Indian Journal of Public Health

: 2020  |  Volume : 64  |  Issue : 5  |  Page : 71--75

Variation in injecting drug use behavior across different North-eastern States in India

Subrata Biswas1, Piyali Ghosh2, Debjit Chakraborty3, Arvind Kumar4, Sumit Aggarwal5, Malay Kumar Saha6,  
1 Project Coordinator, ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, West Bengal, India
2 Project Assistant, ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, West Bengal, India
3 Scientist D, ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, West Bengal, India
4 Associate Consultant, Surveillance-SI Division, National AIDS Control Organization, New Delhi, India
5 Scientist C, Indian Council of Medical Research, New Delhi, India
6 Scientist F, ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, West Bengal, India

Correspondence Address:
Dr. Malay Kumar Saha
ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, West Bengal


Prevalence of adult HIV infection in India is still high in certain North-eastern (NE) states, particularly among injecting drug users (IDUs). This study aims at exploring IDU behavior profile and their variation across the different states of NE region, India. Data were drawn from a population-based, cross-sectional survey of IDU in the integrated bio-behavioral surveillance from 2014 to 2015. A total of 4272 IDUs from four states (Manipur, Meghalaya, Mizoram, and Nagaland) aged ≥15 years were interviewed. Descriptive analysis was conducted to identify the variation in demographic and IDU behavior across four states. Youth predominance in Mizoram was evident by the mean age of initiation <18 years; 74% and 65% had the first exposure of any drug and injecting drug in <20 years. In Manipur and Nagaland, 60% and 49% of IDUs, respectively, were ≥30 years of age. These specific age groups may be targeted for IDU risk mitigation addressing the state-specific determinants.

How to cite this article:
Biswas S, Ghosh P, Chakraborty D, Kumar A, Aggarwal S, Saha MK. Variation in injecting drug use behavior across different North-eastern States in India.Indian J Public Health 2020;64:71-75

How to cite this URL:
Biswas S, Ghosh P, Chakraborty D, Kumar A, Aggarwal S, Saha MK. Variation in injecting drug use behavior across different North-eastern States in India. Indian J Public Health [serial online] 2020 [cited 2022 May 27 ];64:71-75
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Full Text

The prevalence of adult HIV infection in India is still high in certain North-eastern (NE) states such as Mizoram (2.04%), Manipur (1.43%), and Nagaland (1.15%).[1] Among the different high-risk group (HRG) typologies, injecting drug users (IDUs) are a major concern in these NE states as the high HIV prevalence in IDU sites is reported from Mizoram (19.81%), Tripura (8.55%), Manipur (7.66%), Meghalaya (1.62%), and Nagaland (1.15%).[2]

These states share boundaries with other countries such as Myanmar, Bangladesh, and Bhutan, leading to increase practice of illicit drug handling.[3] In order to strategize a customized, contextual, and region-centric risk reduction approach, in-depth understanding of specific IDU behavior patterns across the different NE states is highly required, and this builds the rationale for undertaking the present study. The present study was conducted to ascertain the variation in demographic and IDU behavior profiles across the different states of NE regions, India.

The data were drawn from a cross-sectional survey of IDUs, namely the National Integrated Bio-Behavioral Surveillance (IBBS) 2014–2015. Four districts (Chandel, Imphal East, Senapati, and Thoubal) from Manipur, two districts (East Khasi hills and West Jaintia hills) from Meghalaya, four districts (Aizawl, Lawngtlai, Saiha, and Mamit) from Mizoram, and three districts (Dimapur, Kiphire, and Mokokchung) from Nagaland were selected for this population-based surveillance as considerable number of IDUs were concentrated in those districts. The sampling method used to sample HRGs was the cluster sampling method.

Men aged ≥15 years using drugs for recreational or addiction purposes through injection in the past 3 months were eligible. A sample size of 400 was estimated for each survey district termed as “domain” (a combined sample size of 400 was used for East Khasi hills and Jaintia hills districts and also for Lawngtlai and Saiha districts). In each domain, the list of hotspots (IDUs concentration) was prepared and validated along with the identification of novel hotspots. Each mobile hotspot was divided into the following clusters: peak day-peak time, peak day-lean time, lean day-peak time, and lean day-lean time. The final selection of the cluster was random. More details of the sampling strategy are available in the online report.[4] A total of 4272 IDUs were interviewed across 11 domains in four states during the survey.

After written informed consent, participants were interviewed with a precoded, closed-ended questionnaire using the integrated information management system linked with computer-assisted personal interviewing technique. The questionnaire was administered in different regional languages (Khasi, Manipuri, Mizo, and Nagamese). Data entered by the trained interviewer were reviewed and finalized by regional institutes. The IBBS study was approved by the ethics committee constituted by the National AIDS Control Organization and ICMR-National Institute of Cholera and Enteric Diseases vide no. A-1/2015 IEC, dated September 14, 2015.

The manuscript describes the findings of in-depth analysis of primary data from the study.

Statistical software SAS version 9.2 (SAS software, SAS Institute Inc., Cary, NC, USA) was used for the extraction and analysis of the data. A descriptive analysis was conducted to characterize the study population. This was followed by the bivariate analyses (i.e., Chi-square tests and ANOVA) to examine the associations among four different states and selected demographic and injectable use behavior of the IDUs.

A total of 4272 male IDUs were enrolled in the survey from four NE states, i.e., Manipur (1594 [37%]), Meghalaya (396 [9%]), Mizoram (1084 [25%]), and Nagaland (1198 [28%]).

The details of their demographic attributes are presented in [Table 1]. The mean age was the highest in Manipur (32.1 years) and the lowest in Mizoram (26.1 years). The proportion of IDUs <20 years of age was the highest in Mizoram (11%) as compared to other states. In Manipur, 60% were aged 30 years and above. More than 90% of participants had an education of 5 years and above, and over 50% received education of 10 years at least in all four states. More than half of the participants were never married in all four states. In Mizoram, the proportion of widower/divorced/separated was much higher (21%) than other states and within this divorced group was predominant. Most of the participants lived with family members/relatives without any sexual partner in all four states; however, proportion living with spouse was much higher in Nagaland (35%). In all the above parameters, variation across the states was statistically significant (P < 0.00).{Table 1}

The details of their IDU behavior attributes are presented in [Table 2]. The mean age of initiation of the drug in any form and in injecting form was the lowest in Mizoram (17.8 and 20 years) and the highest in Manipur (22.5 and 25.3 years). A mean gap of 3 years was observed between the initiation of the drug in any form and injecting form in all four states. The average number of injections taken on the last day was around 2 for all states, and the number of injections taken in group in the last week was around 3 except Meghalaya (2.2). In Manipur (52%) and Meghalaya (39%), majority started taking drug in any form when their age was 20–29 years, but in Mizoram (74%) and Nagaland (55%), most people started when they were <20 years. Maximum participants took the first drug in oral form in all states except Meghalaya. In Mizoram, 31% of IDU initiated their drug intake by the injection mode. Mizoram was the only state where as high as 65% of participants used the first injection below the age of 20 years. We observed heroin as the most frequently consumed drug in the past 3 months except in Nagaland where dextropropoxyphene led the list. Regarding the sharing of needle/syringe, around 12% IDU in Mizoram and Nagaland used a perused needle/syringe from fellow IDU during the last injection. When it comes to the past 3 months, around 23% from Mizoram, 12% from Nagaland, and 10% from Manipur applied preutilized needle/syringes. In Mizoram and Nagaland, drawing of solutions from common containers and injecting in groups were frequent practices compared to the other two states. The disposal of needle/syringe through the needle syringe-exchange programme was more common in Nagaland and Meghalaya than in Manipur and Mizoram.{Table 2}

We observed distinct diversity in regard to demographic and behavioral attributes of IDUs across four NE states, leading to the requirement of state-specific policy and interventions. Mizoram was unique in terms of its youth-driven approach. The phenomenon was just reverse in the states of Manipur and Nagaland where 60% and 49% of IDU respondents, respectively, were ≥30 years of age though around 35%-40% of them initiated their injection drug use below their 20 years of age. Another study from the same region also reported youth predominance, thereby emphasizing the need for youth-driven intervention.[5] Studies from other countries also corroborated the association of unsafe injection practices with younger IDUs.[6],[7] Above 90% of IDUs were literates in all four states, and years of education were found to lower the risk of needle/syringe sharing significantly in Meghalaya and Mizoram. Hence, the education system in respective states may be targeted from early years, and course curriculum may be tailor made to the context, so that from the initial adolescent period, the harmful effects of injection practices and illicit drug use can be educated, and harm reduction strategies are undertaken. Specifically, for Mizoram, school health and other formal and non-formal arena may be integrated with behavior change communication programs. In Manipur and Nagaland, higher schools and colleges' platforms may be utilized along with the primary education system also to curtail the IDU exposure. As the proportion of unmarried was also very high in these groups, family education is also very important to prevent diversion toward drug addiction by the virtue of peer pressure, social networks, lack of family responsibility, and the absence of a regular licit sexual partner.[8],[9]

Except for Mizoram, less than one-fourth of the drug users started with the injecting route. All the rest choose routes other than injection primarily and then gradually had shifted to injecting habits. There is an average interval of 3 years from the first use of drug in other form to first injecting. This may be a point of intervention where the switch to injecting behavior can be prevented at the very beginning of the drug addict life. Injecting in a group and drawing solutions from common containers were the high predictors of needle-sharing behavior uniformly in all four states with varying risk estimates. Particularly in Mizoram, around 24% still practiced the use of a shared needle from fellow IDU in the past 3 months. More than 75% injected drug in groups in the past 3 months in Nagaland and Mizoram. From the various aspects of demography and unsafe injection behavior, Mizoram appears to be the state with the highest risk of HIV transmission followed by Manipur. Meghalaya confers the lowest vulnerability. HIV prevalence among IDUs also in agreement with this observation as Mizoram clearly standing out with a very high HIV prevalence of 19.8% among IDUs.[2]

This study provided an understanding that even NE regions were perceived as a unity, even there exists a lot of heterogeneity in terms of population profile, sociodemography, IDU behavior, etc. Therefore, a state-specific intervention strategy customized to state-specific determinants instead of a uniform national or regional package of services specifically, late adolescent-driven approach for late adolescent-driven approach for Mizoram and young adult-driven strategy for Manipur and Nagaland concentrating on formal education, family counseling, peer-based behavioral rehabilitation may be appropriate, to effectively bring down the risk of HIV transmission, also in a cultural centric, demand-driven, and resource prioritized fashion.

Since the study was conducted based on available IBBS data, no new variable besides those in the IBBS questionnaire had been included. Furthermore, as in all surveys, the analysis had to take account missing values and varied denominators for a different response.


The authors acknowledge the National AIDS Control Organization, New Delhi, Manipur AIDS Control Society, Meghalaya AIDS Control Society, Mizoram State AIDS Control Society, and Nagaland State AIDS Control Society, for supporting the study. The authors also acknowledge the receipt of a financial grant from the National AIDS Control Organization for conducting the IBBS, authorship, and publication of this article.

Financial support and sponsorship

National AIDS Control Organization, New Delhi.

Conflicts of interest

There are no conflicts of interest.


1India HIV Estimation 2017, Technical Report. New Delhi: NACO, Ministry of Health and Family Welfare, Government of India. Available from: [Last accessed on 2019 Jun 12].
2HIV Sentinel Surveillance: Technical Brief, India 2016-17. New Delhi: NACO, Ministry of Health and Family Welfare, Government of India. Available from: [Last accessed on 2019 Jun 12].
3Kermode M, Deutschmann P, Arunkumar MC, Manning G. Injecting drug use and HIV in northeast India: Negotiating a public health response in a complex environment. South Asian Hist Cult 2010;2:239-49.
4National AIDS Control Programme. National Integrated Biological and Behavioural Surveillance (IBBS), India 2014–2015. New Delhi: National AIDS Control Programme; 2015. Available from: [Last accessed on 2019 Jun 12].
5Armstrong G, Nuken A, Medhi GK, Mahanta J, Humtsoe C, Lalmuanpuaii M, et al. Injecting drug use in Manipur and Nagaland, Northeast India: Injecting and sexual risk behaviours across age groups. Harm Reduct J 2014;11:27.
6Horyniak D, Dietze P, Degenhardt L, Higgs P, McIlwraith F, Alati R, et al. The relationship between age and risky injecting behaviours among a sample of Australian people who inject drugs. Drug Alcohol Depend 2013;132:541-6.
7Bautista CT, Todd CS, Abed AM, Botros BA, Strathdee SA, Earhart KC, et al. Effects of duration of injection drug use and age at first injection on HCV among IDU in Kabul, Afghanistan. J Public Health (Oxf) 2010;32:336-41.
8Kermode M, Longleng V, Singh BC, Hocking J, Langkham B, Crofts N. My first time: Initiation into injecting drug use in Manipur and Nagaland, North-East India. Harm Reduct J 2007;4:19.
9Kermode M, Longleng V, Singh BC, Bowen K, Rintoul A. Killing time with enjoyment: A qualitative study of initiation into injecting drug use in North-east India. Subst Use Misuse 2009;44:1070-89.