To the Editors:
People who inject drugs (IDU) are commonly co-infected with HIV and hepatitis C virus (HCV). HIV/HCV co-infection threatens to undermine the effectiveness of antiretroviral therapy (ART) by increasing the frequency of dose-limiting adverse effects to ART and mortality.1 Hence, the World Health Organization advises that all HIV-infected individuals be screened for HCV.2 Thailand is listed among the top 10 countries where IDU are most severely affected by dual epidemics of HIV and HCV, with an estimated prevalence of 30%-42% and 90%, respectively, among IDU.3,4 Although Thailand is vigorously promoting access to ART, concerns persist regarding the extent of HCV case finding in this setting.5 Therefore, we sought to examine the uptake of HCV testing and correlates of unknown HCV serostatus among a community-recruited sample of HIV-positive IDU in Bangkok. We also sought to identify rates of HCV risk behavior among HIV-positive Thai IDU with unknown HCV serostatus.
Data were obtained from the Mitsampan Community Research Project, a collaborative research effort involving the Mitsampan Harm Reduction Center (Bangkok, Thailand), the Thai AIDS Treatment Action Group (Bangkok, Thailand), Chulalongkorn University (Bangkok, Thailand), and the British Columbia Centre for Excellence in HIV/AIDS (Vancouver, Canada). During June and July of 2009, local IDU were recruited into a cross-sectional study through outreach and word-of-mouth. Individuals who had injected drugs in the past 6 months were eligible for participation in the study. Participants provided informed consent and completed an interviewer-administered questionnaire eliciting a range of demographic, behavioral, and health-related data. The study was approved by the research ethics boards at Chulalongkorn University and the University of British Columbia.
Using descriptive statistics, we identified rates of HCV testing and reasons for not having accessed HCV testing. We then used Pearson χ2 test to compare the social, demographic, and behavioral characteristics of HIV-positive IDU who knew their HCV serostatus with those who did not. Unknown HCV serostatus referred to either having never been tested for HCV or having not received the results of HCV testing. Fisher exact test was used when one or more of the cells contained values less than or equal to 5. All P values were 2-sided.
In total, 67 HIV-positive IDU enrolled in this study; 14 (20.9%) were female and the median age was 37 years. Thirty participants (44.8%) reported being on ART at the time of the interview. In total, 35 (52.2%) participants reported a history of HCV testing. However, as 2 of these individuals never received a test result, 34 (50.8%) participants did not know their HCV serostatus. Among the 33 individuals who received a test result, 17 (51.5%) reported that they were HCV positive. Primary reasons given for not having accessed HCV testing included “never heard of HCV” (65.6%) and “not aware of HCV risks” (37.5%). In bivariate analyses, as shown in Table 1, unknown HCV serostatus was associated with injecting midazolam twice or more per week [odds ratio (OR) = 5.17; 95% confidence interval (CI): 1.15 to 31.43], injecting with others on a frequent basis (OR = 3.00; 95% CI: 1.08 to 8.32), and seeing a doctor for HIV-related concerns at least biannually (OR = 0.23; 95% CI: 0.06 to 0.81). Among the 34 HIV-positive IDU with unknown HCV serostatus, 13 (38.2%) reported lending or borrowing syringes to/from others in the previous 6 months.
We found that only half of our sample of HIV-positive IDU in Bangkok had a history of HCV testing. Our findings also suggest that the low uptake of HCV testing might be related to a lack of awareness of HCV in this setting. Given the high prevalence of HIV and HCV among Thai IDU3,4 and the observed rate of syringe sharing among HIV-positive IDU with unknown HCV serostatus, programs that increase awareness of HCV risks and access to HCV prevention tools and diagnostic testing among Thai IDU are urgently needed. Only recently have such educational efforts begun at a grass-roots level. For example, the staff at the Mitsampan Harm Reduction Center have received training on the epidemiology of HCV.6
We also found that HIV-positive IDU who reported seeing an HIV doctor at least biannually were 4 times more likely to know their HCV serostatus. This may suggest that HIV doctors recommended HCV testing, or that IDU who access HIV care were more likely to seek HCV testing. Regardless, the deficit in HCV case finding uncovered in our study is significant in view of the independent contribution of HCV to morbidity and mortality among HIV-infected IDU. This is particularly the case as effective HCV treatment exists in the form of pegylated interferon and ribavirin, and new generation oral treatments are currently in late phase trials. In Thailand, neither pegylated interferon nor ribavirin is on the national list of essential medicines. Consequently, an HCV treatment using these medications is not covered under the universal health care scheme and remains prohibitively expensive. Multisectoral efforts to ensure access to HCV treatment are therefore needed.
This study has limitations. First, we cannot infer causation from this observational study. Second, as the study sample was small and not randomly recruited, the generalizability of our findings may be limited. Third, the self-reported data may be biased. Last, we did not distinguish between HCV antibody tests and viral load tests, as our primary interest was whether HIV-positive Thai IDU have undergone any kind of HCV testing. Future research should investigate rates of access to each test, and awareness of and access to HCV treatment among this population.
In summary, we found low uptake of HCV testing among HIV-positive IDU in Bangkok. This seems to be related to a lack of awareness of HCV within this population. We also observed high rates of HCV risk behavior among HIV-positive Thai IDU with unknown HCV serostatus. These findings add further evidence regarding the need to promote HCV awareness and access to HCV prevention tools, diagnostics, and treatment for HIV-positive IDU in Thailand.7
We would particularly like to thank the staff and volunteers at the Mitsampan Harm Reduction Center for their support. We also thank Dr Niyada Kiatying-Angsulee of the Social Pharmacy Research Unit, Faculty of Pharmaceutical Sciences, Chulalongkorn University, for her assistance with developing this project. We also thank Daniel Miles Kane, Deborah Graham, Tricia Collingham, and Calvin Lai for their assistance with data management; and Prempreeda Pramoj Na Ayutthaya and Puripakorn Pakdirat for their assistance with data collection.
Kanna Hayashi, MIA, MPH*†
Julio Montaner, MD, FRCPC, FCCP, FRSC*‡
Evan Wood, PhD, MD*‡
Jiezhi Qi, MSc*
Thomas Kerr, PhD*‡
*British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, Canada,
†Interdisciplinary Studies Graduate Program, University of British Columbia, Vancouver, Canada,
‡Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada,
§Mitsampan Harm Reduction Center/Thai AIDS Treatment Action Group, Bangkok, Thailand
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