Risk factors of HIV and variation in access to clean needles among people who inject drugs in Pakistan

ABSTRACT

We identified key risk factors for HIV among people who inject drugs (PWID) in Pakistan and explored access to free clean needles. Multivariable logistic regression was used to investigate associations between HIV prevalence and demographic, behavioral, and socio-economic characteristics of PWID. Data came from the Government of Pakistan’s Integrated Biological and Behavioral Surveillance (IBBS) Round 5 (2016–17; 14 cities). A secondary analysis investigated associations with reported access to clean needles. Unweighted HIV prevalence among 4,062 PWID (99% male) was 21.0%. Longer injecting duration (Odds ratio [OR] 1.06 [95% confidence interval: 1.02–1.10]; per year), higher injecting frequency (OR 1.67 [1.30–2.13]; per unit increase), and injecting heroin (OR 1.90 [1.11–3.25]) were positively associated with HIV prevalence. There was no association between using a used syringe at last injection and HIV. Having>10 years of education had lower odds of HIV than being illiterate (OR 0.58 [0.35–0.95]). Having a regular sexual partner (OR 0.74 [0.57–0.97]) or paying for sex with the opposite sex (OR = 0.62 [0.45–0.85]) had lower odds of HIV than not. Conversely, PWID paying a man/hijra for sex had higher odds of HIV (OR 1.20 [1.00–1.43]). Receipt of clean needles varied by city of residence (0–97% coverage), whilst PWID with knowledge of HIV service delivery programs had higher odds of receiving clean needles (OR 4.58 [3.50–5.99]). Injecting behaviors were associated with HIV prevalence among PWID, though risks related to paying for sex remain complicated. Geographical variation in access to clean needles suggests potential benefits of more widely spread public health services.

Key Messages

What is already known on this topic

The HIV epidemic in Pakistan is concentrated among key populations including people who inject drugs.

What this study adds

Injecting practices, sexual behaviors, and socio-economic factors are associated with HIV prevalence among people who inject drugs. Access to harm reduction services is varied in Pakistan.

How this study might affect research, practice, or policy

Access to clean free needles, as well as service delivery programs, with a broad geographical reach remain important to curb the HIV epidemic among people who inject drugs in Pakistan.

KEYWORDS:

• HIV epidemic
• PWID
• IBBS
• NSP
• risk-group

List of abbreviations

AIDS – Acquired immunodeficiency syndrome

HIV – Human immunodeficiency virus

IBBS – Integrated biological and behavior survey

MV – Multivariable

PWID – People who inject drugs

SDP – Service delivery programme

STI – Sexually transmitted infection

UV – Univariable

Acknowledgements

PV and AGL acknowledge support from the NIHR Health Protection Research Unit in Behavioral Science and Evaluation at the University of Bristol. AT, PV, and AGL acknowledge support from the Wellcome Trust.

Disclosure statement

PV has received unrestricted research grants from Gilead, outside the submitted work. All other authors have nothing to declare.

Author contributions

FC performed the analyses and wrote the original draft of the manuscript, with supervision from AGL, AT, and PV. LHT, TR, FE, FC, JFB, and CA were involved in the collection of the original data. All authors contributed to the interpretation and critical revision of the manuscript.

Data availability statement

Due to the sensitive nature of this research, data analyzed in this study are not publicly available.

Ethics approval and consent to participate

The study was designed to meet international ethical guidelines and the study protocol was reviewed and approved by the Pakistan Medical Research Council (Approval No NBC-178).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/20477724.2023.2191234.

Additional information

Funding

This work was not funded. However, it was made possible through the University of Bristol and Integrated Biological and Behavioral Surveillance data provided by the Government of Pakistan National AIDS Control Program.