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HIV Prevalence, Estimated Incidence, and Risk
Behaviors Among People Who Inject Drugs in Kenya
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JAIDS Journal of Acquired Immune Deficiency Syndromes: Dec 1 2015
Kurth, Ann E. PhD, CNM, MPH*; Cleland, Charles M. PhD*; Des Jarlais, Don C. PhD; Musyoki, Helgar MPH; Lizcano, John A. MPH*; Chhun, Nok MS, MPH*; Cherutich, Peter MBChB, MPH *New York University College of Nursing, New York, NY; Baron Edmond de Rothschild Chemical Dependency Institute, Mount Sinai Beth Israel, New York, NY; and National AIDS & STI Control Programme (NASCOP), Nairobi, Kenya.
HIV infection in sub-Saharan Africa increasingly occurs among people who inject drugs (PWID). Kenya is one of the first to implement a national needle and syringe program. Our study undertook a baseline assessment as part of evaluating needle and syringe program in a seek, test, treat, and retain approach.
Methods: Participants enrolled between May and December 2012 from 10 sites. Respondent-driven sampling was used to reach 1785 PWID for HIV-1 prevalence and viral load determination and survey data.
Results: Estimated HIV prevalence, adjusted for differential network size and recruitment relationships, was 14.5% in Nairobi (95% CI: 10.8 to 18.2) and 20.5% in the Coast region (95% CI: 17.3 to 23.6). Viral load (log10 transformed) in Nairobi ranged from 1.71 to 6.12 (median: 4.41; interquartile range: 3.51-4.94) and in the Coast from 1.71 to 5.88 (median: 4.01; interquartile range: 3.44-4.72). Using log10 viral load 2.6 as a threshold for HIV viral suppression, the percentage of HIV-infected participants with viral suppression was 4.2% in Nairobi and 4.6% in the Coast. Heroin was the most commonly injected drug in both regions, used by 93% of participants in the past month, typically injecting 2-3 times/day. Receptive needle/syringe sharing at last injection was more common in Nairobi (23%) than in the Coast (4%). Estimated incidence among new injectors was 2.5/100 person-years in Nairobi and 1.6/100 person-years in the Coast.
Conclusions: The HIV epidemic is well established among PWID in both Nairobi and Coast regions. Public health scale implementation of combination HIV prevention has the potential to greatly limit the epidemic in this vulnerable and bridging population.
Little has been published on injection drug use in sub-Saharan Africa, where HIV continues to be a leading cause of death and disability.1,2 In Kenya, where the epidemic is largely driven by sexual transmission, parenteral transmission is increasingly becoming recognized3,4; an estimated 18.7% of incident HIV infections on the Kenyan coast and 7.5% nationally are attributed to people who inject drugs (PWID).5 However, evidence-based prevention and care for PWID including needle syringe programs (NSP) and PWID-specific antiretroviral therapy (ART) support have been nearly nonexistent in this region.6 Recent size estimation in Kenya revealed a growing PWID population, high background HIV prevalence,7 and high-risk behaviors.8,9
PWID are highly vulnerable to HIV and can be a bridge for HIV transmission to general populations. Needle sharing10,11 and other high-risk behaviors (including “flashblood,” wherein users who cannot afford heroin inject the blood of a PWID who recently injected) are common.12,13 HIV prevalence among PWID in sub-Saharan Africa is estimated to range from 5.5% to 42.9%.14 In Kenya, PWID HIV prevalence is estimated at 18% versus 5.6% in the general population; 29.8% reported sex without a condom in the past month; 51.6% reported use of sterile injecting equipment the last time they injected.15 An analysis of a multicountry survey found that 12 of 14 (86%) female injectors in Nairobi engaged in sex work.16 In sub-Saharan Africa, the region with highest HIV prevalence globally, injectors can exacerbate HIV epidemics, given the rapid nature that is the hallmark of HIV epidemics among PWID.14,17
Key interventions are highly effective in reducing risk of HIV acquisition [male circumcision, preexposure prophylaxis (PrEP)] and transmission (early initiation of ART), especially when used in a “combination prevention” approach.18 Nine evidence-based interventions have been endorsed for prevention, treatment, and care of HIV in PWID,19 with NSP, opioid substitution therapy (OST), and ART for HIV positives recommended as an international minimum standard. PrEP use has been recommended by the Centers for Disease Control and Prevention as a potential option to reduce HIV among high-risk PWID,20 although PrEP has not yet been widely implemented in many countries.21 The World Health Organization (WHO) notes that NSPs are effective in reducing HIV transmission,22 especially in high-income countries.23-26 NSPs can be effective in reducing HIV in lower income country settings if implemented on a public health scale,23,27,28 and OST can also be effective for reducing illicit drug use and associated HIV risk behavior in middle/low-income settings if implemented according to WHO guidelines.29,30 Still, interventions in low/middle income countries do not have the benefit of high-income countries' more available resources, stronger health systems, and generally stable policy structures that influence HIV epidemic control, so that additional research on controlling HIV among PWID in transitional/low/middle income countries is clearly needed.
In 2013, Kenya implemented NSP at a countrywide level. This article is one of the first to describe baseline PWID risks before evaluating the potential effect of NSP in this key population. Our study leverages the Government of Kenya's decision to launch NSP for PWID. Using time series and stepped wedge cluster-randomized design elements, our “Testing and Linkage to Care for Injecting Drug Users” study will provide among the first data regarding implementation of a “seek, test, treat, and retain” approach to PWID in sub-Saharan Africa.31 Lessons learned will inform how Kenya and other countries in the region can best address the growing PWID contribution to the HIV epidemic. We present baseline data on HIV prevalence, estimated incidence, drug use and injecting behaviors, sexual risk behaviors, and viral load distribution among the PWID population in Kenya, Nairobi and the Coast region and consider the possible future HIV transmission in these areas.
Years Injecting
In the Nairobi region, years injecting ranged from 1 to 37, with a median of 2 years. One and 6 years of injecting marked the lower and upper quartiles of years injecting. Thus, 75% of Nairobi participants injected for 6 or fewer years. In the Coast region, years injecting ranged from 1 to 36, with a median of 4 years. Two and 8 years marked the lower and upper quartiles of years injecting. Thus, 75% of Coast participants injected for 8 or fewer years.
Injection Drug Use and Injection Risk Practices
Heroin was the most commonly injected drug in both Nairobi and the Coast and was the most commonly used drug in the past month for 93% of participants. Participants typically injected 2-3 times per day nearly everyday in the past month. Receptive needle/syringe sharing at the last injection was more common in Nairobi (23%) than the Coast region (4%). At the times the surveys took place, there were no active needle and syringe programs in the areas where PWID were recruited. Participants were asked about the sources of their syringes. The most common sources identified were pharmacy (72%), the place where the PWID injects (12%), and dealers (8%).

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