Accepted Manuscript Title: HIV prevalence and risk among people who inject drugs in five South African cities Author: Andrew Scheibe David Makapela Ben Brown Monika dos Santos Fabienne Hariga Harsheth Virk Linda-Gail Bekker Olga Lyan Nancy Fee Margarete Molnar Alina Bocai Jason Eligh Riku Lehtovuori PII: DOI: Reference:
S0955-3959(16)00027-X http://dx.doi.org/doi:10.1016/j.drugpo.2016.01.004 DRUPOL 1701
To appear in:
International Journal of Drug Policy
Received date: Revised date: Accepted date:
10-8-2015 19-12-2015 8-1-2016
Please cite this article as: Scheibe, A., Makapela, D., Brown, B., dos Santos, M., Hariga, F., Virk, H., Bekker, L.-G., Lyan, O., Fee, N., Molnar, M., Bocai, A., Eligh, J., and Lehtovuori, R.,HIV prevalence and risk among people who inject drugs in five South African cities, International Journal of Drug Policy (2016), http://dx.doi.org/10.1016/j.drugpo.2016.01.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Highlights
Ac ce p
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M
an
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ip t
We conducted the largest cross-sectional HIV prevalence and risk survey among people who inject drugs in South Africa to date We provide a description of participant demographics, drug using and sexual history and findings from bi-variate and multi-variate analysis for HIV infection. The study identified high-risk injecting and sexual practices among PWID in South Africa. We provide recommendations to inform future HIV prevention and treatment interventions for PWID in South Africa
1 Page 1 of 33
HIV prevalence and risk among people who inject drugs in five South African cities Andrew Scheibe1, David Makapela2, Ben Brown1, Monika dos Santos3,4, Fabienne Hariga5, Harsheth Virk6, Linda-Gail Bekker,1 Olga Lyan7, Nancy Fee8, Margarete Molnar9, Alina Bocai 10, Jason Eligh10, Riku Lehtovuori5
ip t
1. Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
cr
2. International Organisation for Migration, Pretoria, South Africa
us
3. Foundation for Professional Development, Pretoria, South Africa
4. Department of Psychology, University of South Africa, Pretoria, South Africa
an
5. United Nations Office on Drugs and Crime, Vienna, Austria 6. United Nations Office on Drugs and Crime, Lagos, Nigeria 7. UNAIDS, Geneva, Switzerland
9. UNAIDS, Cotonou, Benin
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8. UNAIDS, Pretoria, South Africa
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d
10. United Nations Office on Drugs and Crime, Pretoria, South Africa
Ac ce p
Corresponding author: Andrew Scheibe, [email protected]. 10 Upper Towers Road, Muizenberg, 7945, South Africa. + 27 (0) 79 882 7726 (tel.)
2 Page 2 of 33
HIV prevalence and risk among people who inject drugs in five South African cities Abstract Policy and programming for people who inject drugs (PWID) in South Africa is limited by the scarcity of epidemiological data. We conducted a cross-sectional survey among 450 PWID
ip t
(362 males and 88 females) from five South African cities in 2013, using outreach and peer referral to recruit participants. We carried out rapid HIV tests on participants’ saliva and
cr
assessed drug-using and sexual practices by means of a questionnaire. We found that 26%
us
of females and 13% of males reported to always share injecting equipment, while 49% of all participants had used contaminated injecting equipment the last time they injected. Only 6%
an
of participants usually used bleach to clean their injecting equipment. We found that half of participants reported using a condom the last time they had sex. A quarter of participants reported symptoms of a sexually transmitted infection (STI) in the previous 12 months and
M
22% had ever worked as a sex worker (51% of females).
d
HIV prevalence among participants was 14% (18% among females and 13% among males).
te
In multivariate analysis HIV was significantly associated with being 25 years and older (adjusted odds ratio (aOR) 2.1, 95% confidence interval (CI) 1.0-4.6, p=0.06), belonging to a
Ac ce p
racial group other than white (aOR 4.2, 95% CI 1.9-9.4, p 12 months ago
8 (7%)
6 (23%)
27 (23%)
16 (47%)
3 (2%)
4 (15%)
108 (88%)
23 (85%)
114 (98%)
29 (85%)
104 (84%)
25 (96%)
11 (9%)
4 (15%)
0
2 (6%)
11 (9%)
1 (4%)
Last injected with a new/ sterile needle
62 (50%)
17 (63%)
49 (42%)
21 (62%)
67 (54%)
14 (54%)
Shares needles: always or most times
59 (48%)
12 (44%)
65 (56%)
17 (50%)
39 (32%)
16 (52%)
Cleans needles (any method): always or most times
111 (90%)
24 (89%)
92 (79%)
21 (62%)
104 (84%)
18 (69%)
Does not reuse needles
5 (4%)
0
15 (13%)
7 (21%)
10 (8%)
2 (8%)
Max. # of people that a needle was shared with on one occasion (IQR)
2 (1-4)
3 (1-4)
1 (1-2)
1 (1-2)
1 (1-2)
2 (1-3)
cr
te
ATS
22 (85%)
us
Heroin
an
Last drug injected
M
Timing of last injection
ip t
Male N=123
d
Biological sex
KwaZulu-Natal
Ac ce p
*Not all totals add up due to rounding off and due to the presentation of selected data.
29 Page 29 of 33
Table 3 Participant sexual practices and HIV testing Province
Gauteng
Western Cape
Female N=27
Male N=116
Female N=34
Male N=124
Female N=26
2 (1-3)
2 (1-3)
2 (1-4)
2 (1-60)
2 (1-3)
2 (1-25)
Condom used at last sex
50 (40%)
13 (50%)
54 (47%)
15 (43%)
66 (54%)
16 (59%)
STI symptoms, last 12 months
17 (14%)
6 (23%)
50 (43%)
13 (37%)
19 (15%)
7 (26%)
Ever had sex with someone of same sex
29 (30%)
7 (27%)
18 (16%)
16 (46%)
37 (30%)
Ever exchanged sex for drugs or sex for money for drugs
52 (42%)
20 (74%)
59 (51%)
21 (62%)
54 (44%)
Ever worked as sex worker
24 (19%)
8 (31%)
12 (10%)
22 (63%)
20 (16%)
Had HIV test in last 12 months and knows result
61 (50%)
13 (48%)
57 (49%)
24 (71%)
11 (41%) 18 (69%) 15 (56%)
73 (59%)
18 (69%)
Ac ce p
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Median number of sexual partners, last 12 months (IQR)
ip t
Male N=123
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Biological sex
KwaZulu-Natal
30 Page 30 of 33
Table 4 Summary of HIV prevalence stratified by province, sex and race Gauteng
KwaZulu-Natal
Western Cape
Total
16% (24)
17% (26)
9% (14)
14% (64)
15% (18)
16% (18)
10% (13)
14% (49)
Black
18% (7)
18% (9)
0
17% (16)
White
12% (8)
7% (3)
11% (4)
10% (15)
Coloured
21% (3)
20% (2)
10% (8)
13% (13)
Asian
0
29% (4)
33% (1)
25% (5)
22% (6)
24% (8)
4% (1)
17% (15)
Black
75% (3)
85% (6)
0
81% (9)
White
7% (1)
0
0
2% (1)
Coloured
17% (1)
33% (1)
11% (1)
Asian
50% (1)
100% (1)
0
16% (3)
42% (3)
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Female (N=87)
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Male (N=363)
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Province Overall prevalence % (n)
31 Page 31 of 33
Table 5 Summary of unadjusted odds ratios for HIV infection Males Variable
Females
OR (95% CI)
p value
OR (95% CI)
p value
≥25 years
2.6 (1.1-6.4)
0.034
0.6 (0.2-1.9)
0.392
Race **, ^^^
Non-white
1.5 (0.7-2.9)
0.234
32.4 (4.0-264.5)
0.001
0.7 (0.4-1.4)
0.412
0.9 (0.2-3.5)
0.851
1.1 (0.6-2.1)
0.681
0.4 (0.11-1.4)
0.150
0.9 (0.5-1.6)
0.675
0.6 (0.2-1.9)
0.376
1.0 (1.00-1.00)
0.778
1.00 (1.00-1.00)
0.257
Homeless Did not complete high school
Education
Employed
Employment Median, monthly income (ZAR) Province
ip t
Age ^
Western Cape
-
Gauteng
1.3 (0.6-2.9)
0.435
7.1 (0.8-64.1)
0.079
KwaZulu-Natal
-
0.338
7.7 (0.9-66.0)
0.063
Years
1.0 (1.0-1.1)
0.138
1.0 (0.9-1.1)
0.526
Needle cleaning
Most times or always
0.7 (0.2-1.9)
0.469
0.9 (0.2-3.9)
0.933
Needle sharing ^
Maximum number of people that needle
1.0 (0.9-1.2)
0.380
1.3 (1.1-1.6)
0.008
1.0 (0.5-1.8)
0.874
1.2 (0.4-4.0)
0.732
Ever overdosed
0.9 (0.5-1.7)
0.800
1.0 (0.3-3.0)
0.936
Number of sexual partners in last 12 months
1.0 (1.0-1.0)
0.330
1.0 (1.0–1.0)
0.077
Same sex practices (ever)
2.2 (1.2-4.0)
0.024
1.6 (0.5-5.1)
0.386
Ever exchanged sex for drugs or sex for money for drugs***
2.3 (1.1-3.0)
0.021
3.7 (0.8-17.6)
0.103
Worked as a sex worker (ever)***
3.9 (2.0-7.8)
S0955-3959(16)00027-X http://dx.doi.org/doi:10.1016/j.drugpo.2016.01.004 DRUPOL 1701
To appear in:
International Journal of Drug Policy
Received date: Revised date: Accepted date:
10-8-2015 19-12-2015 8-1-2016
Please cite this article as: Scheibe, A., Makapela, D., Brown, B., dos Santos, M., Hariga, F., Virk, H., Bekker, L.-G., Lyan, O., Fee, N., Molnar, M., Bocai, A., Eligh, J., and Lehtovuori, R.,HIV prevalence and risk among people who inject drugs in five South African cities, International Journal of Drug Policy (2016), http://dx.doi.org/10.1016/j.drugpo.2016.01.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Highlights
Ac ce p
te
d
M
an
us
cr
ip t
We conducted the largest cross-sectional HIV prevalence and risk survey among people who inject drugs in South Africa to date We provide a description of participant demographics, drug using and sexual history and findings from bi-variate and multi-variate analysis for HIV infection. The study identified high-risk injecting and sexual practices among PWID in South Africa. We provide recommendations to inform future HIV prevention and treatment interventions for PWID in South Africa
1 Page 1 of 33
HIV prevalence and risk among people who inject drugs in five South African cities Andrew Scheibe1, David Makapela2, Ben Brown1, Monika dos Santos3,4, Fabienne Hariga5, Harsheth Virk6, Linda-Gail Bekker,1 Olga Lyan7, Nancy Fee8, Margarete Molnar9, Alina Bocai 10, Jason Eligh10, Riku Lehtovuori5
ip t
1. Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
cr
2. International Organisation for Migration, Pretoria, South Africa
us
3. Foundation for Professional Development, Pretoria, South Africa
4. Department of Psychology, University of South Africa, Pretoria, South Africa
an
5. United Nations Office on Drugs and Crime, Vienna, Austria 6. United Nations Office on Drugs and Crime, Lagos, Nigeria 7. UNAIDS, Geneva, Switzerland
9. UNAIDS, Cotonou, Benin
M
8. UNAIDS, Pretoria, South Africa
te
d
10. United Nations Office on Drugs and Crime, Pretoria, South Africa
Ac ce p
Corresponding author: Andrew Scheibe, [email protected]. 10 Upper Towers Road, Muizenberg, 7945, South Africa. + 27 (0) 79 882 7726 (tel.)
2 Page 2 of 33
HIV prevalence and risk among people who inject drugs in five South African cities Abstract Policy and programming for people who inject drugs (PWID) in South Africa is limited by the scarcity of epidemiological data. We conducted a cross-sectional survey among 450 PWID
ip t
(362 males and 88 females) from five South African cities in 2013, using outreach and peer referral to recruit participants. We carried out rapid HIV tests on participants’ saliva and
cr
assessed drug-using and sexual practices by means of a questionnaire. We found that 26%
us
of females and 13% of males reported to always share injecting equipment, while 49% of all participants had used contaminated injecting equipment the last time they injected. Only 6%
an
of participants usually used bleach to clean their injecting equipment. We found that half of participants reported using a condom the last time they had sex. A quarter of participants reported symptoms of a sexually transmitted infection (STI) in the previous 12 months and
M
22% had ever worked as a sex worker (51% of females).
d
HIV prevalence among participants was 14% (18% among females and 13% among males).
te
In multivariate analysis HIV was significantly associated with being 25 years and older (adjusted odds ratio (aOR) 2.1, 95% confidence interval (CI) 1.0-4.6, p=0.06), belonging to a
Ac ce p
racial group other than white (aOR 4.2, 95% CI 1.9-9.4, p 12 months ago
8 (7%)
6 (23%)
27 (23%)
16 (47%)
3 (2%)
4 (15%)
108 (88%)
23 (85%)
114 (98%)
29 (85%)
104 (84%)
25 (96%)
11 (9%)
4 (15%)
0
2 (6%)
11 (9%)
1 (4%)
Last injected with a new/ sterile needle
62 (50%)
17 (63%)
49 (42%)
21 (62%)
67 (54%)
14 (54%)
Shares needles: always or most times
59 (48%)
12 (44%)
65 (56%)
17 (50%)
39 (32%)
16 (52%)
Cleans needles (any method): always or most times
111 (90%)
24 (89%)
92 (79%)
21 (62%)
104 (84%)
18 (69%)
Does not reuse needles
5 (4%)
0
15 (13%)
7 (21%)
10 (8%)
2 (8%)
Max. # of people that a needle was shared with on one occasion (IQR)
2 (1-4)
3 (1-4)
1 (1-2)
1 (1-2)
1 (1-2)
2 (1-3)
cr
te
ATS
22 (85%)
us
Heroin
an
Last drug injected
M
Timing of last injection
ip t
Male N=123
d
Biological sex
KwaZulu-Natal
Ac ce p
*Not all totals add up due to rounding off and due to the presentation of selected data.
29 Page 29 of 33
Table 3 Participant sexual practices and HIV testing Province
Gauteng
Western Cape
Female N=27
Male N=116
Female N=34
Male N=124
Female N=26
2 (1-3)
2 (1-3)
2 (1-4)
2 (1-60)
2 (1-3)
2 (1-25)
Condom used at last sex
50 (40%)
13 (50%)
54 (47%)
15 (43%)
66 (54%)
16 (59%)
STI symptoms, last 12 months
17 (14%)
6 (23%)
50 (43%)
13 (37%)
19 (15%)
7 (26%)
Ever had sex with someone of same sex
29 (30%)
7 (27%)
18 (16%)
16 (46%)
37 (30%)
Ever exchanged sex for drugs or sex for money for drugs
52 (42%)
20 (74%)
59 (51%)
21 (62%)
54 (44%)
Ever worked as sex worker
24 (19%)
8 (31%)
12 (10%)
22 (63%)
20 (16%)
Had HIV test in last 12 months and knows result
61 (50%)
13 (48%)
57 (49%)
24 (71%)
11 (41%) 18 (69%) 15 (56%)
73 (59%)
18 (69%)
Ac ce p
te
d
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an
us
Median number of sexual partners, last 12 months (IQR)
ip t
Male N=123
cr
Biological sex
KwaZulu-Natal
30 Page 30 of 33
Table 4 Summary of HIV prevalence stratified by province, sex and race Gauteng
KwaZulu-Natal
Western Cape
Total
16% (24)
17% (26)
9% (14)
14% (64)
15% (18)
16% (18)
10% (13)
14% (49)
Black
18% (7)
18% (9)
0
17% (16)
White
12% (8)
7% (3)
11% (4)
10% (15)
Coloured
21% (3)
20% (2)
10% (8)
13% (13)
Asian
0
29% (4)
33% (1)
25% (5)
22% (6)
24% (8)
4% (1)
17% (15)
Black
75% (3)
85% (6)
0
81% (9)
White
7% (1)
0
0
2% (1)
Coloured
17% (1)
33% (1)
11% (1)
Asian
50% (1)
100% (1)
0
16% (3)
42% (3)
Ac ce p
te
d
M
an
us
Female (N=87)
cr
Male (N=363)
ip t
Province Overall prevalence % (n)
31 Page 31 of 33
Table 5 Summary of unadjusted odds ratios for HIV infection Males Variable
Females
OR (95% CI)
p value
OR (95% CI)
p value
≥25 years
2.6 (1.1-6.4)
0.034
0.6 (0.2-1.9)
0.392
Race **, ^^^
Non-white
1.5 (0.7-2.9)
0.234
32.4 (4.0-264.5)
0.001
0.7 (0.4-1.4)
0.412
0.9 (0.2-3.5)
0.851
1.1 (0.6-2.1)
0.681
0.4 (0.11-1.4)
0.150
0.9 (0.5-1.6)
0.675
0.6 (0.2-1.9)
0.376
1.0 (1.00-1.00)
0.778
1.00 (1.00-1.00)
0.257
Homeless Did not complete high school
Education
Employed
Employment Median, monthly income (ZAR) Province
ip t
Age ^
Western Cape
-
Gauteng
1.3 (0.6-2.9)
0.435
7.1 (0.8-64.1)
0.079
KwaZulu-Natal
-
0.338
7.7 (0.9-66.0)
0.063
Years
1.0 (1.0-1.1)
0.138
1.0 (0.9-1.1)
0.526
Needle cleaning
Most times or always
0.7 (0.2-1.9)
0.469
0.9 (0.2-3.9)
0.933
Needle sharing ^
Maximum number of people that needle
1.0 (0.9-1.2)
0.380
1.3 (1.1-1.6)
0.008
1.0 (0.5-1.8)
0.874
1.2 (0.4-4.0)
0.732
Ever overdosed
0.9 (0.5-1.7)
0.800
1.0 (0.3-3.0)
0.936
Number of sexual partners in last 12 months
1.0 (1.0-1.0)
0.330
1.0 (1.0–1.0)
0.077
Same sex practices (ever)
2.2 (1.2-4.0)
0.024
1.6 (0.5-5.1)
0.386
Ever exchanged sex for drugs or sex for money for drugs***
2.3 (1.1-3.0)
0.021
3.7 (0.8-17.6)
0.103
Worked as a sex worker (ever)***
3.9 (2.0-7.8)
