Research paperPrevalence and risk factors associated with HIV and tuberculosis in people who use drugs in Abidjan, Ivory Coast
Introduction
In West Africa, institutional weakness due to decades of political conflict has led to a worrying growth of cocaine and other drug trafficking. Local consumption has also dramatically increased, though the real extent of illicit drug use remains unknown. While efforts to address the problem have mostly focused on arrests of users and petty drug dealers, very few investments have been made in treatment and harm reduction services (WACD, 2014).
Yet drug use poses significant public health risks. Globally, injecting drug users (IDU) are disproportionately infected with HIV, with incidence estimated to be up to 22 times greater than in the general population (Mathers et al., 2008). Increased HIV prevalence is also reported in non-injecting drug users (NIDU), especially because of increased sexual risk behaviors, and overlapping social and sexual networks with IDU (Strathdee & Stockman, 2010). The small amount of data available in West Africa reports higher HIV rates in People who use drugs (PWUD) than in the general population (5.2% in Senegal, and between 3% and 9.3% in Nigeria) (Eluwa et al., 2013, Leprêtre et al., 2015). PWUD also remain disproportionately affected by viral hepatitis B and C (HBV, HCV), and syphilis (Coffin et al., 2010, Nelson et al., 2011). In addition, drug use is associated with a number of factors that together contribute to higher risks of tuberculosis (TB), including direct detrimental effect on the immune system, use of tobacco, homelessness, or repeated incarcerations (Deiss, Rodwell, & Garfein, 2009).
With a HIV prevalence of 3.7% in the general population, Ivory Coast is one of the most affected countries of West Africa (DHS, 2013). Abidjan, the main city, shows even higher rates, with an HIV prevalence estimated at 5.1% (DHS, 2013). The smoking of heroin “Pao” and crack cocaine “Yo” is very common in Abidjan, taking place most of the time in “fumoirs”, which are insalubrious and crowded spaces dispersed within urban slums. Heroin is mainly used in a rolled cigarette of cannabis, whereas crack cocaine is smoked using handmade pipes “Zeb”. Other, less frequent, consumption patterns are observed, such as chasing the dragon, snorting cocaine, or oral consumption of psychotropic pharmaceutical drugs (amphetamine pills known as “Bleu bleu”, clonazepam “Rivo”, barbiturate “sekou touré” and different ephedrine combinations). Injecting drug use exists, but is uncommon and deprecated by Ivorian PWUD.
Ivorian authorities are determined to develop a public health approach adapted to populations at high risk of HIV. They already work closely with sex workers (SW) and men having sex with men (MSM), who face alarmingly high HIV prevalence rates: 26.6% in female SW (Vuylsteke et al., 2012a) and 50% in male SW (Vuylsteke et al., 2012b), and 18% in MSM (Hakim et al., 2015). However, PWUD's health needs are barely known, and very few health organizations are currently working with this population. Our study aimed to collect reliable data on HIV, TB, viral hepatitis, and syphilis among highly vulnerable PWUD in Abidjan.
Section snippets
Methods
We conducted a four-month situational analysis prior to the survey, in collaboration with key informants. The objectives of this preliminary step were to assess major drug use patterns in Abidjan, to map out places of consumption and notably the different “fumoirs”, and to inform the development of the quantitative questionnaire.
Population, demographics, drug use and sexual behavior (Table 1)
In May 2014, the survey recruited 450 participants within 11 waves. Equilibrium was reached as early as the 4th wave for the following variables: proportion of men, age (mean), and proportion of people positive for HIV. Among the surveyed participants, 131 had received one of the 1025 T-shirts distributed a few weeks before, during the capture phase. We estimate that there are 3521 [95CI 3049–3993] heroin and/or cocaine/crack users in Abidjan.
Mean age was 33.5 (standard error 8.6, interquartile
Principal findings and interpretation
This work is the first to assess PWUD's health needs in Abidjan, Ivory Coast. Moreover, very few publications are available with regards to the West African region where drug use is a growing concern. We relied on PWUD key informants to design and implement the study, and we used an appropriate methodology to survey hard-to-reach populations. Although smoking is the main way of consuming heroin and crack cocaine, PWUD in Abidjan show a prevalence of HIV (9.5%) almost two times higher than the
Acknowledgements
We would like to thank the study participants without whose motivation and eagerness the study would not have been possible. We are also indebted to the support of the Ivorian health authorities, the steering committee of the study, and the operational partners: La Croix Bleue, le Cedres, le Centre Anti-Tuberculeux d’Adjamé. The research was made possible through funding from Médecins du Monde France, and the Global Fund – Alliance Côte d’Ivoire.
Conflict of interest statement
The authors declare
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