Harm reduction under fire – people who inject drugs in Kabul, Afghanistan

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

Todd CS, Nasir A, Stanekzai MR, Fiekert K, Sipsma HL, Vlahov D, Strathdee SA. Harm Reduct J. 2015 Oct 16;12:22. doi: 10.1186/s12954-015-0056-z.

Background: Armed 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.

Methods: Consenting 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.

Results: Of 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.

Conclusion: There 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.

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Editor’s notes: This is a relatively rare study, documenting HIV and Hepatitis C infection (HCV) among people who inject drugs in Kabul in Afghanistan.  By combining survey data with information on conflict events from literature/media, the authors can look not only at levels of infection but also how these levels are affected by the conflict. In line with findings from other places experiencing conflict, the authors illustrate that violence did not increase the risk of infection. However, the findings do illustrate the value of needle-syringe distribution and collection programmes in reducing HCV incidence, as the men moved from injecting to smoking. Relatively low levels of HIV prevalence in the Kabul area resulted in low HIV-incidence among the study population. If HIV-prevalence were to rise this could change, as reflected in the high levels of Hepatitis C infection. The authors point to the many challenges of providing services for key populations, such as the men they worked with who injected drugs, in many parts of the world. Growing instability and the displacement of a number of the study population because of the closure of the shelter that housed them, made the research challenging.  A shortage of resources for harm reduction in places like Afghanistan, compounds the problems programmes to support people who inject drugs, face.

Asia
Afghanistan
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