Elucidating Drivers for Variations in the Explosive Human Immunodeficiency Virus Epidemic among People Who Inject Drugs in Pakistan

BACKGROUND: Pakistan’s explosive human immunodeficiency virus (HIV) epidemic among people who inject drugs (PWID) varies widely across cities. We evaluated possible drivers for these variations. METHODS: Multivariable regression analyses were undertaken using data from 5 national surveys among PWID (n = 18 467; 2005–2017) to determine risk factors associated with variations in city-level HIV prevalence. A dynamic HIV model was used to estimate the population-attributable fraction (PAF; proportion of HIV infections prevented over 10 years when that risk factor is removed) of these risk factors to HIV transmission and impact on HIV incidence of reducing their prevalence. RESULTS: Regression analyses suggested that city-level HIV prevalence is strongly associated with the prevalence of using professional injectors at last injection, heroin use in last month, and injecting ≥4 times per day. Through calibrating a model to these associations, we estimate that the 10-year PAFs of using professional injectors, heroin use, and frequent injecting are 45.3% (95% uncertainty interval [UI], 4.3%–79.7%), 45.9% (95% UI, 8.1%–78.4%), and 22.2% (95% UI, 2.0%–58.4%), respectively. Reducing to lowest city-level prevalences of using professional injectors (2.8%; median 89.9% reduction), heroin use (0.9%; median 91.2% reduction), and frequent injecting (0.1%; median 91.8% reduction) in 2020 reduces overall HIV incidence by 52.7% (95% UI, 6.1%–82.0%), 53.0% (95% UI, 11.3%–80.2%), and 28.1% (95% UI, 2.7%–66.6%), respectively, over 10 years. CONCLUSIONS: Interventions should focus on these risk factors to control Pakistan’s explosive HIV epidemic among PWID, including a concomitant expansion of high-coverage needle/syringe provision, opioid substitution therapy, and antiretroviral therapy

A matched case control study of factors of heroin addiction among male adults in Lahore, Pakistan

Illicit drug use, especially narcotic addiction is on a continuous rise all over the world. In Pakistan, the number of heroin addicts increased from 20,000 in 1981 to an estimated 1.53 million (3.01 million drug addicts) in 1993. While a number of risk factors have been identified for narcotic addiction in developed countries, information on such factors in developing countries including Pakistan still needs evaluation, as to suggest proper interventions. This matched case control study aimed to evaluate the factors associated with heroin use among male heroin addicts of age 15 to 35 years in Lahore. We enrolled a total number of 233 triplets matched on neighborhood, at a case control ratio of l: 2, during July to September 1999. We defined a case as a male, aged 15 to 35 yrs, has been using at least 0.5 gms of heroin twice weekly for the last 6 months, but not more than 05 years. The neighborhood matched control was a male aged 15 to 35 yrs., who had never used heroin, hash or marijuana in his life. Data were collected through a structured interview, by trained interviewers, using a pre-tested questionnaire. Conditional logistic regression was done to study the independent effect of individual variable. Adjusted matched odds ratios with corresponding 95Vo confidence intervals were used to interpret the model. Formal schooling of the respondent (adj. mOR=2.4; 1.5-3.8), alcohol use (adj. mOR=4.2, 95% Cl ,2.3-7.6) use of prescribed psychoactive drugs (adj. mOR=4.1, 95VoCl; 1.8-10.6) and the presence of drug using peers (adj. mOR=5.6,95% CI;2.6- 12.1), were significantly associated with heroin addiction. Among childhood and early adulthood experiences, absence of father in the childhood (adj. mOR=2.9, 95% CI: 1.6-5.5), and parental disharmony in the family showed statistically significant IY relationships. We measured parental disharmony by categorizing the variable into frequent serious fights (adj. mOR=6.0, 95% CI ;2.8-16.6) and occasional serious fights (adj. mOR=4.3,95VoCI;2.4-7 .8) and comparing it against no serious fights among the parents. Similarly the presence of a drug user among similar age group family members is associated with heroin addiction (adj. mOR=2.4, 95% Cl; 1.3-4.8). Mother\u27s non-formal schooling also showed to be an individual predictor of heroin use (adj. mOR=2.8, 95% CI; 1.7 -4.1) Based on these results, narcotic addiction seems to be a multi-factorial problem. We recommend a public awareness campaign, addressing the various facets of the problems i.e., alcoholism, misuse of licit drugs, educational programs for married couples especially the younger age groups

HIV risk behavior and practices among heroin addicts in Lahore, Pakistan

While the numbers of reported and estimated cases of HIV are still relatively low in Pakistan, behavioral patterns that could lead to an HIV epidemic are reported to exist among injection drug users. Therefore, this cross sectional study was conducted to estimate the prevalence of injection drug use and to assess the level of HIV knowledge and practices among male heroin addicts in Lahore, Pakistan. A total number of 660 male heroin addicts were recruited from 22 drug user sites in the city; data were collected using a pre-tested structured questionnaire. Analysis revealed a poor knowledge of the disease, its modes of transmission and ways to limit transmission with only 30% of the respondents considering them at risk for acquiring the disease. A prevalence of 23.3% of injection drug use was noted. HIV risk injection practices included: group injecting (83.2%), sharing syringes (58.7%), and re-using used syringes (78%). Various risky sexual practices included multiple partners (24%), homosexuality (10.8%), sexual contacts with commercial sex workers (CSW) (20.8%), and with transvestites (3.3%). Condom use was low (11-50%). Of the subjects, 5.5% reported trading sex for drugs or money. We recommend HIV/STD prevention programs encompassing health education and health promotion strategies based on harm reduction techniques be used for drug users

Mapping and Size Estimation of Key Populations in Kosovo, 2016

This is the first study of this nature in Kosovo. The objective of the research was to conduct population size estimate at granular and national level, distribution, settings and typologies of Female Sex Workers (FSWs), Men who have Sex with Men (MSM) and People Who Inject Drug (PWID) in order to provide a sound platform to improve service delivery and suggest ways to scale up the response. Cross sectional survey in 26 municipalities of Kosovo, Feb-April 2016 through two sequential steps: 1. Systematic information-gathering from secondary key informants within each zone and validating each through primary KI. In addition web-sites and mobile apps were mapped in the similar way. KP size estimates were calculated for each spot and rolled up into municipality estimates then aggregated into national estimates. MSM is the largest key population identified with a total number of 6814 range total number of spots MSM, with an overall national rate of 12 MSM per 1000 adult men across six types of spots including geo and virtual mapping. Fewer MSM operate at geographic spots, due to social norms MSM keep their activities hidden and mostly operate through internet and cell phones. An estimated number of FSW was 5037, rate of 8.9 FSWs per 1000 adult females and eight different spot typologies. Approximately 10% of FSW in Kosovo use websites to connect with clients. A total of 5819 PWID were calculated with rates of 10.2 PWID per 1000 adult men in five spot typologies. No female PWID were identified at geographic spots. These size estimates were calculated through community involvement and finalized with their agreement. Simple and straightforward community-led approach was used, ensuring active leadership and involvement of the KPs themselves in validating estimates

Programmatic mapping and size estimation of female sex workers, transgender sex workers and men who have sex with men in Istanbul and Ankara, Turkey

Objectives Despite a growing HIV threat, there is no definition and characterisation of key populations (KPs), who could be the major drivers of the epidemic in Turkey. We used programmatic mapping to identify locations where KPs congregate, estimate their numbers and understand their operational dynamics to develop appropriate HIV programme implementation strategies. Methods Female and transgender sex workers (FSWs and TGSWs), and men who have sex with men (MSM) were studied in Istanbul and Ankara. Within each district, hot spots were identified by interviewing key informants and a crude spot list in each district was developed. The spot validation process was led by KP members who facilitated spot access and interviews of KPs associated with that spot. Final estimates were derived by aggregating the estimated number of KPs at all spots, which was adjusted for the proportion of KPs who visit multiple spots, and for the proportion of KPs who do not visit spots. Results FSWs were the largest KP identified in Istanbul with an estimate of 30 447 (5.8/1000 women), followed by 15 780 TGSWs (2.9/1000 men) and 11 656 MSM (2.1/1000). The corresponding numbers in Ankara were 9945 FSWs (5.2/1000 women), 1770 TGSWs (1/1000 men) and 5018 MSM (2.5/1000 men). Each KP had unique typologies based on the way they find and interact with sex partners. MSM were mostly hidden and a higher proportion operated through internet and phone-based applications. Night time was the peak time with Friday, Saturday and Sunday being the peak days of activity in both Istanbul and Ankara. Conclusions This study has highlighted the presence of a substantial number of FSWs, TGSW and MSM in Istanbul and Ankara. The information obtained from this study can be used to set priorities for resource allocation and provide HIV prevention services where coverage could be the highest.Gilead SciencesThis project was funded by a non-conditional grant from Gilead Sciences

Equity trends for the UHC service coverage sub-index for reproductive, maternal, newborn and child health in Pakistan: evidence from demographic health surveys

Abstract Background Pakistan, the world's sixth most populous country and the second largest in South Asia, is facing challenges related to reproductive, maternal, newborn and child health (RMNCH) that are exacerbated by various inequities. RMNCH coverage indicators such as antenatal care (ANC) and deliveries at health facilities have been improving over time, and the maternal mortality ratio (MMR) is gradually declining but not at the desired rates. Analysing and documenting inequities with reference to key characteristics are useful to unmask the disparities and to amicably implement targeted equity-oriented interventions. Methods Pakistan Demographic Health Survey (PDHS) based UHC service coverage tracer indicators were derived for the RMNCH domain at the national and subnational levels for the two rounds of the PDHS in 2012 and 2017. These derivations were subgrouped into wealth quintiles, place of residence, education and mothers’ age. Dumbbell charts were created to show the trends and quintile-specific coverage. The UHC service coverage sub-index for RMNCH was constructed to measure the absolute and relative parity indices, such as high to low absolute difference and high to low ratios, to quantify health inequities. The population attributable risk was computed to determine the overall population health improvement that is possible if all regions have the same level of health services as the reference point (national level) across the equity domains. Results The results indicate an overall improvement in coverage across all indicators over time, but with a higher concentration of data points towards higher coverage among the wealthiest groups, although the poorest quintile continues to have low coverage in all regions. The UHC service coverage sub-index on RMNCH shows that Pakistan has improved from 45 to 63 overall, while Punjab improved from 50 to 59 and Sindh from 43 to 55. The highest improvement is evident in Khyber Pakhtunkhwa (KP) province, which has increased from 31 in 2012 to 51 in 2017. All regions made slow progress in narrowing the gap between the poorest and wealthiest groups, with particularly noteworthy improvements in KP and Sindh, as indicated by the parity ratio. The RMNCH service coverage sub-index gap was the greatest among women aged 15–19 years, those who belonged to the poorest wealth quintile, had no education, and resided in rural areas. Conclusions Analysing existing data sources from an equity lens supports evidence-based policies, programs and practices with a focus on disadvantaged subgroups