Injecting drug use is a significant contributor to morbidity and mortality among people who inject drugs (PWID) through direct or indirect consequences. Direct consequences include local and systemic complications arising from injecting drug use, such as addiction, dependence, and blood-borne infections. The indirect consequences are difficult to measure, including the burden on families and society, and medicolegal issues associated with drug use. Worldwide estimates indicate that there were approximately 11.3 million PWID in 2018.
The risk of death among PWID is reported to be 15 times higher compared with the general population. Drug-related deaths, such as overdose deaths and infections, are commonly seen among young people, and noncommunicable diseases cause significant mortality among older people. Hepatitis C virus (HCV) infection was reported to be the most common cause of morbidity (52%) among PWID, followed by human immunodeficiency virus (HIV) (18%) and hepatitis B virus (HBV) (9%).[4,5] The World Health Organization aims to eliminate HCV, a global public health threat, by 2030. It is estimated that approximately 78% of future transmission of HCV in high-income countries and approximately 39% of transmission in low- and middle-income countries would be prevented between 2018 and 2030 by removing risky injection practices like sharing needles among PWID.
Opioid substitution therapy (OST), needle and syringe exchange programs (NSP), HIV counseling and testing, and highly active antiretroviral therapy (HAART) are harm reduction modalities designed to mitigate the morbidity and mortality associated with injecting drug use. However, the global coverage for OST and HAART remains poor, and caters to only approximately 8% and 4% of PWID, respectively. The coverage of OST with buprenorphine is even lower (5% of PWID) in India. However, a little attention has been paid to the infection status of PWID and their associated social characteristics in India. Hence, the present study was conducted to (1) evaluate the prevalence of HIV, TB, HBV, and HCV among PWID; and (2) to assess the social profile and high-risk behaviors of PWID receiving OST.
MATERIALS AND METHODS
The present cross-sectional observational study was conducted between November 2016 and March 2018 at the Department of Forensic Medicine in collaboration with the Department of Psychiatry, Lady Hardinge Medical College & Associated Hospitals, New Delhi. The psychiatrist on admission clinically evaluated each PWID, and buprenorphine maintenance therapy was instituted after the assessment. The Institutional Ethics Committee approval was obtained before commencement of the study. (Approval No. vide LHMC/ECHR/2016/55R1, Dated 02-Oct-2016).
All PWID who were currently receiving OST, above 18 years of age, and consented to participate in the study were included. PWID who were below 18 years of age, had a mental illness, or did not consent to participate in the study were excluded. Written informed consent was obtained after explaining the purpose of the study and the confidentiality of the collected information. PWID were interviewed personally using an interviewer-administered structured questionnaire, and self-reported information about clinical profile, which included health status, infections associated with drug use, and social life characteristics such as the impact of injecting drug use on family and employment, was collected.
The data were entered in MS EXCEL spreadsheet, and analysis was performed using Statistical Package for Social Sciences(SPSS) version 21.0 by IBM Corp., Armonk, NY, USA. Categorical variables were presented in number and percentage (%), and continuous variables were presented as mean ± standard deviation and median. Chi-square test and Fisher’s exact test (where appropriate) were applied to understand the association between the categorical variables, and P < 0.05 was considered statistically significant.
A total of 100 male PWID were identified eligible in accord with the inclusion criteria and enrolled in the study. Of these participants, 46% were not aware of the deleterious effects of substance use (SU). In addition, 48% of PWID were satisfied with their lives, whereas 28% reported dissatisfaction with their lives. Moreover, 15% of PWID reported a history of hospitalizations for surgical or medical reasons [Table 1].
Importantly, 14% of PWID were HIV positive, and seven had tuberculosis. Although no PWID reported having HCV, 2% had HBV. Among HIV-infected PWID, only two PWID reported receiving antiretroviral treatment (ART). In addition, 26% of PWID had undergone HIV testing within 3–6 months before the interview, and 21% of PWID reported HIV testing in the preceding 3 months. However, 24% of PWID did not undergo HIV testing. It should be noted that 41% of PWID reported they had shared needles with other users in the preceding 3 months [Table 1].
Of the PWID, 19% reported the presence of SU among their family members. Nearly 17% of PWID had a history of commercial sex in the preceding 3 months, and 10 PWID (n = 17) reported a history of high-risk sexual behavior, like unprotected sexual intercourse with a partner or sex worker. In addition, 69% of PWID were alienated from their families, and 71% were living on the street (i.e. homeless) [Table 2]. Moreover, 16% of PWID reported that they had lost a job due to their SU.
Furthermore, PWID who were unmarried had a significantly higher rate of homelessness (χ2 = 4.570; P = 0.032) and were more likely to have had commercial sex in the preceding 3 months (χ2 = 4.163; P = 0.041). Homelessness was also associated with an increased rate of injecting practices (P = 0.020), and unemployment was significantly associated with dissatisfaction about life among PWID in the present study (P = 0.002) [Table 3]. No other significant differences were observed among other study variables.
This study was conducted to evaluate the clinical and social profile of PWID receiving OST at our tertiary care center. The main findings from this study were that 14% of PWID were infected with HIV, and 41% reported that they had shared needles in the preceding 3 months. While 69% of PWID were alienated from their families, and 71% of PWID reported that they were homeless due to their SU.
Opioid use is associated with the highest morbidity and mortality among users. Mortality in opioid use is typically caused by drug overdose, trauma including suicide or homicide, and somatic infections such as HIV, HBV, and HCV. Unsafe injection practices such as the use of unsterile apparatus, reuse of used needles, nonuse of alcohol swabs to clean the site of injection, longer duration and/or higher frequency of injection, more frequent sharing of needles among injecting drug users, and high-risk sexual behaviors like unprotected sexual intercourse, are known to result in various injuries and infections.[10,11] It has been suggested that PWID have a 22-times higher risk of acquiring HIV compared with the general population.
In our study, 14% of PWID self-reported being infected with HIV, which is two times higher than the national (India) prevalence (7.2%) of HIV among PWID, and only two PWID with HIV stated that they were receiving ART. The stigmatization and criminalization of drug use among PWID have been identified as the key barriers in accessing ART. Testing for HIV at the time of starting OST and initiation of HAART may benefit the individual and the community at large.
None of the PWID in our study reported being infected with HCV. This result is in contrast with the worldwide estimates of the prevalence of HCV (52%) and HBV (9%) among PWID. In addition, previous studies conducted in China reported a much higher prevalence of HCV antibody (71.6%) and HBV (19.6%) among PWID. This discrepancy may have occurred because testing for HCV and HBV is not a routine procedure in India, or due to the lack of knowledge of HCV and HBV among our study population. However, homelessness among PWID in our study was significantly associated with an increased frequency of injecting drugs. In addition, homelessness among PWID has been reported to contribute to a higher prevalence of HCV due to more frequent injecting practices, lack of treatment adherence, and loss of follow-up due to unstable housing.
A higher frequency of needle sharing can result in a higher prevalence of blood-borne infections and fatal or nonfatal overdose. A systematic review and meta-analysis of 464 studies from 88 countries revealed that 18% of PWID had a history of sharing needles and syringes, and 24% had a history of sharing in the past month. A national survey of SU in India estimated that 27% of PWID shared needles and syringes in the past 12 months. Another study conducted in 11 Indian states revealed that 14% of PWID had shared needles and syringes in the past 3 months. In contrast, the current results revealed that an alarmingly high proportion of PWID (41%) had a history of sharing needles and syringes with other users. This finding is in accord with the results of studies conducted by Sarin et al. and Wu et al. However, Anwar et al. and Li and Li reported a much higher percentage of needle sharing among PWID.
Approximately 90% of all deaths among opioid dependent people are modifiable and preventable with effective interventional strategies such as OST, HAART, and NSP. The World Health Organization recommends the distribution of at least 200 needles and syringes per PWID per year by countries through needles and syringe programs However, it has been reported that countries with an increased prevalence of needle sharing had no or minimal coverage by NSP, which is evident from the global estimates indicating that only 33 needles–syringes per PWID were distributed yearly through NSP.[16,26]
SU often leads to a breakdown in interpersonal relations and poses a threat of social exclusion in all stages of life, resulting in homelessness. Low levels of education, a lack of strong family relationships, death of parents or close relatives at an early age, and unstable income are other reasons for homelessness. Homelessness is a significant factor in depression and various other psychopathologies among PWID. It has been reported that SU is one of the most common causes of death among homeless persons, and the risk is approximately seven times higher than that in the general population. Furthermore, higher rates of infectious diseases and cardiovascular diseases contribute to morbidity among homeless substance users. Importantly, our results indicated that 71% of PWID live on the streets in New Delhi, which is partially in accord with the results of two previous studies, in which Sarin et al. reported a homelessness rate of 89% and Armstrong et al. reported a rate of 69% in New Delhi. However, previous studies in the United States have reported lower homelessness prevalence rates among PWID, with Havens et al. reporting a rate of 19% and Hotton et al. reporting a rate of 41%. These differences could potentially be explained by the differences in the selection of study participants.
It should also be noted that among PWID in our study, being unmarried was significantly associated with homelessness and an elevated risk of commercial sex in the preceding 3 months. Furthermore, homelessness was significantly associated with an increased sharing of needles and syringes in the preceding 3 months. Family therapy is hugely beneficial for drug users, because it helps the family members understand the effects of drug use and ways to care for the drug user.
Several limitations of this study should be taken into account. First, we were not able to compare the study groups; for instance, infection status among PWID and general population and could not establish causal relationships among study variables due to the cross-sectional study design. Second, the results may have been affected by selection bias due to the inclusion of PWID from a single OST center. Third, a larger sample size might have helped to improve the generalizability of the results. Fourth, there is a possibility that recall bias occurred in the self-reported information in the current study, although this was mitigated by cross-checking the information available from patient files at the OST center. Despite these limitations, the present findings add to the growing literature on the clinical and social profile of PWID in India.
The prevalence of HIV infection among PWID in our study was much higher than that found in the general population. Notably, HCV and HBV testing are not currently being performed among PWID in most OST centers in India, despite the higher global prevalence of HCV and HBV. The availability and accessibility of NSP, OST, HIV counseling and testing, HIV, ART, condom distribution programs, HBV and HCV testing, and treatment should be increased to benefit PWID. In addition to awareness programs, preventive strategies such as programs working with families, schools, and communities should be enhanced to minimize SU among youth. Future studies with a longitudinal study design and larger sample sizes will be needed to analyze the comprehensive clinical social issues among PWID. Finally, forensic surgeons should not overlook the significance of exercising universal precautions in all suspected drug abuse deaths to prevent a potential infection transmission.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
The authors thank all the faculties and residents of the Department of Forensic Medicine, Department of Psychiatry, and all Opioid Substitution Therapy Center staff, Lady Hardinge Medical College and Associated Hospitals, New Delhi.
1. Vearrier L. The value of harm reduction for injection drug use:A clinical and public health ethics analysis. Dis Mon 2019;65:119–41.
2. United Nations Office on Drugs and Crime. World Drug Report 2020. Vienna: United Nations Publication; 2020.
3. Lewer D, Jones NR, Hickman M, Nielsen S, Degenhardt L. Life expectancy of people who are dependent on opioids:A cohort study in New South Wales, Australia. J Psychiatr Res 2020;130:435–40.
4. Degenhardt L, Peacock A, Colledge S, Leung J, Grebely J, Vickerman P, et al. Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs:A multistage systematic review. Lancet Glob Health 2017;5:e1192–207.
5. Strang J, Volkow ND, Degenhardt L, Hickman M, Johnson K, Koob GF, et al. Opioid use disorder. Nat Rev Dis Primers 2020;6:3.
6. Trickey A, Fraser H, Lim AG, Peacock A, Colledge S, Walker JG, et al. The contribution of injection drug use to HCV transmission globally, regionally, and at country level:A modelling study. Lancet Gastroenterol Hepatol 2019;4:435–44.
7. United Nations Office on Drugs and Crime. World Drug Report 2010: Drug Statistics And Trends [Internet]. United Nations. 2010. Available from: https://www.unodc.org/documents/wdr/WDR_2010/2.0_Drug_statistics_and_Trends.pdf
8. Armstrong G, Kermode M, Sharma C, Langkham B, Crofts N. Opioid substitution therapy in Manipur and Nagaland, north-east India:Operational research in action. Harm Reduct J 2010;7:29.
9. Clausen T, Waal H, Thoresen M, Gossop M. Mortality among opiate users:Opioid maintenance therapy, age and causes of death. Addiction 2009;104:1356–62.
10. Colledge S, Larney S, Bruno R, Gibbs D, Degenhardt L, Yuen WS, et al. Profile and correlates of injecting-related injuries and diseases among people who inject drugs in Australia. Drug Alcohol Depend 2020;216:108267.
11. Joint United Nations Programme on HIV/AIDS. Global report: UNAIDS report on the global AIDS epidemic 2010. UNAIDS; 2010.
12. Sebastian MP, Dasgupta A, Saraswati LR, Singh A, Sharma V, Madan I, et al. Service utilization and cost of implementing a comprehensive HIV prevention and care program among people who inject drugs in Delhi, India. Harm Reduct J 2020;14:38.
13. Ferraro CF, Stewart DE, Grebely J, Tran LT, Zhou S, Puca C, et al. Association between opioid agonist therapy use and HIV testing uptake among people who have recently injected drugs:A systematic review and meta-analysis. Addiction 2020;116:1664–76.
14. Bao Y, Larney S, Peacock A, Colledge S, Grebely J, Hickman M, et al. Prevalence of HIV, HCV and HBV infection and sociodemographic characteristics of people who inject drugs in China:A systematic review and meta-analysis. Int J Drug Policy 2019;70:87–93.
15. Valerio H, Alavi M, Silk D, Treloar C, Martinello M, Milat A, et al. Progress towards elimination of hepatitis C infection among people who inject drugs in Australia:The ETHOS Engage Study. Clin Infect Dis 2021;73:e69–78.
16. Colledge S, Leung J, Larney S, Peacock A, Grebely J, Hickman M, et al. Frequency of injecting among people who inject drugs:A systematic review and meta-analysis. Int J Drug Policy 2020;76:102619.
17. Tran LT, Peacock A, Colledge S, Memedovic S, Grebely J, Leung J, et al. Injecting risk behaviours amongst people who inject drugs:A global multi-stage systematic review and meta-analysis. Int J Drug Policy 2020;84:102866.
18. Ambekar A, Agrawal A, Rao R, Mishra A, Khandelwal S, Chadda R. Magnitude of Substance Use in India. New Delhi: National Survey on Extent and Pattern of Substance Use in India, Ministry of Social Justice and Empowerment, Government of India; 2019.
19. 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.
20. Sarin E, Singh B, Samson L, Sweat M. Suicidal ideation and HIV risk behaviors among a cohort of injecting drug users in New Delhi, India. Subst Abuse Treat Prev Policy 2013;8:2.
21. Wu J, Huang J, Xu D, Lu C, Deng X, Zhou X. Infection status and risk factors of HIV, HBV, HCV, and syphilis among drug users in Guangdong, China –A cross-sectional study. BMC Public Health 2010;10:657.
22. Anwar Z, Agrawal R, Sinha V, Gurnani KC, Mitra S, Mishra AK. Injectable opioid use:An insight into the problem. Indian J Community Health 2016;28:185–91.
23. Li J, Li X. Current status of drug use and HIV/AIDS prevention in drug users in China. J Food Drug Anal 2013;21:S37–41.
24. Degenhardt L, Larney S, Randall D, Burns L, Hall W. Causes of death in a cohort treated for opioid dependence between 1985 and 2005. Addiction 2014;109:90–9.
25. WHO, UNODC, UNAIDS Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting drug Users–2012 Revision. UNAIDS; 2012.
26. Larney S, Peacock A, Leung J, Colledge S, Hickman M, Vickerman P, et al. Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs:A systematic review. Lancet Glob Health 2017;5:e1208–20.
27. de Espíndola MI, Bedendo A, da Silva EA, Noto AR. Interpersonal relationships and drug use over time among homeless people:A qualitative study. BMC Public Health 2020;20:1746.
28. 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.
29. Havens JR, Sherman SG, Sapun M, Strathdee SA. Prevalence and correlates of suicidal ideation among young injection vs. noninjection drug users. Subst Use Misuse 2006;41:245–54.
30. Hotton A, Mackesy-Amiti ME, Boodram B. Trends in homelessness and injection practices among young urban and suburban people who inject drugs: 1997-2017. Drug Alcohol Depend 2021;225:108797.
31. Lin W, Zhou W. Factors associated with the physical and mental health of drug users participating in community-based drug rehabilitation programmes in China. Health Soc Care Community 2020;28:584–90.