Rapid Assessment of Drug Use Patterns (RADUP) in Sri Lanka

To inform risk reduction interventions for People Who Use / Inject Drugs (PWUD/PWID)

REPORT
January 2018
Study at a glance
Title Rapid Assessment of Drug Use Patterns (RADUP) among
People Who Use and/or Inject Drugs (PWUD/PWID) in
Sri Lanka
Duration July – November 2017

Conducted by National STD/AIDS Control Program, (NSACP), Sri

Lanka
National Dangerous Drugs Control Board, NDDCB, Sri
Lanka
Technical Support Alliance Regional Technical Support Hub/Alliance India,
New Delhi
Ethics Clearance Faculty of Medicine, University of Colombo

Funding Support Global Fund for AIDS TB and Malaria

(NFM Grant 2016-2018 budget line – 201)
Researchers
Dr Sathya Herath - Principle Investigator
Consultant Community Physician, Activity coordinator
Global Fund Grant, National STD/AIDS Control
Program, Sri Lanka

Dr. Atul Ambekar - Co-Investigator

Professor, National Drug Dependence Treatment Centre,
AIIMS, New Delhi, India

1
 CONTENTS
EXECUTIVE SUMMARY ........................................................................................................................ 3
1. INTRODUCTION: ............................................................................................................................. 6
2. OBJECTIVES: .................................................................................................................................... 7
3. REVIEW OF LITERATURE ............................................................................................................ 7
4. METHODOLOGY: .......................................................................................................................... 12
Study Design .............................................................................................................................................. 12
Data Collection:......................................................................................................................................... 15
Data Analysis:............................................................................................................................................ 17
Implementation arrangements: ............................................................................................................... 18
Ethical issues: ............................................................................................................................................ 19
Training: .................................................................................................................................................... 20
5. RESULTS .......................................................................................................................................... 20
5.1. Reliability of data collected, response rate, and coverage ............................................................. 21
5.2. Socio Demographic profile of respondents ..................................................................................... 22
5.3. Drug use profile of respondents ....................................................................................................... 24
5.4. Consequences of drug use of respondents....................................................................................... 31
5.5. Sexual Practices of respondents ....................................................................................................... 34
5.6. Legal problems among respondents ................................................................................................ 35
5.7. Treatment seeking and access .......................................................................................................... 35
5.8. Results of KII..................................................................................................................................... 37
6. DISCUSSION .................................................................................................................................... 40
7. CONCLUSION & RECOMMENDATION.................................................................................... 46

2
EXECUTIVE SUMMARY

Introduction:

Research on details of pattern of drug use among People Who Use Drugs (PWUD) and People
Who Inject Drugs (PWID) in Sri Lanka is relatively scarce. In order to initiate interventions aimed
at reduction of risks due to drug use in the country, adequate information about pattern of drug use
is critical. Thus, the NSACP along with NDDCB has conducted this “Rapid Assessment of Drug
Use Pattern (RADUP) in Sri Lanka to inform risk reduction interventions for PWUD/PWID”. The
Alliance Regional Technical Support Hub South Asia provided technical support. The study was
aimed at (i) understanding the pattern of drug use among the non-institutionalized PWUD and
PWID in selected districts in Sri Lanka and (ii) recommending policies and programmes related
to drug use issues in Sri Lanka.

Methods:

In this exploratory, observational, cross-sectional, mixed-method study, a combination of

qualitative and quantitative methods was used. Quantitative data were obtained from non-
institutionalized PWUD (n=283) and PWID (n=174), recruited through a snow-ball sampling
strategy, from six districts of the country: Colombo, Gampaha, Kaluthara, Galle, Kandy and
Rathnapura. These respondents were interviewed in one-to-one setting by trained interviewers
from National Dangerous Drug Control Board (NDDCB), after obtaining informed consent. For
the qualitative component, Key Informant interviews were conducted with a variety of
stakeholders (PWUD / PWID; Treatment provider; Family member / Spouse / partner of
PWUD/PWID; Law enforcement personnel; Total n=36) from these six districts. Ethics clearance
was obtained from faculty of medicine, University of Colombo.

Results:

On the socio-demographic parameters, PWUD and PWID groups were strikingly similar. More
than 95% were males and tended to be in their late 30s. Overall, a large majority (>90%) of PWUD
/ PWID were educated and employed.

3
Almost all the respondents in both the groups were poly substance users. In the last one year while
more than 98% in both the groups used tobacco, 60% of PWUD and 45% of PWID also used
alcohol. Among illegal drugs, about two-third in both the groups used cannabis and while 93% of
PWUD used heroin with the ‘Chinese’ method, about 45% of PWID also reported so. About one-
fourth respondents in both the groups also used sedative tablets. Most common drug of injecting
among PWID was heroin (reported by 91%). It was also evident from the results that while a
number of drugs are being used, the dependence or addiction is largely on Opioids (i.e. heroin); as
many as 64% of PWID and 73% of PWUD had scores on WHO Alcohol, Smoking and Substance
Involvement Screening Test (ASSIST) more than 26 (corresponding to opioid dependence). The
data on onset of drug use displayed a specific pattern; while heroin smoking starts around 19-20
years of age, heroin injecting starts around 28 years of age. ‘Peer pressure’ and ‘curiosity’ were
the most common reasons behind onset of drug use.

About 83% of PWID injected ‘daily’ with about 64% injecting ‘2-3 times per day’. As many as
85% had shared their injecting equipment ‘ever’, while 64% shared in the last one month. Indeed,
about 68% of PWID shared their injecting equipment in the first instance of injecting.

A wide variety of adverse consequences of drug use (physical, social, psychological, familial and
occupational) were reported. In terms of sexual behaviors, among those who reported sex with
commercial sex partners (i.e. with female sex workers), 52% of PWID and 38% of PWUD reported
unprotected sex.

While as many as 85% of PWID and 79% of PWUD reported receiving counselling in the past as
an intervention for their drug use problems, just about 41-42% reported receiving any medical
treatment (despite an overwhelming majority being opioid dependent). In contrast more than 90%
had been apprehended by police and large majority (84% PWID and 78% PWUD) had been to
jail.

The key informant interviews with a variety of respondents highlighted the deep-seated prejudices
against drug use exemplifying widespread stigma and discrimination faced by PWUD / PWID.
The widely prevalent misconceptions regarding harm reduction approaches were evident.

Conclusion and recommendations:

4
Among key vulnerabilities and challenges in Sri Lanka, results show that the country has young,
productive men suffering from heroin dependence and its serious adverse consequences. While
PWUD are at risk of transition to injecting, major concern is the High prevalence of risky injecting
and sexual practices. The response to drug problems appears to be heavy skewed toward the
criminal justice system (which appears ineffective) and there is poor access to effective, evidence-
based treatment for opioid dependence with a virtual non-existence of specific harm – reduction
interventions.

Regarding Recommendations from these results, there is an urgent need of Legal and Policy
reforms aimed at a conducive environment for provision of evidence-informed services for
affected communities. Similarly, promoting the involvement of civil society and affected
communities in the decision-making process will be important. We need urgent and strong
advocacy measures for initiating evidence-based treatment for drug dependence (Opioid
Substitution Treatment) and harm-reduction interventions (including access to clean injecting
equipment) for PWID. For building capacities, exposure visits and study tours to neighbouring
countries for exposure to the programs for drug dependence treatment and harm-reduction and
collaboration between academic institutes of Sri Lanka and other countries is highly
recommended.

5
1. INTRODUCTION:
Use of Psychoactive substances (or ‘Drugs’) is a known phenomenon in Sri Lanka since the
ancient time. However, while traditionally drugs were used largely for medicinal purposes, in the
recent times, use of drugs for recreational purpose appears to be on the rise. A major reason for
this could be the arrival of synthetic and potent drugs like heroin in the country. While traditional
substances like Cannabis and opium are still being used for medicinal purposes under the
traditional ‘Ayurvedic’ system of medicine, from the early 1980’s onward heroin use started
surfacing among the Youth.

The Government of Sri Lanka has formulated an intensive programme to address the issues related
to drug use in the country. The National Dangerous Drugs Control Board (NDDCB) is the
principal government agency entrusted with the task of coordinating all the activities related to
drug control in the country. In addition, the National STD / AIDS Control Programme
(NSACP) spearheads the national response to HIV/AIDS in Sri Lanka, and is mandated to provide
prevention as well as care and support services to the vulnerable populations. Since People Who
Use Drugs (PWUD) and particularly, People Who Inject Drugs (PWID) are known ‘Key
Populations (KP)’, issues related to the behaviours and practices of PWUD and PWID are
extremely important to be studied.

Thus, the National STD/AIDS Control Program along with National Dangerous Drugs Control
Board (NDDCB) has conducted this “Rapid Assessment of Drug Use Pattern (RADUP) in Sri
Lanka to inform risk reduction interventions for PWUD/PWID” in the country. The Alliance
Regional Technical Support Hub South Asia was selected to provide technical
support/consultancy to NSACP and NDDCB for the study.

6
2. OBJECTIVES:
1. To understand the pattern of drug use among the non-institutionalized people who
use drugs and people who inject drugs in selected districts in Sri Lanka

2. To generate recommendations for policies and programmes related to drug use issues
in Sri Lanka

3. REVIEW OF LITERATURE
Drug use: Global & Regional situation
Use of psychoactive substances for recreational purposes is a global phenomenon and a major
public health problem. An estimated quarter of a billion people, or around 5 per cent of the global
adult population, used drugs at least once in 2015. Even more worrisome is the fact that about
29.5 million of those drug users, or 0.6 per cent of the global adult population, suffer from drug
use disorders. This means that their drug use is harmful to the point that they may experience drug
dependence and require treatment.

Among various types of drugs used globally, opioid use results in most significant problems.
Global prevalence of the use of opioids is estimated to be 0.7% of the world’s adult population (or
35 million users). The global number of opiate users (i.e., users of opium, morphine and heroin)
continued to increase, although marginally, from 17.3 million in 2014 to 17.7 million in 2015.
Opioid use disorders account for the heaviest burden of disease attributable to drug use disorders.
In 2015, almost 12 million DALYs, or 70 per cent of the global burden of disease attributable to
drug use disorders, were attributable to opioids. More worrisome in the trend of using drugs,
particularly opioids, by injecting route. Almost 12 million people worldwide inject drugs, of whom
one in eight (1.6 million) are living with HIV and more than half (6.1 million) are living with
hepatitis C.1

South Asia has a sizeable problem of drug use. The region is close to high opium producing areas,
the Golden Triangle and Golden Crescent. United Nations Office on Drugs and Crime notes that,
this unique location has increased the availability and use of illicitly produced opiates in South

1
United Nations Office on Drugs and Crime (UNODC), World Drug Report 2017. Vienna:
UNODC
7
Asia. Injecting drugs adds to the problem as the sharing of drug-taking equipment, particularly
infected needles, is an extremely effective way of transmitting HIV to the general population.

Although cannabis is the most widely consumed drug, the most problematic group of substances
for most South Asian countries are opiates. Increased use of synthetic and prescription drugs has
also been reported in several countries of the region. In South Asia region, the following
substances are most often used: Afghanistan and Myanmar-originated heroin; locally produced
heroin; synthetic opioids and prescription drugs such as codeine-based cough syrups, diazepam
and proxyvon produced mainly in India and Bangladesh; synthetic drugs originating from South
East Asia; cannabis and alcohol. 2

The problem of drug use in most parts of the world, and specifically in South Asia is compounded
by the Stigma and discrimination which are widespread. Moreover, existence of punitive laws
make it difficult or even impossible for drug users to ask for help or access services. Under the
prevailing legal provisions, many drug users may be arrested as they trade drugs to sustain their
habit. Drug use and possession are a punishable offence in all countries of South Asia, contributing
to a high number of inmates imprisoned for drug-related offences. 2

Drug use: Situation in Sri Lanka

Despite being talked about and discussed extensively in the general media3,4,5, the exact
dimensions and contours of the drug problem in Sri Lanka are not well known. While there have
been certain surveys conducted to estimate the number of people who use drugs in Sri Lanka, an
in-depth analysis of pattern of drug use is not available.

One of the important sources of information regarding drug use in Sri Lanka has been the data
from people seeking treatment for their drug addiction. Reports of Drug Abuse Monitoring
System (DAMS) are regularly compiled and published which provide a glimpse of profile of
treatment seekers. For instance, the latest report of DAMS provides data from 2355 drug users
who received treatment of drug addiction in various treatment centres in the country.6 Of these an

2
UNODC ROSA. Regional Programme for South Asia (2013-2015). New Delhi: UNODC, ROSA
3
http://www.dailymirror.lk/30046/narcotics-the-silent-killer-haunting-the-schools-in-sri-lanka
4
http://www.ft.lk/article/527158/551-school-children-arrested-for-drug-abuse-since-2010
5
http://groundviews.org/2009/08/13/illicit-drug-abuse-in-sri-lanka-shows-clear-signs-of-worsening/
6
National Dangerous Drugs Control Board. Drug Abuse Monitoring System: Annual Report – 2016.
8
overwhelming majority were men (98.5%), and almost equal proportion were married (48%) or
single (49%). Proportion of young men was highest among treatment seekers; about 48% were in
the age group of 25-39 years. Majority had some years of schooling with 54% having studied
between grade 5 and 10. The largest proportion (92%) reported using heroin, followed by 68% of
cannabis users. Notably, a very small proportion (1%) were injecting drug users. While the study
report does provide some important data on profile of treatment seekers at Sri Lanka, there is no
detailed information on behaviours and practices of drug use, nor is there data on consequences
of drug use.

Another report also provides the similar data and confirms the trends. The handbook of DAMS
(2016)7 compiles the data on treatment seekers for the years 2011 to 2016. For each year of
reporting, the common and consistent trends are:

• Largest majority of treatment seekers report heroin use (75% to 86%);

• Largest proportion report use of drug by smoking / inhalational method (67% to 78%);
• A very small minority reports injecting route of drug use (1.6% to 4.3%);
Drug users are overwhelmingly males (98% to 99%), educated (2.3% to 5.9% without
schooling) and in their productive years of life (55% to 67% between the ages of 20 and
39 years).

However, an in-depth information on pattern of drug use is not available from this report either.

In addition to the large-scale DAMS reports, there have been other small-scale studies on
treatment seekers, from Sri Lanka. De Sliva and Fonseka (2008)8 reported data on 381
institutionalized drug addicts from Galle district and found the profile to be remarkably similar to
that reported in the recent large-scale studies (i.e. DAMS). In other words, it appears that the
profile of treatment seeking drug users in Sri Lanka has remained largely the same over the years.

Apart from these reports, which are based upon data collected from people seeking treatment for
their drug addiction, there is a dearth of literature from Sri Lanka on people who use drugs, from
the community settings (i.e. non-institutionalized population). Overall, in the country there are an

7
National Dangerous Drugs Control Board.Handbook of Drug Abuse Information 2016.
8
De Silva and Fonseka.Galle Medical Journal, Vol 13: No. 1, September 2008
9
estimated 45,000 heroin users. Four districts of the country – Colombo, Gampaha, Galle and
Kandy – are believed to have higher prevalence of drug use.

Data on People Who Inject Drugs (PWID) is really scanty. Although available surveys as well as
data from DAMS does confirm existence of Injecting Drug Use in Sri Lanka, many details of the
behaviours and practices related to this phenomenon are not available. Senanayake et al (2005) 9
reported data from an exploratory study and found that PWID in Sri Lanka could be broadly
categorised into three groups: regular injectors, intermittent injectors and occasional injectors.
Interestingly this study revealed that the crisis of not getting enough heroin for chasing (the
‘Chinese’ method) was cited as a reason for starting drug use through injecting route. Another
indication of low prevalence of IDU in Sri Lanka came from the study on prison inmates by
Niriella et al (2015)10, where among the 393 randomly selected inmates in two prisons of Sri
Lanka, 167 (42.5%) reported drug use through non-injecting route, but only 17 (4.3%) were PWID.
Fortunately, the Prevalence of HBV and HCV was found to be very low in the study. In yet another
study on incarcerated drug users, Dissabandara et al (2009) reported the prevalence of IDU to be
15% among 278 drug users interviewed in three prisons.11

Across various studies, the estimated numbers of PWID in Sri Lanka is small and very low as
compared to the number of PWUD (i.e. non-injectors). The size estimation of Most At Risk
populations (MARP)12 reported the number of PWID to be 218 ‘on a usual day’ to about 423 ‘on
a peak day’. This was in contrast to the estimated number of PWUD, an average of 12,618 PWUD
‘on a usual day’, to, 17,459 ‘on a peak day.’

As per a recent report by NDDCB13 involving 721 PWID, almost 99% were males, with about
81% between the ages of 26 to 50 years. A large majority (89%) reported injecting ‘regularly’ and

9
Senanayake, B., Kandiah, R. and Ratnayake, Y., 2005. Injecting Drug Users in Sri Lanka, In: Proceedings
of the 10th International Conference on Sri Lanka Studies, University of Kelaniya, pp 158.
10
M A Niriella, A Hapangama, H P D P Luke, A Pathmeswaran, K A L A Kuruppuarachchi, H J de Silva,
Prevalence of hepatitis B and hepatitis C infections and their relationship to injectable drug use in a cohort
of Sri Lankan prison inmates. Ceylon Medical Journal 2015; 60 18-20
11
Dissabandara LO, Dias SR, Dodd PR, Stadlin A. Patterns of substance use in male incarcerated drug users
in Sri Lanka.Drug Alcohol Rev 2009;28:600–607
12
National STD/AIDS Control Programme (NSACP) 2013. National Size Estimation of Most at Risk
Populations (MARPs) for HIV in Sri Lanka.
13
National Dangerous Drugs Control Board (2015). Trend, Patterns and Prevalence of Injecting Drug Users
in Sri Lanka.
10
a large proportion (44%) reported sharing injecting equipment. However most of the details of
pattern of drug use and actual practices of injecting were not available in this study.

Thus, the available literature indicates the following about drug use pattern in Sri Lanka:
• Heroin use, through chasing (or Chinese method) is established in Sri Lanka
• Most drug users coming in contact with treatment providers or the criminal justice system
report heroin use followed by cannabis use
• Drug use is overwhelmingly male phenomena
• Injecting Drug Use does exist in Sri Lanka and its prevalence is much lower as compared
to use of drugs through other routes. There is a possibility that PWUD switch to the taking
drugs through injecting route, for certain reasons, which are not understood well.

However, the following issues remain unanswered through the existing data in Sri Lanka.
• What is the pattern of drug use (in terms of frequency of drug use) by PWUD?
• Do people who use drugs also suffer from drug use disorders (such as harmful use of drugs
or Drug dependence)?
• What are the consequences of drug use?
• What are other risk-behaviours, PWUD and PWID engage in?
• To what extent the profiles of PWUD and PWID, similar or different in Sri Lanka?
• What is the drug use pattern among PWID? How frequently do they inject? What are the
behaviours and practices surrounding injecting drug use? Are there specific adverse
consequences of injecting?

It is important to find the answers to these questions, in order to help formulation of evidence-
based policies and programmes to address the issue of drug demand reduction and harm reduction
in Sri Lanka. Thus, answers to some of these questions were sought from this study.

11
4. METHODOLOGY:

Study Design
In this exploratory, observational, cross-sectional, mixed-method study, a combination of
qualitative and quantitative methods was used for data collection. The quantitative data formed the
main basis of assessment of drug use pattern. The qualitative data was collected to enrich the data
obtained through quantitative methods and provides a descriptive and narrative account of drug
use practices, behaviors and issues surrounding them which would help in informing formulation
of appropriate intervention strategies.

Study locations:
The study was conducted in six districts in Sri Lanka. These districts were selected considering
the available data which indicates that these six districts carry higher risk than that to the other
district in Sri Lanka and are known for a high prevalence of drug use / injecting drug use; namely
Colombo, Gampaha, Kalutara, Galle, Kandy & Rathnapura.

Sample Size - Quantitative Survey:

In spite lack of information on same type of community based cross sectional research in drug use
patterns, according to the WHO Practical Manual on, Sample size determination on health studies,
an estimate of 0.5 was used for the population proportion, since the sample size required is largest
and safe when population proportion is 0.5. The estimate of 50% was therefore used as prevalence
of drug use to calculate the sample size of the present study.

The following formula was used to calculate the sample size.

n = Z2 p (1-p)/ d2
n – Sample size, p – Preliminary estimation of proportion of a characteristic,
Z – Critical value of specified confidence. Usually we need 95% confidence level, and
Z = 1.96 (approximate to 2),
(1-p) = Proportion without the characteristic.
If one work in percentage, (1-p) will be (100- p),
d = Acceptable amount of absolute error.
n = 1.96 2 x 0.5 x0.5 / 0.05 2

12
 n = 3.84 x 0.25/ 0.0025
n = 0.96/ 0.0025
n = 384.
The sample size was 384. Non-participation rate of 5% was added to the sample.
Non-participation = 5%
= 5/100 x 384
= 19
= 403
The ideal sample would have been approximately 400 according to the sample size calculation.
However, considering the available funds, other resources and the purpose of the study (to provide
valid information to the policy and program implementation to drug use in Sri Lanka) it was
decided to go for larger sample than this.
Hence, the sample was decided considering the likely prevalence of drug use. Since credible data
on drug use prevalence does not exist, drug use arrest was taken as a proxy to calculate the sample.
Out of total number of drug arrests, 1% of the arrests in 2016 was considered as sample size,
amounting to 600. Again, for reporting quantitative data on both non-injections and injections it
was decided to go for equal number in both groups: 300 PWUD and 300 PWID. The sample size
was proportional to the population; thus, sample was high from high prevalence districts and low
from low prevalence districts. The Table 1 explains the sample size in each district.

Table 1: Sample size calculation by proportionate to population

District Drug related Sample size based on PWUD study PWID study
arrest for the drug related arrest sample sample
year 2016 (about 1% of the
arrests)
Colombo 35,572 366 183 183
Gampaha 11,185 115 57 58
Kaluthara 2718 28 14 14
Galle 2811 29 15 14
Kandy 3143 32 16 16
Rathnapura 2834 30 15 15
Total 58,263 600 300 300

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Sampling technique
The PWUD and PWID are hidden population in Sri Lanka. Therefore, for reaching out to the study
population (PWUD or PWID) a chain referral (also called snow balling technique) was followed;
this sampling technique was decided considering the nature of target population and operational
aspects of conducting this rapid assessment.

For the purpose, initially seeds of the snowball were selected from each district. Thereafter the
seeds were requested to facilitate inclusion of other respondents from their network into the study.
Those thus, reached and interviewed were asked to help in recruitment of others and so on.

However, as stated earlier, despite the best attempts by the trained interviewers, the desired sample
size could not be reached. Still, the available sample is adequate to make important inferences
about the drug use pattern among PWUD / PWID in Sri Lanka.

Sample Size – Qualitative Interviews:

At every district, at least eight -twelve KIIs were planned to be conducted with informants of a
varied profile (one- two each of: PWUD/PWID; Treatment Provider; Family member / Spouse /
partner of PWUD/PWID; Law enforcement personnel depending on the size of the drug user
population) as listed in the table 1. A total of 48 qualitative interviews were decided.

Table 2: List of planned sites and sample size

Quantitative Qualitative Interviews (KIIs)

Site
Survey
Family member / Law
PWUD / Treatment Spouse / partner of enforcement
PWUD PWID PWID provider PWUD/PWID personnel
Colombo 183 183 2 2 2 2
Gampaha 57 58 2 2 2 2
Kaluthara 14 14 1 1 1 2
Galle 15 14 1 1 1 2
Kandy 16 16 1 1 1 2
Rathnapura 15 15 1 1 1 2
Total 300 300 8 8 8 12
Quantitative Survey: 600
Grand Total
Qualitative Interviews (KIIs): 36

14
Inclusion and Exclusion criteria – Quantitative component

Inclusion Criteria:
• Age: more than 18 years
• History of having taken any psychoactive drug14 in a non-medical context at least once in
preceding one month
or
• History of having injected any psychoactive drug in a non-medical context at least once in
preceding one month
• Willing to participate and provide informed consent

Exclusion criteria
• Not able to communicate
• Currently receiving treatment in a residential treatment setting
• Current residing in a custodial setting (like jail)

Inclusion criteria – Qualitative component

Informants for the qualitative survey were chosen if they were
• Believed to possess the relevant information about the phenomena of drug use in the
locality
• Willing to participate in the interview process

Data Collection:
Entire data collection was conducted by field researchers who work at the NDDCB. They were
recruited on part-time basis and underwent thorough training for data collection on the study
(described under the heading ‘training’).

For finding the potential respondents a variety of methods and approaches were employed:

• Contacting the known PWUD and PWID from the community and asking for their friends

14Use of only Tobacco as a psychoactive drug, not considered.

15
 • Contacting the PWUD and PWID currently receiving treatment services and asking them
to refer their friends
• Contacting key opinion leaders in the community and asking them to refer PWUD / PWID
known to them
• Contacting key opinion leader in the community and asking them to facilitate the
interviews of non-drug-using respondents like Treatment providers, law enforcement
officers and family member(s) of PWUD / PWID

Data collection from PWUD / PWID already inside the institutional settings (Hospitals / treatment
centers / prisons / detention centers was avoided since such data may not reflect the true situation
in the community.

Data Collection - quantitative component

A specifically developed Interviewer Administered questionnaire (IAQ) was administered in a

one-to-one setting, ensuring adequate privacy.

Semi-structured questionnaire for quantitative survey. The quantitative data was collected with a
semi structured questionnaire, developed specifically for the study. This questionnaire is an
adaptation of the multiple questionnaires used in similar studies conducted elsewhere15,16,17,18.

Thus, the questionnaire has been by-and-large, validated and field tested. The questionnaire has
instructions for the data collection team as well and thus serves the purpose of booklet / manual.
This questionnaire was translated into local languages (Sinhalese / Tamil). Then both translated
Sinhala & Tamil IAQ were back translated into English by an independent person to test the
translation validity and the IAQ was pilot tested among drug users of both language who are not
included in the study to prove feasibility in local context.

15
Ambekar et al (2016) Punjab Opioid Dependence Survey. New Delhi: SPYM and NDDTC, AIIMS
16
Ambekar et al (2015). “Pattern of drug use and associated behaviours among female injecting drug users
from northeast India: a multi-centric, cross-sectional, comparative study”, Substance Use and Misuse
17
Ambekar et al (2014), Drug Use Patterns among Clients Receiving Services from Targeted
Interventions for People Who Inject Drugs: Findings from Bihar, Haryana, Jammu and Uttarakhand,
New Delhi: India HIV/AIDS Alliance.
18
Ambekar et al (2014). “Type of opioids injected: Does it matter? A multicentric cross-sectional study of
people who inject drugs”, Drug Alcohol Rev.
16
Data Collection –qualitative component

The qualitative interviews were conducted by the trained field researchers using the Interview
guides especially prepared for the qualitative survey which were also translated into local
languages. The qualitative interviews were audio recorded. Then the audio recorded interviews
were transcribed in Sinhala and translated into English for analysis purpose.

Guides for key informant interview. The qualitative data was collected through Key Informant
Interviews (KIIs) with a variety of key informants (as listed in table 2 above), using specially
prepared interview guides, based on the previous experiences (Annexure 2).15 These guidelines
were in the form of open ended questions which were asked during the interview. Detailed
responses were audio-recorded. The same interviewers were responsible for transcription and
translating the responses into English for which they received training.

Data Analysis:
All the data from the quantitative survey was entered into the data entry formats designed using
MS Excel, by the identified and trained staff of NSACP. Similarly, the interviewers for the
qualitative data collection were tasked with, listening to the audio recording of the interviews, and
making transcripts of it in the English language (as MS Word documents).

All the data so entered (in MS Excel and MS Word) was sent through internet to the team
responsible for analysis.

Analysis of Quantitative Data:

The quantitative data has been analyzed using SPSS (V.21.0), in terms of frequency distribution
and measures of central tendency.

Analysis of Qualitative Data:

Qualitative data is analyzed on the principles and approaches of content analysis. Major themes
emerging from the data have been identified. Finally, triangulation of data collected from

17
quantitative and qualitative data has been conducted to derive conclusion and to formulate
recommendations.

Implementation arrangements:
The source of funding for this research was the Global Fund to Fight AIDS TB and Malaria
(GFATM), which has been funding various high impact HIV projects since past many years in Sri
Lanka. .

The scientific and technical aspects of the study were led by a team of researchers from Alliance
Regional Technical Support Hub, New Delhi, India. The ground-level implementation of the
survey was governed and managed by the NSACP and NDDCB. Responsibilities and tasks of both
teams (Technical and Logistics) are listed in the table 3.

Table 3: Responsibilities and tasks of both teams.

Scientific and Technical team (New Implementation and Logistic team (Colombo)
Delhi)
1. Drafting the protocol and 1. Provide feedback and inputs to the protocol
methodology and methodology
2. Developing the data collection 2. Translation of data collection tools
tools 3. Applying and obtaining the Institute Ethics
3. Conducting the training for data Clearance
collection and data entry 4. Identifying / nominating the data collection
4. Monitoring and supporting the team
data collection team during the 5. Organizing the logistics of training and
initiation subsequent data collection
5. Data Analysis 6. Data Entry and transmission of data for
6. Drafting the report analysis
7. Presenting the report 7. Inputs to the draft report and dissemination of
the final report

18
 Figure. Flow-Chart depicting implementation arrangements

Funding Agency (GFATM)

Scientific and Technical Team (Alliance

India Hub New Delhi, NSACP)

Implementation & logistic team

(Colombo) -NSACP

Field research teams at data collection

sites -NDDCB & NSACP

Ethical issues:
• Informed consent was obtained from respondents for participating in this study and the
name and personal identity related questions were not asked to maintain the
confidentiality.
• Data collection took place in locations of respondents’ choice to ensure privacy and
confidentiality.
• Decision to participate was purely voluntary and had no bearing on receipt of services
from the service provider agencies.
• It was ensured that the Information collected during the study was not utilized to penalize
the respondents in any way, even if the information pertains to an act which may be
construed as illegal.
• All the field researchers signed a confidentiality agreement
• Ethical clearance was obtained from ethics committee / review board at faculty of
Medicine, University of Colombo, Sri Lanka.

19
 Training:
A five -day intensive training comprised of 3 days class room and 2 days field was conducted for
the team of field researchers works at the NDDCB in Colombo. Lead researchers from the
scientific and technical team were the facilitators for the training. This training provided
orientation on
(a) Objective of this study,
(b) Methodology
(c) The tools for data collection including interview techniques (incorporating ethical aspects),
(d) Transcription of audio recording to the text format and
(e) Data entry, including the translation of audio scripts from local language to English.

The detailed training involved hands-on experience of using the data collection tools with the aid
of role-play techniques. In addition to this hand on field experience was provided during the field
training.

Thus, this report includes data from quantitative assessment, qualitative assessments and a
triangulation of qualitative and quantitative data.

5. RESULTS
A total of 283 PWUDs and 174 PWID respondents were reached during the data collection in all
the districts through the snow balling sampling.
Results of the study are presented under the following headings:

5.1 Reliability of data collected, response rate, and coverage,

5.2 Socio Demographic profile of respondents,

5.3 Drug use profile of respondents,

5.4 Consequences of drug use of respondents,

5.5 Sexual Practices of respondents

5.6 Legal problems among respondents

20
5.7 Treatment seeking and access

5.8 Results of KII

5.1. Reliability of data collected, response rate, and coverage

Measures were taken to ensure the quality of data by adhering to each step described under
methodology (section 3). Test – retest reliability was checked by administering Sinhala and Tamil
IAQs to eight Sinhala speaking and seven Tamil speaking drug users who complied with the
inclusion criteria. The IAQs were re- administered to the same people after one week for
repeatability. The level of agreement between the test and re-test for selected variables were very
closer to Kappa value 1.00 (means test- retest reliability is good).

Similarly, overall agreement with the Principal Investigator (PI) & data collectors were tested and
found to be in agreement with Kappa value closer to 1.00 for common socio-demographic, drug
use variables. However, some variation was seen in the information collected on certain sensitive
questions regarding sexual practices.

The PI randomly checked 5% (n=30) of filled IAQs for completeness and cross checked with the
study sample. This procedure also yielded high agreement.

Respondents and Non-respondents

Of the 600-sample decided (300 each PWUD &PWID), 283 PWUD were successfully interviewed
giving rise to 95% sample achievement and 174 PWID (58% sample achievement). This rate
cannot be considered non-response. The main reason that can be given for this low rate than that
of the decided sample is sample selection procedure. The study would have been easily done with
400 drug users taking into consideration of true prevalence of PWUD 99% and PWID 1% in Sri
Lanka. The prime objective of the study would have been not achieved. Although the sample size
of PWID is 58% of the sample decided to recruit, according to the true prevalence of PWID in Sri
Lanka this is the maximum number that could be reached (174) due to low prevalence of injection
drug use. Among the PWUD 4 people did not complete the IAQ, therefore these uncompleted
investigations were not included in the analysis. The other three did not want to participate due to
lack of time.

21
 5.2. Socio Demographic profile of respondents
The data was analyzed for a total of 283 PWUDs and 174 PWIDs. Out of these, while there were
11 females in PWUD group, there was only one female in the PWID group.

On many socio-demographic parameters, PWUD and PWID groups were strikingly similar. The
age of respondents was almost same in both the groups, [mean = 38.7 (SD 11.3); median = 37
years in PWUD] [mean = 39.4 (SD 9.2); median = 39 years in PWID]. Such similarity was evident
on other demographic parameters too, as can be seen in the adjoining figures. However, there were
some minor differences; as compared to PWUD, a larger proportion of PWID were separated or
divorced, worked as transport workers or as self-employed, and were living in a joint family.

Figure 1: Marital Status, in %

Widower 1.1
0.6

Separated 6.7
10.4

Divorced 1.8
8.1

Staying together without getting married 2.8

8.1

Never Married 43.8

38.7

Married 43.8
34.1

0 5 10 15 20 25 30 35 40 45

PWUD (n=283) PWID (n=174)

Figure 2: Occupational Status, in %

Other 6.5
1.7

Unskilled worker / laborer 47.3

37.9

Skilled worker 16.6

11.5

Transport worker 10.2

21.3

Business/self-employed 18.4
26.4

Professional / Administrator / Clerical work 1.1

1.1

0 5 10 15 20 25 30 35 40 45 50

PWUD (n=283) PWID (n=174)

22
 Figure 3: Educational Status, in %

0.7
Graduate 0.6
8.1
Higher secondary 7.5
44.2
High school 46
36.7
Primary 41.4
4.6
Just literate 4.6
5.7
Illiterate 0

0 5 10 15 20 25 30 35 40 45 50

PWUD (n=283) PWID (n=174)

Figure 4: Employment Status, in %

8.2
PWUD (n=283)
91.9

2.3
PWID (n=174)
97.7

0 10 20 30 40 50 60 70 80 90 100

Currently unemployed Currently employed

23
 Figure 5: Living arrangments, in %

7.6
Not living with family 8.4

60.1
Nuclear family 47.7

32.5
Joint family 43.7

0 10 20 30 40 50 60 70

PWUD (n=283) PWID (n=174)

Overall however, it is evident that a sizable proportion of drug users in Sri Lanka (whether PWUD
or PWID) are educated, employed, and living with their families. The median family income was
exactly the same, (Rs. 60000 per months) in both the groups.

5.3. Drug use profile of respondents

Legal substances

Almost all the respondents in both the groups were poly substance users. Prevalence of past one-
year use of legal substances – tobacco and alcohol – was high, and almost same in both the groups.

Figure 6: Pattern of Alcohol and Tobacco use, in %

Alcohol-Past 1 months 28.9

12.7

Alcohol-past 1 year 60.6

45.4

Alcohol-ever 88.2
90.2

Tobacco-Past 1 months 98.6

98.3

Tobacco-past 1 year 98.9

98.8

Tobacco-ever 99.3
100

0 10 20 30 40 50 60 70 80 90 100

PWUD (n=283) PWID (n=174)

24
Illegal substances

Among opioid group of drugs, it was interesting to note that even among the PWID a sizable
proportion continue to use opioids drugs through non-injecting route. The commonest opioid drug
used by PWUD and PWID in Sri Lanka appears to be heroin, followed by oral pharmaceutical
opioids (obtained illegally without prescriptions). A negligible proportion use oral opium.

Figure 7: Pattern of Non-injecting Opioid Use, in %

Opium-Past 1 months 1.2

0
Opium-past 1 year 2.4
1.7
Opium-ever 12.7
31.4
Other Oral Pharma Opioids-Past 1 months 12.5
6.9
Other Oral Pharma Opioids-past 1 year 20.6
17.3
Other Oral Pharma Opioids-ever 33.1
53.8
Heroin chasing/smoking-Past 1 months 92.6
20.7
Heroin chasing/smoking-past 1 year 93.6
54
Heroin chasing/smoking-ever 94.7
93.1

0 10 20 30 40 50 60 70 80 90 100

PWUD (n=283) PWID (n=174)

Among other drugs, cannabis use was reported by the largest proportion of respondents in both the
groups, followed by oral pharmaceutical sedatives. A small proportion also reported use of
cocaine. It was also interesting to see that ‘ever’ use of cannabis and sedatives was reported by
more PWID as compared to PWUD. However, the proportion reporting current drug use was
lower, indicating that probably, with the switch to injecting route of drug intake, usage of other
drugs goes down.

25
 Figure 8: Pattern of other drug use, in %

Cocaine INHALATION-Past 1 months 2.8

1.2
Cocaine INHALATION-past 1 year 4.4
4.1
Cocaine INHALATION-ever 10.5 24.6
Oral Pharmaceutical Sedatives-Past 1 months 18.3
16.3
Oral Pharmaceutical Sedatives-past 1 year 26.3
26.7
Oral Pharmaceutical Sedatives-ever 35.9 51.7
Cannabis-Past 1 months 42 56.1
Cannabis-past 1 year 67.7
65.5
Cannabis-ever 79.3 87.9

0 10 20 30 40 50 60 70 80 90

PWUD (n=283) PWID (n=174)

Among PWID, most common drug injected is heroin. A small proportion report injecting other
opioids, while a miniscule have reported injecting cocaine, ever. Currently no one was injecting
cocaine.

Figure 9: Pattern of injecting drug use among PWID (n=174), in %

Cocaine -past 1 year 0

Cocaine -ever 6.4
SEDATIVES-Past 1 months 1.2
SEDATIVES-past 1 year 2.9
SEDATIVES-ever 8.1
Opioid Pain Killer -Past 1 months 18.5
Opioid Pain Killer -past 1 year 22.5
Opioid Pain Killer -ever 30.6
Heroin -Past 1 months 86.7
Heroin -past 1 year 91.3
Heroin -ever 93.6

0 10 20 30 40 50 60 70 80 90 100

Thus, looking at figure 9 and figure 7, it is evident that some PWID, continue to use heroin through
chasing too, besides injecting it. A large majority of PWID however, appear to use heroin only
through injecting route. Besides these drugs, a miniscule proportion (PWUD – 6.9%; PWID –
8.8%) also reported using amphetamines, ever.

26
Important findings emerged from the data on WHO – ASSIST. As stated earlier, this tool provides
score taking into account the recent pattern of drug use. Scores more than 26 indicate presence of
‘dependence’ or addiction to that particular drug. The table below shows the mean (SD) scores on
WHO ASSIST for various drugs. In majority of respondents (63%), for opioids the WHO ASSIST
scores are more than 26 indicating presence of Opioid dependence. In other words, most people
who use / inject drugs in Sri Lanka use opioid drugs in a dependent pattern. This is further
substantiated by the fact that among PWID and PWUD both, Opioids was the category for which
the majority of respondents has ASSIST scores, >26. Proportion of respondents with ASSIST
Score >26 for other substances were relatively small.

Number of PWID Median ASSIST score % of respondents with

Substance
using scores >26
Tobacco 174 25.0 43
Alcohol 154 3.0
Cannabis 157 12.0 16
Opioids 162 30.0 63.8
Sedatives 85 3.0 2.9
Cocaine 33 3.0 0
ATS 174 0.0 0
inhalants 1 3.0 0
Hallucinogen 1 17.0 0

Number of PWUD Median ASSIST score % of respondents with

Substance
using scores >26
Tobacco 281 25.0 48.1
Alcohol 240 8.0
Cannabis 228 21.0 24.4
Opioids 261 32.0 73.1
Sedatives 105 10.0 4.2
Cocaine 31 6.0 0
ATS 283 0.0 0.7
inhalants 1 10.0 0
Hallucinogen 2 15.5 0.4

27
Onset of drug use

Data on age of onset of drug use showed that in general, use of legal substances started earlier in
late adolescence, followed by illicit drugs in young adulthood. Indeed, among PWID, use of drugs
by non-injecting route started much earlier than injecting drugs.

Figure 10: Median Age of onset - PWID

27 28 28.5
30 24.5 25.5
24
25 20
19 19 19 19
20 16 17

15
10
5
0

Figure 11: Median Age of onset - PWUD

25 21 21.5 22
20 20
18 18
20 16 16
15
10
5
0

Among reasons behind starting drug use, the most common reason cited by majority of
respondents in both the groups were “curiosity” and “peer pressure”. Other reasons were cited by

28
a small proportion of respondents. It should be noted that respondents had the option to report
more than one reason for staring drug use. Among PWID, when asked about the situation
regarding their first injection, a majority (78%) reported that “A friend / spouse / sex partner /
client injected them”. Only 22% reported that they were alone at the time of first instance of
injecting.

Figure 12: Reason why you Started drugs, in %

(multiple options possible)
86
90 PWID (n=174) PWUD (n=283)
74.7 74
80
70 58.1
60
50
40 28.5
30 19.5
20 10.711.1 9
6.5 5.4
10 0.6 0 1.6
0
Peer Curiosity To seek As a Spouse / To improve To improve
pressure pleasure treatment partner sex work / study
Pressure performance performance

Injecting Practices

Among PWID, an overwhelming majority (83%) reported injecting ‘daily’ among whom, about
64% reported injecting ‘2-3 times per day’. Almost all of them (94%) reported injecting ‘heroin
with or without mixing it with other sedatives’. The common methods used for mixing were
“Mixing in ampoules / vials and then loading in syringes with needle” – 45% and “Mixing in a
separate container with or without ‘cooking’” – 44%. There was variation in terms of size of
syringes used for injecting. About 28% reported using a 1 ml Syringe, and the same proportion
reported preferring a 10-ml syringe. Rest reported using syringes of other sizes with varying
proportions.

A high proportion of PWID reported sharing their injecting equipment. As many as 85% had
shared their injecting equipment ‘ever’ while, 64% shared their needles in the last one month. It
was alarming to find that about 68% of PWID shared their injecting equipment in the first instance
of injecting, while 12% reported that they shared for the first time within one month of starting to
inject drugs. Almost half of the PWID report injecting usually in groups, currently. Among reasons

29
for sharing on the most recent occasion of sharing, the most common reason was “No new needle
/ syringe was available” – 46% followed by “We did not see the need to use a new needle /syringe”
– 39%. About 11% reported that they shared since there was “mutual trust between people who
shared”.

There were other alarming behaviours reported by PWID. Almost half (51%) of PWID reported
throwing their used needles and syringes, ‘anywhere’, while 52% also reported throwing their used
needles and syringes in the ‘garbage bins’. When enquired about the sites on body where they have
injected ‘ever’, while everyone reported injecting on hands, about 23% also reported injecting on
legs. As many as 43% reported experiencing ‘abscess’ at their injection sites, ‘ever’, while 38%
reported experiencing ‘blocked veins’ as a consequence of injecting.

A variety of sources of procuring needles and syringes were reported. Almost everyone (93%)
reported procuring them from pharmacy or peddlers, others procured them from their friends. In
addition, 30% reported borrowing needles and syringes from their friends (with about half of them
borrowing USED syringes and needles).

A majority of PWUD and PWID alike, procure their drugs through black market (i.e. peddlers).
Some also reported ‘friends’ as the source of drugs while a small minority reported ‘pharmacy’.

Figure 13: Source(s) of procurement of drugs, in %

(multiple options possible)

92.4 93.3
100 86
73.5
80

60

40
11.5 12.8
20

0
Black market Friend Pharmacy
PWID (n=174) PWUD (n=283)

A variety of sources of money for expenditure on drugs were reported. Almost all the respondents
spent their own legal earnings on drugs and a majority also reported that they borrowed money

30
from family / others. A sizable proportion also reported resorting to illegal means to fund their
drug use.

Figure 14: Source of expenditure for drugs, in %

(multiple options possible)

16.3
Illegal means 32

58.5
Borrowing from Others 72.7

56.7
Borrowing from family 72.1

93.3
Own legal income 98.3

0 10 20 30 40 50 60 70 80 90 100

PWUD (n=283) PWID (n=174)

5.4. Consequences of drug use of respondents

A wide variety of possible consequences of drug use were enquired into. A majority of PWUD
and PWID reported suffering from physical consequences of drug use like, weakness and weight
loss. Around 12% of respondents in both the groups also reported experiencing overdose in their
lives. However, among those who reported experiencing overdose, most common help they
received was from their peers. Notably, only 3 PWID and 2 PWUD, who experienced overdose,
received specific medical treatment for drug overdose.

31
 Figure 15: Consequences of drug use - Physical, in %
(multiple options possible)

78.6
70.9 74.1 71.5
80
67.1 65.9
70 63.2
60 52.5
50
40
30
15.5
20 10.8
10
0
Weight loss Weakness Bodyaches Respiratory Injury

PWID (n=174) PWUD (n=283)

Similar to physical consequences a majority of respondents also reported suffering from

psychological consequences of drug use. In addition a large majority also reported suffering from
various social consequences of their drug use, indicating the stigma towards drug use and the
discrimination faced by PWUD by their immediate families and communities.

Figure 16: Consequences of drug use - Psychological, in %

(multiple options possible)

80 70.7 68.4
70 60.1 61.7
57.5
60 48.9
44.3
50
40
26.7
30
20
10
0
Stress Depression Abnormal behaviour Anxiety
PWID (n=174) PWUD (n=283)

32
 Figure 17: Consequences of drug use - Social, in %
(multiple options possible)

63
Loss of Social reputation 69
12.4
Homelessness 34.9
35.8
Loss of Family support 59.8
27
Arguments with neighbours 31.6
62.1
Fights within the family 61.5

0 10 20 30 40 50 60 70

PWUD (n=283) PWID (n=174)

In-spite of majority of respondents reporting themselves to be employed, most of them also

reported frequent problems with holding their jobs and poor work performance. This is also evident
from the data on financial consequences where most respondents found it difficult to meet their
expenses and were dependent on others for their living. A sizable minority also reported resorting
to illegal activities.

Figure 18: Consequences of drug use - Financial, in %

(multiple options possible)

20.2
Resorting to lllegal activities 29.9
58.7
Dependence on family 69.5
68.6
Debt 78.2
75.5
Difficult to meet expenditure on living expenses 85.1
79.1
Difficult to meet expenditure on drugs 82.2

0 10 20 30 40 50 60 70 80 90

PWUD (n=283) PWID (n=174)

33
 Figure 19: Consequences of drug use - Occupational, in %
(multiple options possible)

54.4
Decreased work Performance 68.2

31.9
Loss of job 43.4

39
Frequent job change 47.4

48.2
Irregular in work 46.6

0 10 20 30 40 50 60 70

PWUD (n=283) PWID (n=174)

5.5. Sexual Practices of respondents

It was not surprising to find that most respondents (being in their 30s) were sexually experienced.
However, besides their regular partners, a sizable proportion also reported having sex with casual
and commercial sex partners. More concerning finding was that a significant number of
respondents reported having unprotected sex with causal as well as commercial partners. The table
below shows the number of respondents who reported having sex with different types of partners
in the last 12 months while, the figure shows the proportion of respondents reporting unprotected
sex with different types of partners. About 21% of PWID and 14% of PWUD also reported
symptoms suggestive of sexually transmitted infections.

PWID (n=174) PWUD (n=283)

Frequency Percent Frequency Percent
Ever had Sexual intercourse 162 93.6 251 89.0
In last 12 months, Sex with
84 52.2 141 58.3
REGULAR partner
In last 12 months, Sex with CASUAL
62 43.1 93 38.1
partner
In last 12 months, Sex with
27 19.4 56 24.9
COMMERCIAL partner

34
 Figure 20: Unprotected sex, among those who experienced sex with different types of
partners, in %
PWID PWUD
68 68
70 58 60
60 52

50 38
40
30
20
10
0
With REGULAR partner With CASUAL partner With COMMERCIAL
partner

5.6. Legal problems among respondents

Among legal problems, almost everyone had an encounter with police and law enforcement. The
figure below shows the proportion of PWUD and PWID who have experienced a brush with the
law enforcement and criminal justice system.

Figure 21: Experiences with criminal justice system, in %

(multiple options possible)

78
Been to Jail 84.5

89.4
Been to police lock up 87.4

38.3
Beaten by police 53.4

91.1
Apprehended by Police 90.8

0 10 20 30 40 50 60 70 80 90 100

PWUD (n=283) PWID (n=174)

5.7. Treatment seeking and access

Interestingly, while a large majority has had an encounter with the criminal justice system, a much
smaller proportion has received treatment services. Surprisingly while a majority report having

35
received ‘counselling’ on drug use and HIV, despite being drug dependent less than half have
received medical treatment for drug addiction. Access to HIV prevention interventions like needles
/ syringes and condoms is negligible.

Figure 22: Recieving treatment and interventions, in %

(multiple options possible)

HIV Testing / treatment 41

55.2
Condoms 18.1
8.6
Needle Syringe 0
4
Counselling on HIV 72.9
76.4
Medicines for treatment of addiction 41.5
42.5
Residential treatment for drug use 45.1
49.4
Counselling on drug use 79.1
85.1

0 10 20 30 40 50 60 70 80 90

PWUD (n=283) PWID (n=174)

36
 5.8. Results of KII
In order to supplement the quantitative data collected directly from PWUD/PWID, a qualitative
survey was conducted with certain categories of Key Informants from the same localities. These
qualitative data were collected by the trained interviewers, using especially prepared Interview
Guides, were translated and transcribed. This data is available from:

1. Spouses of PWUD/PWID (n=7)

2. PWUD / PWID themselves (n=7)
3. Law Enforcement Officials (n=8)
4. Service Providers (n=6)

Major insights obtained from the qualitative data (organized as per the major themes explored):

• Drug use pattern by the PWUD/PWID: Data from the key informants also appeared to
support the data obtained through quantitative survey that most PWUD in Sri Lanka use a
variety of substances but the predominant among them is Heroin. Most of them use heroin
by inhalational route ‘Chinese method’ but injecting of heroin intake does exist. Most
respondents – spouses, service providers, law enforcement personnel or PWUD themselves
– reported being aware of existence of Injecting phenomena in Sri Lanka, including in their
vicinity. It also appears that there is widespread realization about injecting method being
more severe and harmful route of drug use, as compared to the smoking or Chinese method.
Existence of risky behaviours among PWID of sharing injecting equipment was also
reported.

• Consequences of drug use: Significant socio-occupational dysfunction is reported

because of drug use in Sri Lanka. The family appears to be adversely affected. Most
spouses reported that the PWUD are not able to take the household responsibilities. While
domestic violence was not reported, the neglect of wife and children certainly came across
as a consequence of drug use. Sexual relations between PWUD and their wives ranged
from routine unprotected sex to no conjugal relationship. Instances of PWUD having
extramarital affairs were also reported. In one instance it was reported that daughters of a
PWUD had to turn to prostitution owing to the poor economic condition of the family.
Occupational and economic consequences of drug use came across as prominent adverse

37
 consequence of drug use. Indulgence in criminal activities by PWUD to support their drug
use was also widely reported by the law enforcement officials as well as by the spouses.

• Help for drug use problems: It was evident that family members had tried getting help
for PWUD for quitting drug use but were not successful in the absence of availability of
effective treatment. Relapse of drug use, after quitting for some time, appears to be a norm.
The treatment facilities appear to rely largely upon ‘counselling’ instead of evidence-based
medical treatment. In the words of a doctor ”we don’t give medicine to heroin addicts. We
give medicine to people who are addicted to alcohol and cigarettes. If we give medicine
treatment to heroin consumers they get addicted to that”. This statement highlights poor
understating of addiction and its treatment. Most PWUD on the other hand, expressed the
need for better and more effective treatment for people like them. In the words of a person
who uses drugs, “Programmes like "Mathata Thitha" are not practical……..It is good to
provide tablets based treatment services in rehabilitation centres.” Most service providers
expressed the need to make their programs more effective by enhancing the numbers and
quality of treatment services and providing training to the service providers.
• Law enforcement response: It appears to be a norm for PWUD to be arrested and put into
jails. Most of the times the charge is of drug possession (for personal consumption), but
committing petty crimes (for supporting their drug use) is also reported. However, it was
evident from the Key Informant Interviews that putting PWUD in jail was not an effective
intervention at all. All the PWUD interviewed who had been to jail, relapsed to using drugs
again after their jail terms. In the words of a law enforcement official “Most of them are
jailed for possession and only few are convicted for selling drugs.” Other officials reported
that “…most of the arrested people only have about 1 or 2 grams of heroin on them” or
“major challenge is arresting drug dealers. Arresting drug consumers is not a challenge”.
Thus, it appears that the law enforcement response is heavily skewed towards arresting the
people who USE drugs. However even the law enforcers seem to concede that this
approach is not likely to be effective. As per a law enforcement officer, “Some people are
repeated offenders and have been jailed for the same offence more than a half a dozen
times. But if they are still committing the same offence then something is wrong”.

38
• Stigma and Discrimination: Significant amount of stigma and discrimination is faced by
PWUD in Sri Lanka. This begins from the family and involves the neighborhood and the
entire society. PWUD reported their own families “treating them like thieves and not
looking after them”. Spouses of PWUD reported facing embarrassment in the
neighborhood. Wife of a person who uses drugs reported that she “doesn’t like to attend
any wedding or funeral because of her husband’s drug use”. Even children of PWUD were
reported to face discrimination in the society on account of their father’s drug use.
• Attitude towards harm reduction: There appears to be a universal discomfort with the
idea of harm reduction (with the concept of Needle Syringe programs as a proxy) in Sri
Lanka. All the categories of respondents were aware of the existence of the phenomena of
injecting drug use, as well as the practice of sharing needles and syringes (with the
attendant risks) in Sri Lanka. Yet, almost everyone interviewed appeared to harbor the
misconception that making needles and syringes available to PWID amounts to
encouragement of drug use. As per a doctor, “The target (of needle syringe programs) is
harm reduction and preventing the spread of HIV. But if you supply them with equipment
their drug consumption would only increase….. If the government is supplying injecting
equipment it would give heroin legality. Why should we promote something illegal?” One
of the law enforcement officers expressed his misconception that “Supplying injection
would increase the number of drug users and also the number of crimes”! Yet the need of
such an intervention is underscored by the account of a Person who has used drugs through
injections in the past, “I also shared needles and syringes with my friends and we three
friends used one same syringe. To legally supply injecting equipment to PWID is not
possible in Sri Lanka because the government will not supply injecting equipment for free,
we have to buy them. We cannot buy them from shops which are nearby”. This clearly
highlights the risk of continued practices of sharing injection equipment among PWID in
Sri Lanka, owing to the poor access to needles and syringes. However, it is evident that
any kind of program and policy reforms will need to tackle the widespread misconceptions
about needle syringe programs in Sri Lanka.

39
6. DISCUSSION
In this cross-sectional rapid assessment study, the demographic profile, drug use practices, other
risky behaviours and consequences of drug use were assessed among the PWUD and PWID. Since
the methodology was based upon the principles of rapid assessment, estimating the size of PWUD
/ PWID population was not the focus. Instead the study aimed at a quick assessment of risks so as
to guide developing and implementing evidence-informed interventions to reduce that risk.
Besides quantitative data, key informant interviews provided useful qualitative information to
enrich the information.

That heroin use is established in Sri Lanka has been a widely known phenomena for a long time.
However, very few studies have explored the pattern of drug use in Sri Lanka in such details. This
study provides important insights about pattern of drug use among PWUD and PWID in Sri Lanka
(discussed later), on the basis of which pragmatic and evidence-informed intervention programs
can be formulated.

Interventions to address drug use

Worldwide, approaches and interventions to address the drug problems can be loosely categorized
into19:

• Supply Reduction
• Demand Reduction
• Harm Reduction

Supply reduction strategies refer to those which seek to control and disrupt the availability of
drugs. For certain psychoactive substances (like tobacco and alcohol) this entails legal, yet strictly
regulated availability. In case of certain other substances (such as those categorized as Narcotic or
Psychotropic) the controls are much more stringent. In fact most countries, following the three UN
Drug Conventions, have totally banned the use of these substances (accept for medical and
scientific purpose). Drug supply control heavily depends upon deployment of drug law
enforcement machinery for the purpose of intelligence gathering, interdiction, arrests and other
similar activities involving the criminal justice system. The illegal nature of drugs has made them

19
International Narcotics Control Board (2014): Integration of supply and demand reduction strategies:
moving beyond a balanced approach, INCB Annual Report 2014
40
very profitable commodity to trade and traffic in and hence, violence associated with drug trade is
well-known phenomena. Some countries have been engaged in ‘war on drugs’ which takes a heavy
economic toll on national resources, and consequently this War on Drugs has been declared as a
failure20.

However, the failure of this supply control oriented approach to address drug problems is
increasingly being recognized the world over and UNODC has highlighted the unintended side
effects of drug control framework21. Such approaches have led to ‘Policy displacement’ (using
precious national resources for drug law enforcement at the cost of other human welfare activities);
‘Geographical displacement’ (stringent control in one area leads to emergence of problems in other
areas) and ‘Substance displacement’ (control on one drug leads to increased usage of other drug).
The most severe consequence however, is ‘marginalization of people who use drugs’. A criminal-
justice led approach to drug problems, forces affected people away from the social mainstream,
enhances stigma and makes it difficult to access health and welfare services. Indeed, research has
proved that criminalization of drug use is a major factor behind HIV epidemic among PWID22.

Demand reduction approaches entail strategies for prevention of onset of drug use (usually among
youth) and providing treatment for people affected by drug use disorders. Contrary to the supply
reduction strategies – which are employed by law enforcement and criminal justice systems – the
demand reduction strategies are better led by the health and welfare sectors. With the demand
reduction approaches, the health and welfare of the society become the predominant concerns
which are the cornerstones on which the UN Drug Conventions are based. 23 As far as treatment
strategies for drug use disorders are concerned, they need to be evidence-based and should be
sensitive towards the rights of affected populations.24 Provision of accessible, affordable and
effective treatment of drug dependence is regarded as an element of right to health under the
international treaties and conventions.25 Fortunately, medical science has made significant

20
The Global Commission on Drug Policy (2011). The War on Drugs
21
UNODC (2008): A Century Of International Drug Control,
22
DeBeck, Kora et al. (2017). HIV and the criminalisation of drug use among people who inject drugs: a
systematic review. The Lancet HIV , Volume 4 , Issue 8 , e357 - e374
23
International Narcotics Control Board (2015) “The health and welfare of mankind: challenges and
opportunities for the international control of drugs”. INCB Annual Report 2015
24
UNODC and WHO (2008). Principles of Drug Dependence Treatment
25
Csete J and R Pearshouse (2007). Dependent on Rights: Assessing Treatment of Drug Dependence from
a Human Rights Perspective. Toronto: Canadian HIV/AIDS Legal Network.
41
progress in last few decades and effective treatment strategies for drug dependence are now
available. For Opioid use disorders (such as heroin dependence), the strongest evidence base is for
agonist maintenance treatment or ‘Opioid Substitution Treatment (OST).26

Harm reduction is a relatively newer concept which simply refers to those ‘programs and policies
which are aimed at reducing the harmful consequences of drug use without reducing drug use per
se’.27 Harm reduction approaches are regarded as more pragmatic and hence more effective in
preventing the adverse consequences of drug use among individuals and societies. Most
commonly, this philosophy has been employed to reduce the risk of HIV and other blood borne
infections among PWID. A comprehensive package of interventions has been recommended which
– in combination – has been proven to be effective in reducing HIV among PWID and the wider
communities. Notably, this package of interventions includes (among others), Needle Syringe
Programs, as well as OST.28 Contrary to the misconceptions, provision of needles and syringes for
PWID does NOT result in increased drug use. In fact, provision of such services has been found
to adoption of safer behaviors and bringing PWID closer to the health care services.29 Such
strategies and intervention have been endorsed by various UN agencies 30 and are being widely
employed globally, and very few progressive countries deny these services to their citizens. 31

Summary of results of this study

Despite best attempts at data collection, the required sample size for the PWID could not be
achieved. Low prevalence of Injecting Drug Use in Sri Lanka is well known. Among the published
research from Sri Lanka cited earlier (in the Review of Literature), in the DAMS study, just about
1% of 2355 treatment seekers were PWID. Report of the Most At Risk populations (MARP)
reported the number of PWID to be ranging between 218 and 423 on a given day. The largest of
the published reports did provide data on 721 PWID.

26
WHO (2009). Guidelines for Psychosocially Assisted Pharmacological Treatment of Opioid Dependence
27
Single E. (1995). Defining harm reduction. Drug Alcohol Rev. 1995;14(3):287-90
28
WHO, UNODC, UNAIDS (2012). WHO, UNODC, UNAIDS technical guide for countries to set targets
for universal access to HIV prevention, treatment and care for injecting drug users.
29
WHO (2004). Effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among
injecting drug users
30
United Nations General Assembly (2011): Political Declaration on HIV/AIDS: Intensifying our Efforts
to Eliminate HIV/AIDS (General Assembly resolution 65/277)
31
Harm Reduction International (2016). Global State of Harm Reduction Report - 2016
42
However none of the earlier reports could describe the details of pattern of drug use and other
behaviours of PWID. More importantly there has been no opportunity to compare the PWUD and
PWID on various parameters. Thus, this study provides valuable data and insights in this regard.

Demographically, PWUD and PWID were very similar. Both groups were in their late 30s.
Majority were married. However a larger proportion of PWID tended to report separation or
divorce after their marriage. An overwhelmingly large proportion of PWID and PWUD are
currently employed (largely as unskilled workers) and more than 90% were currently living with
their families. This has important implications for interventions, since it shows that a large
proportion of PWUD / PWID in Sri Lanka have a reasonable degree of social stability. This was
also reflected in the responses during the KII.

A large majority of the respondents were using multiple substances. While almost everyone was a
tobacco smoker, about 60% of PWUD and 45% of PWID reported current alcohol use as well.
Almost two-thirds in both the groups were using cannabis too. A much smaller proportion reported
using pharmaceutical sedatives (about one-fourth in both groups) or cocaine (just about 4% in both
groups).

The predominant illicit drug used is Sri Lanka is heroin. Almost all PWUD reported using heroin
(through Chinese method) currently. Interestingly among PWID too (where almost all inject
heroin), a sizable proportion (about 54%), report using heroin through Chinese method! Thus, it is
clear that it is the use of heroin which should be the focus of interventions; some people may use
heroin through both – inhalational and injecting routes. Data on onset of drug use further validates
this point; while average age of onset of heroin smoking is 19 years, it is 28 years for heroin
injecting. In other words, people spend about 9 years as ‘PWUD’ before switching to the category
of ‘PWID’. Similar trends in the pattern of drug use have been reported from India as well, where
a majority of PWID began their drug use with the non-injecting route.32 Unfortunately, this
window of 9 years is not being utilized to provide them appropriate interventions, to prevent their
switch to the injecting route. Indeed, about 78% reported that during their first instance of injecting
they were injected by someone else (who was a PWID). This indicates that PWUD remain at risk

32
Ambekar A (2012), Association of Drug Use Pattern with vulnerability and service uptake among
IDUs, New Delhi: United Nations Office on Drugs and Crime (UNODC) Regional Office for South Asia,
and National AIDS Control Organization
43
of transition to injecting route in Sri Lanka, in the absence of effective interventions. If PWID are
provided appropriate interventions today, it would result in reduction of risk of other PWUD
switching to the injecting route, under their influence.

A very important piece of data (not available from the available studies from Sri Lanka, so far) is
the prevalence of drug use disorders among PWUD / PWID. A majority of PWUD (73%) and
PWID (64%) have WHO ASSIST scores in the range suggesting that they are suffering from
Opioid Dependence. Contrast this with Cannabis; while more than 90% PWUD / PWID use
cannabis, only about 16% - 24% have ASSIST scores suggesting cannabis dependence. This
further underscores the need of effective interventions for their opioid (heroin) dependence.

Indication of presence of heroin dependence also comes from the data on frequency of injecting.
Majority of PWID inject daily, about 3-4 times a day. Such high frequency of injecting heroin is a
feature of heroin dependence which, owing to painful withdrawal symptoms, compels the
individual to keep injecting frequently.

A major issue which should be of concern for Sri Lanka, is the prevalence of risky injecting
practices. About two-third of PWID reported sharing their injecting equipment in last one month.
It was also alarming to note that as many as 68% of PWID had shared their injection equipment at
the first instance of injecting (it may be recalled that 78% were given their first injection by another
PWID). Non availability of injecting equipment (46%) as well as poor knowledge about safe
injecting practices (39%) both contribute to such high prevalence of sharing practices among
PWID in Sri Lanka. Indeed, this limited access to clean injecting equipment is a serious concern.
While 93% of PWID procure their injection equipment from drug peddlers or pharmacies about
30% also borrow used syringes and needles from their friends.

Practices and behaviours of PWID not only put them and their peers at risk but the larger
community as well. In the absence of access to safe-disposal systems, more than half of PWID
dispose their used injecting equipment indiscriminately, putting others in the community at the
risk of accidental infection. Unsafe injecting practices are also evident from the fact that as many
as 43% of PWID reported having suffered from injection site abscess.

In the absence of access to effective interventions, and considering that majority of PWUD / PWID
are heroin dependent (requiring frequent drug intake) it is not surprising that most of them not only

44
spend their own or their families’ income on drugs, but many are also forced to borrow from
others or even resort to illegal means. The similar finding was highlighted in the KIIs as well.

Since most PWUD / PWID are suffering from heroin dependence various other physical, social
and financial consequences were reported. Majority of respondents reported suffering from social
stigma, a finding, which was echoed in the KIIs too. It may be noted that despite an overwhelming
majority being employed, a significant proportion experience occupational problems, which in-
turn results in financial complications (which forces them to indulge in illegal activities).

While a majority of PWUD / PWID were sexually experienced, as many as one-fourth of PWUD
and one-fifth of PWID also reported sex with commercial sex partners, in last 12 months. Almost
half of those who reported sex with commercial partners, reported un-protected sex. This finding
indicates the risk of transmission of HIV from one group (PWID) to another (sex workers) and
from them onwards to the general population. Such phenomena have been reported at other places
earlier. In the states of Manipur and Nagaland, India, HIV epidemic began among PWID, then
spread among the female sex workers eventually resulting in a generalized epidemic.33

Despite such existence of high-risk sexual behaviours and the finding that around 21% of PWID
and 14% of PWUD had sexually transmitted infections, just about 9% of PWID and 18% of PWUD
received condoms as an intervention from any source. Indeed, data on access to treatment and
intervention for PWUD / PWID is quite alarming. While a majority in both the groups reported
having received ‘counseling’ in the past 12 months, despite being drug dependent, less than half
have received medical treatment for drug addiction. In contrast, a large majority reported having
been subjected to criminal justice interventions; more than 90% had been apprehended by the
police and a majority (84% PWID, 78% PWUD) had been to jail. However, as the KII data also
shows, jail term does not appear to be an effective intervention at all. Research has demonstrated
that imprisonment neither instils fear in people nor does it deter people from restarting drug use
after release from prisons.34

Among the limitation of the study, despite best attempts the teams working on the ground could
not achieve the desires sample size of PWID. Still, the recruited sample of PWID is large enough

33
Narain JP (2004). AIDS in Asia: The Challenge Continues. New Delhi: Sage Publications
34
Bewley-Taylor, D., Hallam, C., & Allen, R. (2009). The incarceration of drug offenders: An overview.
The Beckley Foundation Drug Policy Progamme Report sixteen.
45
to provide important insights about pattern of drug use and resulting consequences. The study
collected data only on behavioural parameters. Data on prevalence of HIV and other blood borne
viral infections (which are known consequences of risky injecting practices) would have been
useful. However, irrespective of their HIV status, PWID in Sri Lanka remain vulnerable on account
of their injecting practices and this risk if further compounded by lack of access to effective
interventions.

The key vulnerabilities and challenges in Sri Lanka – on the basis of the results of this study –
have been listed in the box below.

KEY VULNERABILITIES AND CHALLENGES IN SRI LANKA

• Young, productive men engaged in drug use
• Majority suffering from heroin dependence and the serious adverse consequences of
the same
• Majority of PWUD at risk of transition to injecting
• High prevalence of risky injecting practices among PWID
• Existence of risky sexual behaviors (with risk of onward transmission of HIV to other
population groups)
• A heavy criminal justice system response (which appears ineffective)
• High levels of stigma and discrimination – exacerbating vulnerability
• Poor access to effective, evidence-based treatment for opioid dependence
• No access to specific harm – reduction intervention

7. CONCLUSION & RECOMMENDATION

It is evident that from this study there is a virtual time bomb ticking in Sri Lanka. PWID are
certainly much less in number as compared to the PWUD. However, as the data indicates, PWUD
(being heroin dependent) remain at risk of switching to the injecting route of drug intake. In
addition a high proportion of PWID are forced to indulge in risky practices (both injecting and
sexual) which puts them and their partners at risk of acquiring HIV infection. At many places in
the world, explosive HIV epidemics among PWID have been documented, which eventually
resulted in a generalized HIV epidemic. Sri Lanka is uniquely poised to avert such a situation.

46
Indeed, most of the HIV prevention interventions work best when they are implemented early in
course of epidemic or in the low HIV prevalence settings (like Sri Lanka of today)35. Thus the
following set of recommendations must be urgently implemented:

Structural and Policy reforms

The overall policy response to drug problems in Sri Lanka appears to be heavily skewed towards
supply control, law enforcement and criminal justice interventions. Availability of evidence-based
interventions for treatment of opioid dependence as well for HIV prevention (i.e. harm reduction)
is severely limited. In addition, there is considerable degree of stigma in the society which results
in discrimination, further limiting the access of affected populations to the health and welfare
services.

In view of this, it is important for Sri Lanka to formulate policies which supports provision of
effective, evidence-based interventions. For this to occur, wider consultations would be necessary.
Specifically the concerns that a policy which promotes harm reduction interventions, is against the
UN Drug Conventions, will have to be addressed. It has been repeatedly examined and commented
in many contexts across the globe that provision of effective and life-saving interventions like
Opioid Substitution Treatment or Needle Syringe Programs does not violate any of the provisions
of three UN Drug Conventions.36-37

An additional aspect of structural reforms would be to promote and encourage the participation of
civil society – notably the affected communities – in decision making regarding policies and
programmes. As yet there is hardly any visibility of networks of affected people in Sri Lanka.
Globally, as well as in the neighborhood of Sri Lanka such groups are active (such as International
Network of People Who Use Drugs (INPUD); Asian Network of People Who Use Drugs
(ANPUD) and Indian Drug Users Forum (IDUF)). Such groups play a valuable role in advocating
for evidence-informed policies and programs and serve as a bridge between the authorities and the

35
WHO (2016). Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key
populations.
36
United Nations Economic and Social Council. (2002). The Commission on Narcotic Drugs, Resolution
45/1: Human immunodeficiency virus/acquired immunodeficiency syndrome in the context of drug abuse.
United Nations, Office on Drugs and Crime
37
International Narcotics Control Board (1987). Report of the International Narcotics Control Board for
1987
47
beneficiaries.38 Even if the establishment of such civil society entities take some time, a beginning
can be made at the level of service delivery points by obtaining the perspective of service
beneficiaries and involving them in the decision making process.

Implementation and scale-up of intervention programs

Notably, Sir Lanka is one of the rarer countries in the world which has existence of phenomena of
Injecting Drug Use including a high prevalence of risky injecting practices, yet there is no access
of the vulnerable populations to the harm reduction interventions. Even the existing interventions
have a poor coverage; WHO notes that less than 10% of drug dependent people in Sri Lanka have
access to medical treatment which is oriented to abstinence.39 The most evidence based treatment
of Heroin dependence – OST – is simply non-existent in Sri Lanka.

Thus, it is recommended that evidence-based and cost-effective interventions like OST should be
urgently instituted in Sri Lanka. Contrary to the perceptions, such interventions are not only low-
cost and hence feasible in developing countries, but are highly cost-effective as well. Almost all
the countries in South Asia (which are all low and middle income countries like Sri Lanka) have
provisions of OST for treatment of heroin dependence.40 It must be noted that OST is an
intervention primarily addressing Opioid Dependence (irrespective of the route of opioid intake).

Thus, having such an intervention in place, would minimize the risk of injecting and sharing by
PWID (thereby serving as a HIV prevention intervention). At the same time, provision of OST to
heroin dependent PWUD would minimize the risk of transition to injecting as well and serve as an
effective treatment of opioid dependence.

Both the medications used for OST – buprenorphine and methadone – have been included in the
list of Essential Medicines by World Health Organization (WHO).41 These medications are

38
Cai T (2017). How Civil Society can influence national drug policy. Available at
http://www.aidsalliance.org/blog/898-how-civil-society-can-influence-national-drug-policy
39
WHO Atlas. Country Profile: Sri Lanka. Available at
http://www.who.int/substance_abuse/publications/atlas_report/profiles/sri_lanka.pdf
40
Rao R, Agrawal A, Kishore K, Ambekar A (2013). “Delivery models of opioid agonist
maintenance treatment in South Asia: A good beginning.” Bulletin of the World Health
Organisation, Volume 91, Number 2
41
Kermode at al (2011). “Opioid substitution therapy in resource-poor settings.” Bulletin of the World
Health Organization, Volume 89, Number 4

48
available in the neighboring countries and have been proven to be very effective treatment for
opioid dependence.

Considering the prevalence of high risk injecting practices among PWID in Sri Lanka – and with
the backdrop of poor access to safe injecting equipment - harm reduction programs are urgently
required. These programmes must constitute provision of outreach and peer education for PWID,
access to information and skills for safer injecting practices, access to the means for safer injecting
(i.e. sterile injecting equipment and condoms), access to HIV testing and treatment as well as
access to evidence based treatment of drug use disorders and other health conditions. Keeping
PWID safe, is essential to keep the general population safe in Sri Lanka.

Such programs and interventions could begin initially at a smaller scale and then through utilizing
the learning during the implementation, should be scaled-up to provide an optimum level of
coverage.

Building capacities

In order to bring about such reforms and institute such initiatives as described above, it will be
imperative to build capacities at all the levels – from the top levels of decision making to the level
of implementation in the field. Fortunately, ample opportunities and avenues exist in the
neighborhood of Sri Lanka. India, Bangladesh, Maldives and Nepal, all have well-established OST
programs. India has one of the richest experiences of implanting harm reduction programs at a
large scale (which includes all the elements of harm reduction – needle syringe program, OST,
condom distribution, peer education, and access to health care services). Study tours and training
programs should be organized for Key Personnel from the relevant departments and agencies of
Sri Lanka (NDDCB, NSACP, Ministry of Health etc.) to India. Collaboration between academic
institutes of both the countries can also be explored aimed at transfer of skills and technology.
Eventually, in-house capacities will be developed within the country to provide technical expertise
and inputs for initiation and scale-up of interventions.

Generating data and utilizing the evidence

One-off studies like this, are valuable sources of information to bring about changes in the policies
and programmes. However, for sustaining the momentum and taking the initiatives forward,
ongoing mechanism for data collection, monitoring and evaluation should be established. Looking

49
at the trends in data observed in this study, recommendation of larger studies conducted at more
locations, with larger sample sizes and more robust methodology can be made. However, there are
enough indications from the data presented here, which highlight the need of urgent reforms and
institution of appropriate, policies and programs, which keep health, welfare and rights of affected
communities in focus.

Specific recommendations on the basis of results of this study have been listed in the box below.

Recommendations for Sri Lanka

• Legal and Policy reforms aimed at a conducive environment for provision of

evidence-informed services for affected communities
• Promotion of involvement of civil society and affected communities in the decision-
making process
• Advocacy for initiation of evidence-based treatment for drug dependence (Opioid
Substitution Treatment)
• Advocacy for initiation of harm-reduction interventions (including access to clean
injecting equipment) for PWID
• Organization of exposure visits and Study tours to neighbouring countries for
exposure to the programs for drug dependence treatment and harm-reduction
• Promotion of collaboration between academic institutes of Sri Lanka and other
countries
• Retaining the focus on generating and utilizing the evidence through ongoing
research, monitoring and surveillance

50