Drug Users in Pakistan During the Afghanistan War,” appears in the July 2003 issue of the journal Drug and Alcohol Dependence.

Steffanie Strathdee, PhD, senior author of the study and associate professor of epidemiology and international health in the School of Public Health, said, “Situational factors associated with the U.S.-Afghan war appear to have indirectly affected needle-sharing behaviors among drug users. Increases in police presence and changes in heroin purity, availability, and price can lead to increased needle sharing and transitions from non-injection to injection drug use. These risky behaviors have important implications with respect to the prevention of HIV/AIDS and hepatitis B and C. Rates of HIV/AIDS in Pakistan have been low, but with high levels of needle sharing, low HIV/AIDS awareness, and virtually nonexistent levels of condom use, this could change rapidly.”

The researchers examined drug use and needle patterns of 224 drug users receiving services, such as food, bathing facilities, needle exchange, drug abuse counseling, and wound care, from a non-governmental organization in Lahore, Pakistan, before and after the beginning of the military campaign in Afghanistan. Before the war began, 57 percent of the study participants shared needles as compared with 76 percent of injection drug users after the war began. After accounting for other factors associated with needle sharing, injection drug users interviewed after the war began were more than three times as likely to report sharing needles.

High-quality, inexpensive heroin has been easily available in Pakistan due to its close proximity to Afghanistan, one of the world’s leading producers of opium. Most drug users typically inhaled or smoked heroin. However, in the period following the war in Afghanistan, decreased heroin availability and purity and increased price led some drug users to shift to injection of synthetic opiates, which are readily available at pharmacies without a prescription. Increases in injection drug use and needle sharing could pave the way for the spread of HIV and other blood-borne infections, warned the authors.

Dr. Strathdee and colleagues also recently reported in an article in the June 2003 issue of the Journal of Urban Health that 30 percent of injection drug users in Pakistan were paid for donating blood, which could further exacerbate the spread of blood-borne diseases in the country.

The researchers call for an expansion of needle-exchange and drug-treatment programs, as well as education and supportive services to avoid an explosive HIV epidemic among injection drug users in Pakistan.

Heena Brahmbhatt, MPH, PhD, an assistant scientist in the Department of Population and Family Health Sciences at the School of Public Health, co-authored the study. Additional researchers included Tariq Zafar, BBS; Ahmed Baksh; and Salman ul Hassan, BSc; all with Nai Zindagi, in Islamabad, Pakistan.

Research was supported by grants from UNAIDS, the European Commission, and the National Institute on Drug Abuse.

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 are available upon request.