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New Published Study Discusses Global Epidemiology of PWID, People Who Inject Drugs, & HIV & HCV Prevalence
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http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001663#pmed.1001663-Mirzoyan1
This paper examined the epidemiology of HIV infection among people who inject drugs (PWID) in the Middle East and North Africa (MENA) and HCV as well to a lesser degree.
We estimated that there are 626,000 PWID in MENA (range: 335,000-1,635,000, prevalence of 0.24 per 100 adults). We found evidence of HIV epidemics among PWID in at least one-third of MENA countries, most of which are emerging concentrated epidemics and with HIV prevalence overall in the range of 10%-15%. Some of the epidemics have however already reached considerable levels including some of the highest HIV prevalence among PWID globally (87.1% in Tripoli, Libya). The relatively high prevalence of sharing needles/syringes (18%-28% in the last injection), the low levels of condom use (20%-54% ever condom use), the high levels of having sex with sex workers and of men having sex with men (15%-30% and 2%-10% in the last year, respectively), and of selling sex (5%-29% in the last year), indicate a high injecting and sexual risk environment. The prevalence of HCV (31%-64%) and of sexually transmitted infections suggest high levels of risk behavior indicative of the potential for more and larger HIV epidemics.
Whilst it is conceivable that HIV prevalence may not grow in countries currently at low level, there are settings where HIV prevalence increased considerably in a short period of time. For example in Karachi, Pakistan, after several years of near zero prevalence [74],[75],[81],[82], HIV prevalence in 2004 increased to 23% in less than 6 months [83], and reached 42% in 2011 [37]. This pattern is not surprising given the reported risky practices and high HCV prevalence. When HIV prevalence was still very low in Karachi, HCV prevalence was over 85% [74],[75], indicating substantial use of non-sterile injecting equipment and suggesting connectivity of injecting networks. In Iran, the substantial HCV prevalence (up to 80%) was predictive of the explosive HIV epidemic that occurred subsequently. In both Iran and Pakistan, injecting networks often seem to be well connected and we found reports of injecting and sharing occurring among persons who are not necessarily socially related, e.g. in shooting galleries [84],[85]. Data on HCV prevalence among PWID in MENA countries with low-level HIV epidemics are limited. However, HCV prevalence of 40%-61% among some PWID groups such as in Lebanon, OPT, and Syria suggest moderate HIV epidemic potential once the virus is introduced to the PWID community.
Overall, harm reduction programs still remain limited in MENA, and there is a need to integrate such programs within the socio-cultural framework of the region [95]. Several countries though have made significant strides in initiating such programs in recent years [11],[96]. Needle/syringe exchange programs are currently implemented in nine countries, and opioid substitution therapy in five [96]. Iran remains the leader in the provision of harm reduction services to PWID with the highest coverage of needle/syringe exchange programs in the region [12],[96]. It appears also to be the only country in MENA to provide such services in prisons [96],[97] and to provide female-operated harm reduction services targeted at female drug users [96].
We estimate that there are 626,000 PWID in the MENA region. Overall, the mean prevalence of injecting drug use (0.24%) is comparable with global figures which range from 0.06% in South Asia to 1.50% in Eastern Europe [31]. Prevalence of injecting drug use in MENA varied between countries and was higher in the eastern part of the region. Injecting drug use appears to be heavily concentrated among men; but female PWID are one of the hardest-to-reach populations in MENA, thereby limiting our knowledge of this vulnerable group. From limited available data, it appears that injecting drug use among females has a strong association with sex work and having a PWID sexual partner [78],[79].
HIV prevalence measures from reports and databases are summarized in Tables 3 and S4, respectively. Considerable variation in HIV prevalence was seen, with an overall median of 8% (interquartile range [IQR]: 1%-21%) (Table 3). HIV prevalence among PWID in MENA ranged between 0% in some prevalence measures in almost every country up to 7% in Cairo, Egypt in 2010 (n = 274) [42]; 18% in Afghanistan in one city near the Iranian borders, Herat, in 2009 (n = 159) [38]; 21% in Manama, Bahrain, in the early nineties (n = 242) [60]; 27% in Oman among incarcerated PWID (n = 33) [58]; 38% in Nador, northern Morocco, in 2008 (n = 233) [61]; 52% in the third largest metropolis in Pakistan, Faisalabad, in 2011 (n = 364) [37]; 72% in rural Iran in 2004-5 (n = 61) [62]; and 87% in Tripoli, Libya in 2010 (n = 328) [47] (Table 3). HIV prevalence was consistently low among PWID in Jordan, Lebanon, OPT, Syria, and Tunisia (0%-3.1%). Substantial intra-country variability in HIV prevalence was observed in Afghanistan, Iran, Morocco, and Pakistan (Table 3). In most countries with high HIV prevalence, recent studies report increasing HIV prevalence starting around 2003 (Tables 3 and S4).
Analysis of notified HIV cases indicated that in 2011, injecting drug use contributed 20% (80/409), 23% (50/216), 38% (6/16), 49% (52/107), and 60% (948/1,588) of all newly notified cases in this year in Egypt, Pakistan, Bahrain, Afghanistan, and Iran, respectively. A smaller contribution was reported in the remaining countries (Table 4).
Concentrated HIV epidemics among PWID were observed in Iran, Pakistan, Afghanistan, Egypt, Morocco, and Libya (Table 5). Iran is the only country with conclusive evidence for an established concentrated epidemic at the national level. The first HIV outbreaks among PWID in Iran were reported around 1996. HIV prevalence then increased considerably in the early 2000s, reaching a peak by the mid-2000s (Figure 3A). HIV prevalence in the 2006 and 2010 multi-city IBBSS was stable at 15% (n = 2,853 and n = 2,479, respectively) (Figure 4C) [43],[44]. The evidence suggests that the HIV epidemic among PWID in Iran is now established at concentrated levels of about 15%.
HIV among People Who Inject Drugs in the Middle East and North Africa: Systematic Review and Data Synthesis
epidemiology of HIV infection among people who inject drugs (PWID) in the Middle East and North Africa (MENA)
We estimated that there are 626,000 PWID in MENA (range: 335,000-1,635,000, prevalence of 0.24 per 100 adults). We found evidence of HIV epidemics among PWID in at least one-third of MENA countries, most of which are emerging concentrated epidemics and with HIV prevalence overall in the range of 10%-15%. Some of the epidemics have however already reached considerable levels including some of the highest HIV prevalence among PWID globally (87.1% in Tripoli, Libya). The relatively high prevalence of sharing needles/syringes (18%-28% in the last injection), the low levels of condom use (20%-54% ever condom use), the high levels of having sex with sex workers and of men having sex with men (15%-30% and 2%-10% in the last year, respectively), and of selling sex (5%-29% in the last year), indicate a high injecting and sexual risk environment. The prevalence of HCV (31%-64%) and of sexually transmitted infections suggest high levels of risk behavior indicative of the potential for more and larger HIV epidemics.
The researchers identified 192 reports that reported the prevalence/incidence of HIV, other sexually transmitted infections and infection with hepatitis C virus (HCV, another virus transmitted through drug injection) among PWID, the prevalence of injecting or sexual risk behaviors among PWID, or the number/proportion of PWID in MENA. From these data, the researchers estimated that there are about 600,000 PWID in MENA (a prevalence of 0.24 per 100 adults, which is comparable with figures from other regions). The data provided evidence for HIV epidemics among PWID in at least a third of MENA countries, mainly emerging concentrated epidemics (epidemics that are still growing but in which HIV infection and transmission are already considerable). HIV prevalence among PWID in MENA varied considerably, reaching an extremely high prevalence of 87.1% in Tripoli, Libya. The data also revealed a high injecting and sexual risk environment among PWID in MENA (for example, on average, about a quarter of PWID shared a needle or syringe in their most recent injection and only a third reported ever using condoms) that, together with a high prevalence of HCV and sexually transmitted infections among PWID, indicates the potential for more and larger HIV epidemics.
PWID are one of the key populations at high risk of HIV in MENA, a region with several vulnerability factors for injecting drug use. For example, 83% of the global supply of heroin is produced in Afghanistan [16], and over 75% of this is trafficked through Iran and Pakistan. In 2009, Iran bore the highest fraction of the global opium and heroin seizures (89% and 33%, respectively) [16]. Increased availability and purity of heroin at lower prices in MENA appears to have led to a subsequent rise in injecting drug use
The primary objective of this study was to assess the status of the HIV epidemic among PWID in MENA by describing HIV prevalence and incidence. The secondary objective was to describe the risk behavior environment and the HIV epidemic potential among PWID by describing (1) their injecting and sexual risk behavior and knowledge, and (2) prevalence of proxy biological markers of these behaviors, namely hepatitis C virus (HCV) and sexually transmitted infections (STIs), respectively. The study also estimated the proportion and number of PWID in MENA.
Our review covered the 23 countries included in the MENA definitions of the three international organizations leading the regional HIV response efforts in the region: the Joint United Nations Programme on HIV/AIDS (UNAIDS), the Eastern Mediterranean Regional Office of the World Health Organization (WHO/EMRO), and the World Bank (Figure 1). These countries share specific similarities, whether historical, socio-cultural, or linguistic; and are conventionally included together as part of HIV/AIDS programming for the region.
Figure 1
The following sources of data were searched up to December 16, 2013: (1) Scientific databases (PubMed, Embase, and regional databases [WHO African Index Medicus [21] and WHO Index Medicus for the Eastern Mediterranean Region [22]]), with no publication date or language restrictions. A generic search of "drug use" in MENA was performed in PubMed and Embase using MeSH/Emtree and text terms. The term "HIV" was not included to avoid detection bias. (2) The MENA HIV/AIDS Synthesis Project database of grey and mainly unpublished literature [11],[12]. (3) Abstracts of the International AIDS Conference 2002-2012 [23], the International AIDS Society Conference on HIV Pathogenesis and Treatment 2001-2013 [24], and the International Society for Sexually Transmitted Diseases Research Conferences 2003-2013 [25]. (4) International and regional databases of HIV prevalence measures including the US Census Bureau database of HIV/AIDS [26], the WHO/EMRO HIV testing database [27], and the UNAIDS epidemiological fact sheets database [28].
Prevalence of Injecting Drug Use
Table 2 describes national estimates of the number and prevalence of PWID. These national estimates were extracted from included reports where they were derived using different methodologies including indirect methods (such as capture-recapture and multiplier methods), population-based surveys, registered number of PWID, and rapid assessments. In two of the sources of data in Table 2 [4],[31], some of the country estimates are the collation of several such country-specific estimates using methods described in the original reports [4],[31].
Based on available data, the number of PWID in MENA ranges between a low bound of 335,000 and a high bound of 1,635,000, with a middle estimate of 626,000 PWID. Iran, Pakistan, and Egypt have the largest number, with a median of about 185,000, 117,000, and 89,000 PWID, respectively. The weighted mean prevalence of injecting drug use in MENA is 0.24 per 100 adults. It is lowest in Somalia (0.03%) and highest in Iran (0.43%) (Table 2).
Studies of sub-national populations showed geographical heterogeneity (Table S3). For example, in Iran, the prevalence of injecting drug use varied between 0.0% in rural Babol province [55] to 1.0% in Tehran [56]; and in Pakistan it ranged from 0.02% in Rawalpindi to 0.87% and 1.07% in Sargodha and Faisalabad, respectively [57].
Data on the prevalence of female PWID in MENA were scarce. Overall, the mean proportion of females among PWID in included studies was 2.3% (range: 0%-35%). In two studies in Oman and Syria, 25%-58% [58] and 48% [59] of PWID, respectively, reported knowing at least one female PWID.
HIV Prevalence, Incidence, and Mode of Transmission
HIV prevalence measures from reports and databases are summarized in Tables 3 and S4, respectively. Considerable variation in HIV prevalence was seen, with an overall median of 8% (interquartile range [IQR]: 1%-21%) (Table 3). HIV prevalence among PWID in MENA ranged between 0% in some prevalence measures in almost every country up to 7% in Cairo, Egypt in 2010 (n = 274) [42]; 18% in Afghanistan in one city near the Iranian borders, Herat, in 2009 (n = 159) [38]; 21% in Manama, Bahrain, in the early nineties (n = 242) [60]; 27% in Oman among incarcerated PWID (n = 33) [58]; 38% in Nador, northern Morocco, in 2008 (n = 233) [61]; 52% in the third largest metropolis in Pakistan, Faisalabad, in 2011 (n = 364) [37]; 72% in rural Iran in 2004-5 (n = 61) [62]; and 87% in Tripoli, Libya in 2010 (n = 328) [47] (Table 3). HIV prevalence was consistently low among PWID in Jordan, Lebanon, OPT, Syria, and Tunisia (0%-3.1%). Substantial intra-country variability in HIV prevalence was observed in Afghanistan, Iran, Morocco, and Pakistan (Table 3). In most countries with high HIV prevalence, recent studies report increasing HIV prevalence starting around 2003 (Tables 3 and S4).
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