It started with a phone call. Then another. And another. Mujeeb’s (name changed) phone rang non-stop on March 27, as friends and fellow Human Immunodeficiency Virus (HIV) survivors reached out in a panic. The news of an HIV outbreak among injecting drug users (IDUs) at Valanchery in Malappuram district had spread like wildfire, sparking fears of stigma and rejection.
As many as 10 persons were found infected in a routine screening held in the district. It was the single largest HIV outbreak reported in recent memory in Kerala, a State known for its lowest HIV prevalence in the country.
A routine HIV screening of a prisoner at the Tavanur Central Prison last August uncovered a disturbing trend. The prisoner, detained for drug possession, tested positive, sparking concerns of an HIV spread among his fellow drug users in and around the area. After months of careful outreach, health officials coaxed several suspected individuals into testing, yielding alarming results: 10 were HIV-positive. Several of them are married.
Rude shock for health sector
The situation is even more worrying as six of the 10 HIV cases were identified as migrant labourers from Assam and West Bengal, a figure disputed by some health officials. They argue that all but three cases are local IDUs. The finding has come as a rude shock to those in the health sector as Kerala is preparing to achieve its ambitious goal of zero new HIV infections by 2030.
Mujeeb knew those fears all too well. He had lived with HIV for 25 years and had spent years fighting to overcome the shame and silence that surrounded the disease. He remembered the dark days of his diagnosis, the feelings of isolation and despair. But he also remembered the moment he found his voice, his strength, and his community.
A 1,100-member organisation
Now, as he listened to his friends’ worried voices, Mujeeb felt a surge of determination. He plays a key role in the Malappuram District Network of Positive People, a 1,100-member organisation that not only works to prevent HIV transmission but also helps those living with the virus to lead a dignified life. He would do everything in his power to support them, to reassure them and to keep their community safe. He took a deep breath and began to answer the calls, one by one.
“There’s no need to worry, and this isn’t an extraordinary situation. The cases were detected through routine screenings of injecting drug users who shared needles. Let this serve as a warning to injecting drug users elsewhere in the State. But for us, there’s no cause for concern,” he pacifies one of the callers who was trembling with fear on the other side of the phone.
R. Renuka, the Malappuram District Medical Officer, confirmed that 10 IDUs who shared syringes tested HIV positive. “The rate of HIV transmission through sexual contact is much lower than through blood transfusion and shared needles. Still the risk of their partners becoming infected cannot be ignored,” she cautions.
“Yes, there are worries. But we understand that four spouses tested so far have been negative,” chips in Mujeeb.
Problem of shared syringes
The latest HIV incident sent shock waves through the State’s IDU community, who often share syringes. Many individuals connected to those diagnosed with HIV have gone underground, making it challenging to reach them. Unfortunately this means they are likely to skip the prevention programmes implemented by the Kerala State AIDS Control Society.
“The results should not have been revealed. It created panic. Many are worried that they will be identified,” points out R. Sreelatha, the project director of the Society.
The HIV and AIDS (Prevention and Control) Act of 2017, which requires informed consent for HIV testing, further complicates efforts to get them tested. As a result, identifying and supporting this vulnerable group has become a time-consuming and difficult task. “But we are confident that we will rope them in. We have already won their confidence,” says Dr. Sreelatha.
Therapy reduces viral load
“The source of the infection in this case must have had a very high viral load, making it easier to transmit the virus to others. This is particularly surprising given that Kerala has a well-established system for managing HIV, including antiretroviral therapy that can significantly reduce the viral load in individuals living with HIV,” says T.S. Anish, Professor of Community Medicine at Government Medical College, Kozhikode.
Law enforcement officers tasked with combating drug and human trafficking are often puzzled by the tactics employed by migrant workers. Vulnerable women from northern States are reportedly coerced into prostitution, confides a law enforcement officer.
“We found several instances of involvement of young women in murky deals in some parts of the district during our raids. When questioned, the migrant workers would invariably say the women are their family members. But the truth is they broadcast the women’s pictures to a large number of other men, inviting them for flesh trade. When the sex trade and drugs combine, it becomes a dangerous proposition,” says P.K. Jayaraj, Deputy Excise Commissioner, Malappuram.
Soon after news spread about the HIV outbreak, the excise, civic, police and health authorities sprang into action. “We have formed a special task force under an Assistant Excise Commissioner. They have started silent work at the grassroots level,” says Jayaraj.
Valanchery Municipal Chairperson Ashraf Ambalathingal says that the civic body has launched a multi-pronged initiative to address the crisis: medical screening camps are being planned to target high-risk groups, including migrant workers, sex workers and injecting drug users.
“We have formed a 50-member vigilance team to monitor drug hotspots in and around the local body,” says Ashraf.
“Injection drugs, particularly brown sugar and heroin, are showing a disturbing resurgence while synthetic drugs like MDMA are increasingly captivating the youth,” says Jayaraj.
Two drug-trafficking channels
Excise authorities have pinpointed two distinct drug trafficking channels: one bringing brown sugar from Gujarat and Rajasthan to Kerala via Mumbai and supplying to locals, and another smuggling in brown sugar from Myanmar through Nagaland and Assam, targeting migrant workers. Both substances reach Kerala in different forms.
“We suspect that women from some northern States are bringing brown sugar and heroin to Perumbavoor, a key hub for migrant workers in Kerala,” says Jayaraj. From there, the substance is distributed to other areas.
“The highly addictive nature of brown sugar, characterised by intense cravings and severe withdrawal symptoms, drives users to take the intravenous routes. Desperate for a quick fix, the users often become reckless. Impatience and desperation lead them to share needles, abandoning safety precautions and exposing them to all sorts of risks,” says Dr. Anish.
“The growing number of IDUs poses a significant threat as their risky behaviours can rapidly spread HIV among them and the general public,” says C. Shubin, District Surveillance Officer in charge of the District AIDS Control Office.
Concealed identities
With over three million migrant workers, Kerala is facing the challenge of tracking and supporting those with HIV. Many conceal their identities and constantly move, hindering data collection and follow-up efforts. “The challenge is circumvented by making targeted interventions with focus on vulnerable groups such as female sex workers, single male migrant workers, transgenders and injecting drug users,” says Dr. Shubin.
“The Society’s needle exchange programme and Opioid Substitution Therapy (OST) have had positive results among injecting drug users, despite evoking criticism from some quarters,” says Shubin.
While the needle exchange programme prevented the drug users from sharing needles, the OST could considerably reduce the opioid dependence of the users. The OST, one of the key intervention strategies of the National AIDS Control Programme (NACP), involves replacing an opioid drug with a safer, long-acting medication like buprenorphine or methadone to help individuals overcome opioid dependence and reduce associated harms like HIV infection, explain health experts.
Even when the State witnessed a significant drop in HIV infections and related deaths in recent years, the floating migrant population, increased drug use, and inter-state and international travel constitute major reasons for concern for Kerala. “Kerala has a low risk of HIV transmission. This is largely attributed to high awareness levels in the State. However, the influx of people from other States with higher risk factors poses a potential threat, which could alter the current scenario at any time,” says Anish.
Kerala has one of the lowest HIV prevalence rates in the country, according to India HIV Estimates 2023, the latest data released by the National AIDS Control Organisation on December 17, 2024. “Kerala’s HIV prevalence rate is 0.07% against the national average of 0.22%,” points out Dr. Sreelatha.
Kerala’s prevalence rate
Kerala’s prevalence rate is 684 cases per million, which is way below in comparison to neighbouring Tamil Nadu, Karnataka, and Andhra Pradesh. When Kerala has 24,416 people living with HIV, Andhra Pradesh has 3.20 lakh and Karnataka 2.80 lakh, she points out.
The Valanchery episode reminds Kerala that it cannot remain complacent. While being proactive and pushy, the State needs to introspect whether its awareness drives have only had positive results. “I think our awareness campaigns have had some negative impact too. It should be studied,” says B. Harikumar, former coordinator of the Nasha Mukt Bharat Abhiyan, a platform for the campaign against drug use.
Mujeeb’s telephone keeps on ringing throughout the day. He patiently attends each call and consoles the caller. For, he knows that every word of solace means a lot to the caller. It also makes the difference between death and survival.
Published – April 04, 2025 08:40 am IST
