AIDS Care, 2015 Vol. 27, No. 3, 288–292, http://dx.doi.org/10.1080/09540121.2014.972322

Undiagnosed HIV among people who inject drugs in Manipur, India Gregory Armstronga*, Gajendra K. Medhib, Jagadish Mahantab, R.S. Paranjapec and Michelle Kermodea a Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Carlton, VIC, Australia; bRegional Medical Research Centre (RMRC), Indian Council of Medical Research (ICMR), Dibrugarh, India; cNational AIDS Research Institute (NARI), Pune, India

(Received 6 June 2014; accepted 30 September 2014) Manipur is a geographically isolated state of India characterised by a high HIV prevalence among people who inject drugs (PWID). A low-to-moderate lifetime rate of HIV testing has been documented amongst PWID in Manipur. Little is known about the extent of undiagnosed HIV in this setting and whether uptake of HIV testing (and knowledge of a positive diagnosis) leads HIV-positive PWID to change their risk behaviours. The cross-sectional data (n = 821) analysed for this paper were collected in 2009 for the Integrated Behavioural and Biological Assessment (IBBA) using interviewer-administered questionnaires and the collection of de-linked blood and urine samples. Almost one-third (30.7%) of the participants tested HIV positive. The majority knew where to obtain a confidential HIV test (80.7%), however, half of the HIV-positive participants had either never had an HIV test (37.7%), or had undertaken a test without collecting the result (12.7%). Almost one-quarter (23.4%) of the HIV-positive participants and 17.4% of the HIV-negative participants had shared a needle/syringe with at least one other injector during the preceding month. Encouragingly, HIV-positive participants were significantly more likely than HIV-negative participants to use condoms with their regular sexual partners, however, there was still a high proportion of HIV-positive participants who did not use a condom at last sex with their regular (47.2%) or casual (48.0%) partners. Having taken an HIV test and collected the result was associated with a reduction in HIV-risk behaviours among HIV-positive participants, but not among HIVnegative participants. In conclusion, we found that a substantial proportion of the HIV-positive PWID in Manipur were not aware of their positive status, and risky injecting and sexual practices were commonplace. However, HIV-positive PWID appear to reduce their high-risk behaviours when they become aware of their HIV status highlighting the importance of taking HIV testing coverage to scale. Keywords: injecting drug use; undiagnosed HIV; HIV testing; HIV risk

Background High uptake of HIV testing is a critical component of HIV prevention among people who inject drugs (PWID). People can reduce their engagement in HIV-risk behaviours when they know their HIV-positive status (Marks, Crepaz, Senterfitt, & Janssen, 2005) and having been tested is an essential prerequisite for access to antiretroviral therapy (ART) (Cohen et al., 2011). The state of Manipur, which is located in North-east India, consistently reports a high prevalence of HIV among PWID (29% in 2008–2009) (National AIDS Control Organisation, 2012). A low-to-moderate lifetime rate of HIV testing has been observed among PWID in Manipur, ranging from 41% to 46% (Armstrong, Humtsoe, & Kermode, 2011). Consequently, it is probable that a substantial proportion of the HIV-positive PWID remain undiagnosed. This paper presents information on HIV testing among PWID in Manipur. The objectives of our analyses were (1) to estimate the proportion of HIVpositive PWID in Manipur who have either never taken an HIV test or have taken an HIV test yet never collected the *Corresponding author. Email: [email protected] © 2014 Taylor & Francis

result, (2) to describe the level of injecting and sexual risk behaviours among HIV-positive PWID and (3) to assess whether exposure to HIV testing is correlated with reduced injecting and sexual risk behaviours. Methods This paper presents secondary analyses of cross-sectional data that was collected in 2009 for the Integrated Behavioural and Biological Assessment (IBBA) (Chandrasekaran et al., 2008; Saidel et al., 2008), using interviewer-administered questionnaires and the collection of blood and urine samples. The study protocol was approved by the Institutional Ethical Committees of Regional Medical Research Centre, the National AIDS Research Institute and the Family Health International. PWID were recruited using respondent-driven sampling (RDS) (Salganik & Heckathorn, 2004) from two districts of Manipur, Churachandpur and Bishnupur; a sample size of 400 per district was estimated for the IBBA (Indian Council of Medical Research & FHI 360, 2011). Eligible participants were males (very few PWID

AIDS Care in North-east India are females, ≤5%) aged 18 years or older who had injected drugs at least once within the last six months. Participation in HIV testing was measured by three questions: (1) have you ever taken an HIV test? (yes/no), (2) when did you last take an HIV test? (less than one year ago/more than one year ago), and (3) did you collect the result (yes/no)? The first and third questions were combined to create a composite HIV testing variable with three categories: (1) never had an HIV test, (2) had an HIV test, but did not collect the result and (3) had an HIV test and collected the result. By constructing this variable and disaggregating the results by HIV status, we are able to estimate the proportion of HIV-positive PWID who had either never taken an HIV test or had taken the test but without collecting the result; this provides a lower bound estimate of the proportion of HIV-positive participants who would not have known their status. De-linked blood samples were tested for HIV and hepatitis B and C. Data analysis All analyses were performed using STATA 10.0. Data on participant characteristics, HIV testing, awareness of ART and injecting and sexual risk behaviours are disaggregated by HIV status with differences tested for statistical significance using the chi-square test. Multivariate logistic

regression analyses were conducted to estimate the strength of association between HIV testing and engagement in needle/syringe sharing during the preceding month and unprotected sex at last sex with regular partners. Results The proportion of PWID participants who were positive for HIV was 30.7% (n = 252). Characteristics of the IBBA participants are tabulated in Table 1, disaggregated by HIV status. The participants were typically long-term heroin injectors (mean = 7.2 years, median = 6.0) with 62.2% having injected drugs for 5 or more years. Coinfection with viral hepatitis was common (HCV, 95.2%; HBV, 11.1%). HIV-positive participants were significantly more likely to be older; be currently married or divorced, separated or widowed; be injecting multiple times daily; have been injecting for five or more years and to test positive for HCV. The majority of participants knew where to obtain a confidential HIV test (80.7%) and had heard of ART (79.1%; Table 2). A higher proportion of HIV positive (62.3%) than HIV negative (50.1%) participants had previously taken an HIV test. However, a substantial proportion of HIV-positive participants would not have known that they were infected. Half (50.4%) had either never had an HIV test or had undertaken a test without

Table 1. Participant characteristics.

Age (n = 821) 18–24 years 25–34 years 35 years and older Literate – can read and write (n = 821) No Yes Marital status (n = 821) Currently married Divorced, separated and widowed Never married Years since first injected illicit drugs (n = 817) 0–1 years 2–4 years 5+ years Frequency of injecting (n = 821) Once a week or less Two–seven times a week Multiple times daily Tested positive for different types of infections (n = 821) Hepatitis C (HCV) Hepatitis B (HBV)

289

HIV-positive sub-group % (n)

HIV negative sub-group % (n)

Total % (n)

3.6 (9) 54.4 (137) 42.1 (106)

25.1 (143) 64.9 (369) 10.0 (57)

18.5 (152) 61.6 (506) 19.9 (163)

9.9 (25) 90.1 (227)

6.9 (39) 93.2 (530)

7.8 (64) 92.2 (757)

43.7 (110) 21.8 (55) 34.5 (87)

35.2 (200) 7.0 (40) 57.8 (329)

37.8 (310) 11.6 (95) 50.7 (416)

2.4 (6) 12.9 (32) 84.7 (211)

12.9 (73) 34.9 (198) 52.3 (297)

9.7 (79) 28.2 (230) 62.2 (508)

14.7 (37) 24.2 (61) 61.1 (154)

32.7 (186) 20.6 (117) 46.8 (266)

27.2 (223) 21.7 (178) 51.2 (420)

95.2 (240) 11.1 (28)

64.5 (367) 10.2 (58)

73.9 (607) 10.5 (86)

p-value

Undiagnosed HIV among people who inject drugs in Manipur, India.

Manipur is a geographically isolated state of India characterised by a high HIV prevalence among people who inject drugs (PWID). A low-to-moderate lif...
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