Risk factors of HIV and variation in access to clean needles among people who inject drugs in Pakistan

Abstract

We identified key risk factors for HIV among people who inject drugs (PWID) in Pakistan and explored access to free clean needles. Multivariable logistic regression was used to investigate associations between HIV prevalence and demographic, behavioral, and socio-economic characteristics of PWID. Data came from the Government of Pakistan’s Integrated Biological and Behavioral Surveillance (IBBS) Round 5 (2016–17; 14 cities). A secondary analysis investigated associations with reported access to clean needles. Unweighted HIV prevalence among 4,062 PWID (99% male) was 21.0%. Longer injecting duration (Odds ratio [OR] 1.06 [95% confidence interval: 1.02–1.10]; per year), higher injecting frequency (OR 1.67 [1.30–2.13]; per unit increase), and injecting heroin (OR 1.90 [1.11–3.25]) were positively associated with HIV prevalence. There was no association between using a used syringe at last injection and HIV. Having>10 years of education had lower odds of HIV than being illiterate (OR 0.58 [0.35–0.95]). Having a regular sexual partner (OR 0.74 [0.57–0.97]) or paying for sex with the opposite sex (OR = 0.62 [0.45–0.85]) had lower odds of HIV than not. Conversely, PWID paying a man/hijra for sex had higher odds of HIV (OR 1.20 [1.00–1.43]). Receipt of clean needles varied by city of residence (0–97% coverage), whilst PWID with knowledge of HIV service delivery programs had higher odds of receiving clean needles (OR 4.58 [3.50–5.99]). Injecting behaviors were associated with HIV prevalence among PWID, though risks related to paying for sex remain complicated. Geographical variation in access to clean needles suggests potential benefits of more widely spread public health services.

Notable transmitted HIV drug resistance among people who inject drugs in Pakistan

“…Differences in DRM prevalence among cities might also be partially explained by varying rates of heroin injection, observed to be high in Karachi and Quetta (96.9% and 81.1% respectively) (59). Heroin has been associated with high-risk injection practices, such as needle sharing and “jerking”, where heroin is mixed with blood and shared amongst injectors (6), facilitating transmission of resistant strains among PWID.…”

“…In Pakistan, HIV prevalence is estimated to be 0.1% in the general population, but is known to be much higher among people who inject drugs (PWID), with estimates as high as 40% of PWID in the country living with HIV (1,2). This considerable burden is attributable to the marginalization of PWID due to contextual factors, including illiteracy, poverty, homelessness, and criminalization (3–5), which constrain access to both harm reduction programs and antiretroviral therapy (ART) (6). Further, the requirement of individuals actively injecting drugs to undergo a two-week drug detoxification prior to ART initiation (7) and lack of a national opioid substitution therapy program in Pakistan presents structural barriers which might contribute to higher rates of HIV transmission among PWID overall, hindering effective HIV management and posing challenges to overall HIV epidemic control efforts in the country (8–10).…”