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ORIGINAL ARTICLE
Year : 2019  |  Volume : 63  |  Issue : 2  |  Page : 114-118  

Prevalence and predictors of self-reported risk behaviors among male injecting drug users


1 Assistant Professor, Department of Community Medicine, Government Medical College and Hospital, Chandigarh, India
2 Prof. and Head, Department of Community Medicine, Government Medical College and Hospital, Chandigarh, India
3 Statistician Cum Associate Professor, Department of Community Medicine, Government Medical College and Hospital, Chandigarh, India
4 Projector Director, Targeted Interventions, State AIDS Control Society, Chandigarh, India
5 Deputy Director, Targeted Interventions, State AIDS Control Society, Chandigarh, India

Date of Web Publication18-Jun-2019

Correspondence Address:
Deepak Sharma
Department of Community Medicine, GMCH, Sector 32, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_279_18

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   Abstract 


Background: Unsafe injecting drug use is a documented risk factor for the transmission of human immunodeficiency virus infection. Harm reduction strategy aims at reducing this deleterious consequence. Objectives: To study the prevalence and predictors of injecting as well as sexual risk behavior among male injecting drug users (IDUs). Methods: A cross-sectional study was conducted among 250 male IDUs from January 2017 to March 2018. Risk behavioral data were collected after obtaining informed consent of the study participants. This included information on sharing, reusing needles/injections, and sexual behavior. Descriptive statistics and logistic regression model was run using the Epi Info software version 7.2 for Windows. Results: In the past one month, 25.3% had shared needles/syringes by either borrowing or lending or both. Inconsistent condom use during sexual intercourse with a regular, casual, and paid sex partner was practiced by 64.7% (77/119), 65.8% (48/73), and 45.0% (18/40), respectively. The binary logistic regression analysis revealed that unsafe injecting drug behavior was higher among daily users: (OR = 3.0 [1.3–6.6]) and comparatively lower among those who preferred to avail needles/syringes from Needle Syringe Exchange Program (OR = 0.4 [0.2–0.9]); as compared to their counterparts. Conclusions: The findings suggest that IDUs in the study area are engaging in risk behaviors. Behavior change communication and harm reduction strategy should be strengthened.

Keywords: Harm reduction, injecting drug use, risk behavior


How to cite this article:
Sharma D, Goel NK, Walia DK, Thakare MM, Gupta V, Mittal S. Prevalence and predictors of self-reported risk behaviors among male injecting drug users. Indian J Public Health 2019;63:114-8

How to cite this URL:
Sharma D, Goel NK, Walia DK, Thakare MM, Gupta V, Mittal S. Prevalence and predictors of self-reported risk behaviors among male injecting drug users. Indian J Public Health [serial online] 2019 [cited 2019 Sep 17];63:114-8. Available from: http://www.ijph.in/text.asp?2019/63/2/114/260602




   Introduction Top


Injecting drug use is a global public health issue. It is estimated that around 15 million people worldwide inject drugs, of which around 17% have human immunodeficiency virus (HIV) infection.[1],[2] In India, the prevalence of HIV among injecting drug users (IDUs) at the national level is 9.9%.[3] The vulnerability of IDUs to HIV infection is attributed to their behavior of sharing contaminated injecting equipment, having unprotected sex and multiple sexual partners.[4],[5],[6] IDUs practice this unsafe behavior either due to lack of perceived risk for HIV infection or due to peer norm, wherein it might be considered a normal activity by them.[4] Apart from HIV infection, reusing an unsterilized needle by IDUs can lead to dermatological infections, abscesses, and visible scarring.[7]

The harm-reduction strategy has been endorsed by the National AIDS Control Organization (NACO). In this, IDUs are provided with needles/syringes to reduce the chance of sharing. Apart from this, IDUs are counseled to switch over from injecting to medically supervised orally prescribed medicine. Studies conducted worldwide[8],[9],[10] and in India[11] have shown that high-risk behaviors such as sharing needles, reusing needles after cleaning, and unsafe sexual practices are common among IDUs. Studying this behavior of IDUs is vital as it provides information about the possible risk of spread of infection from them to the general population. In this backdrop, the current study was conducted to find out the prevalence and predictors of injecting as well as sexual risk behavior among male IDUs.


   Materials and Methods Top


A cross-sectional study was conducted among male IDUs in Chandigarh from January 2017 to March 2018. IDU has been defined by the National AIDS Control Program as an individual who has injected drugs at least once in the last 3 months.[12] In the study area, the State AIDS Control Society (SACS) is implementing two “Targeted Intervention” projects for IDUs though Non-government Organizations (NGOs), wherein they are providing specific interventions to reduce the vulnerability. This includes needle syringe exchange, oral substitution therapy, abscess management, and other health-care services. Considering a prevalence of 17.4% for unsafe injecting drug practices,[13] with an allowable error of 5%, 95% confidence level, and 10% nonresponse rate, the estimated sample size was 244 (rounded off to 250).

For enrolling, the desired sample size convenience sampling methodology was followed, wherein IDUs were recruited with the help of outreach workers and peer educators of NGOs. The investigators visited locations where IDUs tend to gather for injecting drugs. Apart from this, peer educators arranged for interviews at some specific locations in the areas as deemed viable by them for enrolling IDUs into the study. All participants in the study were informed about the objectives of the study and that they were free to participate by their own will. Informed consent was obtained from all the study participants.

Risk behavioral data were collected through face-to-face interviews using a validated questionnaire, namely, “HIV Risk-taking Behavior Scale.”[14] It includes questions on assessing the injecting and sexual risk behavior in the past one month. The “unsafe injecting risk behavior” was defined as borrowing, lending used needles or both. The study participants were asked whether they used a condom during sexual intercourse with “regular,” “casual,” and “paid” partners. A “casual female partner” was defined as one other than the regular female partner such as a lover, with whom the IDU had sexual intercourse. “Paid female partners” were those whom IDU had paid cash in exchange for sexual intercourse. “Inconsistent condom use” was defined as “never,” “rarely,” “sometimes,” “often,” but “not always” using a condom in sexual encounter. The risk behaviors were studied for age, education, occupation, living status (married and living with wife, married but living alone, unmarried), frequency of injection (daily, weekly), correct knowledge of modes of HIV transmission, and age of initiating IDU. IDUs were asked about the places from where they get needles for injecting such as Needle Syringe Exchange Program (NSEP), chemist, and friends. They were then asked to tell the place from which they preferred to obtain needles (tend to choose over others and use most often). The reason for preferring the site was also elicited. The knowledge of HIV participants was assessed by asking them about modes of its transmission. Those who correctly answered methods of preventing the transmission of HIV (using condoms during sexual activity and not sharing needles) and rejected misconceptions (transmission via sharing meal, handshake and mosquito bite) were categorized as having “correct knowledge of HIV transmission.”

Data analysis was done using Epi Info Version 7.2 software for Windows (CDC Atlanta, GA, USA). Bivariate analysis was done for “unsafe injecting behavior” and “inconsistent condom use with regular, casual, and paid sex partner.” Variables having a significance level of P < 0.20 in the bivariate analysis were considered for inclusion in the binary logistic regression model. Unadjusted odds ratios, adjusted odds ratio (AOR), and 95% confidence intervals were reported. The logistic regression model fitness was assessed by the Hosmer–Lemeshow test. The study was approved by the Ethics Committee of Government Medical College and Hospital. Prior to fieldwork, an approval was obtained from the State AIDS Control Society (SACS). After collecting the data, the study participants were imparted education regarding harm reduction and HIV.


   Results Top


Out of the 250 study participants, 81 (32.4%) were in the age group of 18–24 years. The median age of the study participants was 28.5 years with age ranging from 18 to 61 years. There were 12.0% illiterates and 37.2% who had studied up to primary level. Half of the study participants (51.2%) were unmarried, 44.8% were married and living with wife, and the remaining 4.0% were married but living alone. There were 74 (29.6%) current daily alcoholics, 168 (67.2%) daily smokers, and 68 (27.2%) daily smokeless tobacco users.

Of the 250 IDUs, 229 (91.6%) had injected drugs in the past one month. Of these, 25.3% (58/229) had shared needles/syringes with others by either borrowing or lending or both in the past one month. The frequency of injecting drugs in the past one month was; once a week or less (19.7%), more than once a week (14.0%), once a day (37.6%), 2–3 times a day (21.0%), and more than three times a day (7.9%). There were 91 (39.7%) study participants who reused needle/syringes after cleaning in the past one month. They mostly used water for cleaning needles. None of the study participants used bleaching powder for cleaning needles. Inconsistent condom use with regular, casual, and paid sex partner was 64.7% (77/119); 65.8% (48/73), and 45.0% (18/40), respectively. In the past one month, 5.8% had indulged in anal intercourse.

The place from which injecting drug users got needles was NSEP (87.6%) followed by chemist shops (54.4%). Around one-tenth of them got the needles and syringes from friends (14.5%). The most preferred site for getting needles/syringe was NSEP (79.6%) followed by drug store (13.6%). The reason for preferring the site of availing needles/syringes was the easy availability factor (80.0%) followed by the cost factor (26.4%) and that they can get more needles (23.2%). Almost all of the study participants had heard about HIV/AIDS (246/250; 98.4%). With regard to the mode of HIV transmission, 90.8% correctly answered that using a condom during sexual activity can protect a person from HIV. Most of them were aware that shaking hands (92.0%) and sharing meals (89.2%) did not transmit HIV. Around one-third had a misconception that a person can have HIV from mosquito bite (29.2%). Knowledge of risk of HIV transmission by sharing needles/syringes was high, with 86.0% responding correctly to this question. Overall 138 of the 246 study participants (56.1%) had “correct knowledge of HIV transmission” [Table 1].
Table 1: Sociodemographic factors and risk behaviors of the study participants

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Bivariate analysis shows that unsafe injecting behavior was significantly more among daily injectors (31.6%) compared to nondaily ones (13.0%). Furthermore, those preferring to take needles from NSEP were less likely to share needles (20.3%) as compared to their counterparts (44.7%). Both risk behaviors, i.e., injecting drugs and sexual activity with regular, casual, and paid sex were not related with factors such as age, occupation, education and knowledge of HIV transmission [Table 2]. The binary logistic regression analysis revealed that unsafe injecting behavior was higher among daily users (AOR = 3.0 (1.3–6.6) and comparatively lower among those preferring to avail needles from NSEP (AOR = 0.4 (0.2–0.9); as compared to their counterparts. It was unrelated to age, occupation, and education of the study participants. The “correct knowledge of HIV transmission” did not influence the injecting risk behaviors. The logistic regression model showed a good fit Hosmer–Lemeshow; P = 0.862. The Cox and Snell R2and Nagelkerke pseudo-R2 value for the model was 9.7% and 14.3%, respectively [Table 3].
Table 2: Predictors of unsafe injection and sexual risk behavior among the study participants

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Table 3: Binary logistic regression model of predictors of unsafe injecting risk behavior

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   Discussion Top


The results of our study depict that IDUs by virtue of their harmful behavior are vulnerable for acquiring blood-borne infections such as HIV. In the current study, we found that one fourth of the study participants shared needles/syringes with others in the past one month. Similar to this finding, a study conducted by Solomon et al. in South India reported that 37% IDUs used a previously used syringe at least once.[11] Das et al. studied risk behaviors of IDUs in Chandigarh and observed that 17.4% shared needles/syringes during last month.[13] Other studies conducted worldwide have also documented a high proportion of unsafe injecting drug sharing practices. Shariful Islam et al. in Bangladesh observed that around three-fourth of IDUs shared needles sometimes.[9] Chikovani et al. in his study among IDUs in Georgia reported that unsafe injecting behavior at the last injection was 51.9%.[10] In our study, it was found that few study participants practiced safe sexual practices. Similar observations have been reported in studies conducted by Chavan et al.[15] and Tyndall et al.[16]

The present study found that IDUs who were injecting drugs on daily basis had higher injection sharing risk behavior. Moraros et al. in a study among Canadian IDUs inferred that higher frequency of injection was associated with high-risk behavior.[17] Further, we found that those preferring to avail needles/syringes from NSEP had comparatively low-risk behavior. This finding may be explained by the fact that IDUs who visit a NSEP site for needle have more probability of coming in contact with a physician, health worker, counselor, nurse, outreach worker, or peer educator and thus may become motivated to practice safe injecting practices. Furthermore, the easy availability of needles from NSEP as compared to drug stores may desist them from sharing needles. Luo et al. reported that participation in needle and syringe exchange program was associated with a lower risk of HIV infection.[18]

In the current study, age of the study participants, education, living status, and age of initiation was not related to injection sharing practices. In contrast to these findings, a study conducted by Parviz in Pakistan reported that younger age at first injection and fewer years of schooling were associated with needle sharing.[19] Bhatta et al. reported that sharing of syringe was statistically higher among those respondents who were married.[20] We found that knowledge of HIV was unrelated to injecting and sexual risk behavior of IDUs. This might be related to the fact that IDUs during the process of injecting drugs have impaired judgment and are in an intoxicated state; wherein knowledge has little role to play. In contrast to our finding, Moraros et al. in a study among Canadian IDUs reported that lack of HIV knowledge predicted high-risk behavior.[17]

A limitation of the study is the cross-sectional design and thus cannot address the point regarding causality of association in this study. Additional limitation is the self-reported injecting and sexual risk behavior which may have led to under or overestimation. Despite these limitations, the findings of the study provide vital data for HIV policy-makers. To conclude, in spite of an existing harm reduction program in the study area, unsafe practices continue among the IDUs. It was found that it is not the correct knowledge of HIV transmission, but the less frequency of injecting drugs coupled with preferring to take needles from NSEP which decreased the risk behavior. It is thus imperative to strengthen the existing harm reduction services and compliment it by preventing uptake of gateway drugs. Efforts should be made to increase the awareness and acceptance of existing NSEP services. A visit of IDUs to NSEP should be utilized as an opportunity for promoting behavior change communication among them.

Acknowledgments

The authors would like to thank the study participants for their contribution in this research. The authors would also like to thank the staff of NGOs working for IDU in the study area for their cooperation.

Financial support and sponsorship

We are thankful to the Department of Science and Technology, Chandigarh, India for providing financial assistance.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Gyarmathy VA, Li N, Tobin KE, Hoffman IF, Sokolov N, Levchenko J, et al. Unprotected sex in heterosexual partnerships of injecting drug users in St. Petersburg, Russia. AIDS Behav 2011;15:58-64.  Back to cited text no. 5
    
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Rahimi-Movaghar A, Razzaghi E. A qualitative study on opioid overdose in injecting drug users in Tehran. Tehran Univ Med J 2006;64:43-53.  Back to cited text no. 8
    
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Chikovani I, Bozicevic I, Goguadze K, Rukhadze N, Gotsadze G. Unsafe injection and sexual risk behavior among injecting drug users in Georgia. J Urban Health 2011;88:736-48.  Back to cited text no. 10
    
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14.
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Tyndall MW, Patrick D, Spittal P, Li K, O'Shaughnessy MV, Schechter MT. Risky sexual behaviours among injection drugs users with high HIV prevalence: Implications for STD control. Sex Transm Infect 2002;78 Suppl 1:i170-5.  Back to cited text no. 16
    
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Moraros J, Falconer J, Rogers M, Lemstra M. Risk factors associated with higher injection drug use and HIV rates: Findings from Saskatchewan, Canada. J AIDS Clin Res 2012;S1:9.  Back to cited text no. 17
    
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19.
Parviz S, Fatmi Z, Altaf A, McCormick JB, Fischer-Hoch S, Rahbar M, et al. Background demographics and risk behaviors of injecting drug users in Karachi, Pakistan. Int J Infect Dis 2006;10:364-71.  Back to cited text no. 19
    
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