ABSTRACT
Background:
This study emphasized the necessity of evaluating both covered and non-covered People Who Inject Drugs (PWIDs) to identify implementation issues and enhance service delivery. The objective was to assess the availability and accessibility of Targeted Intervention (TI) services and factors influencing their implementation.
Methods:
A mixed-methods study was conducted from September 2024 through March 2025, utilizing a cross-sectional survey (of both TI and non-TI PWID) alongside focus group discussions (FGDs).
Results:
Quantitative data were collected from 646 PWID (TI: 454; non-TI: 192), complemented by 10 FGDs. The participants’ mean age was 28 years, with a mean age of initiation for substance use at 22 years. PWID enrolled in TIs were significantly more likely to reside in their home districts, inhabit urban areas, and be engaged in small-scale business. Although TI-enrolled participants showed higher rates of human immunodeficiency virus (HIV) awareness, testing, and access to sterile needles/syringes, overall coverage remained low for Opioid Substitution Therapy (OST), routine screenings for sexually transmitted infections/reproductive tract infections (STIs/RTIs), and consistent condom use. Narrative analysis revealed general satisfaction with existing services but highlighted a critical demand for localized OST, expanded needle/syringe access, and vocational rehabilitation.
Conclusions:
Coverage of TI services was better for HIV testing and fresh needles/syringes. TI services need to be strengthened and expand their coverage for OST, improving local access to needles/syringes, and sexual health services (RTIs/STDs and condom programming). TI program should also devise a mechanism to engage non-TI PWIDs to provide services.
Keywords: Coverage, people who inject drugs (PWIDs), services, targeted intervention (TI)
BACKGROUND
People Who Inject Drugs (PWID) are classified as a “high-risk group” as they face human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) burden and socio-cultural discrimination. They also have a “Syndemic effect,” that is, co-occurring infections like Hepatitis C and Tuberculosis. In India, they seek services under a harm reduction model with Targeted Interventions (TIs). Under the National AIDS Control Program (NACP), TIs for PWID are implemented by community-based organizations (CBOs) and non-governmental organizations (NGOs) utilizing peer-led outreach. Under the NACP, these TIs deliver a comprehensive service package including the Needle Syringe Exchange Programme (NSEP), Opioid Substitution Therapy (OST), and referrals for HIV and Reproductive Tract/Sexually Transmitted Infections (RTI/STI). Outreach workers (ORWs) facilitate these services via a peer-led approach, recruiting PWID directly from their communities.
Social network analysis suggests that recruiting influential substance users as peers enhances both the accessibility and acceptability of these services.[1] A core component of the TI framework is the Needle and Syringe Exchange Program (NSEP), designed to mitigate HIV transmission risks. While this strategy has successfully increased the use of sterile injecting equipment, its effectiveness varies significantly across Indian states.[2,3] Experience indicates that implementation barriers persist at the individual, familial, societal, and health-system levels, ultimately limiting access to services and treatment adherence.[4,5,6] Given that opioids, such as heroin and pharmaceutical drugs, are the primary substances injected in India, OST serves as another critical intervention. Under the NACP, OST centers provide buprenorphine as a directly observed treatment to eliminate needle sharing and further reduce the risk of HIV transmission.[7]
While TIs have proven instrumental in managing the HIV epidemic among key populations, continuous programmatic assessment is essential to ensure service availability and accessibility. Because TIs are delivered via CBOs/NGOs with support from the State AIDS Control Society (SACS), coverage may be limited by an “unreached” population of PWID due to socio-cultural and legal factors like fear of social stigma and discrimination, criminalization under Narcotic Drugs and Psychotropic Substances Act, 1985, and police harassment.[2,4,5,6] Evidence has shown that improving the coverage of needle/syringe exchange as a harm-reduction strategy requires implementation assessment to provide tailored, safe access service points. It requires a shift from commodity distribution to comprehensive structural intervention.[8,9,10,11] This study assesses the accessibility and acceptability of TI services in Himachal Pradesh, emphasizing the importance of evaluating both covered (TI-enrolled) and non-covered (non-TI) PWID to identify implementation gaps. By simultaneously assessing non-TI PWID, this research provides insights into coverage disparities and the factors influencing service delivery.
MATERIALS AND METHODS
This mixed-methods study was conducted from September 2024 to March 2025 across all TIs in Himachal Pradesh. The state comprises 12 districts, with 13 TIs providing services to PWID across 10 of 12 districts. Following a mapping exercise, the Himachal Pradesh State AIDS Control Society (HPSACS) allocated two TIs to three districts and one TI to each of the remaining seven. For this study, PWID was defined as any individual who injected drugs for non-medical purposes at least once in the preceding three months. Participants were categorized into TI-registered (enrolled in the state program) and non-TI registered. Individuals who did not provide consent or exhibited signs of drug overdose (OD) were excluded. Availability of TI services was considered as physical existence of resources (TI center, staff, and logistics) for services like fresh needles/syringes, condoms, OST, and linkages to additional services. The additional services were routine medical checkups, RTIs/STDs examination and management, HIV testing and counselling, overdose management, and anti-retroviral therapy. Whereas accessibility of TI services was considered as the ability to reach TI services geographically.
Quantitative design: Programmatic data from 2024 indicated 3,332 registered PWID in the state. Sample sizes were calculated separately for both groups:
TI-registered PWID: Based on an assumed 23.0% prevalence of shared needle/syringe use during the last injection episode, a 5.0% precision, and a 95.0% confidence interval, the initial sample was 273. Adjusting for a 1.5 design effect and a 10.0% refusal rate, the final target was 449, distributed proportionally across the 13 TIs.
Non-TI registered PWID: Assuming a 13.0% prevalence of shared needle use, the sample size was determined to be 261, distributed equally (approximately 30 per district) across the state. The sample size was calculated to ensure adequate representation of unregistered PWID to identify extent of accessibility of TI services.
Qualitative design of the study: To explore the “why” behind service utilization and “how” to improve delivery, 10 focus group discussions (FGDs) were conducted (one per district) among TI-registered PWID. This number was deemed sufficient to reach thematic saturation, as literature suggests 4–8 FGDs are typically required to ensure no new insights emerge.
TI-registered participants were selected via simple random sampling using a computer-generated list based on HPSACS records. Conversely, non-TI PWID were recruited via consecutive sampling at Stand-alone Integrated Counselling and Testing Centres (SAICTC), non-TI OST facilities, Red-Ribbon Clubs (RRCs), and Drug De-addiction Centres (DDCs). Trained research staff also conducted personal interviews using pre-structured questionnaires at locations convenient for participants. After the interview, TI-registered PWID were invited to participate in FGDs; those willing provided a second written consent. Standard operating procedures (SOPs) were developed to conduct FGDs. SOPs included study context, sampling strategy, invitation for participation, identifying a convenient place, seating arrangement, required logistics, questions, systematic recording of responses, and debriefing methods. Research staff with a master’s degree in science and five years of research experience in field settings were trained for FGDs by an expert. They were further trained to encourage participants to speak and to ensure prolonged engagement. FGDs focused on service availability (support for NSEP, OST, and linkages) and accessibility (the ability of users to physically obtain and utilize these services). In field settings, narratives were recorded by staff, and participants were assigned numerical codes to maintain anonymity.
Quantitative data were managed in Microsoft Excel. We performed descriptive analysis, reporting means and standard deviations for continuous variables and proportions for categorical data. Statistical significance was assessed using Student’s t-tests and Chi-square tests, respectively. For qualitative data, manual thematic analysis was employed, focusing on five key themes: availability, accessibility, facilitators, barriers, and areas for improvement. The analysis followed a deductive approach, independently executed by two trained investigators. Initially, each narrative was read line-by-line, with relevant segments assigned descriptive codes. Following this, individual codes were synthesized and grouped into five primary themes. The coding framework was validated by two independent reviewers, with a pre-established plan to resolve disagreements through consensus or senior-level adjudication. Three instances of misclassification were identified during this process and subsequently rectified through adjudication.
The study received approval from the Institutional Ethics Committee of Dr. RPGMC Kangra at Tanda (IEC/98/2024, Date: 06/08/2024). All personal identifiers (e.g., names, father’s names, and contact details) were kept strictly confidential. Research staff were sensitized to maintain a respectful, non-judgmental, and private environment for all participants.
RESULTS
A quantitative assessment was conducted among 646 PWID (TI: 454; non-TI: 192), supplemented by 10 FGDs. The groups demonstrated demographic parity across several key variables, with no statistically significant differences in mean age (approximately 28 years), gender, marital status, age of initiation into drug use (approximately 22 years), or number of female sexual partners. Both cohorts were predominantly male (approximately 96.0%), and approximately two-thirds had never been married. The age distribution skewed toward late adolescence (15–18 years) and young adulthood (19–24 years). However, significant differences emerged regarding residency and socioeconomic status. A vast majority of the TI group resided within the same district (97.1%) and in urban areas (67.6%), proportions that were notably lower in the non-TI group. Educational attainment also varied; the TI group was largely educated to primary or secondary levels, whereas a higher fraction of non-TI participants were university graduates. Occupationally, TI participants were more likely to be engaged in small businesses, whereas the non-TI group was largely comprised of the service class. While general travel history over the preceding three months was comparable, the non-TI group reported significantly longer durations away from their primary residence. Regarding sexual health, nearly half of all participants reported regular female sexual partners. Although the number of participants with regular male sexual partners was small, it was significantly higher in the TI group. Notably, condom use during recent encounters with regular partners was significantly higher among TI participants (90.4%) compared to the non-TI group (56.7%), despite a similar frequency of intercourse (approximately five times per month) across both groups [Table 1].
Table 1.
Background characteristics and sexual practices of persons who inject drugs (PWIDs) surveyed in Himachal Pradesh, India. 2024
| Characteristics | TI (454) | Non-TI (192) |
|---|---|---|
| Mean age in years (SD) | 28.1 (5.9) | 28.1 (5.7) |
| Mean age of drug use start (SD) | 22.0 (4.9) | 21.0 (4.3) |
| Age group for start of drug use, n (%) | ||
| 10-14 | 10 (2.2) | 1 (0.5) |
| 15-18 | 104 (22.9) | 65 (34.2) |
| 19-24 | 216 (47.6) | 85 (44.7) |
| 25-35 | 115 (25.3) | 41 (21.4) |
| >35 | 9 (2.0) | 0 (0.0) |
| Male, n (%) | 438 (96.5) | 185 (96.3) |
| Never Married, n (%) | 298 (65.6) | 134 (69.8) |
| Resident of same district, n (%) | 441 (97.1) | 133 (69.2)* |
| Urban, n (%) | 308 (67.8) | 94 (48.9)* |
| Level of Education, n (%) | ||
| No formal education | 14 (3.0) | 10 (5.2) |
| Primary | 61 (13.4) | 15 (7.8)* |
| Secondary | 107 (23.6) | 37 (19.3) |
| Senior Secondary | 161 (35.5) | 84 (43.8)* |
| Graduate and above | 111 (24.4) | 46 (24.0) |
| Common Occupation, n (%) | ||
| Self-employed/Large business | 110 (24.2) | 36 (18.8) |
| Unemployed | 91 (20.0) | 52 (27.0) |
| Service (Government/Private) | 54 (11.9) | 65 (33.9)* |
| Small Business | 43 (9.5) | 9 (4.7)* |
| Student | 24 (5.3) | 13 (6.8) |
| Skilled/semi-skilled worker | 23 (5.1) | 8 (4.1) |
| Agriculture | 37 (8.1) | 9 (4.7) |
| Travel history from residence, n (%) | 138 (30.4) | 49 (25.5) |
| Mean times travel outside in last 3 months (SD) | 5.4 (8.6) | 7.5 (14.0) |
| Mean days stayed outside in last 3 months (SD) | 11.8 (14.1) | 25.0 (19.0)* |
| Regular female sexual partner, n (%) | 219 (48.2) | 97 (50.5) |
| Regular male sexual partner, n (%) | 14 (3.1) | 1 (0.5)* |
| Condom use in last sexual intercourse with partner, n (%) | 198 (90.4) | 55 (56.7)* |
| Mean sexual encounters with regular partner in last month (SD) | 5.2 (4.7) | 4.7 (4.5) |
*P<0.05
Regarding the location of substance use, non-TI PWIDs were significantly more likely to report using at home (79.7% vs. 67.4%). Though heroin was the most common substance identified in both groups, its prevalence was significantly higher within the TI group (85.7% vs. 77.0%). Notably, the non-TI group demonstrated a significantly higher rate of non-disclosure regarding the specific substances injected. Despite these differences in substance type and location, injection frequency remained consistent across both groups, with a mean of two injections on the most recent day of use. The most profound differences emerged in injection safety and disposal practices. TI participants consistently demonstrated significantly lower rates of needle and syringe sharing across all temporal measures, such as lifetime sharing [1.8% (TI) vs. 8.4% (non-TI), in the past three months [4.6% (TI) vs. 22.9% (non-TI)], and in the last injection episode [3.0% (TI) vs. 31.8% (non-TI)]. Correspondingly, the use of fresh needles and syringes was significantly higher among TI PWIDs (93.2% vs. 79.7%). Interestingly, TI participants were more likely to reuse their own personal syringes (11.2% vs. 3.6%) before disposal. In terms of community safety, TI participants were less likely to inject in groups and were significantly more likely to utilize safe disposal methods, such as returning used equipment to TI staff [Table 2]. Regarding disease literacy, TI PWIDs demonstrated significantly greater awareness of RTIs/STDs compared to the non-TI group (82.2% vs. 57.8%). This group also exhibited higher knowledge of correct HIV transmission routes, the availability of Antiretroviral Therapy (ART) (87.9% vs. 59.9%), and the specific mechanisms of mother-to-child transmission [Table 3].
Table 2.
Pattern of substance use among persons who inject drugs (PWIDs) surveyed in Himachal Pradesh, India. 2024
| Characteristics | TI (454) | Non-TI (192) |
|---|---|---|
| Common place of drug use, n (%) | ||
| Home | 306 (67.4) | 153 (79.7)* |
| Public Toilet/Market/Street corner | 41 (9.0) | 19 (9.9) |
| Abandoned building | 21 (4.6) | 7 (3.6) |
| Park/garden | 1 (0.2) | 0 (0.0) |
| Lodge Hotel | 6 (1.3) | 3 (1.6) |
| Other | 79 (17.4) | 10 (5.2)* |
| Sharing of needle/syringe in last 3 months, n (%) | 21 (4.6) | 44 (22.9)* |
| Drug use in last visited place, n (%) | 134 (29.5) | 22 (11.5)* |
| Sharing of needle/syringe in last visit | 4 (3.0) | 7 (31.8)* |
| Substance used in last 3 months, n (%) | ||
| Heroin | 389 (85.7) | 147 (77.0)* |
| No Response | 39 (8.6) | 42 (22.0)* |
| Mean times drugs injected in recent day (SD) | 1.9 (2.9) | 2.0 (1.7) |
| Shared needle/syringe, n (%) | 8 (1.8) | 16 (8.4)* |
| Shared container for drawing of drug in last use, n (%) | 7 (1.5) | 8 (4.2)* |
| Used fresh needle/syringe in last use, n (%) | 423 (93.2) | 153 (79.7)* |
| Injected in groups in last 3 months, n (%) | 35 (9.6) | 29 (17.1)* |
| Repeated use of syringe/Needle before disposal, n (%) | 51 (11.2) | 7 (3.6)* |
| Common ways of disposal of syringe/needle, n (%) | ||
| Back to TI staff | 355 (73.8) | 0 (0.0)* |
| Dustbin | 62 (13.7) | 112 (58.3)* |
| Left at injection site | 37 (8.1) | 32 (16.6)* |
*P<0.05
Table 3.
Awareness and accessibility to targeted intervention (TI) services among persons who inject drugs (PWIDs) surveyed in Himachal Pradesh, India. 2024
| Characteristics | TI (454) | Non-TI (192) |
|---|---|---|
| Heard about RTIs/STDs, n (%) | 373 (82.2) | 111 (57.8)* |
| Heard about HIV/AIDS | 425 (93.6) | 178 (92.7) |
| Heard about HIV/AIDS from TI staff | 377 (90.0) | 22 (14.6)* |
| Awareness about route of transmission for HIV, n (%) | ||
| Unprotected sexual intercourse | 420 (98.8) | 165 (92.7)* |
| Needle/syringe sharing | 423 (99.5) | 167 (93.8)* |
| Blood transfusion | 417 (98.1) | 167 (93.8)* |
| Heard of ART, n (%) | 399 (87.9) | 115 (59.9)* |
| Knows ART can be availed from government hospital, n (%) | 387 (97.0) | 111 (96.5) |
| Mother to child HIV transmission, n (%) | ||
| Aware | 395 (87.0) | 100 (52.1)* |
| Breastfeed | 389 (85.7) | 100 (52.1)* |
| ART reduces HIV transmission risk | 376 (82.8) | 99 (51.6)* |
| Tested for HIV in last 12 months, n (%) | 406 (96.0) | 170 (91.9)* |
| Mean HIV tests in last 12 months (SD) | 2.0 (1.1) | 1.7 (1.0)* |
| HIV testing available from government hospitals, n (%) | 414 (98.3) | 74 (49.0)* |
| Referred by TI member for HIV testing, n (%) | 387 (85.2) | 60 (31.2)* |
| Services received from/assisted by TI staff/NGO, n (%) | ||
| New needle/syringe | 414 (91.2) | 15 (7.8)* |
| Condoms | 213 (46.9) | 3 (1.6)* |
| Oral Substitution therapy | 83 (18.3) | 6 (3.1)* |
| Check-ups for RTIs/STDs | 41 (9.0) | 0 (0.0)* |
| Mean needle/syringe received from TI staff in last month (SD) | 10.7 (16.3) | NA |
| Mean contacts by TI staff in last month (SD) | 8.1 (9.8) | NA |
| Felt disrespected by TI staff n (%) | 6 (1.3) | NA |
| Routine medical checkup in last three months, n (%) | 415 (91.4) | 84 (43.8)* |
*P<0.05; NA: Not Applicable
While HIV testing rates over the preceding 12 months were high across both groups (96.0% for TI; 91.9% for non-TI), the frequency of testing was significantly higher among TI participants. Furthermore, TI PWIDs were almost exclusively tested at government health facilities (98.3%), whereas only 49.0% of the non-TI group utilized these public services. As anticipated, TI participants reported significantly higher access to sterile injection equipment via program staff. However, OST coverage remained low at 18.3%, suggesting systemic barriers to availability or accessibility. Unexpectedly, the TI group also showed limited coverage for RTI/STD medical examinations, condom distribution, and correct-use demonstrations. Staff interaction metrics indicate robust engagement within the TI framework. On average, TI participants received 10 sterile needles/syringes and were contacted by program staff 13 times over the preceding month. Notably, only 1.3% of participants reported experiencing disrespect from staff, suggesting high levels of satisfaction and the maintenance of respectful provider-client interactions [Table 3].
Qualitative insights were gathered from 10 FGDs, with an average of six participants per session. Narrative analysis revealed a high level of awareness regarding available TI services, including medical checkups, needle/syringe programs (NSP), condom distribution, and HIV testing. A strong rapport with TI staff was a recurring theme, with several participants describing the staff as “supportive” and “like family.” While satisfied with harm reduction services, there was a clear and urgent consensus regarding the need for OST and de-addiction services to be integrated at the TI level. Participants identified the lack of local OST as a primary barrier to quitting substance use, citing the difficulty of managing withdrawal symptoms without pharmacological assistance.
Beyond OST, participants suggested expanding the TI services to include medications for common comorbidities, specifically Hepatitis B and C, to reduce the burden of hospital visits. Two significant barriers to service uptake emerged: fear of police interference and restricted access during holidays. Participants reported that the “friction” of traveling to a TI center often involves the risk of being detained, suggesting a need for decentralized needle/syringe availability or TI-mediated advocacy with local law enforcement. It was also stated that needles/syringes were not available in certain situations, like on holidays. It was suggested that there should be some mechanism for their accessibility and availability even on holidays. The narratives concluded with a forward-looking focus on economic independence. Participants linked their inability to stay away from substances to a lack of employment, requesting vocational training in trades such as tailoring, salon services, and ITI (Industrial Training Institute) courses [Table 4].
Table 4.
Thematic analysis for TI services among people who injects drugs (PWID) surveyed in Himachal Pradesh, India. 2024
| Theme | Key Finding | Participants’ Quote/District |
|---|---|---|
| Satisfaction and Rapport | High awareness and satisfaction regarding core harm reduction services (medical checkups, needle/syringe programs, condom distribution, HIV testing). Strong rapport with supportive, “family-like” staff reduces needle sharing | “Medical facility acchi hain, staff cooperative hai, test ke liye zayada wait nahi karna padta” (The medical facilities are good and the staff is cooperative; we do not have to wait long for testing). [PWID, district-5] “Sara staff bhaut motivate karta hai, meri needle sharing kam hui hai” (The entire staff motivates us... my needle sharing has decreased because of their encouragement) [PWID, district-12] |
| Improved local access | Urgent consensus on opening-up of local de-addiction facilities directly at the TI level to manage withdrawal symptoms and support quitting substance use. |
“Hume XXX mein OST chahiye” (We need OST services in XXX). (PWID, district-2] “Holiday wale din needle nahi milti, nahi toh purna use karne padta hai” (On holidays, needles are unavailable, which forces us to reuse old ones) [PWID, district-8] “Deaddiction centre khul jaye to aacha ho, taki torture na ho” (It will be useful if we have a drug deaddiction centre in our area, it will help us from withdrawal symptoms) [PWID, district-2] |
| Comorbidities management | Demand to expand the TI pharmacy inventory to include treatment for prevalent co-infections, specifically Hepatitis B and C, reducing the logistical burden of hospital visits. | “Hepatitis B-C hua hai, aagar iski dawai yahi mil jaye to accha ho” (It would be very helpful if we get Hepatitis-C medicine at TI level to avoid visits to hospital) [PWID, district-7] |
| Law enforcement | Fear of police detention during travel to TI centers acts as a deterrent. |
“Deaddiction centre khul jaye to aacha ho, taki torture na ho” (It will be useful if we have a drug deaddiction centre in our area, it will help us from withdrawal symptoms) [PWID, district-2]
“needle/syringe lene aate hai hum TI mein toh kai bar dar dar ke aana padeta hai ki kahi police na paked le. Agar is tareh ki koi problem aati hai to TI staff maddad kare” (W e feel scared coming to get needles because of the police. If problems arise, we wish the TI staff would intervene and help us) [PWID, district-12] |
| Socio-economic integration and vocational training | Participants explicitly linked sustained recovery to economic independence, requesting vocational skill training (e.g., tailoring, salon, ITI trades) to stay away from substance use. |
“aise koi Suvidha ho ki jisse humara rojagar chal sake taki hum nashi se dur rahein” (We need employment opportunities to help us stay away from drugs). [PW
ID, distri
ct-2]
“Some course on ITI, beauty parlour, salon, kapade silai ho jaye to accha ho” (Courses on ITI, beauty parlor, saloon, stitching will be useful) [district-10] |
Abbreviations: TI- Targeted Interventions, HIV- Human Immunodeficiency Virus, PWID- Person who inject drugs, ITI- Industrial Training Institute
DISCUSSION
Current study was done to evaluate the availability and accessibility of services provided through TIs and to identify the socio-behavioral factors associated with service access. The analysis employed a comparative framework, evaluating outcomes between PWIDs registered with TIs and those who were not (non-TI). Additionally, FGDs were conducted to explore service satisfaction, facilitators of care, and structural barriers. The quantitative assessment revealed a demographic preponderance of males who typically initiated substance use during late adolescence or young adulthood. It observed key distinctions in residency and socioeconomics where TI-registered PWIDs were primarily urban residents within the same district and were often engaged in small-scale businesses. Conversely, non-TI PWIDs were more likely to belong to the “service class” and reported significantly longer durations of stay outside the district. Another difference was observed in the sexual health behavior of participants, in which approximately half of both the groups reported having a regular female sexual partner; TI participants reported significantly higher rates of condom use during their most recent sexual encounter. Another difference was observed in their injection practices. Heroin was identified as the most common substance. Non-TI PWIDs were significantly more likely to inject at home, a setting associated with higher rates of non-sterile practices. Crucially, the TI group demonstrated significantly lower rates of needle and syringe sharing. Knowledge about disease was also observed to be different, where TI-registered PWIDs exhibited superior awareness regarding Reproductive Tract Infections (RTIs), Sexually Transmitted Diseases (STDs), and HIV transmission routes, as well as higher frequencies of regular HIV testing. Expectedly, TI group had better coverage for the comprehensive service package overall; no significant difference was found in the coverage of OST or regular RTI/STD medical checkups.
In this study, both TI and non-TI participants represented a young demographic (aged 15–24 years), with a mean age of injection initiation at approximately 22 years. These findings align with existing evidence indicating that PWID frequently belong to younger age cohorts and initiate substance use early in life.[12] Retrospective data from 2003 regarding North-East Indian states indicate a clear preference for outreach-based services, though programmatic gaps were evident. Specifically, 38.0% of participants reported receiving only one to two syringes per visit—a volume insufficient for sterile injection practices—while 65.0% reported only weekly contact with an ORW.[13] The current study demonstrates a marked increase in service engagement, with participants averaging eight monthly visits to TI centers—approximately twice per week. Correspondingly, the volume of sterile injection equipment distributed was notably higher, with a mean of 11 needles/syringes provided per month. Comparative analysis revealed that TI service users engaged in significantly fewer high-risk behaviors than non-users. Specifically, registered participants demonstrated a significantly lower prevalence of both used syringe utilization and the sharing of containers for drug preparation. These findings suggest that the increased frequency of contact and higher volume of sterile supplies are directly associated with improved harm reduction practices within this cohort.[13] When contextualized against 2018 data from 15 sites across Northeast India, where needle sharing was prevalent among 65.0% of PWID, the current study demonstrates a profound decline in such risks. Specifically, shared needle/syringe use was recorded at only 2.0% among TI-registered PWIDs and 8.0% among the non-TI group. Furthermore, though historical access to OST was limited to 16.2%,[14] current study observed a higher uptake of 18.3% among TI participants. In contrast, OST access among the non-TI cohort remained negligible at 3.1%. These results align with prior evidence suggesting that robust service coverage is a primary driver of safe injection practices and harm reduction.[15]
The current study demonstrates that clinical literacy regarding HIV transmission and the availability of ART is significantly higher among TI participants than their non-TI counterparts. This is an important programmatic outcome, as established evidence suggests that robust knowledge of blood-borne infection transmission serves as a primary motivator for the cessation of needle and syringe sharing.[16] Comparison between TI and non-TI groups highlights a significant programmatic success: individuals registered with TIs demonstrate substantially better service coverage and a marked reduction in high-risk behaviors. However, a critical gap remains in the availability of OST, a need that was urgently echoed throughout the FGDs. Expanding OST access is not merely a service request; it is a clinical necessity. Evidence consistently shows that OST serves as a foundational pillar of harm reduction by reducing high-risk transmission through decreasing the frequency of needle and syringe sharing, driving behavioral change via directly lowering the overall frequency of illicit substance use, and improving psychosocial outcomes while stabilizing mental health and facilitating social reintegration.[17,18] In India, the expansion of OST has transitioned from a pilot phase to a core national strategy by NACO. This scale-up is driven by a “demand-side” approach, where the increase in centers is a direct response to the rising identification of PWID.[7]
Evidence from this study confirms that the TI outreach model has successfully fostered significant improvements in harm reduction behaviors among PWID. The high frequency of TI visits observed is directly correlated with a robust distribution of sterile injection equipment, ensuring that registered participants receive a more comprehensive package of services than their non-registered counterparts. By employing a mixed-methods approach—utilizing non-TI PWIDs as a comparative cohort and FGDs for qualitative depth—this research provides a multi-dimensional validation of the TI framework’s impact within the state. Despite these positive outcomes, certain methodological constraints must be acknowledged. There was an inherent difficulty in recruiting an adequate and representative sample of non-TI PWIDs, leading to a smaller-than-ideal cohort based on subjective estimates. Qualitative analysis examined 10 FGDs, reaching thematic saturation across all Target Interventions TIs to ensure broad geographical representation within the state. While qualitative findings are not statistically generalizable to broader populations, such as other districts or states, they offer meaningful conceptual transferability. Although participants’ responses may have been affected by subjective and recall bias, research staff were specifically trained to recruit a diverse group of participants rather than focusing on a single social network of PWID. The transient nature of this “hidden” population, combined with a profound reluctance to disclose peer networks, created significant barriers to recruitment. Furthermore, because non-TI participants were engaged individually and independently, the logistics of organizing FGDs for this group were not feasible, limiting our qualitative comparison to the TI cohort only.
To address these gaps and further reduce community-level harm, the following programmatic shifts are recommended; first, diversified engagement for transient populations (non-TI PWID): New outreach strategies must be designed for PWID in the “service class” or for those who are not permanent district residents. These models should prioritize anonymity, convenience, and flexible hours to accommodate their mobile lifestyles and maintain confidentiality, and decentralization of OST: The current shortage of OST centers—with only two available statewide—remains a critical bottleneck. To bridge this gap, the state should aim to integrate OST facilities within every TI center, ensuring that pharmacological support is as accessible as sterile needle distribution.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
Himachal Pradesh State AIDS Control Society (HPSACS), Himachal Pradesh for providing financial assistance.
Funding Statement
Nil.
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