G Model
ARTICLE IN PRESS
DRUPOL-1333; No. of Pages 4
International Journal of Drug Policy xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Short report
High HIV and HCV and the unmet needs of people who inject drugs in Yerevan, Armenia Lisa Johnston a,b,∗ , Samvel Grigoryan c , Arshak Papoyan c , Trdat Grigoryan c , Tatevik Balayan c , Lev Zohrabyan d a
Global Health Sciences, University of California, San Francisco, USA School of International Public Health and Tropical Medicine, Tulane University, New Orleans, USA c National AIDS Center, Yerevan, Armenia d United Nations Joint Program on HIV/AIDS, Regional Support Team, Europe and Central Asia, Moscow, Russia b
a r t i c l e
i n f o
Article history: Received 1 November 2013 Received in revised form 1 February 2014 Accepted 4 February 2014 Keywords: HIV/AIDS Hepatitis C Respondent driven sampling People who inject drugs Armenia
a b s t r a c t Background: In 2010–2011 the Armenia government conducted a survey of PWID to measure HIV and related infections prevalence and risk behaviors. Methods: Respondent driven sampling was used to sample 270 men and women, ≥18 years, who injected drugs in the previous three months and lived in Yerevan. Descriptive analysis was conducted with RDSAT v.6.0. Correlates of HIV and HCV infection were conducted using RDSAT-generated weights for each infection. Results: Most PWID reported injecting drugs < one time a day, using disposable needles/syringes, and neither recently sharing a needle/syringe nor sharing injection paraphernalia. Most reported wanting to get help to stop injecting, however, only 21% sought treatment in the past year. HIV prevalence was 10.9%, HCV was 36.6% and active syphilis was 4.1%; 73.5% of HIV seropositive PWID were also infected with HCV. Conclusion: PWID have high HIV and HCV prevalence but practice moderately risky injection behaviors. Most PWID want to stop injecting drugs, however, there are numerous barriers to treatment and harm reduction programs. Limited government initiative and reductions in international funding will likely impact needed programs targeting PWID in Armenia. © 2014 Elsevier B.V. All rights reserved.
Introduction HIV in the Republic of Armenia is currently considered to be low at 0.2% in the general population with transmission reported to be largely attributed to sexual contact (54.3% of all 1153 cases reported up to 2011) and the use of contaminated needles (37% of cases, all of which were males) (UNAIDS, 2010). Despite the low reported HIV prevalence in Armenia, there are numerous reasons to be concerned that the country will experience dramatic increases in HIV, as well as Hepatitis C (HCV), among people who inject drugs (PWID) and consequently to the wider population. Firstly, Armenia has a high rate of migration to the Russian Federation and Ukraine, where HIV and HCV prevalence among key populations is
∗ Corresponding author at: Nieuwezijds Voorburgwal 64F, 1012 SC, Amsterdam, Netherlands. Tel.: +31 6 19282970E. E-mail address: [email protected] (L. Johnston). URL: http://www.lisagjohnston.com (L. Johnston).
significantly higher and where PWID play a crucial role in the HIV epidemic (Mathers et al., 2008; Taran, Johnston, Pohorilac, & Saliuk, 2011). Secondly, HIV prevalence among PWID is already estimated to be about 7% (Republic of Armenia, 2008). HIV Modeling studies indicate that once HIV has been introduced into the PWID population, transmission spreads quickly (Blower, Hartel, Dowlatabadi, Anderson, & May, 1991; Saidel et al., 2003) with increased opportunities for transmission through sex with non-injecting partners and consequently to the general population (Des Jarlais et al., 2012; UNAIDS, 2010). Indeed, about 58% of predicted new HIV cases are expected to be in the general population, especially among noninjecting female partners of PWID (Grigoryan et al., 2012). Finally, Armenia, highly dependent on outside financing for the few programs available for drug use and general population HIV prevention and treatment, has no HIV counseling and testing (HCT) programs specifically targeting PWID (UNAIDS, 2010). PWID, half of whom inject ‘chernyashka’ (mixture of opium and acetyl anhydride), comprise roughly 0.62% of the adult population (personal communication, second author), translating to roughly
http://dx.doi.org/10.1016/j.drugpo.2014.02.004 0955-3959/© 2014 Elsevier B.V. All rights reserved.
Please cite this article in press as: Johnston, L., et al. High HIV and HCV and the unmet needs of people who inject drugs in Yerevan, Armenia. International Journal of Drug Policy (2014), http://dx.doi.org/10.1016/j.drugpo.2014.02.004
G Model DRUPOL-1333; No. of Pages 4
ARTICLE IN PRESS L. Johnston et al. / International Journal of Drug Policy xxx (2014) xxx–xxx
2
12,700 people in Armenia and 6531 people in the capital and largest city in Armenia, Yerevan (population ≥18 years: 2 million). Efforts to control drug use are hampered by the fact that approximately one quarter of the opium coming out of Afghanistan (source of about 90% of the world’s supply) is trafficked through Armenia (UNODC, 2010) and that drugs are easily trafficked between Turkey and Armenia due to these countries’ long standing tensions which allow neither diplomatic relations nor collaboration with law enforcement agencies along their shared frontiers. This paper presents findings from a survey to measure the prevalence of HIV, HCV and syphilis, and other risk behaviors and presents associations for HIV and HCV infection among PWID conducted in Yerevan in 2010–2011. Methods Eligible participants were males and females who reported injecting drugs in the previous three months, ≥18 years and living in Yerevan. The sample size was calculated for 266 PWID (rounded up to 270) based on a prevalence for condom use of 50%, 15% change between survey rounds, confidence of 95%, power of 80% and a design effect of 2. Sampling was carried out using respondentdriven sampling (RDS), a chain referral sampling method that collects data on social network sizes and recruitment patterns to determine selection probabilities (Salganik & Heckathorn, 2004). Recruitment was initiated with six initial recruits, identified through key contacts. Once participants provided informed consent and completed the survey requirements (face-to-face interview in Armenian, pre-test counseling and venous blood draw for HIV, HCV and syphilis testing), they received three recruitment coupons to use to recruit the other participants into the survey. All participants received ∼USD 9.5 for completing the survey process and ∼USD 4.6 for each eligible recruit who participated in the survey. In addition participants’ degree measurement (the number of persons who fulfill the survey eligibility criteria with whom the participant has a reciprocal relationship and has seen in the previous month) and recruitment links were collected for data analysis. Five milliliters of venous blood, were processed at the National reference laboratory in accordance with the Armenia Ministry of Health guidelines. HIV antibodies were screened with ELISA HIV 1/2 Ag/Ab BIOTEC code 7/003c and confirmed with Genscreen Ultra HIV Ag–Ab. Syphilis infection/exposure was screened with Rapid Plasma Reagin (RPR) and active syphilis infection was confirmed with Treponema Palidum Hemaglutination (TPHA). Antibodies to HCV were detected using ELISA HCV Ab Recombinant BIOTEC, code 7/033. To minimize harm to participants, consultations were held prior to the start of the survey with ministry officials, police authorities, community leaders and key representatives from local non-governmental organizations, UNAIDS and WHO. The survey protocol was reviewed and approved by the ethical review board of the Armenia Ministry of Health. To ensure confidentiality, participants’ coupons, questionnaires, specimens, and test results were identified using a unique number. A coupon manager system was used to monitor recruitment, redundancy, and incentive distribution. No personal identifying information was collected and all participants could receive their test results 3 h after providing a biological sample. Data analysis Data were double entered. Estimates and 95% confidence intervals (CI) were calculated using the RDS I estimator (Salganik & Heckathorn, 2004) in RDS Analysis Tool (RDSAT) version 6.0 (Table 1). Logistic regression was performed to identify statistically
significant correlates of HIV and HCV infection using RDSATgenerated survey weights for each infection. Results Beginning with six seeds, 270 PWID participants were recruited with a maximum chain length of 13 waves. No participants refused biologic testing. Most PWID were male, >29 years, and had secondary schooling or below (Table 1). Most reported injecting drugs < one time a day, currently using disposable needles/syringes, and neither sharing a needle/syringe the last time they injected nor sharing injection paraphernalia in the past one month. Only 26.9% of PWID reported receiving sterile needles/syringes free of charge in the past 12 months. Almost two-thirds of PWID ever wanted to get help to stop injecting, however, only 21% actually sought treatment in the past year. All PWID reported ever having sexual intercourse and 39.6% reported using a condom at last sexual intercourse with any sex partner. Only 16.1% of PWID reported having an HIV test and receiving their test results in the past year. HIV prevalence was 10.9%, HCV antibody was 36.6% and active syphilis 4.1%. Among HIV positive PWID, 73.5% were also infected with HCV and 20.6% had active syphilis. HIV and HCV risk HIV infection was positively associated with using a condom with any sex partner at last sexual intercourse, testing and receiving results for HIV in the past one year, and HCV and syphilis infection. HIV infection was negatively associated with seeking treatment to stop injecting in the past year. HCV infection was positively associated with being older (≤29 years), having higher education, injecting ≥ every day, using disposable needles/syringes, sharing needles at last injection, seeking treatment to stop injecting in the past year and with HIV and syphilis infection. HCV infection was negatively associated with condom use with any sex partner at last sex. Discussion Despite the finding of high HIV and HCV prevalence and HIV/HCV co-infection among PWID in Yerevan, injecting patterns appear to comprise only moderate risk behaviors. With the exception of 44% of PWID reporting sharing injection paraphernalia, only 21% reported injecting daily, 91% were using disposable syringes and needles and 21% shared a needle or syringe at their last injection, all of which are strongly promoted for reducing HIV and HCV transmission (Institute of Medicine, 2006). Likewise, HCV infection, which is predominately transmitted parenterally, was positively associated with injecting ≥1 time per day and sharing needles or syringes. However, HCV was also positively associated with using disposable syringes and needles, which suggests that this practice started after being infected. Nevertheless, the small percentages of PWID who reported high risk injecting behaviors is not inconsequential and provides ample opportunities for continued HIV and HCV transmission. The finding that almost all PWID are using disposable needles and syringes but only 27% received them free of charge from a service in the past year suggests that PWID are purchasing them at pharmacies or receiving them from friends. Currently, Yerevan has only one needle and exchange program. It would be useful to know why PWID are not accessing their disposable needles and syringes from the available services before efforts to expand these programs are undertaken. Common barriers to effective needle and syringe exchange programs include accessibility based on
Please cite this article in press as: Johnston, L., et al. High HIV and HCV and the unmet needs of people who inject drugs in Yerevan, Armenia. International Journal of Drug Policy (2014), http://dx.doi.org/10.1016/j.drugpo.2014.02.004
G Model
ARTICLE IN PRESS
DRUPOL-1333; No. of Pages 4
L. Johnston et al. / International Journal of Drug Policy xxx (2014) xxx–xxx
3
Table 1 Weighted estimates and 95% confidence intervals and predictors of HIV and HCV among people who inject drugs, Yerevan, Republic of Armenia, 2010–2011. People who inject drugs, Yerevan, Republic of Armenia Prevalence (n = 270) a
n
HIV (n = 24)
Weighted %
95% CI
OR
262 7
96.5 3.5
93.2, 99.1 0.9, 6.8
3.5
81 72 61 55
28.5 24.6 25.6 21.2
20.5, 37.3 17.3, 31.9 17.7, 33.2 14.8, 29.1
5.1 4.4 4.7
Education ≤Secondary >Secondary
226 42
84.6 15.4
78.2, 90.2 9.8, 21.8
1.9
Current injection frequency
ARTICLE IN PRESS
DRUPOL-1333; No. of Pages 4
International Journal of Drug Policy xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Short report
High HIV and HCV and the unmet needs of people who inject drugs in Yerevan, Armenia Lisa Johnston a,b,∗ , Samvel Grigoryan c , Arshak Papoyan c , Trdat Grigoryan c , Tatevik Balayan c , Lev Zohrabyan d a
Global Health Sciences, University of California, San Francisco, USA School of International Public Health and Tropical Medicine, Tulane University, New Orleans, USA c National AIDS Center, Yerevan, Armenia d United Nations Joint Program on HIV/AIDS, Regional Support Team, Europe and Central Asia, Moscow, Russia b
a r t i c l e
i n f o
Article history: Received 1 November 2013 Received in revised form 1 February 2014 Accepted 4 February 2014 Keywords: HIV/AIDS Hepatitis C Respondent driven sampling People who inject drugs Armenia
a b s t r a c t Background: In 2010–2011 the Armenia government conducted a survey of PWID to measure HIV and related infections prevalence and risk behaviors. Methods: Respondent driven sampling was used to sample 270 men and women, ≥18 years, who injected drugs in the previous three months and lived in Yerevan. Descriptive analysis was conducted with RDSAT v.6.0. Correlates of HIV and HCV infection were conducted using RDSAT-generated weights for each infection. Results: Most PWID reported injecting drugs < one time a day, using disposable needles/syringes, and neither recently sharing a needle/syringe nor sharing injection paraphernalia. Most reported wanting to get help to stop injecting, however, only 21% sought treatment in the past year. HIV prevalence was 10.9%, HCV was 36.6% and active syphilis was 4.1%; 73.5% of HIV seropositive PWID were also infected with HCV. Conclusion: PWID have high HIV and HCV prevalence but practice moderately risky injection behaviors. Most PWID want to stop injecting drugs, however, there are numerous barriers to treatment and harm reduction programs. Limited government initiative and reductions in international funding will likely impact needed programs targeting PWID in Armenia. © 2014 Elsevier B.V. All rights reserved.
Introduction HIV in the Republic of Armenia is currently considered to be low at 0.2% in the general population with transmission reported to be largely attributed to sexual contact (54.3% of all 1153 cases reported up to 2011) and the use of contaminated needles (37% of cases, all of which were males) (UNAIDS, 2010). Despite the low reported HIV prevalence in Armenia, there are numerous reasons to be concerned that the country will experience dramatic increases in HIV, as well as Hepatitis C (HCV), among people who inject drugs (PWID) and consequently to the wider population. Firstly, Armenia has a high rate of migration to the Russian Federation and Ukraine, where HIV and HCV prevalence among key populations is
∗ Corresponding author at: Nieuwezijds Voorburgwal 64F, 1012 SC, Amsterdam, Netherlands. Tel.: +31 6 19282970E. E-mail address: [email protected] (L. Johnston). URL: http://www.lisagjohnston.com (L. Johnston).
significantly higher and where PWID play a crucial role in the HIV epidemic (Mathers et al., 2008; Taran, Johnston, Pohorilac, & Saliuk, 2011). Secondly, HIV prevalence among PWID is already estimated to be about 7% (Republic of Armenia, 2008). HIV Modeling studies indicate that once HIV has been introduced into the PWID population, transmission spreads quickly (Blower, Hartel, Dowlatabadi, Anderson, & May, 1991; Saidel et al., 2003) with increased opportunities for transmission through sex with non-injecting partners and consequently to the general population (Des Jarlais et al., 2012; UNAIDS, 2010). Indeed, about 58% of predicted new HIV cases are expected to be in the general population, especially among noninjecting female partners of PWID (Grigoryan et al., 2012). Finally, Armenia, highly dependent on outside financing for the few programs available for drug use and general population HIV prevention and treatment, has no HIV counseling and testing (HCT) programs specifically targeting PWID (UNAIDS, 2010). PWID, half of whom inject ‘chernyashka’ (mixture of opium and acetyl anhydride), comprise roughly 0.62% of the adult population (personal communication, second author), translating to roughly
http://dx.doi.org/10.1016/j.drugpo.2014.02.004 0955-3959/© 2014 Elsevier B.V. All rights reserved.
Please cite this article in press as: Johnston, L., et al. High HIV and HCV and the unmet needs of people who inject drugs in Yerevan, Armenia. International Journal of Drug Policy (2014), http://dx.doi.org/10.1016/j.drugpo.2014.02.004
G Model DRUPOL-1333; No. of Pages 4
ARTICLE IN PRESS L. Johnston et al. / International Journal of Drug Policy xxx (2014) xxx–xxx
2
12,700 people in Armenia and 6531 people in the capital and largest city in Armenia, Yerevan (population ≥18 years: 2 million). Efforts to control drug use are hampered by the fact that approximately one quarter of the opium coming out of Afghanistan (source of about 90% of the world’s supply) is trafficked through Armenia (UNODC, 2010) and that drugs are easily trafficked between Turkey and Armenia due to these countries’ long standing tensions which allow neither diplomatic relations nor collaboration with law enforcement agencies along their shared frontiers. This paper presents findings from a survey to measure the prevalence of HIV, HCV and syphilis, and other risk behaviors and presents associations for HIV and HCV infection among PWID conducted in Yerevan in 2010–2011. Methods Eligible participants were males and females who reported injecting drugs in the previous three months, ≥18 years and living in Yerevan. The sample size was calculated for 266 PWID (rounded up to 270) based on a prevalence for condom use of 50%, 15% change between survey rounds, confidence of 95%, power of 80% and a design effect of 2. Sampling was carried out using respondentdriven sampling (RDS), a chain referral sampling method that collects data on social network sizes and recruitment patterns to determine selection probabilities (Salganik & Heckathorn, 2004). Recruitment was initiated with six initial recruits, identified through key contacts. Once participants provided informed consent and completed the survey requirements (face-to-face interview in Armenian, pre-test counseling and venous blood draw for HIV, HCV and syphilis testing), they received three recruitment coupons to use to recruit the other participants into the survey. All participants received ∼USD 9.5 for completing the survey process and ∼USD 4.6 for each eligible recruit who participated in the survey. In addition participants’ degree measurement (the number of persons who fulfill the survey eligibility criteria with whom the participant has a reciprocal relationship and has seen in the previous month) and recruitment links were collected for data analysis. Five milliliters of venous blood, were processed at the National reference laboratory in accordance with the Armenia Ministry of Health guidelines. HIV antibodies were screened with ELISA HIV 1/2 Ag/Ab BIOTEC code 7/003c and confirmed with Genscreen Ultra HIV Ag–Ab. Syphilis infection/exposure was screened with Rapid Plasma Reagin (RPR) and active syphilis infection was confirmed with Treponema Palidum Hemaglutination (TPHA). Antibodies to HCV were detected using ELISA HCV Ab Recombinant BIOTEC, code 7/033. To minimize harm to participants, consultations were held prior to the start of the survey with ministry officials, police authorities, community leaders and key representatives from local non-governmental organizations, UNAIDS and WHO. The survey protocol was reviewed and approved by the ethical review board of the Armenia Ministry of Health. To ensure confidentiality, participants’ coupons, questionnaires, specimens, and test results were identified using a unique number. A coupon manager system was used to monitor recruitment, redundancy, and incentive distribution. No personal identifying information was collected and all participants could receive their test results 3 h after providing a biological sample. Data analysis Data were double entered. Estimates and 95% confidence intervals (CI) were calculated using the RDS I estimator (Salganik & Heckathorn, 2004) in RDS Analysis Tool (RDSAT) version 6.0 (Table 1). Logistic regression was performed to identify statistically
significant correlates of HIV and HCV infection using RDSATgenerated survey weights for each infection. Results Beginning with six seeds, 270 PWID participants were recruited with a maximum chain length of 13 waves. No participants refused biologic testing. Most PWID were male, >29 years, and had secondary schooling or below (Table 1). Most reported injecting drugs < one time a day, currently using disposable needles/syringes, and neither sharing a needle/syringe the last time they injected nor sharing injection paraphernalia in the past one month. Only 26.9% of PWID reported receiving sterile needles/syringes free of charge in the past 12 months. Almost two-thirds of PWID ever wanted to get help to stop injecting, however, only 21% actually sought treatment in the past year. All PWID reported ever having sexual intercourse and 39.6% reported using a condom at last sexual intercourse with any sex partner. Only 16.1% of PWID reported having an HIV test and receiving their test results in the past year. HIV prevalence was 10.9%, HCV antibody was 36.6% and active syphilis 4.1%. Among HIV positive PWID, 73.5% were also infected with HCV and 20.6% had active syphilis. HIV and HCV risk HIV infection was positively associated with using a condom with any sex partner at last sexual intercourse, testing and receiving results for HIV in the past one year, and HCV and syphilis infection. HIV infection was negatively associated with seeking treatment to stop injecting in the past year. HCV infection was positively associated with being older (≤29 years), having higher education, injecting ≥ every day, using disposable needles/syringes, sharing needles at last injection, seeking treatment to stop injecting in the past year and with HIV and syphilis infection. HCV infection was negatively associated with condom use with any sex partner at last sex. Discussion Despite the finding of high HIV and HCV prevalence and HIV/HCV co-infection among PWID in Yerevan, injecting patterns appear to comprise only moderate risk behaviors. With the exception of 44% of PWID reporting sharing injection paraphernalia, only 21% reported injecting daily, 91% were using disposable syringes and needles and 21% shared a needle or syringe at their last injection, all of which are strongly promoted for reducing HIV and HCV transmission (Institute of Medicine, 2006). Likewise, HCV infection, which is predominately transmitted parenterally, was positively associated with injecting ≥1 time per day and sharing needles or syringes. However, HCV was also positively associated with using disposable syringes and needles, which suggests that this practice started after being infected. Nevertheless, the small percentages of PWID who reported high risk injecting behaviors is not inconsequential and provides ample opportunities for continued HIV and HCV transmission. The finding that almost all PWID are using disposable needles and syringes but only 27% received them free of charge from a service in the past year suggests that PWID are purchasing them at pharmacies or receiving them from friends. Currently, Yerevan has only one needle and exchange program. It would be useful to know why PWID are not accessing their disposable needles and syringes from the available services before efforts to expand these programs are undertaken. Common barriers to effective needle and syringe exchange programs include accessibility based on
Please cite this article in press as: Johnston, L., et al. High HIV and HCV and the unmet needs of people who inject drugs in Yerevan, Armenia. International Journal of Drug Policy (2014), http://dx.doi.org/10.1016/j.drugpo.2014.02.004
G Model
ARTICLE IN PRESS
DRUPOL-1333; No. of Pages 4
L. Johnston et al. / International Journal of Drug Policy xxx (2014) xxx–xxx
3
Table 1 Weighted estimates and 95% confidence intervals and predictors of HIV and HCV among people who inject drugs, Yerevan, Republic of Armenia, 2010–2011. People who inject drugs, Yerevan, Republic of Armenia Prevalence (n = 270) a
n
HIV (n = 24)
Weighted %
95% CI
OR
262 7
96.5 3.5
93.2, 99.1 0.9, 6.8
3.5
81 72 61 55
28.5 24.6 25.6 21.2
20.5, 37.3 17.3, 31.9 17.7, 33.2 14.8, 29.1
5.1 4.4 4.7
Education ≤Secondary >Secondary
226 42
84.6 15.4
78.2, 90.2 9.8, 21.8
1.9
Current injection frequency
