2 курс / Микробиология 1 кафедра / Доп. материалы / Kartikeyan_HIV and AIDS-Basic Elements and Properties
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the capital, and Jalalabad. Afghanistan is one of the world’s largest producers of opium, the raw material for heroin. Access to drugs, poverty, and lack of information increases the likelihood of widespread injecting drug use and sharing of needles. Afghanistan has the second largest number of refugees, after Palestine. As a result of two decades of armed conflict, about 3.4 million Afghans have sought refuge in other countries and an additional 200,000 persons are internally displaced. Such displaced groups have little access to HIV prevention services and are vulnerable to HIV infection due to isolation from their families and widespread poverty. Almost 70 per cent of those suffering from tuberculosis are women. Nearly half of all deaths in women of reproductive age are related to pregnancy and childbirth. Most of the population lacks access to basic health care and there is an acute shortage of trained personnel, particularly female personnel. Opportunities available for women in education, health, and employment are extremely low. Militant groups opposed to girls’ education have targeted schools, particularly in rural areas (UNDP, 2006).
1.5.2 – Bangladesh
Bangladesh has a population of over 146 million and a density of 1,061 persons per square kilometre. Almost every year, the country is affected by natural calamities such as floods, tropical cyclones (about 16 in a decade), and tornadoes. The first case of HIV infection was detected in 1989. Significant underreporting of cases is attributed to the country’s limited voluntary counselling and testing (VCT) capacity, and the social stigma attached to HIV/AIDS. Only 465 cases of HIV infection were officially reported till December 2004. In 2005, the estimated number of HIV-infected persons was 11,000, with less than 500 AIDS-related deaths (UNDP, 2006). Bangladesh is among the Asian countries that still have the opportunity to prevent major epidemics. The national adult prevalence of HIV infection is well below 1 per cent. Due to early initiation of focussed HIV prevention efforts, HIV infection in female sex workers is between 0.2 and 1.5 per cent at different sentinel sites (UNAIDS/WHO, 2005).
The identified high-risk groups are commercial sex workers, men who have sex with men, migrant workers, and injecting drug users (IDUs). Sex workers in Bangladesh have the highest client turnover rate in South Asia. The estimated weekly number of clients visiting brothel-based, street-based, and hotel-based sex workers is 18, 17, and 44, respectively. Consistent condom use during commercial sex is rare. The high rates of syphilis and other sexually transmitted infections (STIs) confirm the low level of condom use (UNDP, 2006). The overall prevalence of HIV infection among IDUs in the capital city, Dhaka, was 4 per cent in 2003–2004, while it was 9 per cent in some parts of this city. Many IDUs are involved in commercial sex and among them, less than 10 per cent consistently used a condom (UNAIDS/WHO, 2005). IDUs frequently face homelessness, unemployment, and imprisonment. Illegal sale of blood by drug injectors increases the likelihood of contaminating the national blood supply.
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Lack of human resources, high staff turnover, lack of training and staffing, an inefficient hierarchical programme structure, and stigma and discrimination prevalent in Bangladeshi society are among the identified obstacles that hinder the country’s response to the epidemic. It has been alleged that people in positions of power often remained silent on the issue of stigma and discrimination, or aggravated the situation by misinterpreting surveillance data, or added to the perception that certain groups were responsible for spreading HIV (UNDP, 2006).
Non-governmental organisations (NGOs) involved in HIV/AIDS-related activities have formed a network and are particularly working with marginalised and hard-to-reach groups. The Shaki project of CARE works mainly with vulnerable populations. The World Bank-assisted HIV/AIDS Prevention Project (HAPP) became effective in February 2001. The new National Strategic Plan (2004–2010) aims at rapid scale-up of successful NGO programmes that focus on high-risk populations, and to strengthen government capacity in blood safety, project management, and surveillance. From 2006, students in 21,000 secondary and upper secondary schools in Bangladesh will be taught about HIV/AIDS as part of a “life skills” curriculum (UNDP, 2006).
1.5.3 – Bhutan
The reported number of HIV-infected persons in 2005 is only 76 and estimates put the number of HIV-infected persons at less than 500. Proportion of infected children is relatively high. Seven out of nine new cases among children were attributed to mother-to-child transmission (MTCT). Probable factors that could contribute to spread of HIV infection are presence of STIs, thriving commercial sex, and cross-border trade along the border with Nepal and India, population mobility, and increasing use of amphetamines. About 63 per cent of Bhutan’s population is under 25 years. Lifestyle of migrant workers and truckers are conducive to commercial and casual sex. The Royal Government of Bhutan’s response includes awareness campaigns, establishment of HIV sentinel surveillance system, screening of donated blood, training of all health personnel, promotion of condoms, and ARV drugs for those in need of treatment (UNDP, 2006).
1.5.4 – Cambodia
The first case of HIV infection was detected in 1991 during routine screening of donated blood. The first case of AIDS was diagnosed in late 1993. In the 1990s, the HIV epidemic focussed on the sex industry. The national adult HIV prevalence rate peaked at about 3.3 per cent in 1997–1998 and fell steeply by one-third to 1.9 per cent in 2003. This decline is attributed to possible behaviour changes and the government’s policy of 100 per cent condom use in commercial sex establishments and provision of access to affordable condoms. The HIV prevalence among brothel-based and non-brothel-based sex workers decreased by half between 1999 and 2002. Condom use rates (more than 80 per cent in 2003)
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have been increasing steadily among commercial sex workers since the late 1990s. The potential drivers of the epidemic have changed in recent times. The main route of transmission is between spouses and from mother to child (UNAIDS/WHO, 2005; UNDP, 2006).
There are concerns regarding safety of blood supply in the country and the increasing incidence of HIV infection among pregnant women (from 0.35 per cent in 1999 to 1.48 per cent in 2002) in western Cambodia along the Thai border. This is also the only region in the country where HIV incidence among commercial sex workers has not declined. Cambodia’s VCT services are largely confined to the capital, Phnom Penh. The country’s weak health infrastructure is attributed to genocide, civil war, and famine in the recent past and continuing political instability and persistent poverty. Cambodia has a large commercial sex industry. Due to the country’s political turmoil, there has been considerable population mobility including refugee resettlement. There is considerable rural to urban migration of young people. Most of the 140,000 workers in garment factories around Phnom Penh are migrant rural women below 30 years. Some women move between factory work and shortterm sex work. Cambodia lies on drug trafficking route and illegal amphetamine laboratories have reportedly been established along the border with Thailand. Amphetamines and inhalants are commonly used drugs. At present, drug use does not seem to have a major role in facilitating risk behaviour (UNDP, 2006).
1.5.5 – Indonesia
Indonesia is an archipelago of 18,108 islands, of which about 6,000 are inhabited. It is the fourth most populous country in the world. The epidemic is unevenly distributed in this nation of 210 million people and 11 provinces (Bali, East Java, West Java, Jakarta, Papua, West Kalimantan, East Kalimantan, North Sumatra, North Sulawesi, Riau, and West Irian Jaya) out of the country’s 31 provinces are severely affected. Multiple sexual partnerships are common in parts of Papua province (UNDP, 2006).
Indonesia is on the brink of a rapidly worsening HIV epidemic driven by commercial sex and injecting drug use. The epidemic is spreading to remote parts of this archipelago. During 2002–2003, HIV prevalence ranged from 66 to 93 per cent among IDUs in the capital city, Jakarta. (UNDP, 2006). Most drug injectors are young, relatively well educated and live with their families. Studies have reported that most injectors know where to get sterile needles, yet they are reluctant to carry sterile needles fearing that the police would treat this as proof that they inject drugs, which is a criminal offence. About 88 per cent of drug users use non-sterile injecting equipment. Indonesia’s drug users are regularly arrested and jailed. HIV prevalence among inmates of Jakarta’s Cipinang prison rose from zero per cent in 1999 to 25 per cent in early 2003 (UNAIDS/WHO, 2005; UNDP, 2006).
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Condom use is infrequent or rare among sex workers working from nonbrothel settings (massage parlours, clubs), as well as brothel-based sex workers, despite a decade of HIV prevention efforts. Women are reportedly averse to carrying condoms because the police who might then arrest them regard it as “proof” of commercial sex work. For controlling the growing epidemic, Indonesia may have to adapt the legal and institutional environment to facilitate effective HIV prevention strategies (UNAIDS/WHO, 2005).
1.5.6 – Iran
The first HIV case was detected in 1987. In September 2004, 7,510 HIV-infected persons were registered, of which 95.1 per cent were men. The modes of transmission are injecting drug use (57.4 per cent) and sexual activity (6.8 per cent). However, the World Health Organization (WHO) has estimated the number of HIV-infected persons to be between 22,000 and 30,000. Imprisonment appears to be the biggest risk factor for HIV infection (UNAIDS/WHO, 2005). There is a high risk of increasing HIV prevalence because the country is located on a major drug trafficking route and its north-eastern neighbour is Afghanistan – the world’s biggest producer of opium. The incidence of injecting drug use is rising in Iran. The Central Asian countries to the north of Iran are also experiencing fast growing HIV epidemics. Due to the socio-cultural milieu, infection remains hidden and many infected persons to seek medical help. Though condom use has increased in recent times, the data relates only to married people (UNDP, 2006).
1.5.7 – Lao People’s Democratic Republic
The overall prevalence of HIV infection in this country (formerly called Laos) is low and about two-thirds of infected persons are living in the capital city, Vientaine and Savannakhet. The prevalence of STIs is high among women who work in non-brothel settings that also provide sexual services and about 1 per cent of women in Vientaine and Savannakhet are HIV infected. Behavioural studies have reported increasing sexual activity with multiple partners among young men in Vientaine (UNAIDS/WHO, 2005).
1.5.8 – Malaysia
About 64,000 persons were reportedly living with HIV in Malaysia in late 2004, of whom, about 9,400 had developed AIDS. Most were young men aged 20–29 and three-quarters of them IDUs. Twelve per cent of cases were attributed to heterosexual transmission and less than 1 per cent to male homosexuality or bisexuality. The growing proportion of HIV infections among women (7 per cent of total cases in 2003) is due to unprotected sex with a regular partner or multiple sex partners. There are an estimated 14,000 AIDS orphans in Malaysia.
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HIV prevalence of 10 per cent has been reported among sex workers in parts of Kuala Lumpur. The statistics on geographical distribution indicate the place where the infection has been diagnosed and not the place of usual residence of the infected person. Large numbers of reported cases in the states of Johor and Selangor is possibly due to high rate of detection from their relatively large prisons and drug rehabilitation centres, and the greater number of persons seeking treatment, as compared to the states in Peninsular Malaysia. The highest number of AIDS cases and AIDS-related deaths has been reported in Kuala Lumpur probably because of availability of medical treatment and support facilities in this city (UNDP, 2006).
1.5.9 – The Maldives
The nation’s AIDS Control Programme was launched in 1987, before the first case of HIV infection was identified in 1991. By the end of 2003, there were 135 HIV-infected persons in the country, of which, 12 were Maldivians and the rest were foreigners. Six individuals have died of AIDS-related diseases. Numerous factors make the country susceptible to HIV epidemic. Nearly 50 per cent of the population is under 15 years and prevalence of drug use among youth is rising. The country has a highly mobile population that includes tourists, sailors, migrant workers, and students. In 1998, about 400,000 tourists visited the country, about one and half times the entire population of the Maldives. Influx of tourists and high-risk behaviour, such as unsafe sex and injecting drug use, can possibly introduce different serotypes of HIV from all over the world. However, sex tourism does not exist in the Maldives. The current high rates of divorce and remarriage may lead to infection of serial spouses, casual sex partners, and create large sexual networks capable of transmitting HIV and other STIs. The Maldivian population is dispersed over about 190 islands. In the smaller islands, persons without radio or television constitute 55 per cent and 86 per cent, respectively. These conditions hinder HIV prevention programmes, including education and condom distribution. The situation is complicated by internal displacement of population after the tsunami in 2004 (UNDP, 2006).
1.5.10 – Mongolia
The first case of HIV infection was reported in 1992. By April 2005, nine cases of HIV/AIDS had been reported. Though the numbers are small, Mongolia is vulnerable to HIV epidemic because of its young population (50 per cent below 23 years), increasing incidence of STIs and drug use, rising number of sex workers and street children, increased international and internal mobility, and low levels of condom use. Neighbouring countries (China, Kazakhstan, and Russia) are experiencing HIV epidemics, primarily driven by injecting drug use. It is feared that injecting drug use, may be followed by an HIV epidemic when the region’s drug traffickers start using Mongolia’s trade routes. Due to economic
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hardships, the commercial sex industry has proliferated in the capital, Ulaanbaatar, and in the other smaller cities. The prevalence of sexually transmitted diseases (STDs) is 30 per cent among pregnant women and up to 58 per cent among sex workers. In 2002, the incidence of syphilis and gonorrhoea per 10,000 population was 6.7 and 19.6, respectively. In the capital, donor blood from volunteers is routinely screened for blood-borne pathogens but in the other cities, screening of donor blood depends on availability of laboratory reagents and test kits (UNDP, 2006).
1.5.11 – Myanmar
Myanmar (formerly Burma) has a population of about 50 million. The country has 130 ethnic groups and is rich in natural resources. But, more than five decades of political and armed conflict combined with trade and investment restrictions imposed by the United States and the European Union in 1997 have worsened socio-economic conditions in Myanmar (UNDP, 2006).
Myanmar’s first HIV-infected case was reported in 1988. The HIV epidemic is driven by injecting drug use and unprotected sex (both heterosexual and between men). Inadequate efforts to contain the spread of HIV epidemic during the 1990’s led to its rapid spread initially among high-risk groups and later among the general population. Consequently, Myanmar has one of the most serious epidemics in Asia. In 2005, the estimated number of HIV-infected persons and AIDS orphans was 360,000 and 37,000, respectively with about 110,000 AIDS-related deaths. Geographically, the eastern part of the country is the worst affected. The central and delta regions have moderate rates of infection, while the western part of the country is the least affected. Epidemiologically, the country seems to be close to the “tipping point” – the point at which, the critical mass of infection becomes so great that the epidemic is self-sustaining in the general population even if high-risk behaviour is significantly reduced in the most vulnerable groups (UNDP, 2006).
Myanmar established a HIV surveillance system in 1985 and by 2000 the system was expanded to cover 27 sites nationwide. The mindset of the early years (denying severity of the epidemic) seems to be changing. HIV prevention efforts have been scaled up in recent years. In 2004, 32.6 million condoms were distributed in contrast to the earlier “rule of thumb” target of one condom per capita per year (UNDP, 2006). But, the epidemic continues to rage unabated in the low-risk populations. HIV prevalence among pregnant women estimated at 1.8 per cent in 2004. At eight sentinel sites (out of 29), HIV prevalence among pregnant women has exceeded 3 per cent. Consistently high levels of HIV prevalence (above 25 per cent since 1997) among sex workers have aggravated Myanmar’s epidemic (UNAIDS/WHO, 2005).
Needle exchange programme has been established as part of harm reduction efforts. Nationally, the HIV prevalence among IDUs was 34 per cent in 2004, having decreased since 2001. But in Yangon, the nation’s capital, and Mandalay,
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the prevalence among drug injectors in 2004 was 25 per cent and 30 per cent, respectively (UNDP, 2006). Among military recruits, the prevalence of HIV infection was 1.6 per cent in early 2004. There is a lack of national data on condom use rates during commercial sex and limited behavioural information is available. Stronger prevention efforts are needed to deal with an epidemic that already ranks as the most serious in the region (UNAIDS/WHO, 2005).
1.5.12 – Nepal
The HIV epidemic in Nepal is driven by heterosexual transmission, primarily through commercial sex and prevalence of STIs is also rising. Limited information is available about homosexual/bisexual transmission and rural-to-urban ratio of infected persons owing to inadequate surveillance data. Estimates suggest that at least 10 per cent of the 2–3 million migrant Nepalis are infected with HIV and one-third of the infections in the country are among IDUs. The prevalence consistently exceeds 5 per cent in one or more high-risk groups such as sex workers, their clients and IDUs. Every year, about 12,000 Nepali children are taken to Indian brothels and the Middle East for commercial sex work. Though HIV infection is prevalent in all regions of the country, it is concentrated in central region and the capital, Kathmandu. The national adult HIV prevalence is estimated to be 0.5 per cent in 2005 with 75,000 infected persons, 5,100 AIDS orphans, and 16,000 AIDS-related deaths. The HIV prevalence among IDUs was 38.4 per cent nationwide, while in Kathmandu it was 68 per cent. Nepal was the first developing country to establish a harm reduction programme with needle exchange for IDUs, but this programme is impeded by limited coverage. Nepal’s comprehensive plan of 2002 proclaimed political commitment to halt the spread of HIV epidemic. In June 2003, satellite digital radio was established to impart information related to HIV/AIDS and gender issues to rural communities (UNDP, 2006).
Trafficking of Nepali girls and women into commercial sex work in India continues to challenge HIV control efforts. In addition, girls are also forced into traditionally institutionalised sex work practices, such as Deuki and Badi. There are between 100,000 and 200,000 internally displaced persons in Nepal due to multiple causes ranging from economic and/or political reasons to forced migration because of trafficking. About 1.5–2 million people have migrated to other countries for economic reasons and about one million Nepalis are estimated to be in India. Between 2 and 10 per cent of returning economic migrants are probably HIV-infected (UNDP, 2006).
1.5.13 – Pakistan
Though the rates reported to the country’s National AIDS Control Programme (NACP) are less, the Joint United Nations programme on HIV/AIDS (UNAIDS) estimated 85,000 HIV-infected cases in 2005 with 3,000 AIDS-related deaths.
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Pakistan is currently classified by WHO/UNAIDS as “low-prevalence” (adult prevalence about 0.1 per cent) but “ high-risk” country for the spread of HIV infection. The HIV infection has reached epidemic proportions in Karachi (Pakistan’s main trading city), Lahore, and Larkana (a small rice-growing town in Sindh province). The prevalence of STIs is high among IDUs, male sex workers, and the hijra (a diverse group of castrated males, transvestites, and transsexuals). The sexual network of men having sex with men (MSM) is heterogeneous, and includes the hijra, zenanas (transvestites who usually dress as women), and masseurs. Pakistan is a major transit and consumer country for opiates from neighbouring Afghanistan, the world’s largest producer of opium. Studies have revealed that drug users were switching from smoking or “sniffing” or inhaling to injecting polydrug cocktails (UNDP, 2006).
A combination of high degree of sexual interaction between drug injectors and sex workers, their low condom use, and their limited knowledge about HIV, and a large population of displaced persons favours rapid spread of the epidemic (UNAIDS/WHO, 2005; UNDP, 2006). Of the 1.13 million refugees in the country in January 2006, those from neighbouring Afghanistan numbered nearly 1.12 million. In October 2005, a powerful earthquake in Pakistan’s northern region killed more than 80,000 people. More than 3.5 million were rendered homeless. About 80 per cent of the health facilities were severely damaged or completely destroyed (UNDP, 2006).
Most infections occur between 20–44 years, with males outnumbering females by a ratio of 5:1. Sexual transmission accounted for 67.48 per cent of reported cases. It is estimated that 40 per cent of the 1.5 million annual blood donations are not screened for HIV. About four million people are employed overseas. These migrant workers are away from their homes for extended periods of time and may be exposed to risk of unprotected sex and HIV infection. Pakistan has a high rate of medical injections: about 4.5 per capita per year. Almost 94 per cent of the injections are administered with used injection equipment, and use of unsterilised needles is rampant in health facilities. An estimated 60 per cent of the country’s population has access to the formal health care system, while the remaining population is dependent on traditional healers (or hakims) or self-described “doctors” who have little or no formal medical training (UNDP, 2006).
In 1988, the NACP was launched and HIV/AIDS was declared a notifiable disease. The Government has identified nine priority areas. However, the approach to sex workers and MSM appears to be cautious. There is no legal protection against discrimination so far and federal legislation bill for mandatory testing of blood products is awaiting Senate approval. Foreigners living in Pakistan for longer than 1 year are subject to mandatory HIV testing. Pakistan’s recent Enhanced HIV/AIDS Programme aims to prevent HIV from becoming established in vulnerable populations and combating stigmatisation of those infected (UNDP, 2006).
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1.5.14 – The Philippines
The Philippines is an archipelago of 7,107 islands that stretch from the south of China to the northern tip of Borneo (Indonesia). The country has more than 100 ethnic groups (UNDP, 2006). The national adult HIV prevalence has stayed low even among high-risk populations, probably due to routine screening for STIs along with other HIV prevention services for sex workers. However, condom use is rare among non-brothel-based sex workers. The rate of non-sterile needle use is reported to be 77 per cent in Cebu City and high rates have been reported in other parts of the country. This calls for efforts to close the gaps in the country’s response to the epidemic (UNAIDS/WHO, 2005).
1.5.15 – Sri Lanka
The country’s first case of HIV infection was reported in 1986. In 2005, the estimated number of HIV-infected persons was 5,000 with less than 500 AIDS-related deaths. At the end of 2004, the male to female ratio was 1.4:1 but the proportion of infected females is rising. Of the reported HIV infections, 86 per cent were attributed to heterosexual transmission and 11 per cent to bisexual/homosexual transmission. Since homosexual behaviour is illegal in Sri Lanka, few HIV prevention activities are targeted at this group (UNDP, 2006).
The proportion of IDUs in the country is reported to be less than 1 per cent of all drug users and so far, only one case of HIV infection has been attributed to injecting drug use. Only three cases of blood-borne infection have been reported so far. Donated blood is screened at the Central Blood Bank in the capital city, Colombo and at 56 regional blood banks. ARV therapy is provided free of charge to HIV-infected pregnant women (UNDP, 2006).
Behavioural factors that facilitate the spread of the epidemic include presence of large number of sexually active youth, low rates of condom use, internal displacement of population due to continuing ethnic strife, and increasing number of commercial sex workers (estimated at 30,000 women and girls and 15,000 boys). A significant number of sex workers operate near military camps in the strife-torn country. There are also “beach boys” and women who are involved in sex trade with tourists. Other identified vulnerable groups include women employed in free trade zones, persons seeking foreign employment, plantation workers, and the fishing community. An estimated 1.2 million Sri Lankans work in the Middle East and 79.1 per cent of unskilled migrants are women. In 2001, 48 per cent of Sri Lanka’s HIV cases were among women working as housemaids abroad. High rates of unwanted pregnancies and STIs have been reported among women who comprise 80 per cent of the work force in the free trade zone at Kandy (UNDP, 2006).
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1.5.16 – Thailand
Thailand has been acclaimed for its success in containing the HIV epidemic. However, coverage of HIV prevention programmes is inadequate among men who have sex with men and IDUs (UNDP, 2006). In the 1990s, a rapidly spreading HIV epidemic focussed on the sex industry. In late 2005, the estimated number of HIV-infected adults and children was 560,000 and 16,000, respectively. The prevalence of HIV infection in adults was 1.4 per cent. The number of AIDS-related deaths in 2005 was 21,000 (UNAIDS/WHO, 2005). Thailand’s epidemic has metamorphosed into a more diverse epidemic in recent times. Since new HIV infections each year are occurring within marriage or steady relationships where condom use tends to be very low (UNAIDS, 2002), Thailand’s much acclaimed HIV control programmes (Chapter 27) should adopt strategies to match the shifts in the epidemic (UNAIDS/WHO, 2005).
1.5.17 – Vietnam
The first case of HIV infection was reported in 1990 in Vietnam. In the 1990s, the epidemic was concentrated in a few provinces and cities. By 2004, HIV had spread to all 64 provinces and all cities. Estimates in 2005 put the number of persons living with HIV at 260,000, with 13,000 AIDS-related deaths (UNDP, 2006).
Although the overall prevalence of HIV infection is less than 0.5 per cent, the national prevalence of infection among IDUs is about 33 per cent (UNDP, 2006). In the northern coastal cities of Hai Phong and Quang Ninh, the adult prevalence was estimated at 1.1 per cent in 2003 (UNAIDS/WHO, 2005). The drug injectors are usually young (mean age: 25 years). There is a large overlap between injecting drug use and commercial sex work. Fewer than 50 per cent of drug injectors reportedly use condoms with sex workers. The average HIV prevalence among sex workers in Vietnam is about 16 per cent and the infection levels are even higher in the cities of Can Tho, Hai Phong, Ho Chi Minh City, and Hanoi. Ho Chi Minh City accounts for about one-quarter of all HIV infections in the country (UNAIDS/WHO, 2005).
Most control measures have focused on prevention and resource allocations are not adequate. Implementation and effectiveness of the current programmes are not evaluated. Due to policies to manufacture ARV drugs domestically, many persons in need of ARV treatment do not receive them. The country has only 41 laboratories in 34 provinces and cities to detect HIV infection, and laboratory skills are reportedly low. The majority of blood donations come from professional blood donors, which increases the risk of blood-borne transmission of HIV (UNDP, 2006). Studies reveal that punitive campaigns to combat “social evils” tend to drive drug injectors and sex workers beyond the scope of HIV prevention programmes and can inadvertently entrench risky behaviours (UNAIDS/WHO, 2005).