Abstract
BackgroundThe 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.MethodsWe 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.ResultsIncidence 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).ConclusionsEven 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.
Highlights
The HIV epidemic in Pakistan began in 1986 when a foreign sailor died of AIDS in Karachi; local transmission was documented in 1987 [1,2]
We conducted our study at three drop-in centers that provide basic harm reduction and social services to persons who inject drugs (PWID) exclusive of opiate substitution therapy; the non-governmental organizations (NGOs) that runs the drop-in centers has been working with PWID since 1994
Excluding the 162 men lost to follow-up 2 years, study we had confirmed 118 (24.9%) HIV seropositive and 356 (75.1%) HIV Seronegative PWID (Table 1), at the end of the study (24 month follow-up)
Summary
The HIV epidemic in Pakistan began in 1986 when a foreign sailor died of AIDS in Karachi; local transmission was documented in 1987 [1,2]. In 2003, the prevalence of HIV among persons who inject drugs (PWID; known as injection drug users) was 0.6% in Karachi, Pakistan’s major port and largest city [4]. From 2003 to 2007, HIV prevalence among PWID in Karachi rose from 0.3% to 23% in 2004 and has reached 42% in 2011 [6,7]. The findings of 2011 national surveillance showed an extremely high prevalence in other cities of Pakistan [7]. 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. No cohort study of PWID has ever been conducted
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