Integrated Biological and Behavioral Surveillance Survey (IBBS) among Injecting Drug Users in Pokhara Valley Round IV – 2009

Abstract

As part of the national response to the HIV epidemic, National Centre for AIDS and STD Control (NCASC) conducts surveillance to monitor HIV prevalence rates and risk behaviors. This surveillance among injecting drug users (IDUs), female sex workers (FSWs), male labor migrants (MLM), wives of labor migrants and men having sex with men (MSM) is done on a regular basis conducting Integrated Biological and Behavioral Surveillance Surveys (IBBS). This study is the fourth round of IBBS conducted among 300 male IDUs in the Pokhara Valley. The study was undertaken to measure the prevalence of HIV and syphilis, and associated risk behaviors among IDUs. Demographic, injecting behavior and sexual behavior data were collected through structured questionnaire while the prevalence of HIV and syphilis were measured by testing blood samples using Determine HIV 1/2 test to detect antibodies against HIV, Uni-Gold test as a second test and SD Bioline HIV 1/2 test as a tie breaker test. The Rapid Plasma Reagin (RPR) analysis with quantification was used to diagnosis syphilis and the diagnosis was confirmed by means of Treponema Pallidum Particle Agglutination (TPPA) test. Key Findings Prevalence of HIV and STIs Out of 300 IDUs participating in the study, 3.4 percent were HIV-positive. A history of syphilis was found among 1.1 percent of IDUs, while 0.5 percent was currently infected with syphilis. HIV prevalence differed significantly according to marital status and literacy status. The prevalence of HIV was higher among IDUs who are or were married (6.6%) than among those who had never been married (1.7%) before. HIV prevalence among literate IDUs was 2.3 percent and among illiterate IDUs it was 50.8 percent. The IDUs who were older than 20 years were more likely to be HIV-positive (3.7%) than younger IDUs (1.9%). Likewise, HIV prevalence was higher among those who had been injecting drugs for more than five years (5%) than those who had been injecting drugs for less than five years (3.1%). More markedly, HIV prevalence was significantly higher among those IDUs who had ever injected with a previously-used syringe in the past week (13.6%) than those who had never injected with such a needle/syringe (3%). HIV prevalence among the IDUs has gradually decreased since the first round of IBBS conducted in the Pokhar valley. The first and the second round of the IBBS showed almost the same HIV prevalence rate among IDUs in Pokhara (22% in 2003 and 21.7% in 2005). The prevalence rate, however, decreased to 6.8 percent in 2007 and to 3.4 percent in 2009; this is a significant change since the first round. Socio-Demographic Characteristics The IDUs were mostly young, including 88 percent below 30 years of age and 61 percent younger than 25 years. Many IDUs (65%) were unmarried. Around seven in ten IDUs (71.2%) were living without a sexual partner. The IDUs in Pokhara Valley represented diverse caste/ethnic groups residing in the valley. The Tibeto-Burman communities (Tamang, Lama, Magar, Gurung, Rai, Newar) made up the largest proportion of the respondents (58.5%) followed by the Brahmin, Chhetri/Thakuri community (27.1%). Alcohol Intake, Oral Drugs Use and Injecting Behavior The majority of the IDUs (67.3%) had been using drugs for more than five years. Twenty- nine percent had been using drugs for the past two to five years, while three percent had been injecting for less than two years. Overall 27 percent of the respondents consumed alcohol everyday and 23 percent were consuming alcohol more than once a week. Use of oral/inhaled drugs was common practice among IDUs. Ganja was the most popular drug taken by 71 percent of IDUs in the week preceding the survey followed by Nitrovate (26.4%), Brown Sugar (23.2%), charas (17.3%) and so on. The majority of respondents were 20 or younger (57.4%) when they injected for the first time. Around ninety seven percent of IDUs injected combination of different drugs. Nearly all respondents (99.7%) knew about the sources for getting new syringes. Ninety-six percent of IDUs mentioned that they could get a new syringe whenever necessary from a drugstore. Similarly, a large proportion of IDUs(90.9%) said that the needle exchange program conducted by Naulo Ghumti made new syringes available whenever they needed one. Among those IDUs who had been mobile in the past year seven percent had injected with a pre-used needle/syringe and four percent had given a needle/syringe to someone else after use at the place/s of their visit. The proportion of IDUs who had avoided unsafe injecting practice in the week preceding the survey has been steadily increasing since the first round. High-risk behavior such as injecting with previously used needle/syringe decreased significantly from 21 percent in 2003 to 15 percent in 2005 to 8 percent in 2007 and finally to 5 percent in 2009. Additionally, the proportion of IDUs who had not shared their needle/syringe with anyone in the past week increased from 68 percent in the first round, to 81 percent in second round, to 92 percent in third round and to 95 percent in the fourth round. Sexual Behavior Overall, 96 percent IDUs in Pokhara had had sexual intercourse before the survey. Among them, 78 percent had been sexually active even in the past year. The sex partners of IDUs in Pokhara included regular female parents, non-regular female partners as well as female sex workers. Thirty-three percent of sexually active IDUs had had sex with a regular partner in the past year. Most of them (90.1%) had sexual contact with their regular partners in the month preceding the survey. Twenty-nine percent of IDUs who ever had sex had non-regular female sex partners in the past year. Thirty-five percent of them had sex with their non-regular partners in the previous month. A total of 37 percent of sexually active IDUs had had sexual contact with female sex workers in the past 12 months. Among them, 48 percent had sex with FSWs in the last month. Condom use in last sex with FSWs was reported by 89 percent of IDUs. The proportion of those who used condoms the last time they had sex with a regular partner (26.8%) and with a non-regular partner (56.4%) were comparatively less. A similar pattern was observed in the IDUs’ last year’s sexual contacts. Knowledge and Awareness of HIV/AIDS and STIs All the IDUs had heard about HIV/AIDS while 17 percent of them had not heard about STIs. Four percent of IDUs had genital discharge and 11 percent had genital ulcers/sores in the past year. Among those who had STIs before, 19 percent and 60 percent reported having genital discharge and genital ulcer/sore respectively during the survey. Over two-fifths (44.4%) of those IDUs who had experienced at least one STI symptom in the past year had not sought any treatment. The majority of the respondents (67.8%) knew someone who had been living with HIV/AIDS or had died because of it. Overall 41 percent of IDUs were aware of the ‘ABC’ (A- abstinence from sex, B- being faithful to one partner and C- condom use during each sexual contact) as HIV preventive measures while 62 percent had comprehensive knowledge on HIV i.e. “BCDEF’ (D- a healthy looking person can be infected with HIV, E- a person can not get the HIV virus from mosquito bite and F- sharing meal with an HIV infected person do not transmit HIV virus). Furthermore, almost all IDUs (97.7%) knew that a person can get HIV by using previously used needles/syringes. The majority of respondents (95%) knew that a confidential HIV testing facility was available in their communities. A total of 67 percent had been tested before for HIV of which only 16 percent had done so voluntarily while others had done so as it was a requirement. Most of the IDUs (91.4%) who had been tested for HIV had received their test result. Exposure to the HIV/AIDS Prevention Programs During the preceding year more than nine in ten IDUs (90.8%) had visited a drop-in-centre and 43 percent had visited a VCT centre at least once. Very few IDUs (6.7%) had visited an STI clinic. Ninety-four percent had participated in different HIV/AIDS awareness raising programs in the preceding year while almost eight in ten (78.7%) had interacted with a peer educators/outreach educators (PEs/OEs)