Hepatitis C and HIV incidence and harm reduction program use in a conflict setting: an observational cohort of injecting drug users in Kabul, Afghanistan

Harm Reduction Journal

Steffanie A. Strathdee⁴  David Vlahov¹  Heather L. Sipsma⁵  Katja Fiekert³  Mohammad Raza Stanekzai³  Abdul Nasir³  Catherine S. Todd² 

[1] Department of Community Health Systems, University of California, San Francisco School of Nursing, 2 Koret Way, San Francisco 94143-0602, CA, USA;Asia Pacific Business Unit and Clinical Sciences Division, FHI 360, Sindhorn Building, 130-132 Wittayu Road, Bangkok 10330, Thailand;Health Protection and Research Organisation, Street 4, Taimani, Kabul, Afghanistan;Division of Global Public Health, University of California San Diego School of Medicine, 9500 Gilman Drive, MC 0507, La Jolla 92093-0507, CA, USA;Department of Epidemiology, Yale School of Public Health, 60 College Street, P.O. Box 208034, New Haven 06520-8034, CT, USA

关键词: Harm reduction;    HIV;    Hepatitis C virus;    Afghanistan;    Armed conflict;    Injecting drug use;   

Others  :  1230048
DOI  :  10.1186/s12954-015-0056-z

 received in 2015-03-12, accepted in 2015-07-06,  发布年份 2015

【 摘 要 】

Background

Armed conflict may increase the risk of HIV and other pathogens among injecting drug users (IDUs); however, there are few prospective studies. This study aimed to measure incidence and potential predictors, including environmental events and needle and syringe distribution and collection program (NSP) use, of hepatitis C virus (HCV) and HIV among IDUs in Kabul, Afghanistan.

Methods

Consenting adult IDUs completed interviews quarterly in year 1 and semi-annually in year 2 and HCV and HIV antibody testing semi-annually through the cohort period (November 2007–December 2009). Interviews detailed injecting and sexual risk behaviors, NSP service use, and conflict-associated displacement. Quarters with peak conflict or local displacement were identified based on literature review, and key events, including insurgent attacks and deaths, were reported with simple counts. Incidence and predictors of HCV and HIV were measured with Cox proportional hazards models.

Results

Of 483 IDUs enrolled, 385 completed one or more follow-up visits (483.8 person-years (p-y)). All participants were male with a median age of 28 years and a median duration of injecting of 2 years. Reported NSP use among the participants ranged from 59.9 to 70.5 % in the first year and was 48.4 and 55.4 % at 18 and 24 months, respectively. There were 41 confirmed deaths, with a crude death rate of 93.4/1000 p-y (95 % confidence interval (CI) 67.9–125) and overdose as the most common cause. HCV and HIV incidence were 35.6/100 p-y (95 % CI 28.3–44.6) and 1.5/100 p-y (95 % CI 0.6–3.3), respectively. Changing from injecting to smoking was protective for HCV acquisition (adjusted hazard ratio (AHR) = 0.53, 95 % CI 0.31–0.92), while duration of injecting (AHR = 1.09, 95 % CI 1.01–1.18/year) and sharing syringes (AHR = 10.09, 95 % CI 1.01–100.3) independently predicted HIV infection.

Conclusion

There is high HCV incidence and high numbers of reported deaths among male Kabul IDUs despite relatively consistent levels of harm reduction program use; peak violence periods did not independently predict HCV and HIV risk. Programming should increase awareness of HCV transmission and overdose risks, prepare clients for harm reduction needs during conflict or other causes of displacement, and continue efforts to engage community and police force support.

【 授权许可】

   
2015 Todd et al.

【 图 表 】

Fig. 1.

【 参考文献 】

• [1]Mock NB, Duale S, Brown LF, Mathys E, O’Maonaigh HC, Abul-Husn NK, Elliott S. Conflict and HIV: a framework for risk assessment to prevent HIV in conflict-affected settings in Africa. Emerg Themes Epidemiol. 2004; 1:6. BioMed Central Full Text
• [2]Mills EJ, Singh S, Nelson BD, Nachega JB. The impact of conflict on HIV/AIDS in sub-Saharan Africa. Int J STD AIDS. 2006; 17:713-7.
• [3]Spiegel PB, Bennedsen AR, Claass J, Bruns L, Patterson N, Yiweza D, Schilperoord M. Prevalence of HIV infection in conflict-affected and displaced people in seven sub-Saharan African countries: a systematic review. Lancet. 2007; 369:2187-95.
• [4]Anema A, Joffres MR, Mills E, Spiegel PB. Widespread rape does not directly appear to increase the overall HIV prevalence in conflict-affected countries: so now what? Emerg Themes Epidemiol. 2008; 5:11. BioMed Central Full Text
• [5]Kim AA, Malele F, Kaiser R, Mama N, Kinkela T, Mantshumba JC, Hynes M, De Jesus S, Musema G, Kayembe PK, Hawkins Reed K, Diaz T. HIV infection among internally displaced women and women residing in river populations along the Congo River, Democratic Republic of Congo. AIDS Behav. 2009; 13:914-20.
• [6]Ezard N, Oppenheimer E, Burton A, Schilperoord M, Macdonald D, Adelekan M, Sakarati A, Van Ommeren M. Six rapid assessments of alcohol and other substance use in populations displaced by conflict. Confl Health. 2011; 5:1. BioMed Central Full Text
• [7]Carballo M, Puvacic S, Zeric D. Implications of complex emergencies, uprooting and forced migration on risk of HIV/AIDS: the case of Bosnia and Herzegovina. Abstract 244/14139. XII World AIDS Conference, Geneva; 2002.
• [8]Strathdee SA, Stachowiak JA, Todd CS, Al-Delaimy WK, Wiebel W, Hankins C, Patterson TL. Complex emergencies, HIV, and substance use: no “big easy” solution. Subst Use Misuse. 2006; 41:1637-51.
• [9]Drug use in Afghanistan: 2009 survey. Executive summary. UNODC, Kabul, Afghanistan; 2010.
• [10]Humanitarian update–Afghanistan–December 2010. UN OCHA, Kabul, Afghanistan; 2011.
• [11]Rubin BR. Road to ruin: Afghanistan’s booming opium industry. New York, USA, Center for American Progress & Center on International Cooperation; 2004.
• [12]Chivers CJ. In Eastern Afghanistan, at war with the Taliban’s shadowy rule. The New York Times, February 6, 2011. http://www.nytimes.com/2011/02/07/world/asia/07taliban.html?pagewanted=all. Accessed 26 Feb 2015.
• [13]Research study on IDPs in urban settings–Afghanistan. World Bank/UNHCR, Kabul; 2011.
• [14]Todd CS, MacDonald D, Khoshnood K, Mansoor GF, Eggerman M, Panter-Brick C. Opiate use, treatment, and harm reduction in Afghanistan: recent changes and future directions. Int J Dru Pol. 2012; 23:341-5.
• [15]Todd CS, Abed A, Strathdee SA, Scott PT, Botros BA, Safi N, Earhart KC. Prevalence of HIV, hepatitis C, hepatitis B, and associated risk behaviors among injection drug users in Kabul, Afghanistan. Emerg Infect Dis. 2007; 13:1327-1331.
• [16]Nasir A, Todd CS, Stanekzai MR, Bautista CT, Botros BA, Scott PT, Strathdee SA, Tjaden J. Prevalence of HIV, hepatitis B and hepatitis C and associated risk behaviours amongst injecting drug users in three Afghan cities. Int J Drug Policy. 2011; 22:145-52.
• [17]Ruiseñor-Escudero H, Wirtz AL, Berry M, Mfochive-Njindan I, Paikan F, Yousufi HA, Yadav RS, Burnham G, Vu A. Risky behavior and correlates of HIV and hepatitis C virus infection among people who inject drugs in three cities in Afghanistan. Drug Alcohol Depend. 2014; 143:127-33.
• [18]Beyrer C, Wirtz AL, Baral S, Peryskina A, Sifakis F. Epidemiologic links between drug use and HIV epidemics: an international perspective. J Acquir Imm Def Synd. 2010; 55(S1):S10-6.
• [19]Griffin N, Khoshnood K. Opium trade, insurgency, and HIV/AIDS in Afghanistan: relationships and regional consequences. Asia Pac J Public Health. 2010; 22:159S-167S.
• [20]Rehman S, Rasoul MZ, Wodak A, Claeson M, Friedman J, Sayed GD. Responding to HIV in Afghanistan. Lancet. 2007; 370:2167-9.
• [21]Maguet O, Majeed M. Implementing harm reduction for heroin users in Afghanistan, the worldwide opium supplier. Int J Drug Policy. 2010; 21:119-21.
• [22]Mapping and situation assessment of key populations at high risk of HIV in three cities of Afghanistan. Washington D.C., World Bank; 2008.
• [23]ANSO quarterly data report Q4. 2009. ANSO, Kabul, Afghanistan; 2010.
• [24]Todd CS, Nasir A, Stanekzai MR, Fiekert K, Rasuli MZ, Vlahov D, Strathdee SA. Prevalence and correlates of HIV, syphilis, and hepatitis B and C infection and harm reduction program use among male injecting drug users in Kabul, Afghanistan: a cross-sectional assessment. Harm Reduct J. 2011; 8:22. BioMed Central Full Text
• [25]Todd CS, Stibich MA, Stanekzai MR, Rasuli MZ, Bayan S, Wardak SR, Strathdee SA. A qualitative assessment of injection drug use and harm reduction programmes in Kabul, Afghanistan: 2006–2007. Int J Drug Policy. 2009; 20:111-20.
• [26]Ezard N. Substance use among populations displaced by conflict: a literature review. Disasters. 2012; 36:533-57.
• [27]Rhodes T, Singer M, Bourgois P, Friedman SR, Strathdee SA. The social structural production of HIV risk among injecting drug users. Soc Sci Med. 2005; 61:1026-44.
• [28]Friedman SR, Rossi D, Braine N. Theorizing “Big Events” as a potential risk environment for drug use, drug-related harm and HIV epidemic outbreaks. Int J Drug Policy. 2009; 20:283-91.
• [29]Hankins CA, Friedman SR, Zafar T, Strathdee SA. Transmission and prevention of HIV and sexually transmitted infections in war settings: implications for current and future armed conflicts. AIDS. 2002; 16:2245-52.
• [30]Blomé MA, Björkman P, Flamholc L, Jacobsson H, Molnegren V, Widell A. Minimal transmission of HIV despite persistently high transmission of hepatitis C virus in a Swedish needle exchange program. J Viral Hepat. 2011; 18:831-9.
• [31]Fuller CM, Ompad DC, Galea S, Wu Y, Koblin B, Vlahov D. Hepatitis C incidence–a comparison between injection and noninjection drug users in New York City. J Urban Health. 2004; 81:20-4.
• [32]Des Jarlais DC, Diaz T, Perlis T, Vlahov D, Maslow C, Latka M, Russell Rockwell R, Edwards V, Friedman SR, Monterroso E, Williams I, Garfein RS. Variability in the incidence of human immunodeficiency virus, hepatitis B virus, and hepatitis C virus infection among young injecting drug users in New York City. Am J Epidemiol. 2003; 157:467-71.
• [33]Patrick DM, Tyndall MW, Cornelisse PG, Li K, Sherlock CH, Rekart ML, Strathdee SA, Currie SL, Schechter MT, O’Shaughnessy MV. Incidence of hepatitis C virus infection among injection drug users during an outbreak of HIV infection. CMAJ. 2001; 165:889-95.
• [34]Ruan Y, Qin G, Yin L, Chen K, Qian HZ, Hao C, Liang S, Zhu J, Xing H, Hong K, Shao Y. Incidence of HIV, hepatitis C and hepatitis B viruses among injection drug users in southwestern China: a 3-year follow-up study. AIDS. 2007; 21S:S39-46.
• [35]Wand H, Spiegelman D, Law M, Jalaludin B, Kaldor J, Maher L. Estimating population attributable risk for hepatitis C seroconversion in injecting drug users in Australia: implications for prevention policy and planning. Addiction. 2009; 104:2049-56.
• [36]Emmanuel F, Archibald C, Razaque A, Sandstrom P. Factors associated with an explosive HIV epidemic among injecting drug users in Sargodha. Pakistan. J Acquir Immune Defic Syndr. 2009; 51:85-90.
• [37]Guidance on prevention of viral hepatitis B and C among people who inject drugs. WHO, Geneva; 2012.
• [38]Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users, 2012 revision. WHO, Geneva; 2012.
• [39]Wodak A, Cooney A. Do needle syringe programs reduce HIV infection among injecting drug users: a comprehensive review of the international evidence. Subst Use Misuse. 2006; 41:777-813.
• [40]Hagan H. Hepatitis C virus transmission dynamics in injection drug users. Substance Use & Misuse. 1998; 33:1197-1212.
• [41]Afghanistan mortality Survey 2010. APHI/MoPH, CSO, ICF Macro, IIHMR and WHO/EMRO, Calverton, Maryland, USA; 2011.