HIV Risk Perception among Injecting Drug Users in Egypt.

Author(s) Doaa Oraby1
Affiliation(s) 1Self employed, Self employed, Cairo, Egypt.
Country - ies of focus Egypt
Relevant to the conference tracks Infectious Diseases
Summary Egypt has low HIV prevalence (below 0∙02 %) among the general population mostly attributed to conservative culture. In 2010, transmission through injecting drug use represented around 5∙1% of reported cases and the 2010 second round biological/behavioral surveillance survey (Bio-BSS) conducted in some governorates revealed concentrated epidemic among male injecting drug users. The aim of the current study was to assess HIV risk perception among IDUs; to what extent is that risk perception attributable to the nature of HIV, the characteristics of the IDUs population and cultural considerations in Egypt in addition to identifying possible interventions to mitigate HIV infections among IDUs.
Background Egypt has low HIV prevalence (below 0∙02 %) among the general population mostly attributed to conservative culture. In 2010, transmission through injecting drug use represented around 5∙1% of reported cases and the 2010 second round biological/behavioral surveillance survey (Bio-BSS) conducted in some governorates revealed concentrated epidemic among male injecting drug users (IDUs). IDUs face the risks of HIV through the sharing of contaminated needles and other drug paraphernalia, and engaging in unprotected sex sometimes occurring under the effect of, or in exchange for drugs. Additionally, because of their legal status, IDUs are put in prison, where clean needles are harder to find, thereby raising the threat of HIV. Through sharing injection equipment, IDUs are also at particular risk for acquiring hepatitis C virus (HCV). HCV is one of the major health threats and leading causes of death in Egypt. The 2008 Egyptian Demographic Health Survey tested a representative sample of both urban and rural populations in the entire country for HCV antibody and the overall prevalence positive for antibody to HCV was 14.7 %. The current harm reduction interventions do not tackle HCV and only focus on HIV.
Objectives The aim of the current study was to assess HIV risk perception among IDUs; to what extent is that risk perception attributable to the nature of HIV, the characteristics of the IDUs population and cultural considerations in Egypt in addition to identifying possible interventions to mitigate HIV infections among IDUs.
Methodology The assessment included in-depth interviews with 50 IDUs (45 males and 5 females, who were very hard to locate as they are poorly connected compared to male IDUs) who were reached using respondent driven sampling technique. The interviews were structured around the themes of HIV transmission, how IDUs perceive their own risk of contracting HIV and their knowledge of the protective role of safe sex and safe injection practices, in addition to exploring the barriers that keep them from abiding to safe sex and injection behaviors. The study was conducted late in 2012. Informed consent was obtained from all interviewees after explaining the purpose of the study, asking permission to record the interview and assuring voluntary participation and confidentiality. Analysis was based on grounded-theory.
Results For most interviewed IDUs were poor and unemployed, and getting high is their only escape from the hardships they face daily so they inject drugs. Some tried to quit but failed. The majority of the interviewed sample reported that they never perceived HIV as a threat because they do not deal with HIV patients, HIV is uncommon in their communities and they do not go to the countries famous for the high rate of HIV infection. This is contrary to HCV which they perceive as a high threat prevalent among themselves. None of the interviewed IDUs could list all the correct methods of HIV transmission; the majority stated sexual contact as the mode of transmission and some stated infected blood but none mentioned syringes apart from them leading to abscess if frequently used. Interviewed IDUs stated sharing needles, syringes or paraphernalia at least once in the 3 months preceding the interviews. Sharing needles, syringes and paraphernalia when probed was affirmed as a mode of transmission of HCV, yet they do not consider they have an alternative. IDUs clarified that although syringes are cheap and available in pharmacies yet they share syringes rather than buying new ones because IDUs fear being detained as carrying syringes, particularly if drug contaminated, is a sufficient excuse for arrest by policemen who easily identify IDUs. Male IDUs revealed that under the influence of drugs they engage in sexual relations sometimes with the same sex though they are heterosexuals while few female IDUs admitted that they exchanged sex for drugs. Both admitted that in such impromptu encounters, using condom never crosses their minds. All interviewed male IDUs knew about condoms, some use condoms when not under the influence of drugs but not on regular basis while others hate condoms because they reduce pleasure. On the other hand, female IDUs stated that using condoms is not their decision. None of the interviewed IDUs linked non-use/irregular use of condoms to the possibility of contracting HIV but did link non-use to urinary discharge, itching and other genital manifestations.
IDUs revealed that owing to the sensitivity and stigma of drug use in Egypt conservative culture they fear disclosing their sexual and drug injection practices. Hence, they resort to self-treatment rather than going to doctors in case of abscess development or sexually transmitted infections which are common ailments among IDUs. When probed, IDUs stated that if acceptance by service providers, in addition to maintained  confidentiality was guaranteed, they would access health services in the case of aliments.
Conclusion Approaches that address the perceived benefits of safe injecting and safe sex and barriers to behavioral change among IDUs are needed with regard to HIV. Listening to IDUs enabled better understanding of HIV-related knowledge and perceptions which may contribute to the innovation of HIV prevention interventions for IDUs that could also lead to benefits regarding HCV which is currently a public health priority in Egypt. Addressing HIV and HCV simultaneously through competent trained providers will increase IDUs acceptability and commitment to the delivered interventions.

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