HIV prevalence, related risk behaviors, and correlates of HIV infection among people who use drugs in Cambodia

"Take services to the people": strategies to optimize uptake of PrEP and harm reduction services among people who inject drugs in Uganda

BACKGROUND

People who inject drugs (PWID) are at increased risk of HIV acquisition and often encounter barriers to accessing healthcare services. Uganda has high HIV prevalence among PWID and lacks integrated pre-exposure prophylaxis (PrEP) and harm reduction services. Understanding PWID experiences accessing and using harm reduction services and PrEP will inform strategies to optimize integration that align with PWID needs and priorities.

METHODS

Between May 2021 and March 2023, we conducted semi-structured interviews with PWID in Kampala, Uganda. We recruited participants with and without previous experience accessing harm reduction services and/or PrEP using purposive and snowball sampling. Interviews were audio recorded, translated, and transcribed. We used thematic analysis to characterize motivations for uptake of harm reduction and HIV prevention services, and strategies to optimize delivery of needle and syringe programs (NSP), medications for opioid use disorder (MOUD), and PrEP.

RESULTS

We conducted interviews with 41 PWID. Most participants were relatively aware of their personal HIV risk and accurately identified situations that increased risk, including sharing needles and engaging in transactional sex. Despite risk awareness, participants described engaging in known HIV risk behaviors to satisfy immediate drug use needs. All reported knowledge of harm reduction services, especially distribution of sterile needles and syringes, and many reported having experience with MOUD. Participants who had accessed MOUD followed two primary trajectories; limited resources and relationships with other PWID caused them to discontinue treatment while desire to regain something they believed was lost to their drug use motivated them to continue. Overall, PrEP knowledge among participants was limited and few reported ever taking PrEP. However, participants supported integrating PrEP into harm reduction service delivery and advocated for changes in how these services are accessed. Stigma experienced in healthcare facilities and challenges acquiring money for transportation presented barriers to accessing current facility-based harm reduction and HIV prevention services.

CONCLUSIONS

Meeting the HIV prevention needs of PWID in Uganda will require lowering barriers to access, including integrated delivery of PrEP and harm reduction services and bringing services directly to communities. Additional training in providing patient-centered care for healthcare providers may improve uptake of facility-based services.

A Scoping Review of Knowledge, Awareness, Perceptions, Attitudes, and Risky Behaviors of Sexually Transmitted Infections in Southeast Asia

This scoping review synthesizes literature to examine the extent of research focusing on knowledge, awareness, perceptions, attitudes, and risky behaviors related to sexually transmitted infections (STIs) in Southeast Asia (SEA). The PRISMA-Scoping approach was adopted targeting articles published from 2018 to 2022, sought from CINALH, PubMed, Web of Science and Scopus. A process of screening and elimination resulted in a total of 70 articles reviewed. Most of the studies were conducted in Indonesia, Thailand, Vietnam, and Malaysia, with the majority focusing on HIV/AIDS. In general, studies examining knowledge, awareness, and risky behaviors related to STIs in SEA reported low levels across various cohorts. However, evidence suggests that these issues are more prominent among individuals with low levels of education or low socioeconomic status, those living in rural areas or those working in the sex/industrial sectors. Engaging in unsafe sex and having multiple partners are the key examples for risky sexual behavior, while fear of being rejected/discriminated/stigmatized and lacking STI awareness were identified as social risky behaviors in SEA. Overall, cultural, societal, economic and gender inequality (male dominance) greatly impact people's knowledge, awareness, perceptions, attitudes, and risky behaviors in SEA. Education is an important factor influencing healthy behavior; therefore, this scoping review calls for increased investment in educating vulnerable populations to prevent STIs, particularly in less-developed countries/regions of SEA.

Sex Under the Influence of Drugs Among People Who Use Drugs in Cambodia: Findings From a National Survey

Studies in drug use settings rarely use sex under the influence of drugs as an indicator of sexual risk behaviors. This study explored the prevalence of sex under the influence of drugs and its correlates among people who use drugs (PWUD) in Cambodia. We included 1147 PWUD from 12 provinces in this study. A multiple logistic regression analysis was conducted to identify factors associated with sex under the influence of drugs. Of the total, 39.7% reported having had sex under the influence of drugs in the past three months. After adjustment, sex under the influence of drugs was significantly associated with living in urban areas (AOR 2.97, 95% CI 1.68-5.27), having two to three (AOR 2.48, 95% CI 1.76-3.49) and four or more sexual partners (AOR 6.46, 95% CI 4.24-9.85), engaging in transactional sex (AOR 1.69, 95% CI 1.19-2.39), using methamphetamine (AOR 2.97, 95% CI 2.06-4.31), using drugs for three years or longer (AOR 1.67, 95% CI 1.15-2.41), having been to a drug rehabilitation center (AOR 1.77, 95% CI 1.18-2.41), having a network of ten or more PWUD (AOR 1.82, 95% CI 1.25-2.66), and having high psychological distress (AOR 1.66, 95% CI 1.25-2.22). This study documents the high prevalence of sex under the influence of drugs and its risk factors among male and female PWUD in Cambodia. These findings point to the need for integrating HIV and harm-reduction programs using innovative approaches to address the overlapping risks in this key population.

Recent HIV testing and associated factors among people who use drugs in Cambodia: a national cross-sectional study

OBJECTIVE

To estimate the prevalence of HIV testing and examine factors associated with recent HIV testing among people who use drugs (PWUD) in Cambodia.

DESIGN

Cross-sectional study.

SETTING

Twelve major provinces with a high burden of HIV and drug use in Cambodia.

PARTICIPANTS

This study included 1677 PWUD recruited using a peer-based social network recruitment method. Participants' selection criteria included being at least 18 years old and using any illicit drugs via any administration routes in the past 12 months.

PRIMARY OUTCOME MEASURE

Recent HIV testing, defined as having an HIV test in the past 6 months.

RESULTS

The median age of the participants was 28 (IQR 22-34) years, and 56.6% were men. The prevalence of lifetime and recent HIV testing was 70.7% and 42.9%, respectively. After adjustment in multivariable logistic regression analysis, recent HIV testing remained positively associated with being female (adjusted OR (AOR) 1.55, 95% CI 1.18 to 2.04) or third gender identity (AOR 2.06, 95% CI 1.11 to 3.80), having ever been to a drug rehabilitation centre (AOR 1.60, 95% CI 1.13 to 2.29), having used any HIV services in the past 6 months (AOR 7.37, 95% CI 5.61 to 9.69), having received HIV education in the past 3 months (AOR 3.40, 95% CI 2.63 to 4.40) and having self-perception of higher HIV risk (AOR 1.81, 95% CI 1.19 to 2.73).

CONCLUSIONS

Recent HIV test uptake among PWUD in Cambodia was suboptimal. This study highlights the roles of outreach HIV education and services in promoting regular HIV testing among PWUD. Strengthening the coordinated effort of government agencies and local civil society organisations to prioritise expanding community-based peer-driven interventions to reach out to this hidden population is warranted.

Willingness to initiate pre-exposure prophylaxis (PrEP) and its use among opioid-dependent individuals in drug treatment

BACKGROUND

People who use drugs (PWUD) continue to experience a disproportionate HIV burden due to drug- and sex-related risk behaviors. Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV infection, but very little is known about PrEP use among PWUD and their willingness to initiate PrEP.

METHODS

We conducted a cross-sectional survey among 234 HIV-negative, opioid-dependent individuals recruited from an urban methadone clinic. Participants were assessed using an audio-computer assisted self-interview technique. Bivariate and multiple logistic regressions were used to explore independent correlates of actual PrEP use and willingness to initiate PrEP.

RESULTS

One-fourth (25.6 %) of participants had previously used PrEP. Over two-thirds (67.1 %) of participants had previously heard of PrEP, and 65.0 % were willing to take it. In multivariable logistic regression analyses, the number of times participants engaged in HIV testing (aOR = 1.66, p < 0.01) and whether they visited a healthcare provider (aOR=20.81, p = 0.02) were associated with a higher likelihood of PrEP use, while perceived HIV risk (aOR=2.71, p < 0.01) and previous use of PrEP (aOR=3.57, p < 0.01) were significantly associated with willingness to initiate PrEP.

CONCLUSION

PrEP use was low among PWUD, but their willingness to initiate PrEP was moderate, which indicated a significant discrepancy between actual PrEP use and willingness to use it. Our findings highlight the importance of healthcare providers engaging opioid-dependent individuals in discussions about PrEP and the need for innovative strategies to increase their awareness of PrEP and modify their perceptions of HIV risk.

Syphilis infection among people who use and inject drugs in Cambodia: a cross-sectional study using the respondent-driven sampling method

This cross-sectional study explored the prevalence and correlates of syphilis infection among people who use and inject drugs (PWUD/PWID) in Cambodia. Data were collected in 2017 from 1,677 PWUD/PWID living in the capital city of Phnom Penh and 11 other major provinces using the respondent-driven sampling method. The SD Bioline HIV/Syphilis Duo test was used to determine human immunodeficiency virus (HIV) and current or past syphilis infection. A multivariable logistic regression analysis was conducted to identify risk factors associated with current or past syphilis infection. The prevalence of current or past syphilis infection was 3.8% (95% confidence interval = 2.4-4.6). After adjustment, current or past syphilis infection remained positively associated with being female, living on the streets, having an average monthly income of US$100-299, having transactional sex in the past three months, and having been to a rehabilitation centre in the past 12 months. Current or past syphilis infection was negatively associated with having attained at least high school level of formal education. The findings indicate vulnerability to syphilis infection among PWUD/PWID in Cambodia, particularly among subpopulations who are more marginalized. Syphilis prevention and control programmes should be systematically integrated into HIV and sexually transmitted infection policy and services in the country.

Psychological distress among Cambodian people who use drugs

INTRODUCTION AND AIMS

People who use drugs (PWUD) face several mental health problems. This report aims to examine the prevalence of and factors associated with psychological distress among Cambodian PWUD.

DESIGN AND METHODS

Data used in our analysis were from the national survey of 1626 PWUD recruited through respondent-driven sampling method in Cambodia in 2012 to 2013. Distress was measured through self-report by using the 10-item Kessler Psychological Distress Scale (K10). All analyses were weighted.

RESULTS

Approximately half of PWUD had mild to severe psychological distress in the past four weeks (K10 ≥ 20). In the adjusted analysis, being female (odds ratio 1.60; 95% confidence interval 1.22, 2.12) and having experienced living in rehabilitation centres (odds ratio 2.46; 95% confidence interval 1.56, 3.87) were associated with a higher risk of having moderate or severe psychological distress (K10 ≥ 25).

DISCUSSION AND CONCLUSIONS

Psychological distress was prevalent among Cambodian PWUD. PWUD who were female or experienced living in rehabilitation centres were more likely to report distress. Policy makers should consider shifting further from compulsory institutionalised treatment model to community-based treatment program. Mental health assessment and mental health care services should be included in drug treatment programs and should be gender-sensitive. Further research investigating other mental disorders among PWUD are also needed.

Prevalence and risk factors of HIV infection among people who inject drugs in Cambodia: findings from a national survey

BACKGROUND

Globally, people who inject drugs (PWID) continue to be among the most vulnerable populations to acquire infection of human immunodeficiency virus (HIV). The most recent national survey found that nearly a quarter of PWID in Cambodia were infected with HIV in 2012. The aim of this study is to estimate the current prevalence of and factors associated with HIV infection among PWID in Cambodia.

METHODS

This national integrated biological and behavioral survey was conducted from June to December 2017. Participants were recruited from the capital city and 11 major provinces using the respondent driven sampling method. Face-to-face interviews were conducted using a structured questionnaire, and blood samples were collected for HIV, syphilis, and hepatitis C virus (HCV) testing. Multiple logistic regression analysis was conducted to identify risk factors for HIV infection. All analyses were estimated with sampling weights that corrected for non-response and sample design.

RESULTS

A total of 310 PWID participated in the study, and the mean age was 31.8 years (SD = 7.8). The prevalence of HIV was 15.2%. More than half (57.4%) of the HIV-positive participants were co-infected with HCV, and 44.7% were not aware of their HIV status prior to this study. After adjustment for other covariates, HIV infection remained positively associated with being female (AOR = 1.88, 95% CI = 1.03-4.04), being in the older age group of ≥35 (AOR = 2.99, 95% CI 1.33-9.22), being widowed, divorced or separated (AOR = 2.57, 95% CI = 1.04-6.67), living on the streets (AOR = 2.86, 95% CI 1.24-4.37), and HCV infection (AOR = 3.89, 95% CI 1.86-1.15). The HIV infection remained negatively associated with having higher level of formal education of ≥10 years (AOR = 0.44, 95% CI 0.13-0.83) and higher average income of ≥US$200 per month (AOR = 0.20, 95% CI = 0.05-0.74).

CONCLUSIONS

The prevalence of HIV among PWID in Cambodia remains high, but is reducing compared with the 24.8% reported in the 2012 national survey. Findings from this study provide critical information for tailoring interventions based on identified vulnerabilities and risk factors for HIV. Our findings underline the importance of socio-structural factors in HIV epidemiology among PWID in Cambodia, which require mitigation.