Integrated Biological and Behavioral Surveillance Survey (IBBS) among Injecting Drug Users in Kathmandu 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 Kathmandu Valley. The study was undertaken to measure the prevalence of HIV and syphilis, and associated risk behaviors among IDUs. Demographic, sexual behavior and injecting behavior data were collected through structured questionnaire while the prevalence of HIV and syphilis were selectively measured by testing blood sample. HIV test was performed 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 The HIV prevalence among IDUs in the Kathmandu Valley in 2009 was as high as 20.7 percent. However, this is a significant decrease from the previous rounds of IBBS conducted in the Valley (68% in first round, 51.7% in second round and 34.8% in third round). STIs among IDUs in the Kathmandu Valley are relatively a minor problem. Syphilis history was detected among 4.1 percent of IDUs, while only 1.5 percent had current syphilis. HIV prevalence differed significantly according toage, literacy status and duration of drug injection. Those IDUs who were older than 20 years were more likely to be HIV-positive (23%) than younger IDUs (5.4%). HIV prevalence among literate IDUs was 19.3 percent, while among illiterate IDUs it was 70.5 percent. Likewise, HIV prevalence was significantly higher among those who had been injecting drugs for more than five years (38.4%) than those who have been injecting drugs for less than five years (12.3%). Socio-Demographic Characteristics The IDUs were predominantly young, including 83 percent below 30 years of age, with nearly half of them (47 %) being younger than 25years. Nine percent of IDUs were illiterate or have no formal education Many IDUs (67.1%) were unmarried. Around 15 percent among married were living without a sexual partner. IDUs in Kathmandu Valley were from all major caste/ethnic groups. The majority of the IDUs (28.7%) were from the Newar community followed by the Chhetri/Thakuri (25.7%) and Tamang/Lama/Magar (19.9%) communities. Alcohol Intake, Oral Drugs Use and Injecting Behavior The majority of the IDUs (38.4%) had been using drugs for more than five years while less than one percent had been injecting drugs for less than two years. Most of them (67.9%) had started injecting drugs at a young age i.e., below 20 years. Overall, 19 percent of the respondents were consuming alcohol everyday. However, 30 percent had never consumed alcohol. Use of oral/inhaled drugs was common practice among IDUs. Ganja was the most popular drug, taken by 80 percent of IDUs in the week preceding the survey followed by Nitrovate, brown sugar, and Proxygin. The majority of respondents were 20 or younger (67.9%) when they injected for the first time. Eighty-seven percent of IDUs injected combination of different drugs. All of the respondents knew about the sources for getting new syringes. Almost all of IDUs mentioned that they could get a new syringe whenever necessary from a drugstore. Similarly, a large proportion of IDUs (81.2%) said that the needle exchange program conducted by LALS made new syringes available whenever they needed one. Among those IDUs who had been mobile in the past year two percent had injected with a pre-used needle/syringe and six 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 practices in the week preceding the survey has been increasing steadily since the first round. High-risk behavior such as injecting with previously used needles/syringes decreased significantly from 45 percent in the first round to seven percent in the current fourth round. Additionally, the proportion of IDUs who had not shared their needle/syringe with anyone in the past week increased from 41 percent in 2003 to 93 percent in 2009. Sexual Behavior Overall 95 percent IDUs in Kathmandu had had sex before the survey. Seven in ten were sexually active in the past year also. The sex partners of IDUs in Pokhara included regular female parents, non-regular female partners as well as female sex workers. In the year preceding the survey, 29 percent each had sex with regular partner and with FSWs, while 27 percent had non-regular sex partners. Among those IDUs who had regular sex partner, eighty-seven percent had sex with them in the past month. Likewise, among those IDUs who had sex with non-regular partner, 65 percent had it in last month and among those who had non-regular partner, fifty percent had sex with them in the past month. Condom use in the last sex with FSWs was reported by 67 percent of respondents. The proportion of those who used condoms in last sex with regular partner was 54 percent and with non-regular partner was 39 percent. A similar pattern was observed in consistent condom use in the past year. It was highest with FSWs (49.4%) followed by with non-regular partners (33.4%). Consistent use of condoms with the regular sex partners was lowest, with only about six percent of IDUs using condom consistently in the past year. Knowledge of HIV/AIDS/STIs and exposure to the HIV/AIDS Prevention Programs Six percent of IDUs had genital discharge and three percent had genital ulcers/sores in the past year. Among those who had STIs before, 20 percent and 29 percent reported having genital discharge and genital ulcers/sores respectively during the survey. More than half (57.2%) of those IDUs who had experienced at least one STI symptom in the past year had not sought any treatment. More than nine in ten IDUs (94.4%) 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 only two-thirds (67.6%) 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 (97.8%) knew that a person can get HIV by using previously used needles/syringes. The majority of respondents (95.9%) knew that a confidential HIV testing facility was available in their communities. Only half of the IDUs (53%) had ever tested themselves for HIV. The majority (85.3%) had tested voluntarily and others had done so as per requirement. Most of the IDUs (88.7%) who have had tested for HIV had received the test result. During the preceding year three-fourths (75) had interacted with a peer educator/outreach educator and a similar proportion (75.7%) had visited a drop-in-centre. Only 20 percent of IDUs had visited a VCT centre at least once. Very few IDUs (2%) had visited an STI clinic. Sixty-two percent of IDUs had participated in different HIV/AIDS awareness raising programs.