Human immunodeficiency virus (HIV) infection rates and heroin trafficking: Fearful symmetries

There is mounting evidence that the spread of the human immunodeficiency virus (HIV) is associated with heroin trafficking routes. The relationship between the two is best illustrated by the routes leading from the two primary regions for the illicit opium poppy cultivation and heroin manufacture: the Golden Triangle of South-East Asia and the Golden Crescent of Central Asia. The producers in the Golden Triangle are the Lao People's Democratic Republic and Myanmar, and those in the Golden Crescent are Afghanistan and Pakistan. Together, those States accounted for perhaps 80-90 percent of the world heroin supplies in 2007. HIV outbreaks resulting from unsafe injection practices among injecting drug users (IDU) in trafficking zones have been documented in Myanmar itself, in Belarus, China, India, Indonesia, the Islamic Republic of Iran, Malaysia, Pakistan, the Russian Federation, Tajikistan, Thailand, Ukraine, Uzbekistan, Vietnam, and in several States in Eastern Europe. Heroin trafficking in those States has led to serial epidemics: first of heroin use, then of injection, then of blood-borne pathogens, including hepatitis C and HIV. Ethnic and trade relationships in heroin trafficking zones appear to facilitate such epidemics, as does drug testing by petty traders in market nodes. Policy responses, or the lack thereof, have increased the vulnerability of users and their communities, as have the limited drug treatment options available in those zones. While supplyside approaches, including interdiction and policing, are likely to continue, those HIV epidemics will require improved drug treatment, access to HIV prevention services, including harm reduction, and new approaches to the prevention of HIV in areas where heroin trafficking occurs.