IF: 1.578
Cite Score:
1.45
THOMSON REUTERS - SCOPUS

Hepatitis C Infection Among HIV-Positive Injection Drug Users and Non-Injection-Drug Users in Tajikistan

AUTHORS

Arash Alaei 1 , 2 , Kathryn Mishkin 1 , * , Saifuddin Karimov 3 , Dilshod Saidi 3 , Kamiar Alaei 1 , 4

AUTHORS INFORMATION

1 Global Institute for Health and Human Rights, University at Albany, State University of New York, Albany, NY, USA

2 Department of Health Policy, Management, and Behavior, University at Albany School of Public Health, State University of New York, Albany, NY, USA

3 Republican AIDS Center, Tajikistan Ministry of Health, Dushanbe, Tajikistan

4 Rockefeller College, University at Albany, State University of New York, Albany, NY, USA

How to Cite: Alaei A, Mishkin K, Karimov S, Saidi D, Alaei K. Hepatitis C Infection Among HIV-Positive Injection Drug Users and Non-Injection-Drug Users in Tajikistan, Hepat Mon. 2018 ; 18(3):e64860. doi: 10.5812/hepatmon.64860.

ARTICLE INFORMATION

Hepatitis Monthly: 18 (3); e64860
Published Online: April 28, 2018
Article Type: Brief Report
Received: December 7, 2017
Revised: January 18, 2018
Accepted: April 20, 2018
Crossmark

Crossmark

CHEKING

READ FULL TEXT
Abstract

Background: HIV and Hepatitis C (HCV) infections are increasing in Tajikistan. While injection drug use (IDU) is a known risk factor for coinfection, little is known about non-injection drug users (NIDU).

Objectives: The aim of this study was to identify factors associated with HIV-HCV coinfection and HIV infection alone among IDU and NIDU.

Methods: Data from Tajikistan’s national HIV/AIDS registry data for all adults aged 18 years and older who had received a HCV test from 2006 to 2016 were obtained. Chi-square analyses identified factors associated with coinfection and injection drug use.

Results: Of the 1849 people living with HIV who received a Hepatitis C test, 36.2% were positive for HCV and 63.8% were negative. Coinfection occurred among 74.4% of IDU and 18.5% of NIDU. In bivariate analyses, among both IDU and NIDU, coinfection was associated with urbanness of living location, having partner with a positive HIV test, marital status, region, and being imprisoned. Among IDU, coinfection was also associated with migrant status. Among NIDU, coinfection was also associated with gender, age at diagnosis, and AIDS stage at first diagnosis.

Conclusions: This study shows that coinfection occurs most frequently among IDU in general, but that NIDU represent an important population deserving of additional study and tailored HIV and HCV prevention programs. Additional research to identify best practices for targeting NIDU and people living in at-risk regions for screening and are required to effectively prevent and then appropriately manage coinfection.

Keywords

HIV HCV IDU NIDU Tajikistan

Copyright © 2018, Hepatitis Monthly. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

In Central Asia, HCV and HIV coinfection is increasing as it decreases in other parts of the world (1). The ministry of health of Tajikistan reports that HIV cases have increased by more than 25% in the past 10 years, with a 8,892 people living with HIV (PLWH) in 2017 (2). Of people living with HIV, 33% are also infected with HCV, although this proportion may be inaccurate because of infrequent HCV testing (3).

Injection drug use (IDU) is an established risk factor for both HIV and HCV transmission, and users are a key population (4-6). Other key populations are vulnerable to coinfection because they engage in IDU, including prisoners and migrants (7).

Recently, research has focused on non-IDU (NIDU) transmission of HIV and HCV, such as through unprotected sexual intercourse, to complement IDU-focused analysis (8). Commercial sex workers (9), migrants, and prisoners engage in this risky behavior (10). Additionally, transmission can occur from husband to wife through unprotected intercourse if the husband uses drugs, is a migrant, or has a prison history (1). An estimated 39% of HIV cases are transmitted to women through in this way (9).

Because of the international community’s interest in NIDU transmission of HIV and HCV, this paper explores factors associated with HIV-HCV coinfection and HIV infection alone among IDUs and NIDUs. This research serves as the first presentation of sociodemographic and risk factors associated with HIV-HCV coinfection compared to HIV infection alone in Tajikistan.

2. Methods

The Tajikistan National AIDS Program provided data that included all new HIV cases aged 18 or older when entered into the national HIV registry from January 1, 2006 to January 30, 2016 who had also completed a Hepatitis C test (n = 1,849).

HIV-positive patients were informed about the HIV registry surveillance questionnaire and patients who agreed to participate provided informed oral consent. The questionnaire was conducted through in-person interviews. Responses were linked with confidential electronic HIV medical records.De-identification of the dataset was conducted to ensure confidentiality.

Factors in the analysis included age at diagnosis; region (Dushanbe, Sughd, Republican Subordination, Gorno-Badakhshan) ; urbanness of living location (urban vs. rural), marital status; education level; migrant status (if person had ever left Tajikistan for employment outside of Tajikistan or not); employment status; prior HIV test history; partner HIV status; AIDS stage at first visit (Stage 1, 2, 3, and 4); IDU status; drug treatment status; prison history; and AIDS death status.

2.1. Analysis

Descriptive statistics were calculated for all variables using SAS 9.4 (SAS Institute, Cary, NC). Chi-square tests assessed bivariate associations for categorical data.

2.2. Ethical Considerations

The University at Albany institutional review board determined that this study was exempt from review because the study used de-identified secondary data.

3. Results

Of the 1849 PLWH who received a Hepatitis C test, 36.2% were positive for HCV. Table 1 shows the characteristics of the entire cohort. Roughly half lived in a rural area most (66%) were married, 10.2% were migrants, and most (85.6%) had at least a secondary-level education.

Table 1. Factors Associated with Being Coinfected with HIV and HCV vs. Infected with HIV in Tajikistana
VariableOverall (n = 1849)Coinfected with HCV/HIV (n = 669)Infected with HIV only (n = 1180)Chi-Square
Injection Drug User< 0.0001
No1250 (68.34)232 (18.56)1018 (81.44)
Yes579 (31.66)431 (74.44)148 (25.56)
Gender< 0.0001
Male1105 (59.76)566 (51.22)539 (48.78)
Female744 (40.24)103 (13.84)641 (86.16)
Age at diagnosis< 0.0001
18 - 24233 (12.60)36 (15.45)197 (84.55)
25 - 34783 (42.35)237 (30.27)546 (69.73)
35 - 44594 (32.13)289 (46.65)305 (51.35)
44+239 (12.93)107 (44.7)132 (55.23)
Urbanness of living location< 0.0001
Rural982 (53.20)238 (24.24)744 (75.76)
Urban864 (46.80)430 (49.77)434 (50.23)
Region< 0.0001
Dushanbe466 (25.20)241 (51.72)225 (48.28)
Republican Subordination361 (19.52)114 (31.58)247 (68.42)
Gorno-Badakhshan200 (10.82)101 (50.50)99 (49.50)
Khatlon586 (31.69)148 (25.26)438 (74.74)
Sughd236 (12.76)65 (27.54)171 (72.46)
Marital status< 0.0001
Married1213 (66.68)356 (29.35)857 (70.65)
Not married336 (18.47)182 (54.17)154 (45.83)
Divorced186 (10.23)95 (51.08)91 (48.92)
Widow84 (4.62)22 (26.19)62 (73.81)
Migrant0.05
No1661 (89.83)613 (36.91)1048 (63.09)
Yes188 (10.17)56 (29.79)132 (70.21)
Employment status0.02
No1642 (91.83)603 (36.72)1039 (63.28)
Yes146 (8.17)40 (27.40)106 (72.60)
Education level0.45
None/Primary33 (1.90)12 (36.36)21 (63.64)
Secondary1468 (84.56)525 (35.76)943 (64.24)
Tertiary235 (13.54)94 (40.00)141 (60.00)
Prior HIV Test0.002
No1640 (92.08)602 (36.71)1038 (63.29)
Yes58 (3.26)16 (19.28)67 (80.72)
Unknown83 (4.66)15 (25.86)43 (74.14)
Partner is HIV-positive< 0.0001
No904 (49.70)432 (47.79)472 (52.21)
Yes915 (50.30)226 (24.70)689 (75.30)
Stage AIDS at first visit< 0.0001
Stage 1509 (28.04)119 (23.38)390 (76.62)
Stage 2501 (27.60)156 (31.14)345 (68.86)
Stage 3496 (27.33)204 (41.13)292 (58.87)
Stage 4309 (17.02)176 (56.96)133 (43.04)
Drug Treatment (if used drugs)0.34
No264 (46.07)192 (72.73)72 (27.27)
Yes272 (47.47)203 (74.63)69 (25.37)
Unknown37 (6.46)31 (83.78)6 (16.22)
Prison history< 0.0001
No1717 (94.24)583 (33.95)1134 (66.05)
Yes105 (5.76%)75 (71.43)30 (28.57)
Sex worker status0.91
No1624 (97.60)582 (35.84)1042 (64.16)
Yes40 (2.40)14 (35.00)26 (65.00)
Death from AIDS (of those who died)0.16
No132 (45.67)83 (62.88)49 (37.12)
Yes157 (54.33)86 (54.78)71 (45.22)

aValues are expressed as No. (%).

3.1. Factors Associated with HCV-HIV Coinfection

Coinfection status was significantly associated with gender, age at diagnosis, urbanness of living location, region, marital status, migrant status, employment status, having a prior HIV test, having an HIV-positive partner, AIDS stage, IDU status, and prison history (Table 1).

3.2. Factors Associated with Coinfection Among IDU

Among IDU, coinfection status was significantly associated with urbanness of living location, region, marital status, migrant status, having a HIV-positive partner, and prison history (Table 2).

Table 2. Factors Associated with Being Coinfected with HIV and HCV vs. Infected with HIV Among IDU and NIDU in Tajikistana
VariableIDU (n = 579)NIDU (n = 1250)
Coinfected (n = 431)HIV alone (n = 148)Chi-SquareCoinfected (n = 232)HIV alone (n = 1018)Chi-Square
Gender0.22< 0.001
Male415 (74.91)139 (25.09)146 (27.14)392 (72.86)
Female16 (64.00)9 (36.00)86 (12.08)626 (87.92)
Age at diagnosis0.55< 0.001
18 - 2415 (78.95)4 (21.05)19 (8.96)193 (91.04)
25 - 34144 (70.94)59 (29.06)92 (16.17)477 (83.83)
35 - 4463 (23.77)202 (76.23)85 (26.15)240 (73.85)
44+22 (23.91)70 (76.09)36 (25.00)108 (75.00)
Urbanness of living location< 0.0001< 0.001
Rural125 (63.45)72 (36.55)112 (14.43)664 (85.57)
Urban306 (80.10)76 (19.90)120 (25.32)354 (74.68)
Region0.00020.0002
Dushanbe165 (81.28)38 (18.72)71 (28.17)181 (71.83)
Republican Subordination63 (67.02)31 (32.98)50 (19.16)211 (80.84)
Gorno-Badakhshan87 (77.68)25 (22.32)14 (16.09)73 (83.91)
Khatlon73 (77.66)21 (22.34)75 (15.31)415 (84.69)
Sughd43 (56.58)33 (43.42)22 (13.75)138 (86.25)
Marital status0.03< 0.001
Married219 (70.65)91 (29.35)137 (15.27)760 (84.73)
Not married135 (76.27)42 (23.73)47 (29.56)112 (70.44)
Divorced67 (85.90)11 (14.10)28 (26.17)79 (73.83)
Widow8 (66.66)4 (33.33)14 (19.44)58 (80.56)
Migrant0.040.40
No406 (75.46)132 (24.54)201 (18.22)902 (81.78)
Yes25 (60.98)16 (39.02)31 (21.09)116 (78.91)
Employment status0.290.35
No393 (74.86)132 (25.14)17 (15.18)95 (84.82)
Yes22 (66.67)11 (33.33)205 (18.65)894 (81.35)
Education level0.230.82
None/Primary9 (90.00)1 (10.00)3 (13.64)19 (86.36)
Secondary335 (72.98)124 (27.02)190 (18.89)816 (81.11)
Tertiary66 (79.52)17 (20.48)28 (18.67)122 (81.33)
Prior HIV Test0.140.10
No401 (74.26)139 (35.74)201 (18.34)895 (81.66)
Yes3 (42.86)4 (57.14)12 (23.53)39 (76.47)
Unknown9 (81.82)2 (18.18)7 (9.72)65 (90.28)
Partner is HIV-positive0.0005< 0.001
No305 (78.81)82 (21.19)127 (24.61)389 (75.39)
Yes124 (65.26)66 (34.74)102 (14.11)621 (85.89)
Stage AIDS at first visit0.44< 0.001
Stage 171 (78.02)20 (21.98)47 (11.44)364 (88.56)
Stage 2106 (71.62)42 (23.38)48 (13.75)301 (86.25)
Stage 3138 (73.80)49 (26.20)64 (21.19)238 (78.81)
Stage 4106 (79.10)28 (20.90)69 (39.88)104 (60.12)
Prison history0.68< 0.001
No363 (74.08)127 (25.92)220 (17.96)1005 (82.04)
Yes64 (76.19)20 (23.81)11 (53.38)10 (47.62)
Sex worker status0.650.08
No385 (74.61)131 (25.39)197 (17.83)908 (82.17)
Yes4 (66.67)2 (33.33)10 (29.41)24 (70.59)
Death from AIDS (of those who died)0.950.33
No63 (73.26)23 (26.74)20 (44.44)25 (55.56)
Yes59 (72.84)22 (27.16)27 (35.53)49 (64.47)

aValues are expressed as No. (%).

3.3. Factors Associated with Coinfection Among NIDU

Among NIDU, coinfection status was significantly associated with gender, age at diagnosis, urbanness of living location, region, marital status, having a HIV-positive partner, AIDS stage at first diagnosis, and prison history (Table 2).

4. Discussion

This paper presents the first analysis of a) people coinfected with HCV and HIV compared to HIV alone and b) HIV-HCV coinfection status by IDU status in Tajikistan. Results show that 36.2% were coinfected. This rate is similar to from other global studies including in Canada where half of PLWH were coinfected (11), and in Gabon where 76% were coinfected (12). Coinfection occurred among 74.4% of IDU and 18.5% of NIDU, confirming IDU as an important factor for coinfection (8,11).

Stratification by IDU status resulted in no significant difference in rate of coinfection by region and urbanness of living location, with coinfection occurring more frequently among urban dwellers. Coinfection occurred most frequently among people in Dushanbe and least frequently among people in Sughd. Because of this, PLWH living in Dushanbe and urban areas should be prioritized for HCV testing. Additional exploration of knowledge, attitudes, and beliefs surrounding coinfection is suggested to understand why people in Sughd are protected from coinfection compared to people living in other regions.

Coinfection rates among migrants and past prisoners also differed by IDU status. Migrants were more likely to be coinfected if they were IDU, but not if they were NIDU. It is hypothesized that our results confirm migrants engage in IDU more often than non-migrants (1). Prison history was associated with coinfection among NIDU, but not among IDU, indicating that unprotected sex could be responsible for the coinfection (7). Prisoners are known to engage in unprotected sex with multiple partners. These results suggest that each key population requires its own prevention and intervention plan.

Finally, while no difference in coinfection status was identified by AIDS stage among IDU, coinfection was positively associated with an increase in AIDS stage among NIDU. We hypothesize that this is because of a delay in HIV testing among NIDU, which results in people being older people at diagnosis. While it is essential for IDU be targeted for early and often for HIV and HCV testing, our study findings demonstrate the need for testing among other key populations. Health interventions must be adapted to meet the needs of NIDU to receive HIV testing and services.

4.1. Conclusions

This study shows that coinfection occurs most frequently among IDU in general, but that NIDU represent an important population deserving of additional study and tailored HIV and HCV prevention programs. Additional research to identify best practices for targeting NIDU and people living in at-risk regions for screening and are required to effectively prevent and then appropriately manage coinfection.

Acknowledgements

Footnote

References

  • 1. Thorne C, Ferencic N, Malyuta R, Mimica J, Niemiec T. Central Asia: hotspot in the worldwide HIV epidemic. Lancet Infect Dis. 2010;10(7):479-88. doi: 10.1016/S1473-3099(10)70118-3. [PubMed: 20610330].
  • 2. National AIDS Program Data Report. Dushanbe: Tajikistan Ministry of Health; 2017.Tajikistan Ministry of Health.
  • 3. Walsh N, Maher L. HIV and HCV among people who inject drugs in Central Asia. Drug Alcohol Depend. 2013;132 Suppl 1:S37-40. doi: 10.1016/j.drugalcdep.2013.06.030. [PubMed: 23906997].
  • 4. Altice FL, Azbel L, Stone J, Brooks-Pollock E, Smyrnov P, Dvoriak S, et al. The perfect storm: incarceration and the high-risk environment perpetuating transmission of HIV, hepatitis C virus, and tuberculosis in Eastern Europe and Central Asia. Lancet. 2016;388(10050):1228-48. doi: 10.1016/S0140-6736(16)30856-X. [PubMed: 27427455].
  • 5. Jolley E, Rhodes T, Platt L, Hope V, Latypov A, Donoghoe M, et al. HIV among people who inject drugs in Central and Eastern Europe and Central Asia: a systematic review with implications for policy. BMJ Open. 2012;2(5). doi: 10.1136/bmjopen-2012-001465. [PubMed: 23087014].
  • 6. Roy K, Hay G, Andragetti R, Taylor A, Goldberg D, Wiessing L. Monitoring hepatitis C virus infection among injecting drug users in the European Union: a review of the literature. Epidemiol Infect. 2002;129(3):577-85. [PubMed: 12558341].
  • 7. Mansfeld M, Ristola M, Klinte J, Bultman J, Kastelic A, Rotberga S. HIV programme review in Tajikistan. WHO; 2015.
  • 8. Scheinmann R, Hagan H, Lelutiu-Weinberger C, Stern R, Des Jarlais DC, Flom PL, et al. Non-injection drug use and Hepatitis C Virus: a systematic review. Drug Alcohol Depend. 2007;89(1):1-12. doi: 10.1016/j.drugalcdep.2006.11.014. [PubMed: 17174481].
  • 9. Strengthening the capacity of the Republican AIDS center to implement HIV program in the Republic of Tajikistan under the president's emergency plan for AIDS relief (PEPFAR). 2015.CDC.
  • 10. Belaunzaran-Zamudio PF, Mosqueda-Gomez JL, Macias-Hernandez A, Sierra-Madero JG, Ahmed S, Beyrer C. Risk factors for prevalent hepatitis C virus-infection among inmates in a state prison system in Mexico. PLoS One. 2017;12(6). e0179931. doi: 10.1371/journal.pone.0179931. [PubMed: 28654650].
  • 11. Buxton JA, Yu A, Kim PH, Spinelli JJ, Kuo M, Alvarez M, et al. HCV co-infection in HIV positive population in British Columbia, Canada. BMC Public Health. 2010;10:225. doi: 10.1186/1471-2458-10-225. [PubMed: 20429917].
  • 12. Bivigou-Mboumba B, Rouet F, Mouinga-Ondeme A, Deleplancque L, Sica J, Ndjoyi-Mbiguino A, et al. Hepatitis B, C, and E infection among HIV-infected patients in Franceville, Gabon: retrospective cross-sectional study. Med Sante Trop. 2017;27(3):274-80. doi: 10.1684/mst.2017.0698. [PubMed: 28947403].
  • COMMENTS

    LEAVE A COMMENT HERE: