HIV, HBV, and HCV Prevalence
The prevalence of HIV among PWID in Tripoli was 87% (Table 1). Similarly, 94% tested positive for HCV and 83% were HIV/HCV coinfected. In contrast, the HBV prevalence was about 5% with 4% of PWID being HIV/HBV coinfected.
Thirty-four percent of respondents injected for a period of >15 years, 84% used Subutex for injecting and 54% injected at least once a day (Table 2). Eighty-five percent of PWID reported having shared needles in the past, 29% in the past month, and 18% at last injection. More than a third of all PWID reported having shared drugs in a high equipment sharing situation (ie, shooting galleries, prison, or as injection by a dealer) in the past month. Of the 23% of respondents who reported having had sex during the past month (among those who ever had sex) about two-thirds used a condom. Condom use varied with the type of sexual partner, but sample sizes for these indicators were small. Twelve percent of PWID reported having had symptoms of STI and about 5% had experienced sexual and 9% physical violence in the past year.
Access to Services, Knowledge, and Attitudes
Access to HIV prevention services among PWID was limited (see Table S5, SDC3, http://links.lww.com/QAI/A387). Although >90% of PWID indicated that they would always be able to access new needles when needed, the main source of needles was pharmacies (97%) rather than health facilities or outreach workers; About 60% of PWID accessed drug abuse–related treatment or assistance during the past year; however, none of the health or drug-abuse rehabilitation facilities in Libya offered opioid substitution therapy (OST), and the type of treatment received was mostly restricted to detoxification (62.5%).
Most PWID (88%) said they can always access condoms when needed, but few (2.6%) received condoms through outreach services, drop-in centers or health facilities during the past year. Almost all PWID (95%) knew where to get tested for HIV, and about half of them received a test and learned the result in the past year; 29% of PWID confirmed that they got tested voluntarily, meaning that they were not directly forced to be tested.
Only 45% of PWID succeeded in both correctly identifying ways to prevent HIV transmission and rejecting major misconceptions about HIV transmission. STI-related knowledge was poor with only about 5% of PWID being able to name most common STI symptoms. Despite the high HIV prevalence, only 55% of PWID revealed an absence of HIV-related stigma as assessed by a series of standard questions.
Factors Associated with HIV Seropositivity
The adjusted multiple logistic regression analysis revealed that the odds of HIV infection were 7.9 times higher among people injecting for >15 years compared with those injecting for <10 years (P = 0.001), and 3.7 times higher among those who ever shared needles (P = 0.015, Table 3). For details see Table S6, Supplemental Digital Content 3 (http://links.lww.com/QAI/A387).
This first BBSS in Libya not only provides sound evidence for the classification of Libya's HIV epidemic as at least ‘concentrated among PWID’ but also reveals the disturbing scale of the problem by detecting an alarmingly high level of HIV infection.3,23–25 Existing limited evidence puts our results into context. The National AIDS Program reported HIV prevalence among the general population as being below 1%11 and a recent systematic review3 indicated the “possibility, but no direct empirical evidence” for a concentrated epidemic among PWID in Libya. An unpublished report displayed the spread of HIV among PWID over time at a rehabilitation center indicating no cases of HIV among 400 PWID in 1996, but a sudden increase 4 years later, with 50% of 1182 PWID being infected.9 A recent internal report revealed that 84% of 493 PWID from Tripoli admitted to the only drug-treatment center in the country in 2009–2010 were HIV positive.26 Although these data are not necessarily representative of the actively injecting population in the community, they are in line with the HIV prevalence of 87% among PWID in our study.
Results of this shocking scale are comparable only with very few rates in other regions with rates in neighboring countries being substantially lower, for example, 2.6% in Tunis27 and 7.7% in Cairo.28 A recent systematic review23 reported HIV prevalence rates among PWID of >40% for 9 out of 61 countries with the highest midpoint prevalence in Estonia (72.1%).
The behavioral results partly explain the high HIV and HCV prevalence rates among PWID, by revealing a number of risk factors in the context of poor access to comprehensive services for HIV prevention and mitigation. Eighty-five percent of PWID had shared needles in the past, 29% in the past month, and 18% at last injection. Adjusted logistic regression results showed that not only PWID with an experience of needle sharing but also those who injected for >15 years were more likely to be HIV positive. This information suggests a long history for the HIV epidemic in Tripoli. However, the proportion of current sharing of needles and other injection equipment is still far too high and poses an ongoing risk of HIV transmission. Additional sexual risk behavior not only adds to the overall risk but might also lead to the spread of HIV, HCV, and HBV to other subpopulations.8 Although due to low sample sizes our data on condom use are difficult to interpret, other indicators indicate an elevated risk of sexual transmission, such as the level of reported STIs, and history of sexual violence.29
Our results are in line with findings from a qualitative study from 2003 to 2004 showing that 70% of PWID in a rehabilitation program reported previous engagement in risk behaviors.30 It also suggested possible explanations for the explosive elevation of HIV transmission among PWID, including an increase in the number of heroin addicts in the late 1990s, a transition from drug smoking to injection coupled with a lack of HIV awareness,26,30 and reduced availability of syringes in pharmacies since 1997. Although the majority of our study respondents indicated they can access new, unused needles when needed, most of them indicated pharmacies as their only source. However, since the mid-1990s, pharmacists have been reluctant to sell needles to suspected drug addicts due to the perceived or real existence of a law that had been introduced in the mid-1990s restricting the sale of needles.26 Because accounts by different stakeholders on this topic were contradictory, more research is needed to explain this fact. Further clarification is also needed on what respondents perceived as ‘voluntarily’ undergoing HIV testing in the absence of voluntary counseling and testing sites and in the context of mandatory screening for health certificates, required for employment, marriage, and driving licenses.11
So far, prevention efforts in Libya have focused primarily on awareness campaigns among the general public, fear-based education in schools, and training of selected professions.11 Few self-support groups assisted in accessing tools and services for HIV/AIDS prevention and care, and drug rehabilitation treatment. More than half of all PWID in our study had received drug abuse-related treatment in the past, but none of the drug-treatment facilities in the country offered OST. Although the effectiveness of OST and needle exchange programs has been proved,23 they still meet resistance among key stakeholders, so that the country lacks a comprehensive harm-reduction program.11,31
Although we surmounted challenges related to the lack of established links with PWID networks, difficulties remained in identifying female seeds and recruiting female PWID, which is probably related to both, their relatively small number in Tripoli, and greater stigma attached to female PWID. The latter has also been observed in other countries.32 It is interesting that most PWID in our study were >35 years old, which might relate to younger PWID, should they exist in Libya, being less connected and more hidden than older PWID. A more likely alternative explanation could be that the younger generation is less likely to inject drugs due to a positive effect of the education campaigns in schools or due to the higher cost of Buprenorphine, which has replaced Heroin in Tripoli's black market. Future research could shed light on drug use patterns, and on the dynamics of shifting from noninjecting to IDU.12 The fast recruitment into our study indicates good network connectivity and possibly a large number of PWID in Tripoli, but further research is needed to determine the IDU prevalence in Tripoli and other cities, in which so far IDU has been much less frequent. Reports indicate that heroin dealers have recently moved from Tripoli to Benghazi to establish a market place.26 This development and recent conflict-related changes call for an extension of BBSS to other areas and vulnerable groups, including men having sex with men, female sex workers and their clients, sex partners of PWID, and migrant populations.
Our findings constitute a crucial first step to tackle a major crisis. Swift and decisive action is essential, given that in the current postconflict era additional factors may have escalated the epidemic. Increased migration, sexual and gender-based violence, the disruption of infection control and blood safety system, and a nationwide stock-out of antiretroviral drugs raise the specter for an expansion of the epidemic and the development of drug resistance with catastrophic consequences for individuals and the population at large.11 There is an urgent need for the implementation of a National Strategy that is informed by the results of this research, and by existing evidence of the effectiveness of harm-reduction interventions and international recommendations. In 2010, a series of high-impact publications fervently called on countries to abandon the myths and prejudices about HIV in drug users that hamper the role-out of evidence-informed, rights-based combination interventions that could avert as many as two-thirds of HIV infections associated with drug use.33–35 That year, a consensus statement of the Reference Group to the United Nations called for the scale-up of a comprehensive package of 9 harm-reduction interventions as outlined by the World Health Organization.23 For this to be possible, many countries including Libya first need to adapt their policy and legislation and shift from an ineffective approach that is hostile toward PWID, to an effective one that is based on scientific evidence and human rights.23,33
The authors gratefully acknowledge Ms Amal el Karouaoui, Dr Lisa G. Johnston, Prof Mehdi Karkuri, Dr Abdalla Toufik, Dr Simon D.W. Frost, Mr William Vargas, and Prof Patricia Cane for their consultancy work. The authors are also very grateful to Prof Abdulhafid Abudher, then director of the NCDC, Dr. Omar El Ahmar, director of the NCDC laboratory and his team, and to Dr Nabil Abumaer, then head of Department of HIV/AIDS Treatment-Management. The authors express their great appreciation to Mr Abdullah Aljadi, Mr Hussein Rahiel, Mr Owais Al Wahedi, Dr Fannir Abdallah, Ms Sarah Moxon, Dr Gibby Koshy, and all other members of the study team in Tripoli, and the data management teams at the NCDC in Tripoli and at LSTM. Last, but not least, the authors wish to thank all those who participated in this survey for their time and trust.
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Keywords:© 2013 Lippincott Williams & Wilkins, Inc.
HIV; injecting drug use; harm reduction; respondent-driven sampling; North Africa; Libya