Overland heroin trafficking routes and HIV-1 spread in south and south-east Asia

Objectives: Burma produces approximately 60% of the world's heroin, Laos is the third leading producer. Recent outbreaks of injecting drug use and HIV -1 in Burma, India, China, and Vietnam have been associated with Burmese an d Laotian overland heroin trafficking routes. We analyzed findings from nar cotics investigations, molecular epidemiology studies of HIV-1, and epidemi ologic and behavioral studies of injecting drug use, to evaluate the roles that the heroin export routes play in the spread of drug use and HIV-1 in s outh and south-east Asia. Methods: We reviewed the medical and narcotics literature, the molecular ep idemiology of HIV, and did key informant interviews in India, China, and Bu rma with injecting drug users, drug traffickers, public health staff, and n arcotics control personnel. Results: Four recent outbreaks of HIV-1 among injecting drug users appear l inked to trafficking routes. Route 1: From Burma's eastern border to China' s Yunnan Province, with initial spread of HIV-1 subtype BI and later C. Rou te 2. Eastern Burma to Yunnan, going north and west, to Xinjiang Province, with B, C, and a B/C recombinant subtype. Route 3: Burma and Laos, through northern Vietnam,to China's Guangxi Province, subtype E. Route 4: Western B urma, across the Burma-India border to Manipur, predominant subtype C, and B and E. Conclusions: Overland heroin export routes have been associated with dual e pidemics of injecting drug use and HIV infection in three Asian countries a nd along four routes. Molecular epidemiology is useful for mapping heroin r outes. Single country narcotics and HIV programs are unlikely to succeed un less the regional narcotic-based economy is addressed. (C) 2000 Lippincott Williams & Wilkins.