ABSTRACT
Objectives:
Despite receiving opioid substitution therapy (OST), injectable drug consumption is not uncommon among the injecting drug users (IDUs) that increases the risk of contracting HIV. The current study was aimed at exploring the injection related and sex related high-risk behaviour among IDUs, choices of injectable opioids consumed and treatment adherence.
Materials and Methods:
An observational study was conducted among 168 IDUs attending the OST centre. Structured questionnaire included sociodemographic characteristics, high-risk behaviour as well as injectable opioids consumption. Descriptive statistics were used to summarize the data.
Results:
Nearly 30% of the IDUs were engaged in injecting practice while on OST. Of 143 male IDUs, 5.6% of the clients had had sex with commercial sex worker, whereas 3.5% of them had multiple partners. Four of 143 men were MSM, whereas 32 IDUs had sex without condom in the preceding 1 year. Regarding treatment adherence, 62.9% IDUs were very regular. As far as the retention rate was concerned, the findings were promising, i.e. 77.8% at the end of 3 months and 70.7% at the end of 6 months. Buprenorphine was the commonest opioid consumed by the IDUs before attending the OST centres while heroine used to be drug of choice when they first started injecting.
Conclusion:
The study revealed high-risk behaviour of IDUs attending an OST centre. The study provided useful information about the choices of opioids injected by the IDUs. The findings of the study might be of help in designing appropriate strategies for the improvement of treatment adherence among IDUs.
Keywords: Buprenorphine, drug users, human immunodeficiency virus, opioid substitution therapy, recurrence, risk taking, treatment adherence and compliance
Introduction
Transmission of HIV among IDUs is predominantly a sequel of sharing of injecting equipment as well as sex-related high-risk behaviour.[1,2,3] Although technically IDUs may elect to inject any psychoactive substance, several studies have demonstrated that in India, the majority prefers opioids as their primary substance of choice.[1,2,3]
A number of IDUs resort to sharing of needles/syringes or other injecting equipment and paraphernalia which may be due to nonavailability of needles/syringes, nonaffordability of needles/syringes or due to prevalent practices in group/peer norms, etc., IDUs also engage in high-risk sex behaviours including sex with female sex workers, sex without condoms, and sex with multiple partners. They may also sell sex in exchange for drugs or money. These behaviours put IDUs at risk for acquiring and transmitting HIV to not just other IDUs but also to the general population.
Needle Syringe Programme (NSP) and Opioid Substitution Therapy (OST) are the core interventions for IDUs.[2] Although NSP ensures no sharing by providing with sterile needle-syringe among the IDUs who continue to inject, OST, on the other hand, stabilizes the opioid dependent IDUs by prescribing long-acting oral opioid so that they give up their injecting habit. IDUs suffer from opioid dependence syndrome characterized by repeated relapses and remissions.[4,5] Worldwide adherence and compliance have been recognized as essential components of successful treatment outcome. Longitudinal studies have shown changes in HIV risk behaviours for clients under treatment as has also been found that longer retention as well as completion of treatment, is correlated positively with reduction in HIV risk behaviours.
There are relatively few studies available in less resourced countries like India. This study was aimed at exploring the choices of injectable opioid, risk taking behaviour as well as treatment adherence and retention on OST among IDUs in a medical college in Kolkata.
The objectives of the current study were as follows:
To describe the choices of injectable opioids consumed by the IDUs before attending the OST center of a medical college in Kolkata.
To explore the high-risk behavior among the IDUs attending the OST center.
To assess treatment adherence and retention on OST among IDUs.
Materials and Methods
A facility-based, observational study was conducted at an OST centre in a Medical College of Kolkata from April 2016 to March 2018. The novelty of the study was assessed by the Institutional Review Board of a post-graduate Institute of Kolkata. Ethical approval was subsequently obtained from the Ethics Committees of the above-mentioned Medical College where the study was conducted.
Inclusion criteria
The IDUs aged over 18 years and agreed to provide written informed consent were included in the study.
Exclusion criteria
IDUs with severe cognitive deficits were excluded from the study.
Sampling method
A total of 198 IDUs were enrolled in the OST centre. A register was maintained at the centre, and a complete enumeration was done. Out of all the attendees, 168 met the inclusion criteria. Therefore, a total of 168 IDUs were recruited using the census method.
Study tool
A predesigned and pretested semistructured questionnaire was used, which included sociodemographic characteristics, pattern of substance abuse, behavioural characteristics (injection-related risky behaviour and sex-related risky behaviour).
Study setting and study area
OST centre of a Medical College and Hospital in Kolkata was a collaborative public health OST centre, jointly working with nearby IDU TI for outreach (NSP) and follow-up. There are two IDU TIs associated with this OST centre. One of the two sites is in the Park Circus area with five Hot-spots: 1. Beniapukur, 2. Beckbagan, 3. CIT Road, 4. Haddibagan, and 5. Darapara under Beniapukur Police Station. Another site is near Elite Cinema Hall area with three Hotspots: 1. Elite area near Esplanade, 2. Sudder Street, and 3. Kyd Street under New Market Police Station.
Working definitions
High risk behaviours
Injection-Related Risky Behaviour: Receptive sharing of needle-syringe, paraphernalia.
Sex-Related Risky Behaviour: Sex with FSW/CSW, sex with multiple partners, MSM, selling sex in exchange for drugs or money, sex without condom.
Treatment adherence
As OST is a directly observed therapy each client needs to attend the centre daily to receive tablet buprenorphine sublingually dispensed by the nurse. Treatment adherence of the IDUs to the OST in the preceding one month is evaluated from the hospital records.
Very Regular: Those who attend the OST centre for 24/25 days or more per month are given the status of very regular attendee.
Regular: IDUs whose attendance is 15-24/25 days in a month are called regular.
Irregular: Clients attending less than 15 days per month are termed irregular.
Retention to OST
Engagement to the treatment programme- Whether an IDU remained engaged to the treatment programme at 3 and 6 months. An IDU who attended OST at least once in a month was considered retained on OST.
Data Analysis
Statistical package for social sciences (SPSS version 21, IBM) was used for analysis of data. Descriptive statistics were used to summarize the data. Measures of central tendency and dispersion were used to summarize numerical data and proportions for categorical variables.
Results
Out of 168 IDUs who fulfilled the inclusion criteria and were approached and invited to participate, 167 agreed, giving a response rate of 99.4%.
A large proportion of IDUs belong to the age category 30-39 years. As shown in Table 1, almost 98% of study participants were males. As far as financing for addiction was concerned, 47 (28.1%) out of 167 were dependent on immoral means of financing.
Table 1.
Distribution of study participants according to their sociodemographic characteristics (n=167)
| Characteristics | Categories | Number (%) | Central tendency & dispersion |
|---|---|---|---|
| Age (in years) | 19-29 | 41 (24.6%) | Mean (±SD)=36.53 (9.514) Median=35 (IQR 30-45) Range=38 (19-57) |
| 30-39 | 62 (37.1) | ||
| 40-49 | 48 (28.7%) | ||
| 50 and above | 16 (9.6%) | ||
| Gender | Male | 164 (98.2%) | |
| Female | 3 (1.8) | ||
| Religion | Hindu | 61 (36.5%) | |
| Muslim | 96 (57.5%) | ||
| Christian | 10 (6%) | ||
| Education | Illiterate | 30 (17.9%) | Mean (±SD) year of Schooling=5.2 (±4.08) Median=5 (IQR2-9) |
| Below primary | 43 (25.7%) | ||
| Primary | 39 (23.4%) | ||
| Middle | 26 (15.6%) | ||
| Secondary | 15 (9%) | ||
| Higher Sec and above | 14 (8.4%) | ||
| Marital status | Never married | 45 (26.9%) | |
| Currently married | 67 (40.1%) | ||
| Separated/divorced | 46 (27.6%) | ||
| Widower/widow | 9 (5.4%) | ||
| Living arrangement** | Home | 97 (58.1%) | |
| Unstable housing | 70 (41.9%) | ||
| Main source of income during the previous 6 months | Regular job | 108 (64.7%) | |
| Temporary work or other sources | 59 (35.3%) | ||
| Finance for addiction | Own legal earning or other noncriminal sources | 120 (71.9%) | |
| Illegal/immoral means | 47 (28.1%) |
*Various small jobs like cleaning or working as a handyman for same-day payment, panhandling/begging. **Unstable housing (i.e., living in a workplace, car or other vehicle, abandoned building, shelter or welfare residence, medical care organization, or on the street)
Opioids used by the IDUs through injecting route, varied considerably from person to person [Table 2] during initiation of injecting habit and at the time of entering to the OST.
Table 2.
Distribution of study participants according to injectable opioids used (n=167)
| Injectable opioids | Opioids used during initiation of injecting habit | Opioids used before attending OST centre |
|---|---|---|
| Impure heroin (Smack) | 31 (18.6%) | 1 (0.6%) |
| Pure heroine | 79 (47.3%) | 17 (10.2%) |
| Buprenorphine | 45 (26.9%) | 145 (86.8%) |
| Dextropropoxyphene | 8 (4.8%) | 2 (1.2%) |
| Pentazocine | 4 (2.4%) | 2 (1.2%) |
Table 2 showed that seventy-nine (79) out of 167 IDUs were addicted to injectable pure heroin when they became an IDU. Buprenorphine was the second choice (26.9%) as initial injectable opioid. While injectable buprenorphine was used by 145 IDUs when they entered the OST programme, pure heroin was used by 17 out of 167 IDUs.
Nearly 38% shared needles and 50% shared paraphernalia before attending the centre [Table 3.1], On the other hand, none shared needles or paraphernalia while on OST [Table 3.2].
Table 3.1.
Distribution of study participants according to their injection-related risky behaviours (n=167)
| Injection-related risky behaviour* | Past 1 year before attending OST centre | Ever (At least once in their life time) |
|---|---|---|
| Sharing needle (sharing of syringes to divide drugs)# | 32 (19.2%) | 63 (37.7%) |
| Sharing paraphernalia (cookers, cotton, or water) | 40 (23.9%) | 83 (49.7%) |
*Multiple response. #Sharing implies receptive sharing
Table 3.2.
Distribution of study participants according to their injecting behaviours while on OST in preceding one month (n=167)
| Frequency | Number (%) | Sharing injecting equipment | Mean (±SD) period on OST (in months) |
|---|---|---|---|
| Never | 116 (69.5%) | Not applicable | 5±1.5 |
| Once | 25 (14.9%) | Never | 7±2 |
| More than once | 22 (13.2%) | Never | 6±1.8 |
| Once in every week or more | 4 (2.4%) | Never | 8±2.6 |
| Total | 167 (100%) | ||
Out of 164 male participants, 143 had ever had sex in their lives. Out of 143 male IDUs, 5.6% of the clients had had sex with commercial sex worker, whereas 3.5% of them had multiple partners in preceding one year [Table 4].
Table 4.
Distribution of male study participants according to their sex-related risky behaviour (n=143)
| Variables* | Past 1 year | Ever in life |
|---|---|---|
| Paid sex (FSW/CSW/Escort Service) | 8 (5.6%) | 32 (22.4%) |
| Multiple partner | 5 (3.5%) | 42 (29.4%) |
| MSM# | 4 (2.8%) | 7 (4.9%) |
| Sex in exchange for drug or money | 4 (2.8%) | 11 (7.7%) |
| Sex without condom | 32 (22.4%) | 104 (72.7%) |
*Multiple response. #MSM: Men who have sex with men (considered MSM even if bisexual)
Out of three female study subjects 2 had ever had sex. One of them used to be an FSW, but not sexually active for the last 10 years. She had always used condom when she used to work as an FSW.
Another woman whose husband was an HIV positive IDU always used condom in the past 1 year.
Table 5 showed 14.3% IDUs were irregular in attendance.
Table 5.
Distribution of participants according to their status of treatment adherence (n=167)
| Treatment Adherence | Number of days in a month | Number (167) |
|---|---|---|
| Very regular | Attending OST centre ≥24/25 days/month | 105 (62.9%) |
| Regular | Attending OST centre 15-24/25 per month | 38 (22.8%) |
| Irregular | Very irregular=attending OST centre <15 days per month | 24 (14.3%) |
| Total | 167 (100%) |
Table 6 showed that retention rate at the end of 6 month was 70.7%.
Table 6.
Distribution of study participants according to their retention to OST programme (n=167)
| Treatment outcome | Follow up after 3 months | Follow up after 6 months |
|---|---|---|
| Cessation/completed the programme | 7 (4.2%) | 12 (7.2%) |
| Retained on OST | 130 (77.8%) | 118 (70.7%) |
| Drop out | 30 (18%) | 37 (22.1%) |
Discussion
Out of 167 participants, 32 (19.2%) shared needle and syringe at least once in previous 1 year before attending OST centre while 40 (23.9%) IDUs shared paraphernalia.
While 70% of the study participants never resorted to injection while on OST in the preceding one month, nearly 30% of IDUs were engaged in injecting practice at least once in the same time period. None of the participants had shared injecting equipment while on OST which was an encouraging development.
Out of 164 male study participants 143 had sex in their life ever. Out of 143 male IDUs, 5.6% of the clients had had sex with commercial sex worker, whereas 3.5% of them had multiple partners in preceding one year. Four out of 143 male clients were MSM, whereas 32 IDUs had sex without condom in the preceding one year. Out of three female study subjects 2 had ever had sex.
One of them used to be an FSW, but not sexually active for the last 10 years. She had always used condom when she used to work as an FSW. Another woman whose husband was an HIV positive IDU, always used condom in the past 1 year.
Regarding treatment adherence in a month, 105 clients out of a total of 167 active clients were very regular and 22.8% regular, whereas 14.3% were irregular in attendance.
As far as the retention rate was concerned, the findings were promising. At the end of 3 months the retention rate was 77.8% and nearly 18% ended up being dropped out of the program. Retention rate at the end of 6 month was 70.7%. Over seven percent of the clients had been able to become drug free at the end of 6 months.
Broz et al.[6] in their report on behavioural surveillance among IDUs demonstrated that large percentages of participants reported receptive sharing of syringes (35%); receptive sharing of other injection equipment, such as cookers, cotton, or water (58%); and receptive sharing of syringes to divide drugs (35%). Many participants reported having unprotected sex with opposite-sex partners during the past 12 months: 70% of men and 73% of women had unprotected vaginal sex, and 25% of men and 21% of women had unprotected anal sex. More women than men reported having sex in exchange for money or drugs (31% and 18%, respectively).
Ghanem et al.[7] conducted a study among 212 MSM with recent HIV infection who were classified into two groups: IDUs and Non IDUs in San Diego, California. IDUs reported having sex at least once with a partner they believed to be HIV-positive more frequently than non-IDUs (100% versus 65%, respectively, P = 0.001) and reported ever having sex with more than one person at a time more frequently than non-IDUs (100% versus 84%, respectively, P = 0.050).
A cross-sectional study conducted by Yao et al.[8] in Yunnan Province, China demonstrated that 37% IDUs had multiple sexual partners. Consistent condom use rates were lowest with regular partners (23.8%), followed by 42.5% with casual partners, and 57.3% with female sex workers.
A longitudinal cohort study of IDUs conducted by Solomon et al.[9] in north Chennai revealed that High risk behaviours were common and included needle sharing, unsafe disposal and inappropriate cleaning of needles as well as limited condom use. Thirty-nine percent reported passing on a used syringe at least once and 29% reported passing on a used cotton filter.
A cross-sectional study conducted by Shariful Islam et al.[10] among IDUs in Dhaka, Bangladesh revealed that 73.3% of participants shared needles sometimes and 57.5% were willing to use the needle exchange programs. Condom use during the last intercourse with regular partners was 11.7% and with any partners 15.8%.
A cross-sectional survey by Kermode et al.[11] among 200 IDUs in Imphal, Manipur and Dimapur, Nagaland revealed that drugs most commonly injected were Spasmo-proxyvon (65.5%) and heroin (30.5%). In 53.5% cases, a needle belonging to someone else was used. Participants were asked about injecting risk behaviours. The majority (81.2%) said they rarely or never used a needle used by someone else, but 12.5% did use a needle used by someone else at least weekly. Among those who have on occasions used a needle or syringe used by someone else, 77.7% always cleaned it before use, most commonly with water and/or saliva. 13
A study by Armstrong et al.,[12] conducted on OST clients in Manipur and Nagaland showed that the retention rates on OST was about 73% at 3 months and 63% at 6 months.
A multisite study by Dhawan et al.[13] showed that retention rates on OST were about 70% at the end of 9 months. The study showed significant decrease in opioid use, high risk behaviours, addiction severity and improvement in quality of life.
A longitudinal cohort study by Lawrinson et al.[14] among OST entrants in purposively selected OST sites in Asia (China, Indonesia, Thailand), Eastern Europe (Lithuania, Poland, Ukraine), the Middle East (Iran) and Australia revealed that Treatment retention at 6 months was uniformly high, averaging approximately 70%.
Limitation(s) and strength
The study may have suffered from a lack of generalisability. The small sample size made it difficult to extrapolate the findings of the study to other IDUs; hence, external validity could not be guaranteed. The information collected for this study relied largely on the participants’ self-reporting, which might have led to over-reporting about perceived stigma. Therefore, the proportion of IDUs with higher perceived stigma might be spurious and overestimated. In addition, due to social desirability, some answers might have been biased and not accurate, particularly regarding sensitive questions.
Author contributions
MP: Conducting the study that included development of study tool, data collection, analysis, write-up of the manuscript. MD: Conceptualization and overall guidance of the study.
Patients’ consent form
Prepared in three languages (Bengali, Hindi, and English) and informed written consent obtained from all the participants.
Ethical approval and/or institutional review board (IRB) approval
Ethical approval has been obtained from Calcutta National Medical College and All India Institute of Hygiene and Public Health (CNMC/8 Dated 11.05.2016).
Conflicts of interest
There are no conflicts of interest.
Acknowledgement
Professor (Dr) Dipendra Narayan Goswami from the Department of Community Medicine and Professor (Dr) A Mukhopadhyay from the Department of Psychiatry, Calcutta National Medical College.
Funding Statement
Nil.
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