|Year : 2020 | Volume
| Issue : 2 | Page : 146-150
A clinical study on risk behaviors and seroprevalence of HIV, hepatitis B, and hepatitis C among injection drug users on opioid substitution therapy: An observational study
Shabir Ahmad Dar, Bilal Ahmad Bhat, Aaliya Khanam, Shazia Kousar
Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
|Date of Submission||11-Jul-2019|
|Date of Decision||01-Sep-2019|
|Date of Acceptance||09-Dec-2019|
|Date of Web Publication||27-Jun-2020|
Dr. Aaliya Khanam
Department of Psychiatry, Government Medical College, Srinagar - 190 003, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Introduction: Hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV infection among IDUs is an emerging trend. Opioid substitution therapy (OST) is an evidence-based treatment for opiate-dependent clients that replaces illicit drug use with medically prescribed, orally administered opiates such as buprenorphine. The objective of this study was to determine the sociodemographic variables; seroprevalence of HIV, hepatitis B, and hepatitis C; associated risk behaviors; comorbid substance use pattern; and psychiatric comorbidity among injection drug users (IDUs). Methods: A total of 57 IDUs aged between 18 and 60 years who attended the OST center during 4 months period of a government medical college in North India were included in the study. Results: All of the IDUs were males with a mean age of 26.55 ± 7.26 years. The mean dose of buprenorphine used for the substitution was 6.24 ± 2.4/day at the start of the therapy. Most of the patients were unemployed, with a maximum of them studied up to high school level. The most common substance abuse among IDU users was tobacco 47 (82.46%), followed by Cannabis 23 (40.35%). High-risk behavior found among OST clients was sharing needles (29.82%), unprotected sexual intercourse (12.28%), and sexual intercourse with multiple partners (3.51%). HCV testing showed positive among 9 (15.78%) clients. Conclusion: Oral substitution with buprenorphine is an effective harm reduction strategy for preventing HCV, HBV, and HIV among IDUs. Buprenorphine is a safe compound, with minimal side effects and minimal chances of overdoses.
Keywords: Buprenorphine, injection drug users, opioids
|How to cite this article:|
Dar SA, Bhat BA, Khanam A, Kousar S. A clinical study on risk behaviors and seroprevalence of HIV, hepatitis B, and hepatitis C among injection drug users on opioid substitution therapy: An observational study. Indian J Soc Psychiatry 2020;36:146-50
|How to cite this URL:|
Dar SA, Bhat BA, Khanam A, Kousar S. A clinical study on risk behaviors and seroprevalence of HIV, hepatitis B, and hepatitis C among injection drug users on opioid substitution therapy: An observational study. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Jul 12];36:146-50. Available from: http://www.indjsp.org/text.asp?2020/36/2/146/288113
| Introduction|| |
Opioids belong to the class of substances with the world's most problematic illegal use. There were approximately 33 million opioid users globally in 2014. Among illegal substances, opioid dependence has the highest contributor to the number of disability-adjusted life years lost and to drug-related deaths aged 15–64 years. The concern is with the injection drug route used to administer opioids. Currently, there are about 12 million injection drug users (IDUs) globally, who face some of the most severe harms due to drug use, including blood-borne infections and deaths due to overdose.
Injection drug users (IDUs) are at high risk for blood-borne infections, including hepatitis C virus (HCV). HCV prevalence among IDUs in most countries has been reported to be at least 50% with some estimates exceeding 90%. In India, population-based studies have shown the prevalence of HCV infection ranging from 0.09% to 7.89%. IDUs are also vulnerable to HIV as a result of sharing contaminated syringes and other injecting equipment, for example, cookers, cotton, and rinse water. Injecting drug use accounts for approximately 10% of HIV infections globally.
IDUs also face other problems including abscesses (56%), blocked veins (53%), and overdose episodes (41%). In addition, almost all IDUs (98%) are dependent on opioids because of which IDUs incur harms associated with opioid dependence as well.
Agonist evidence-based intervention for opiate-dependent persons with medically prescribed orally administered opiates such as buprenorphine has displayed better outcomes, thereby reducing HIV risk behaviors and harms compared with other existing treatment strategies. Opioid substitution therapy (OST) helps in retaining the patient in treatment, reducing the use of illicit opioids overdose, participation in criminal activity, and in improving the individual's productivity and his/her quality of life.,
Opioid use disorders (OUDs) pose a significant public health problem in South Asia, particularly in India. As per the World Drug Report 2010, there were 871,000 heroin and 674,000 opium users in India alone. The National Household Survey data published in 2004 estimates the prevalence of current opioid use to be 0.7% in the general population.
In India, a 26% of treatment seekers at de-addiction centers reported opioid as the major drug of abuse. Five percent of opioid drug users are presently receiving OST mostly delivered through community-based services.
Since there is a paucity of literature from Kashmir, India, on the benefits of OST, we planned to study the sociodemographic variables; seroprevalence of HIV, hepatitis B, and hepatitis C; risk behavior; comorbid substance use pattern; psychiatric comorbidity; and required dose of buprenorphine used for the treatment of injection drug users (IDUs) attending OST center at a tertiary health-care center in North India, Kashmir.
| Methods|| |
This was a hospital-based cross-sectional study conducted among new IDUs seeking treatment. The present study was conducted at the drug de-addiction center of a tertiary care Medical College and Hospital in North India from January 2019 to April 2019 among patients who have injected drugs (heroin) at least once in the past 3 months. Patients treated on both inpatient and outpatient basis recruited through purposive sampling technique were considered. The study was approved by the Institute's Ethics Committee. Written informed consent was obtained from the patients when >18 years old and from the parents when ≤18 years old.
A semi-structured pro forma was prepared to record the sociodemographic parameters; pattern; type; psychiatric comorbidity; frequency of drug used in injection; seroprevalence of hepatitis B virus (HBV), HCV, and HIV status risk behaviors; and comorbid substance use types and path of referral. The socioeconomic status of patients was evaluated using the modified Kuppuswamy's socioeconomic status scale, revised for 2016. All the investigations including triple serology were done free of cost, and those requiring treatments were referred to concerned specialists.
The data about various parameters were entered into Microsoft Excel. Descriptive analysis was carried out with the SPSS version-21 software Statistical package for the social sciences; IBM software, NY, USA. The information thus generated was presented in tables as frequencies and percentages.
| Results|| |
Over 4 month period, a total of 57 patients with injection drug use (heroin) were included in the study. The mean age of our patients was 26.55 ± 7.26 years. All the registered patients were males and one-third of them were married. Most of the patients were unemployed, with a maximum of them studied up to high school level. Most of the patients belonged to either lower-middle (48.65%) or upper-middle class (37.84%). Most of the patients were referred by their peers (54.38%), outreach workers (17.54%), family members (10.53%), or referred by friends or on their own (5.26%). The sociodemographic profile is summarized in [Table 1].
|Table 1: Sociodemographic characteristics of clients on opioid substitution therapy|
Click here to view
The mean dose of buprenorphine used for the substitution was 6.24 ± 2.4 mg/day at the start of therapy. About 58.2% of the participants were using injection drugs with a mean duration use of 1.8 ± 1.6 years and duration of buprenorphine use was 0.9 ± 0.2 years. The most common substance abuse among IDU users was tobacco (82.46%) followed by Cannabis (40.35%) [Table 2].
|Table 2: Comorbid substance abuse among opioid substitution therapy clients|
Click here to view
High-risk behavior found among OST clients was sharing a needle/other paraphernalia ([29.82%], unprotected sexual intercourse [12.28%], and sexual intercourse with multiple partners [3.51%]) [Table 3]. Approximately 45% injected daily and 59% injected more than once on their injecting day. About 46.2% injected alone on most of the occasions during the past 3 months.
|Table 3: Human immunodeficiency virus/hepatitis B and C risk behavior among opioid substitution therapy clients|
Click here to view
HIV ELISA testing showed positive among 2 (3.51%) and hepatitis C and hepatitis B were positive in 9 (15.78%) and 1 (1.75%) individuals, respectively [Table 4].
|Table 4: Human immunodeficiency virus/hepatitis B and C status among opioid substitution therapy clients|
Click here to view
Psychiatric comorbidity made as per the DSM 5 criteria was currently present in 66.65% with attention-deficit hyperactivity disorder (ADHD) in 29.82%, major depressive disorder in 14.03%, panic disorder in 5.26%, obsessive-compulsive disorder in 1.75%, and personality disorders in 15.79%. Psychiatric comorbidity is summarized in [Table 5]. [Table 6] and [Table 7] summarize the choice of the body part used for injecting and consequences of injecting and legal issues among injection drug users (IDUs).
|Table 6: Choice of the body part for injecting and consequences of injecting|
Click here to view
| Discussion|| |
The existing evidence about buprenorphine-based OST in India is more than 20 years old now. Currently, there is a dire need for scaling up of OST in India and emphasis should be put on placing it within the ambit of public health policy.,
The existing experience supports the efficacy of OST with regard to the improvement in treatment retention, reduction in illicit opioid use, improving the quality of life on one hand, and reducing the incidence of infection with human immunodeficiency virus and possibly HCV, mortality, and possible reincarceration on the other hand.,,,
All these have helped OST to be established as one of the harm reduction strategies. In this study, the mean age group was 26.55 ± 7.26 years. Armstrong et al. conducted a study among 420 male IDUs and found a mean age of respondents around 36.7 years, in which one-fourth belonged to the age group of 45 or older.
Medhi et al., in his study, showed that IDUs in India are males, aged between 15 and 35, and therefore, the results are in unison with our study results. Since IDU affects the younger age group, the most productive years of life are wasted, as this age group marks the period of the life cycle when impulsive behavior and risk-taking behavior are most common, and substance abuse and many mental illnesses emerge first. As the age progresses beyond 40 years, the chances of opioid dependence decrease to almost zero, the effect called maturing out.
In our study, majority of the respondents were single 27 (47.36%) which can be possibly explained by the time and money they spent in injection drug use therefore were unable to fulfill their social responsibilities. A study done by Kermode et al. on IDUs in Nagaland showed that 66% of respondents were single and the results are concordant with our study results.
The mean dose of buprenorphine used for the substitution therapy was 6.24 ± 2.4 mg/day at the start of therapy which is less than the set guidelines (6–12 mg).
Our data indicate that more than 15% of IDUs in Kashmir have serological evidence of hepatitis C, but only 3.5% are HIV positive. Low prevalence of HIV and high rates of HCV and HBV infection among IDUs have been described previously as well.
This pattern might reflect the fact that HCV and HBV are more transmissible than HIV among IDUs through unsafe injection practices. High-risk drug-using behaviors, such as sharing needles and injection paraphernalia and using nonsterile cleaning procedures, were significantly associated with HCV and HBV infection but not with HIV infection. It would be useful to investigate IDUs' knowledge, attitudes, and perceptions of risks related to the transmission of blood-borne infections. In this study, participants who reported having been diagnosed with hepatitis were more likely to share drugs and injection paraphernalia than those who did not know their hepatitis status. This finding suggests that either these IDUs are unaware of the risks of transmission of hepatitis or they are not concerned about transmitting hepatitis viruses to others. A study of French IDUs reported that HCV-positive IDUs who were aware of their infection status were more likely to share injection paraphernalia.
In India, a population-based study has reported from different regions with the prevalence of HCV infection ranging from 0.09% to 7.89%.
Similar results were reported from a study in Baltimore. Education of IDUs about the risks of HBV and HCV transmission, along with testing to identify carriers, could be important to containing virus transmission.
IDU is the main mode of transmission of HCV in developed countries, transmitted through blood-to-blood contact, either via direct or indirect sharing of injecting equipment.
Like other parts of the world, blood transfusions and unsafe therapeutic injections are the predominant modalities of transmission of HCV.
The main risk factors which were strongly found to be associated with HCV positivity include the sharing syringes, reuse of injection accessories, and IDU status.
Psychiatric comorbidity was present in more than half of our study participants; therefore, our results are concordant with other Indian studies in OUDs.,
In this study, ADHD was the most frequent disorder present as comorbidity. A recent retrospective chart-based review of 11 years by Basu et al. in addiction patients reported that mood disorders were the most common comorbid disorders with personality disorders reported less frequently and therefore contradicts our study results.
Uptake of OST can have important implications, especially for low- and middle-income countries. Overall, participants in all countries have shown significant and marked reductions in the reported heroin and other illicit opioid use; HBV, HCV, and HIV infection risk behaviors associated with IDU and criminal activity have demonstrated substantial improvement in their physical and mental health and general well-being. We believe that OST is able to be implemented successfully in a diverse range of treatment settings in developing and transitional economies.
It is well established that OST program-related factors, such as dosing policy and availability of ancillary medical and psychosocial services, can impact upon treatment retention and outcome.
Keeping in mind the limited support of OST in India which is partly driven by prejudice toward drug users, poor understanding of the benefits of opioid substitution treatment, and reluctance to examine alternatives to behavioral treatments, we would commend these findings for greater professional and public discourse on OST in India.
| Conclusion|| |
Oral substitution with buprenorphine is an effective harm reduction strategy for preventing HCV, HBV, and HIV among IDUs. Buprenorphine is a safe compound, with minimal side effects and minimal chances of overdoses, if used knowledgeably. The procedure to implement OST is simple and does not require extensive clinical setup. The outcome with OST is best when combined with psychosocial interventions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nations Office on Drugs and Crime. World Drug Report 2016. Vienna: United Nations Pubns Publisher; 2016.
Degenhardt L, Whiteford HA, Ferrari AJ, Baxter AJ, Charlson FJ, Hall WD, et al
. Global burden of disease attributable to illicit drug use and dependence: Findings from the Global Burden of Disease Study 2010. Lancet 2013;382:1564-74.
Aceijas C, Rhodes T. Global estimates of prevalence of HCV infection among injection drug users. Int J Drug Policy 2007;18:352-8.
Mukhopadhyaya A. Hepatitis C in India. J Biosci 2008;33:465-73.
Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, et al
. Global epidemiology of injecting drug use and HIV among people who inject drugs: A systematic review. Lancet 2008;372:1733-45.
Ambekar A, Rao R, Mishra AK, Agrawal A. Type of opioids injected: Does it matter? A multicentric cross-sectional study of people who inject drugs. Drug Alcohol Rev 2015;34:97-104.
Lawrinson P, Ali R, Buavirat A, Chiamwongpaet S, Dvoryak S, Habrat B, et al
. Key findings from the WHO collaborative study on substitution therapy for opioid dependence and HIV/AIDS. Addiction 2008;103:1484-92.
Gowing L, Farrell M, Bornemann R, Sullivan L, Ali R. Substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst Rev 2008;16:CD004145.
Ray R, editor. The Extent, Pattern and Trends of Drug Abuse in India National Survey. Ministry of Social Justice and Empowerment, Government of India and United Nations Office on Drugs and Crime. United Nations Office on Drugs and Crime; 2004. Available From: http://www.unodc.org/India/Indianationalsurvey2004.html
. [Last accessed on 2019 Apr 20].
Mathers BM, Degenhardt L, Ali H, Wiessing L, Hickman M, Mattick RP, et al
. HIV prevention, treatment, and care services for people who inject drugs: A systematic review of global, regional, and national coverage. Lancet 2010;375:1014-28.
Ambekar A, Murthy P, Basu D, Rao GP, Mohan A. Challenges in the scale-up of opioid substitution treatment in India. Indian J Psychiatry 2017;59:6-9.
] [Full text]
Rao R. The journey of opioid substitution therapy in India: Achievements and challenges. Indian J Psychiatry 2017;59:39-45.
] [Full text]
Mattick RP, Kimber J, Breen C, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2008;2:CD002207.
Sordo L, Barrio G, Bravo MJ, Indave BI, Degenhardt L, Wiessing L, et al
. Mortality risk during and after opioid substitution treatment: Systematic review and meta-analysis of cohort studies. BMJ 2017;357:j1550.
Feelemyer JP, Jarlais DCD, Arasteh K, Phillips BW, Hagan H. Changes in quality of life (WHOQOL-BREF) and addiction severity index (ASI) among participants in opioid substitution treatment (OST) in low and middle income countries: An international systematic review. Drug Alcohol Depend 2014;134:251-8.
Tsui JI, Evans JL, Lum PJ, Hahn JA, Page K. Association of opioid agonist therapy with lower incidence of hepatitis C virus infection in young adult injection drug users. JAMA Intern Med 2014;174:1974-81.
Armstrong G, Nuken A, Samson L, Singh S, Jorm AF, Kermode M. Quality of life, depression, anxiety and suicidal ideation among men who inject drugs in Delhi, India. BMC Psychiatry 2013;13:151.
Medhi GK, Mahanta J, dhikary R, Akoijam BS, Liegise B, Sarathy K, et al
. Spatial distribution and characteristics of injecting drug users (IDU) in five Northeastern states of India. BMC Public Health 2011;11:64.
Sadock BJ, Sadock VA, Ruiz P, editors. Substance use and addictive disorders. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 11th
ed. Philadelphia: Wolters Kluwer; 2015. p. 660.
Kermode M, Longleng V, Singh BC, Hocking J, Langkham B, Crofts N. My first time: Initiation into injecting drug use in Manipur and Nagaland, North-East India. Harm Reduct J 2007;4:19.
Des Jarlais DC, Diaz T, Perlis T, Vlahov D, Maslow C, Latka M, et al
. Variability in the incidence of human immunodeficiency virus, hepatitis B virus, and hepatitis C virus infection among young injecting drug users in New York City. Am J Epidemiol 2003;157:467-71.
Sarkar K, Mitra S, Bal B, Chakraborty S, Bhattacharya SK. Rapid spread of hepatitis C and needle exchange programme in Kolkata, India. Lancet 2003;361:1301-2.
Vidal-Trécan G, Coste J, Varescon-Pousson I, Christoforov B, Boissonnas A. HCV status knowledge and risk behaviours amongst intravenous drug users. Eur J Epidemiol 2000;16:439-45.
De Jong W, Tsagarelli T, Schouten E. Rapid assessment of injection drug use and HIV in the republic of Georgia. J Drug Issues 1999;29:843-59.
Thorpe LE, Ouellet LJ, Hershow R, Bailey SL, Williams IT, Williamson J, et al
. Risk of hepatitis C virus infection among young adult injection drug users who share injection equipment. Am J Epidemiol 2002;155:645-53.
Mohanty R, Senjam G, Singh NH. Psychiatric comorbidities among opioid-dependent patients attending department of psychiatry Regional Institute of Medical Sciences hospital Manipur. Indian J Soc Psychiatry 2018;34:132. [Full text]
Vivek K, Dalal P, Trivedi J, Pankaj K. A study of psychiatric comorbidity in opioid dependence. Delhi Psychiatry J 2010;13:86.
Basu D, Sarkar S, Mattoo SK. Psychiatric comorbidity in patients with substance use disorders attending an addiction treatment center in India over 11 years: Case for a specialized “dual diagnosis clinic. J Dual Diagn 2013; 9:23-9.
Ward J, Mattick R, Hall W, editors. Methadone Maintenance Treatment and Other Opioid Replacement Therapies. Amsterdam: Harwood Academic Publishers; 1998.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]