Research paper
Prevalence and risk factors associated with HIV and tuberculosis in people who use drugs in Abidjan, Ivory Coast

https://doi.org/10.1016/j.drugpo.2016.02.010Get rights and content

Highlights

  • Smoking is the main way of cocaine and heroin consumption in Abidjan, Ivory Coast.

  • People who use drugs in Abidjan can be considered at high risk of HIV, due to sexual transmission in women, sex workers, and men having sex with men using drugs.

  • Social vulnerability is a major factor of illness in people who use drugs in Abidjan, with particularly high rates of active pulmonary TB associated with living conditions.

Abstract

Background

The number of people who use drugs (PWUD) has dramatically increased in West Africa over the last 15 years, but targeted interventions are falling behind, notably because of the lack of awareness of the health needs of PWUD. We aimed to assess prevalence and factors associated with HIV and other infections in PWUD in Abidjan, Ivory Coast, one of the countries most affected by HIV in Western Africa.

Methods

We used respondent-driven-sampling to obtain a representative sample of heroin or cocaine/crack users aged 18 years or more. Socio-behavioral data were obtained by face-to-face questionnaires. Blood samples were collected and tested for HIV. Two sputa were obtained in tuberculosis (TB) symptomatic participants for acid-fast-bacilli (AFB) smear testing. After a descriptive analysis, crude prevalence were calculated, then weighted to take account of the sampling method. Factors associated with HIV and TB were studied using adjusted log-binomial regression. Population size was estimated by capture–recapture.

Results

450 PWUD were recruited in May 2014. The mean age was 33.5 years; 10.9% were women. Smoking was the main mode of consumption, ever injecting was reported by 12.7% of the participants (3.6% in the past month). Sex work was reported by 15.8% of the PWUD (13.7% of the men), and 10.2% of the men reported sexual relationships with other men (MSM). We found a weighted prevalence of 9.5% for HIV. Women were 3.4 times more likely to be infected than men. Among men, being a sex worker (SW) (adjusted OR 2.9 [95CI 1.06–7.98]) or MSM (adjusted OR 11.5 [95CI 4.22–31.42]) were the main factors associated with HIV infection in adjusted analysis. Injection was not associated with HIV. TB weighted prevalence was 1.8%, associated with poor living arrangements in adjusted analysis. We estimated that 3521; 95CI 3049–3993 PWUD live in Abidjan.

Conclusion

PWUD in Abidjan are at high risk of HIV due to sexual transmission, especially in women, SW and MSM who also use drugs. Interventions should be developed to improve HIV prevention and linkage to care in these specific populations. More generally, improving the health of PWUD involves a broader reflection on the living environment and access to health care of slum residents in large African cities.

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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