Integrated Biological and Behavioral Surveillance Survey (IBBS) among Male Injecting Drug Users (IDUs) in Western to Far-Western Terai of Nepal Round III

Abstract

The National Center for AIDS and STD Control (NCASC), Nepal, has developed a comprehensive National Surveillance Plan for HIV and AIDS that includes a regular schedule for conducting an Integrated Biological and Behavioral Survey (IBBS) among populations that are most at risk (MARPs). These surveillance studies conducted at regular intervals, helpto assess health risk behaviors and measure the prevalence of HIV and sexually transmitted infections (STIs) among MARPs, as well as monitoring trends in the epidemic to inform the HIV response in Nepal. The IBBS is conducted by NCASC with technical and financial support from Family Health International/Nepal (FHI/Nepal) and the United States Agency for International Development (USAID). This report details the findings of the third round of the IBBS conducted among 300 male IDUs in the Western to Far-Western Terai of Nepal. The study was conducted with the primary objective of measuring HIV and syphilis prevalence among the study population and to assess their HIV/STI related risk behaviours including their sexual and drug using habits. It also aimed to assess their exposure to the HIV/AIDS/STI awareness and prevention programs targeted at IDUs in the Western to Far- Western Terai of Nepal. Study Methodology The study covered seven districts of the Western to Far-Western Terai in Nepal (Rupandehi, Kapilbastu, Dang, Banke, Bardia, Kailali and Kanchanpur). Two-stage cluster sampling was followed to draw the sample of the 300 male IDUs. The first stage was to develop the sampling frame and select the cluster, while the second stage entailed selecting 300 IDUs from the chosen cluster. The study team visited the study districts and collected information regarding IDUs from the concerned stakeholders, including key informants from government as well as from non-government organizations and the local population. At each location, information on population size was collected by direct and indirect counting. After estimating their number in different locations, these locations were divided into clusters. A location with at least 20 IDUs was defined as a cluster. Thirty clusters were selected using the probability proportional to size (PPS) method. In the next stage, 10 respondents were randomly selected from each cluster. Study centers with laboratories/clinics were set up at easily accessible locations in six sites covering five study districts. Structured questionnaires were used to collect behavioral data and information on STI/HIV/AIDS awareness among respondents. The questionnaire was administered after obtaining each participant’s informed consent. In order to draw up a comparative analysis of the behavioral trends over the years, questions asked during the previous rounds were repeated. Strict confidentiality was maintained throughout the study process. The respondents were provided unique ID number. The same ID number was used on the questionnaire, medical records and blood specimens of the respondents. All respondents participated voluntarily in the study. Those who did not meet the study criteria and those who were not willing to participate were not involved in the study. Strict confidentiality was maintained throughout the study process. ‘Ethical’ as well as ‘technical’ approval was obtained from FHI’s ethical review body, the Protection of Human Subject committee (PHSC) and the Nepal Health Research Council (NHRC) prior to the commencement of the fieldwork. Informed consent was obtained in the presence of a witness from all the participants prior to the interview and the collection of blood samples. Pre-test counseling sessions were held before the clinical examination and blood sample collections. All the respondents were then examined for STI identification and blood samples were collected for biological testing of HIV and syphilis. Study participants were provided symptomatic treatment for STI symptoms. HIV and syphilis test results were provided later at locally-established VCT centers, along with post-test counseling given by experienced counselors. Laboratory Methods Syphilis was tested using BD. Micro-Vue Rapid Plasma Regain (RPR) card test. All the samples negative for RPR were recorded as negative. All positive samples for RPR were further tested with serial serum dilution up to 64 times and the test record was recorded with dilution factor. All the RPR positive serums were also tested by Treponema Pallidum Particle Agglutination (TPPA) test using Serodia TPPA as a confirmatory test. HIV antibody screening was performed using serial testing approach. All the serum samples were tested using Determine HIV 1/2 (Abbott Japan Co. Ltd.) as a first test to detect antibodies against HIV. If the first test was negative, no further test was conducted, but if the first test was positive, a second test was performed using Uni-Gold (Trinity Biotech, Dublin, Ireland). In case of a tie between the first two tests, a third test was performed using SD Bioline HIV 1/2 (Standard Diagnostics, Inc., Kyonggi-do, South Korea) as a tie-breaker test. Key Findings Socio Demographic Characteristics The age of the IDUs ranged from between 16 to 50 years, with a median age of 27. Overall, 54 percent of respondents were between 20 to 29 years; while adolescents of 19 years or younger made up eight percent of the respondents. Forty-two percent of the IDUs were currently married. Forty one percent of IDUs were living with their spouse or with a female sexual partner at the time of survey. The majority of the IDUs (93.6%) could read and write, however, 5.3 percent of them had no formal schooling; while 18 percent had completed SLC or above. STI/HIV/AIDS Prevalence HIV prevalence among IDUs in the West and Far-West Terai was eight percent. Three percent of them had a history of syphilis, while 1.7 percent had active syphilis. A significant association has been seen between the prevalence of HIV and the marital status of the IDUs as well as the length of time the respondents had been injecting drugs. Married IDUs had a high prevalence of HIV (12.2%) compared to unmarried ones (3.9%); likewise, those IDUs who had been injecting drugs for more than five years had significantly higher HIV prevalence (12.3%) than those who had injected for a shorter span of time (less than 2 years - 1.6%; 2-5 years - 4.9%). Sexual behavior or the type and number of sexual partners of the IDUs in the past year did not show a significant relationship with HIV prevalence. However, those IDUs who did not have sex with non-regular partners in the past year had a higher HIV prevalence (10.4%) than those who have had such sexual encounters (2.4%). Drug Injecting Practices The IDUs had been injecting drugs for 5.9 years on average. Over half (51.3%) had been injecting for five years or more. The IDUs started injecting drugs at the median age of 21 years. Most of them (70.7%) injected a combination of different drugs. Over 90 percent of IDUs had avoided risky injecting practices in the last three injections. Likewise, the past week's injecting practice also showed that the majority of the IDUs had avoided risky injecting behaviors such as injecting with a used needle/syringe (88.3%); injecting with a syringe kept at a public place (92.3%); and sharing needles/syringes with others (88.7%). Around eight in ten IDUs (81.7%) had injected in places outside their district or in other countries. Among them, 17.6 percent had used a pre-used needle/syringe and 19.6 percent had given their needle/syringe to someone else after use. Sexual Behavior Ninety-eight percent of IDUs had maintained sexual contact before the date of survey. Around 87 percent of them were below 20 when they had their first sexual encounter. Over one half of IDUs (52.8%) had sexual contact with two or more female partners in the past year. Among 300 IDUs, 42.9 percent had sex with regular partners, 28.2 percent with non-regular female sex partners and 32.7 with female sex workers in the past year. Consistent use of condom was high with female sex workers compared to regular and non-regular partners. Fifty-one percent had used condoms consistently with female sex workers, compared to 37.3 percent with non-regular female sex partners and 8.7 percent with regular female sex partners in the past year.

STI and HIV/AIDS Awareness and Treatment Practices Seven percent of IDUs had not heard about STIs before. Overall, 12.3 percent of respondents had genital discharge and 9.7 percent had a genital ulcer/sore in the past year. Among these respondents who had STI symptoms last year, 32.4 percent had genital discharge and 31 percent had a genital ulcer/sore at the time of the survey also. In total, 73.3 percent of IDUs knew about all three major HIV/AIDS preventive measures, such as abstinence from sexual contact , ‘A’; being faithful to one partner, ‘B’; and condom use during each sexual contact, ‘C’. Meanwhile, 56 percent of IDUs were aware of ‘B,C,D,E,F’ (a healthy looking person can be infected with HIV, ‘D’; a person cannot get the HIV virus from a mosquito bite, ‘E’; and sharing meal with an HIV-infected person does not transmit the HIV virus, ‘F’). HIV Test Ninety-four percent of IDUs knew that a confidential HIV testing facility was available in their community. However, 37.3 percent of respondents had never been tested for HIV. Among those who had been tested, most (93.1%) had taken up the test voluntarily, while 80.9 percent had received their test result too. Exposure to HIV/AIDS-Related Programs Altogether, 81.7 percent of IDUs had met peer/outreach educators at least once in the past year; while 77.3 percent had visited a drop-in center (DIC), and 28.3 percent had visited a VCT (Voluntary Counseling and Testing) center in the past year. However, only 6.3 percent of IDUs had been to an STI clinic before. Likewise, 29.7 percent of respondents had participated in at least one HIV/AIDS-related program or similar community event in the past year.