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Official websites use. Share sensitive information only on official, secure websites. We describe the characteristics of injecting drug users IDU in Pakistan in and , and assess the heterogeneity of IDU characteristics across different cities and years as well as factors associated with HIV infection. Cross-sectional, integrated behavioural-biological surveys of IDU were conducted in 10 cities across Pakistan in and Univariate and multivariable analyses were used to describe the differences in HIV prevalence and risk behaviours between cities and over time. Large increases in HIV prevalence among injection drug users in Pakistan were observed, with overall HIV prevalence increasing from There was an increase in risk behaviours between and , anecdotally related to a reduction in the availability of services for IDU. In , larger proportions of IDU reported injecting several times a day and using professional injectors, and fewer reported always using clean syringes. An increase in the proportion living on the street was also observed and this was associated with HIV infection. Cities differ in terms of HIV prevalence, risk profiles, and healthcare seeking behaviours. There is a high prevalence of HIV among injection drug users in Pakistan and considerable potential for further transmission through risk behaviours. HIV prevention programs may be improved through geographic targeting of services within a city and for involving groups that interact with IDU such as pharmacy staff and professional injectors in harm reduction initiatives. Injecting drug use has long played a prominent role in determining the unfolding of the HIV epidemic in various countries around the world. These factors have had significant influence on local drug consuming markets, resulting in substantial numbers of drug users, 10 including a significant number who have transitioned to injecting drug use 11 12 which is now well established in nearly all larger cities throughout the country. Early data indicated high rates of needle sharing in some cities 14 and high prevalence rates of hepatitis C, but low prevalence of HIV infection. The reason for this heterogeneity has not been established and there is a need to better understand the heterogeneity of this population and risk behaviours to guide HIV prevention and control interventions for IDUs across Pakistan. It also assesses the heterogeneity of IDU characteristics across different cities and time, and factors associated with prevalent HIV infection in the latter period. These surveys were conducted under a national strategy of second-generation HIV surveillance, the objective of which was to provide trend data in biological and behavioural information related to HIV. Four rounds of data on IDUs were available, collected in round 1 , round 2 , round 3 and round 4 ; cities representing all four provinces of Pakistan Sindh, Punjab, Khyber-Pakhtunkhwa and Balochistan were included figure 1. For the purposes of this study, and to be consistent with other studies in this supplement, only data from rounds 2 and 4 are presented as these rounds surveyed the largest number of cities. In these two rounds, only cities that were surveyed at both points in time were retained for analyses. Thus, from Punjab province, Lahore the capital city , Dera Ghazi Khan, Faisalabad, Multan and Rawalpindi were included; from Sindh province, Karachi the capital city , Larkana and Sukkur were included; for Balochistan and Khyber provinces, Quetta and Peshawar were included, respectively. For Punjab and Sindh provinces, the non-capital cities were aggregated to simplify analyses. In each round, IDUs were recruited and interviewed individually by trained peer workers using the same sampling methodology which has been described previously. In the first stage, sampling weights were calculated based on the number of IDUs in each geographical zone, and the total number of IDUs to be sampled was proportionately allocated to all zones. In the next stage, the top 10 IDU gathering places spots in each zone were identified from the mapping data, and the study participants were recruited by team members with the help of social mobilisers hired specifically for this purpose. The social mobilisers identified all eligible participants at a selected spot, and the recruiter then randomly selected people to be approached and asked for consent to participate in the study. When mapping data estimated an IDU population size of less than , all eligible people found in the city were asked to participate. Following a process to obtain informed consent for biological and behavioural components, trained field workers administered a structured questionnaire to study participants. Questionnaires were designed in English, but were translated and administered in Urdu; IDUs were interviewed in a central field office. After questionnaires were completed, individuals were debriefed and given the chance to ask any follow-up questions. At this debriefing session, individuals were provided with information on the modes of transmission and prevention of HIV infection, and were made aware of existing services; HIV results from this study were not returned to participants and all participants were referred to free local voluntary HIV counselling and testing centres. The institutional review boards of the Public Health Agency of Canada and the University of Manitoba approved the study. Questionnaires collected information on socio-demographic characteristics, drug use and sexual behaviours, and healthcare seeking behaviour; however, the question on whether IDUs were aware of any Government of Pakistan services for IDUs was the only question on healthcare-seeking behaviour that was consistent across rounds 2 and 4. A professional injector is an individual, likely a drug provider who will inject IDUs for a fee, often using a previously used syringe. Socio-demographic, drug-injecting and sexual behaviour characteristics were compared across rounds 2 and 4 by geographical area. To reduce the number of comparisons, and because the study was powered to detect changes in HIV prevalence and proportion of injectors who used an unclean syringe, we focused on these two outcomes only. Multivariable logistic regression analysis was applied to round 4 data for each of the two largest provinces Punjab and Sindh to assess factors associated with HIV status, use of dirty syringe at last injection, and use of a professional injector at last injection. For comparison with models investigating HIV status as the outcome, variables included in the final HIV model were also used in the final models for use of dirty syringe and use of a professional injector at last injection. Stata 11 was used for all analyses. Table 1 displays socio-demographic, drug-injecting, and sexual behaviour characteristics for round 2 and round 4 by geographical area. With the exception of Quetta, all geographical areas reported an increase in HIV prevalence, with the most dramatic being an increase in HIV prevalence from 6. In terms of socio-demographic characteristics, the mean age across all cities dropped from The proportion of IDUs who were illiterate decreased from Socio-demographic, injection drug use, sexual behaviour and other characteristics of injection drug users in selected cities of Pakistan, round 2 and round 4. For specific geographical areas, this proportion increased from 9. The proportion of IDUs who reported injecting four times or more per day in the last month increased from The proportion of IDUs reporting always using a clean syringe in the last month decreased from Of note, in , only 4. Frequency of injecting three or more times the previous day increased from Injecting in public places at last injection increased from The proportion of IDUs reporting use of a dirty syringe at last injection increased from Between and , use of a professional injector at last injection increased from Types of drug injected showed substantial changes between rounds. For example, the use of heroin among all cities increased from In , It should be noted that many of the drugs used by IDUs in Pakistan including avil and diazepam are easily available over the counter from nearly all pharmacies in the country and there is no age limit for buying these drugs. Among those reporting paying for sex with a FSW, condom use increased from The proportion of IDUs reporting ever being involved with sex work declined slightly, from After adjustment for all variables included in the model, HIV infection was significantly associated with having little or no formal education, place of residence, a longer duration of injecting drug use, and not injecting avil or diazepam. Compared with IDUs who were illiterate, those reporting having primary school education only were 0. In comparison, factors associated with HIV infection among IDUs from Sindh province table 3 included younger age, being separated or divorced, living on the street, being involved in sex work and awareness of IDU programmes. Tables 2 and 3 also show the results of multivariable models examining the correlates of using a dirty syringe at last injection among IDUs from Punjab and Sindh provinces, respectively. Having more than a middle school education vs being illiterate; AOR 0. In comparison, variables positively associated with use of a dirty syringe among IDUs from Sindh included injecting in a public space AOR 1. Factors associated with professional injector use at last injection for IDUs from Punjab and Sindh provinces are included in tables 2 and 3 , respectively. For Punjab IDUs, variables positively associated with use of a professional injector at last injection include living on the streets vs at home; AOR 1. The IDU populations in cities across Pakistan illustrate a great deal of heterogeneity in terms of their injection and sexual risk profiles and their healthcare-seeking behaviours. This increase was observed in all geographical areas except Quetta, and was especially marked in Lahore from 6. It is not known whether this change represents an actual change in HIV prevalence in the IDU population or whether different subpopulations of IDUs participated in different rounds of the study, the latter explanation always being a possibility in hard-to-reach, marginalised populations such as IDUs, despite the sampling methods being the same in the two rounds. This highlights the importance of data triangulation and the use of data from other sources, including programmatic data, to help verify and explain results. However, since the sampling methods were refined within cities to suit the local needs of mapping and the involvement of social mobilisers, we feel the temporal trends within individual cities are more reliable than inter-city comparisons of temporal trends, and therefore that these observed increases likely represent genuine increases in HIV prevalence in IDU populations in Pakistan. The multivariable analyses of factors associated with HIV infection in the provinces of Punjab and Sindh did not identify a common set of variables related to HIV infection, and this may have been due to the underlying heterogeneity of the IDU population between cities. In Punjab, HIV was associated with a longer duration of injecting behaviour, as might be expected, but this association was not observed in Sindh. In contrast, in Sindh there was an association between HIV and living on the street which is generally associated with a more chaotic, risky lifestyle. Overall during this time period, there was a general increase observed in the prevalence of most risk behaviours; in particular, larger proportions of IDUs reported injecting several times a day and using professional injectors, fewer IDUs reported always using clean syringes, and an increased proportion reported living on the street. In addition, during this period of —, available anecdotal evidence points to a reduction in the availability of services for IDUs. We do not have any direct measures to support these anecdotal observations, but we did observe that awareness among participants of government programmes for IDUs declined overall from Therefore, the findings of this study demonstrate increasing HIV prevalence and increasing risk behaviours among IDUs across Pakistan during a time in which the awareness and availability of services for IDUs were decreasing. The data on risk behaviours presented in this report have the potential to guide the design and distribution of HIV prevention and care services for IDUs, and the need for such services is clearly demonstrated by the observed trend of increasing HIV prevalence. The frequent use of professional injectors by IDUs observed in this study was an unanticipated risk behaviour and this information will help guide programmes to improve the targeting and content of local HIV prevention and education activities, and in some circumstances may also encourage public health authorities to work with professional injectors as part of harm reduction initiatives. In addition, the results of this study will impact the development of intervention programmes for IDUs by linking the geographical mapping data of IDU populations and their risk behaviours to the distribution of services provided within a given city. Since at least some IDUs are obtaining a significant proportion of their illicit drugs from pharmacies, intervention initiatives involving pharmacies would also be helpful. Our results are consistent with IDU studies conducted in Chennai, India, where a significant proportion of IDUs obtained their syringes and their injectable drugs from pharmacies. The ultimate impact of injectable prescription drugs on the HIV epidemic in Pakistan is currently unknown and should be a further avenue for research, given the widespread availability of prescription drugs vs heroin and other illicit drugs. Evidence from developed countries suggest heroin injectors who also inject prescription drugs view their risk of HIV as lower than other heroin injectors. The intermingling between at least two high-risk groups gives rise to the potential for a wider spread of HIV in Pakistan. This situation mirrors that of China at the turn of the twentieth century, which saw its HIV epidemic spread from IDUs to commercial sex workers, transitioning from a truncated epidemic to one that is currently more generalised. There are a number of limitations that should be considered when interpreting the findings in this study. The mapping and recruitment methods used were rapid and relied on information from key informants, an approach that is most useful when strong prevention programmes are in place since they increase the availability and knowledge of key informants and other community members. Self-reported behaviours are known to be prone to biases based on social desirability and people exposed to education programmes may be more likely to report lower levels of risk behaviour than those not exposed to programmes. Since exposure to programmes in Pakistan was highly variable and generally low , some differences in self-reported behaviours could be due to this bias. This issue is especially important considering the overlap between IDU populations and other high-risk sexual networks via connections such as non-injecting sexual partners of IDUs that is presented in other papers in this supplement. The rising HIV prevalence among IDUs increases the potential for HIV to spread into these other high-risk sexual networks and from there possibly into the general population. To effectively address HIV among IDUs and other populations, it is important that these surveillance data are used in the planning and delivery of prevention programmes, and that the connection between programmes, surveillance and monitoring activities, and the community be strengthened. We thank the surveillance team for their efforts in mapping, data collection, specimen collection and data entry. We thank Dr Tahira Reza for data management and helpful discussions. We also thank the participants who took part in the surveys for their time and participation. SS was responsible for data analysis and composed drafts and CA critically reviewed and revised drafts. As a library, NLM provides access to scientific literature. Sex Transm Infect. Find articles by Chris P Archibald. Find articles by Souradet Y Shaw. Find articles by Faran Emmanuel. Find articles by Suleman Otho. Find articles by Tahira Reza. Find articles by Arshad Altaf. Find articles by Nighat Musa. Find articles by Laura H Thompson. Find articles by James F Blanchard. Open in a new tab. Provenance and peer review: Commissioned; externally peer reviewed. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

Geographical and temporal variation of injection drug users in Pakistan

Buying Heroin Multan

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Buying Heroin Multan