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 \u3c13 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 (AR  = 2.3, 95%CI:1.5, 3.3, p\u3c0.0001), 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

Incidence of human immune deficiency virus among injection drug users enrolled in a harm reduction program at Karachi

Background HIV in Pakistan has transitioned from low to concentrated level epidemic (\u3e5%) among injection drug users (IDUs). Although the HIV prevalence among general population is still low (\u3c0.1%), yet the prevalence is higher among high risk groups (HRG). We have sufficient surveillance data on prevalence but there is dearth of data on incidence rate of HIV. Since the epidemic in the country is mainly driven by the IDUs, the current study captured the incidence of HIV in this group. Objectives The primary objective was to estimate the HIV incidence rate among IDUs enrolled in harm reduction program at Karachi. The secondary objectives were to estimate the risk factors associated with HIV sero-conversion and predictors of loss to follow up among IDUs in the harm reduction program. Methods A quantitative and qualitative study was conducted among IDUs registered in a harm reduction program in Karachi from March-December 2009. We used descriptive cohort design for incidence rate and nested case-control study for factors associated with HIV sero-conversion. We recruited 474 (IDUs) who were HIV sero-negative at the baseline. The cohort was re-tested for HIV status from April-June 2011. For factors associated with HIV sero-conversion, the HIV positive IDUs were taken as cases and HIV negative as controls. Focus group discussions (FGDs) with IDUs and in-depth interviews with the program\u27s implementers were also conducted to gather perceptions regarding reasons for HIV sero-conversion and loss to follow-up. Findings The incidence rate of HIV among IDUs was 13 per 100 person-years (95% CI: 10.92 — 15.67). The mean age of the clients was 31+8 years. In multivariate regression analysis unemployment (AOR: 2.4, 95% CI 1.30-4.56, p-value \u3c0.01), Injecting drugs at streets (AOR: 5.29, 95% CI 1.36-20.59, p-value 0.01), sharing of syringes (AOR: 5.7, 95% CI 2.89-11.37, p-value \u3c0.01), not getting syringes from drop-in center (AOR: 5.0, 95% CI 2.73- 9.17, p-value \u3c0.01); frequency of daily drug use (AOR: 2.0, 95% CI 1.40-2.85, p-value \u3c0.01), were significantly associated with HIV sero-conversion, after adjusting for other variables in the model. In multivariate analysis for the predictors of loss to follow-up, the enrollment of the clients through sources other than the outreach (AOR: 4.7, 95% CI 2.74-7.93, p-value \u3c0.01), being foreigner (AOR: 13, 95% CI 4.86-39.57, p-value \u3c0.01), being non-Sindhi (AOR: 2.6, 95% CI 1.52-4.50, p-value \u3c0.01), being illiterate (AOR: 2.3, 95% CI 1.34-4.11, p-value 0.003), history of incarceration (AOR: 1.8, 95% CI 1.05-3.00, p-value 0.031), being physically disable (AOR: 22.5, 95% CI 1.92-262.31, p-value 0.01), and getting syringes from pharmacies and friends (AOR: 2.0, 95% CI 1.06-3.86, p-value 0.03) were significantly associated with loss to follow-up, after adjusting for other variables in the model. In qualitative analysis, themes were generated and text was coded on the themes. The perceptions regarding reasons for sero-conversion were consistent with the quantitative analysis. In contrast, completely different predictors of loss to follow up were identified in the qualitative arm of the study. Conclusion Although the study included the IDUs associated with a harm reduction program, the incidence HIV was high, the situation calls for public health and policy measures to curb the epidemi

Risk Factors for Loss to Follow-Up among People Who Inject Drugs in a Risk Reduction Program at Karachi, Pakistan. A Case-Cohort Study.

INTRODUCTION:Retention of male people who inject drugs (PWIDs) is a major challenge for harm reduction programs that include sterile needle/syringe exchange in resource-limited settings like Pakistan. We assessed the risk factors for loss to follow-up among male PWIDs enrolled in a risk reduction program in Karachi, Pakistan. METHODS:We conducted a prospective cohort study among 636 HIV-uninfected male PWIDs enrolled during March-June 2009 in a harm reduction program for the estimation of incidence rate. At 24 months post-enrollment, clients who had dropped out of the program were defined as lost to follow-up and included as cases for case-cohort study. RESULTS:The median age of the participants was 29 years (interquartile range: 23-36). Active outreach accounted for 76% (483/636) of cohort recruits. Loss to follow-up at 24 months was 25.5% (162/636). In multivariable logistic regression, younger age (AOR: 0.97, 95% CI: 0.92-0.99, p = 0.028), clients from other provinces than Sindh (AOR: 1.49, 95% CI: 1.01-2.22, p = 0.046), having no formal education (AOR: 3.44, 95% CI: 2.35-4.90, p<0.001), a history of incarceration (AOR: 1.68, 95% CI: 1.14-2.46, p<0.008), and being homeless (AOR: 1.47, 95% CI: 1.00-2.19, p<0.049) were associated with loss to follow-up. CONCLUSIONS:Our cohort retained 74.5% of male PWIDs in Karachi for 24 months. Its loss to follow up rate suggested substantial ongoing programmatic challenges. Programmatic enhancements are needed for the highest risk male PWIDs, i.e., younger men, men not from Sindh Province, men who are poorly educated, formerly incarcerated, and/or homeless

Crude and adjusted odds ratios of risk factors for loss to follow-up at 24 months among men who inject drugs receiving harm reduction services in Karachi (636).

<p>Crude and adjusted odds ratios of risk factors for loss to follow-up at 24 months among men who inject drugs receiving harm reduction services in Karachi (636).</p

Characteristics of 636 men who inject drugs in a Karachi cohort: 2009 enrollment data and 2-year follow-up status.

<p>Characteristics of 636 men who inject drugs in a Karachi cohort: 2009 enrollment data and 2-year follow-up status.</p

Sensitivity analysis of the estimates for HIV incidence per 100 person-years (py) with 95% exact Poisson confidence intervals (CI), considering persons lost to follow-up (LTFU) in a variety of plausible “high-low” scenarios for their unknown incidence.

<p>Sensitivity analysis of the estimates for HIV incidence per 100 person-years (py) with 95% exact Poisson confidence intervals (CI), considering persons lost to follow-up (LTFU) in a variety of plausible “high-low” scenarios for their unknown incidence.</p

Multivariable Cox regression analysis for associations with HIV seroconversion in a two-year cohort of injection drug users in Karachi, Pakistan (n = 474).

<p>^a Government organization, non-governmental organization, community, and friends.</p><p>^b Non-Muslim included 54 Christians and 2 Hindus vs. 418 Muslims.</p><p>≈US$ 56.^c Approximately 90 rupees per US dollar in this time period, such that 5000 rupees</p><p>^d Pharmacy, friends, and hospital garbage.</p><p>^e Drop-in center (DIC) and mobile service unit (MSU).</p><p> = 0.046).^f If source of registration, physical disability, and monthly income, are excluded from the above Cox regression to achieve a more parsimonious model, then the effect sizes are similar and source of syringes becomes a significant predictor (p</p

Univariate regression analysis of factors associated with seroconversion in a cohort of 474 injection drug users followed for two years in Karachi, Pakistan.

<p>^a Government organization, non-governmental organization, community, and friends.</p><p>^b Non-Muslim included 54 Christians and 2 Hindus vs. 418 Muslims.</p><p>^c Non-Sindhis included Pathan, Punjabi, Hindko, Kashmiri, and Bengali.</p><p>≈US$ 56.^d Approximately 90 rupees per US dollar in this time period, such that 5000 rupees</p><p>^e Pharmacy, friends, and hospital garbage.</p><p>^f Drop-in center and mobile service unit.</p