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

Abstract

BackgroundArmed 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.MethodsConsenting 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.ResultsOf 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.ConclusionThere 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.

Needle exchange programs for the prevention of hepatitis C virus infection in people who inject drugs: a systematic review with meta-analysis

“…Two studies did not report needle exchange participation for the number of participants who were HCV seronegative at baseline [44, 45]. With the exception of one study that only enrolled males [45], all other studies enrolled both genders.…”

Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs

“…No intervention of interest: no OST or NSP Tait 2013b No outcome of interest. No intervention of interest: no OST or NSP Todd 2015 No intervention of interest (NSP shuts down for some of the follow‐up) Tracy 2014 No intervention of interest: no OST or NSP Tsirogianni 2013 No intervention of interest: no OST or NSP Tsui 2009 No intervention of interest: no OST or NSP Valdez 2011 No outcome of interest. No intervention of interest: no OST or NSP Van Ameijden 1993 No intervention of interest: no OST or NSP Van den Hoek 1990 No outcome of interest Van den Laar 2009 No outcome of interest.…”

HIV incidence among people who inject drugs in the Middle East and North Africa: mathematical modelling analysis

“…One example is the lower than expected contribution of PWID to total incidence we estimated in Afghanistan and Pakistan – two countries where the epidemic is apparently largely driven by injecting drug use . In Afghanistan, a similar HIV incidence rate of 1.5% ppy was measured among PWID in a cohort study . Under‐reporting of injecting risk behaviour, hidden HIV epidemics among PWID in sites not covered by the IBBSS, and emerging and/or hidden HIV epidemics among other KPs such as MSM in Pakistan, could be potential explanations to the observed lower contribution of PWID to total incidence.…”

“…Despite noticeable progress in the collection of HIV prevalence data in MENA, HIV incidence data remain scarce among all populations groups . Among PWID, only three cohort‐type HIV incidence studies have been conducted; in Afghanistan , Pakistan and Iran , and all indicated substantial incidence . Quantifying HIV incidence among PWID in MENA is urgently needed to provide baseline data to track progress towards UNAIDS target of reducing the number of new HIV infections among young people and adults by 75% by 2020 .…”