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

Catherine S Todd,Steffanie A Strathdee,Katja Fiekert,Mohammad Raza Stanekzai,David Vlahov,Heather L Sipsma,Abdul Nasir

doi:10.1186/s12954-015-0056-z

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.

Highlights

The effects of armed conflict and displacement on sexual and blood-borne pathogen infection are complex, with multiple and potentially variable outcomes [1, 2]
Using HIV as an example, systematic reviews of countries where HIV is predominantly sexually transmitted indicate that prevalence among communities of individuals fleeing armed conflict is largely equivalent to or lower than surrounding native communities and that populationlevel HIV prevalence is generally lower in countries affected by wide-scale armed conflict [3, 4]
This study aims to estimate hepatitis C virus (HCV) and HIV incidence and modifying factors, including civil insecurity and harm reduction programming, among injecting drug users (IDUs) in Kabul, Afghanistan

Summary

Introduction

The effects of armed conflict and displacement on sexual and blood-borne pathogen infection are complex, with multiple and potentially variable outcomes [1, 2]. There is little information regarding impact of conflict in settings where HIV or other pathogens like hepatitis C virus (HCV) transmission is predominantly through injecting drug use [6, 7]. An illustrative case is Afghanistan, where security has deteriorated since 2006 and injecting as the route of drug administration has become normative in the recent years [8,9,10] Key events shaping this context include poor governance and increasing insecurity resulting in conditions favoring unchecked opiate production and, potentially, consumption [11, 12]. 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

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