HIV/AIDS risk behaviors and correlates of injection drug use among drug users in Pakistan

An exploratory study of knowledge, attitudes, and practices toward HPV associated anal cancer among Pakistani population

Background

Anal cancer, mainly attributed to human papillomavirus (HPV) infection, is rising in prevalence among the general population in Pakistan. This study aimed to examine the knowledge, attitudes, and practices (KAP) towards anal cancer screening and HPV of the general population in Pakistan.

Method

We surveyed anal cancer KAP using social media and snowball sampling from December 2022 to May 2023. The questionnaire had 16 knowledge, 12 attitudes, 6 practice questions, and socio-demographic variables. We applied validity criteria for inclusion and exclusion and used cutoffs ≥50% for each KAP category. We analyzed data in R with Guttman's λ2 for reliability, did univariate and bivariate analysis, and reported frequencies, percentages, p-values, coefficients, odds ratios, and 95% confidence intervals.

Results

We surveyed 1620 people and discovered low awareness of HPV and anal cancer causes prevention, and screening (11%-24%), high stigma and embarrassment for screening (54%-70%), strong moral beliefs (89%), condom nonuse (91%), and low engagement in health services and programs (9.1%-14%). Knowledge (75.23%, OR = 1.0984, p = 0.05) was shaped by socio-demographic factors, attitude, and practice, with higher education enhancing knowledge (OR = 1.0984, p = 0.05). Attitude (78.45%, OR = 6.6052, p< 0.001) was influenced by socio-demographic factors, practice, and knowledge as well. Younger females, single, unemployed, students, living with more family members, earning more income, and residing in Islamabad had a more positive attitude (ORs from 1.0115 to 6.6052, p< 0.05), while religion did not affect attitude (p = 0.51). Practice (9.16%, OR = 0.1820, p< 0.001) was determined by socio-demographic factors, knowledge, and attitude. Older males, employed teachers, living with more family members, earning less income, and residing in Islamabad had better practice (ORs from 0.1323 to 3.8431, p< 0.05), but marital status and religion did not influence practice (p > 0.05).

Conclusion

Pakistani young adults need more education, awareness, health services, and programs on HPV and anal cancer, as they have low awareness, high stigma, and socio-cultural challenges. In addition, it is recommended for more research and policy initiatives are needed to address socio-cultural factors and increase anal Pap to overcome anal cancer.

The Effect of Saffron on Depression among Recovered Consumers of Methamphetamine Living with HIV/AIDS

BACKGROUND

From one hand, depression is one of the symptoms that occur after abstinence from methamphetamine. On the other people living with HIV/AIDS are in isolation due to the nature of their illness and depression is one of the most common mental health problems they experience.

OBJECTIVES

This study was aimed at determining the effectiveness of saffron on reducing depression among recovered consumers of methamphetamine living with HIV/AIDS.

METHODS

The design of this study was semi-experimental with pre-test, post-test and control (placebo) groups. The statistical population consisted of all recovered consumers of methamphetamine living with HIV/AIDS who were referred to the Positive Club. Fifty-seven (57) recovered consumers of methamphetamine, living with HIV/AIDS, were selected by convenience sampling method. They were randomly assigned to an experimental (saffron) group and a control (placebo) group. The experimental group received 30 ml of saffron per day for 8 weeks, whereas the control (placebo) group received placebo the same way. BDI-II was used in this study as a measurement instrument. ANCOVA models were used for statistical inference.

RESULTS

The findings showed that saffron and its ingredients had been effective in reducing depression among this group (P < 0.05).

CONCLUSION

In fact, saffron with its active ingredients (Crusin and Saffranal) by serotonin and dopamine secretion in the brain, help in reducing depression among recovered consumers of methamphetamine living with HIV/AIDS.

High HIV seroconversion rate in hepatitis C virus-infected drug users followed in a harm reduction unit: a lost opportunity for preexposure prophylaxis

OBJECTIVES

Current harm reduction strategies will probably remain insufficient to eliminate HIV transmission among drug users. We aimed to estimate the HIV seroconversion rate among drug users followed at a harm reduction unit (HRU) to evaluate the potential use of preexposure prophylaxis as a prevention tool.

DESIGN AND METHODS

A cohort of drug users has been followed at an HRU in Madrid between 2013 and 2016. Individuals who were HIV negative at baseline and who had at least one retest for HIV infection were eligible. Kaplan-Meier methods were employed to estimate the incidence density.

RESULTS

A total of 954 drug users had at least an HIV test. At baseline, 260 were HIV negative and had at least one follow-up HIV test. After 330.89 person-years of risk for HIV infection, 10 (3.8%) seroconverted. Overall incidence density of HIV seroconversion was 3.02 [95% confidence interval (CI); 1.4-5.5] per 100 person-years, with differences according to hepatitis C virus (HCV) serostatus: 1.17 (95% CI; 0.1-4.2) per 100 person-years in negative HCV individuals and 4.98 (95% CI; 2.1-9.8) per 100 person-years in positive HCV individuals. In the multivariable analysis, infection with HCV remained independently associated with time to HIV seroconversion (adjusted hazard ratio = 6.43; 95% CI; 1.1-36.5, P = 0.035).

CONCLUSION

Despite efforts in HIV prevention in a HRU, a high incidence of HIV was found among active drug users. Positive HCV status is a strong predictor of HIV seroconversion. In this context, preexposure prophylaxis implementation should be considered as an additional tool for HIV prevention in this population.

HIV-1 genetic diversity, geographical linkages and antiretroviral drug resistance among individuals from Pakistan

Worldwide antiretroviral therapy (ART) has reduced the mortality and morbidity rates in individuals with HIV infection. However, the increasing occurrence of drug resistance is limiting treatment options. In recent years, Pakistan has witnessed a concentrated epidemic of HIV. It is very important to identify geographical linkages and mutations that generate selective pressure and drive resistance of HIV in our population. The aim of this work was to identify genetic diversity and drug resistance patterns of HIV in Pakistan, using available sequences and bioinformatics tools, which may help in selecting effective combination of available drugs. A total of 755 Pakistani HIV gag, pol and env sequences were retrieved from the Los Alamos HIV database. Sequences were aligned with reference sequences of different subtypes. For geographical linkages, sequences of predominant subtypes were aligned with sequences of the same subtypes from different countries. Phylogenetic trees were constructed using the maximum-likelihood method in MEGA 7 software. For drug resistance analysis, sequences were entered into the Stanford University HIV Drug Resistance Database. Phylogenetic trees for studying genetic diversity showed that 82% of the sequences were of subtype A, while the rest of the sequences were of subtypes B (9.5%), K (2%), D (2%) and AE (1%). Moreover, trees that were constructed to examine geographical linkages showed close clustering of strains with those of the neighboring countries Afghanistan and India, as well as some African countries. A search for drug resistance mutations showed that 93% of the sequences had no major or minor mutations. The remaining 7% of the sequences contained a major mutation, Y115F, which causes the virus to exhibit low to intermediate resistance against lamivudine and emtricitabine. Our data indicate that HIV subtype A is the major subtype, while subtypes K, D and AE are also present in our country, suggesting gradual viral evolution and possible entry of different subtypes from neighboring countries. These data suggest that HIV is still sensitive to most of the antiretroviral drugs used in Pakistan.

High HIV incidence among persons who inject drugs in Pakistan: greater risk with needle sharing and injecting frequently among the homeless

Background

The incidence of HIV among persons who inject drugs (PWIDU) has fallen in many nations, likely due to successes of clean needle/syringe exchange and substance abuse treatment and service programs. However in Pakistan, prevalence rates for PWID have risen dramatically. In several cities, prevalence exceeded 20% by 2009 compared to a 2003 baseline of just 0.5%. However, no cohort study of PWID has ever been conducted.

Methods

We enrolled a cohort of 636 HIV seronegative PWID registered with three drop-in centers that focus on risk reduction and basic social services in Karachi. Recruitment began in 2009 (March to June) and PWID were followed for two years. We measured incidence rates and risk factors associated with HIV seroconversion.

Results

Incidence of HIV was 12.4 per 100 person-years (95% exact Poisson confidence interval [CI]: 10.3–14.9). We followed 474 of 636 HIV seronegative persons (74.5%) for two years, an annual loss to follow-up of <13 per 100 person years. In multivariable Cox regression analysis, HIV seroconversion was associated with non-Muslim religion (Adjusted risk ratio [ARR] = 1.7, 95%CI:1.4, 2.7, p = 0.03), sharing of syringes (ARR = 2.3, 95%CI:1.5, 3.3, p<0.0001), being homeless (ARR = 1.7, 95%CI:1.1, 2.5, p = 0.009), and daily injection of drugs (ARR = 1.1, 95%CI:1.0, 1.3, p = 0.04).

Conclusions

Even though all members of the cohort of PWID were attending risk reduction programs, the HIV incidence rate was very high in Karachi from 2009–2011. The project budget was low, yet we were able to retain three-quarters of the population over two years. Absence of opiate substitution therapy and incomplete needle/syringe exchange coverage undermines success in HIV risk reduction.

Hepatitis B virus in Pakistan: a systematic review of prevalence, risk factors, awareness status and genotypes

In Pakistan, there are estimated 7-9 million carriers of hepatitis B virus (HBV) with a carrier rate of 3-5%. This article reviews the available literature about the prevalence, risk factors, awareness status and genotypes of the HBV in Pakistan by using key words; HBV prevalence, risk factors, awareness status and genotypes in Pakistani population in PubMed, PakMediNet, Directory of Open Access Journals (DOAJ) and Google Scholar. One hundred and six different studies published from 1998 to 2010 were included in this study. Weighted mean and standard deviation were determined for each population group. The percentage of hepatitis B virus infection in general population was 4.3318% ± 1.644%, healthy blood donors (3.93% ± 1.58%), military recruits (4.276% ± 1.646%), healthcare persons (3.25% ± 1.202%), pregnant women (5.872% ± 4.984), prisoners (5.75% ± 0.212%), surgical patients (7.397% ± 2.012%), patients with cirrhosis (28.87% ± 11.90%), patients with HCC (22% ± 2.645%), patients with hepatitis (15.896% ± 14.824%), patients with liver diseases (27.54% ± 6.385%), multiple transfused patients (6.223% ± 2.121%), opthalmic patients (3.89% ± 1.004%) and users of injectable drugs (14.95% ± 10.536%). Genotype D (63.71%) is the most prevalent genotype in Pakistani population. Mass vaccination and awareness programs should be initiated on urgent basis especially in populations with HBV infection rates of more than 5%.

Factors associated with an explosive HIV epidemic among injecting drug users in Sargodha, Pakistan

BACKGROUND

During a routine surveillance round, an extremely high prevalence of 51.3% was found among injecting drug users (IDUs) in Sargodha, a small town in Pakistan. This sharp increase of HIV among this group warranted an urgent need to explore the factors leading toward this explosion of HIV infection among IDUs at this very location to direct the policy makers in designing preventive activities, especially in the context of HIV prevention.

METHODS

In 2007, 400 current IDUs were recruited through multistage cluster sampling based on mapping studies. Participants provided dried blood spot samples for HIV testing and completed a questionnaire on demographic characteristics and sexual/drug injecting behaviors. Logistic regression was used to examine the independent association of multiple variables with HIV infection.

RESULTS

Of the 400 IDUs tested, 205 (51.3%) were HIV positive confirmed through enzyme-linked immunosorbent assay and Western blot. In multivariate analysis, geographical location of IDUs [adjusted odds ratio (aOR) 2.4 for IDUs located in the northern zone vs southern zone, 95% confidence interval (CI) 1.5 to 3.7], injected in groups (aOR 1.8, 95% CI 1.1 to 3.1), and sharing injecting paraphernalia with other IDUs (aOR 1.5, 95% CI 1.0 to 2.4) were strong correlates of HIV infection.

CONCLUSIONS

Effective outreach programs need to be developed to provide a comprehensive package of HIV prevention services to IDUs not reached by existing services, entry into drug abuse treatment and medical care needs to be facilitated, and essential legal and social services need to be provided with community participation.

High risk behaviors of injection drug users registered with harm reduction programme in Karachi, Pakistan

BACKGROUND

Surveillance data of Sindh AIDS Control Programme, Pakistan suggest that HIV infection is rapidly increasing among IDUs in Karachi and has reached 9% in 2004-5 indicating that the country has progressed from nascent to concentrated level of HIV epidemic. Findings of 2nd generation surveillance in 2004-5 also indicate 104/395 (26.3%) IDUs HIV positive in the city.

METHODS

We conducted a cross sectional study among registered IDUs of a needle exchange and harm reduction programme in Karachi, Pakistan. A total of 161 IDUs were included in the study between October-November 2003. A detailed questionnaire was implemented and blood samples were collected for HIV, hepatitis B & C and syphilis. HIV, hepatitis B and C antibody tests were performed using Enzyme Linked Immunosorbent Assay (ELISA) method. Syphilis tests (RPR & TPHA) were performed on Randox kit. Besides calculating frequencies univariate analysis was performed using t tests for continuous variables as age, age at first intercourse and average age of initiation of addiction and chi square for categorical variables like paid for sex or not to identify risk factors for hepatitis B and C and syphilis.

RESULTS

Average age of IDU was 35.9 years and average age of initiation of drugs was 15.9 years. Number of drug injections per day was 2.3. Shooting drugs in group sharing syringes was reported by 128 (79.5%) IDUs. Over half 94 (58.3%) reported paying for sex and 64% reported never using a condom. Commercial selling of blood was reported by 44 (28%). 1 of 161 was HIV positive (0.6%). The prevalence of hepatitis B was 12 (7.5%), hepatitis C 151 (94.3%) and syphilis 21 (13.1%). IDUs who were hepatitis C positive were more likely to start sexual activity at an earlier age and had never used condoms. Similarly IDUs who were hepatitis B positive were more likely to belong to a younger age group. Syphilis positive IDUs were more likely to have paid for sex and had never used a condom.

CONCLUSION

Prudent measures such as access to sterile syringes, rehabilitation and opiate substitution therapies are required to reduce high risk behaviors of IDUs in Pakistan.

HIV-1 subtype A infection in a community of intravenous drug users in Pakistan

BACKGROUND

Data on the subtypes of HIV in a population help in predicting the potential foci of epidemic, tracking the routes of infection and following the patterns of the virus' genetic divergence. Globally, the most prevalent HIV infection is the HIV-1 subtype C. In Asia, predominant subtypes of HIV-1 are B, C, and CRF-01AE. During the last few years, HIV prevalence in Pakistan has taken the form of a concentrated epidemic in at least two high risk groups, namely, Intravenous Drug Users (IDUs) and Male Sex Workers (MSWs). Factors that have facilitated the proliferation of HIV infection include transmission through a large number of repatriates and needle-sharing intravenous drug users, unscreened blood transfusions, and sexual illiteracy. The HIV subtypes infecting Pakistani populations have not been explored to date. In this study, we analyzed HIV-1 subtypes from in a high-risk community of IDUs in Karachi, the largest city of Pakistan.

METHODS

Samples were collected from 34 IDUs after their informed consent. In addition, the study subjects were administered a questionnaire regarding their sexual behavior and travel history. For HIV analysis, DNA was extracted from the samples and analyzed for HIV types and subtypes using subtype-specific primers in a nested polymerase chain reaction (PCR). The results from this PCR were further confirmed using the Heteroduplex Mobility Assay (HMA).

RESULTS

We found HIV-1 subtype A in all the 34 samples analyzed. A few of the study subjects were found to have a history of travel and stay in the United Arab Emirates. The same subjects also admitted to having contact with commercial sex workers during their stay abroad.

CONCLUSION

Our study therefore shows clade A HIV-1 to be prevalent among the IDUs in Karachi. As the prevalence of HIV in Pakistan continues to rise, more work needs to be done to track the infection, and to analyze the strains of HIV spreading through the country.

High HCV seroprevalence and HIV drug use risk behaviors among injection drug users in Pakistan

Introduction

HIV and HCV risk behaviors among injection drug users (IDUs) in two urban areas in Pakistan were identified.

Methods

From May to June 2003, 351 IDUs recruited in harm-reduction drop-in centers operated by a national non-governmental organization in Lahore (Punjab province) and Quetta (Balochistan province) completed an interviewer-administered survey and were tested for HIV and HCV. Multivariable logistic regression identified correlates of seropositivity, stratifying by site. All study participants provided written, informed consent.

Results

All but two were male; median age was 35 and <50% had any formal education. None were HIV-positive; HCV seroprevalence was 88%. HIV awareness was relatively high, but HCV awareness was low (19%). Injection behaviors and percutaneous exposures such as drawing blood into a syringe while injecting ('jerking'), longer duration of injection, and receiving a street barber shave were significantly associated with HCV seropositivity.

Discussion

Despite no HIV cases, overall HCV prevalence was very high, signaling the potential for a future HIV epidemic among IDUs across Pakistan. Programs to increase needle exchange, drug treatment and HIV and HCV awareness should be implemented immediately.

Background demographics and risk behaviors of injecting drug users in Karachi, Pakistan

OBJECTIVE

To find the prevalence of HIV infection and risk behaviors among injecting drug users (IDUs) in Karachi, Pakistan.

DESIGN

A cross-sectional study of IDUs conducted in Karachi, Pakistan from February through June 1996.

RESULTS

Of the 242 IDUs, 11 (4%) refused HIV testing. One (0.4%; 95% confidence interval (CI) = 0.37-0.48%) was HIV positive. All subjects were male. Over the past 6 months 47% had engaged in receptive needle sharing, 38% had perceived a change in their social network, 22% had had sexual intercourse, of whom only 7% always used condoms, and none had washed their needles with bleach. Younger age (28 vs. 31 years; p = 0.01), younger age at first injection (25 vs. 28 years; p = 0.001), fewer years of schooling (3 vs. 5 years; p = 0.001), lower monthly income (70 dollars vs. 80 dollars; p = 0.03), inhaling fumes of heroin from a foil in the year before injecting (OR = 4.8; CI = 2.2-10.3), injecting first time with heroin (OR = 3.6; CI = 1.2-12.6), having a temporary job (OR = 2.5; CI = 1.2-5.2), and a perceived change in one's social network (OR = 4.4; CI = 2.4-7.9) were all associated with receptive needle sharing. IDUs who knew about HIV spread through contaminated needles were less likely to share (OR = 0.4; CI 0.2-0.8). In the final logistic regression model receptive needle sharing was associated with inhaling of fumes of heroin on a foil in the year prior to injecting (adjusted OR = 5.6; CI = 2.6-12.0), a perceived change in one's social network (adjusted OR = 4.0; CI = 2.2-7.4), and inversely associated with age at first time of injection (beta = -0.07; p = 0.002).

CONCLUSION

Background HIV prevalence was low among IDUs in Karachi despite high-risk behavior in 1996. In order to control HIV transmission among IDUs in Pakistan, continual HIV surveillance with well-coordinated and effective HIV risk reduction, and drug demand reduction programs need to be implemented among drug users.

Drug use, street survival, and risk behaviors among street children in Lahore, Pakistan

There are an estimated 3,500-5,000 street children living on the streets of Lahore, Pakistan. A disproportionate number of these children use drugs and engage in survival sex as coping mechanisms. Since August, 2003, Project Smile provides mobile social and health services to street children 6 days a week in selected neighborhoods. This study utilizes data from Project Smile registration data on the program's initial clients (n=347). The study aimed to compare current, former, and nondrug users regarding their reasons for living on the streets, survival and coping mechanisms, and reasons for drug initiation. Of the total sample, 17.0% reported never having used drugs, 15.9% reported being former drug users, and 67.1% reported having used drugs in the month before registration. Participants were 96% boys with a median age of 13 years. The median length of living on the streets was 18 months, and 52.7% had ever been arrested by the police. Odd jobs, begging, and pickpocketing were the primary sources of reported income. Forty-eight percent reported ever having engaging in transactional sex, and 40% reported cutting themselves, primarily to cope with their anger. Variables that were significantly correlated with being a current drug user (vs. never) in the presence of other variables included: being 13 years or older [adjusted odds ratio (AOR)=3.0; 95% confidence interval (95% CI)=1.3-7.0]; reporting a daily income > or =Rs 60 (AOR=2.7; 95% CI=1.1-6.4); having a history of arrest (AOR=3.3; 95% CI=1.3-8.3); wanting to return home (AOR=0.3; 95% CI=0.1-0.8); feeling hatred from the public (AOR=5.1; 95% CI=2.0-12.9); ever exchanging sex for food, shelter, drugs, or money (AOR=3.4; 95% CI=1.3-8.9); and ever having cut themselves (AOR=15.4; 95% CI=3.4-70.7). Drug use is a major coping mechanism among street children in Lahore and is associated with many behaviors. Targeted programs are needed to meet their special needs.