Hepatitis C and HIV/HCV Co-infection among Methadone

Clients in Dar es Salaam, Tanzania: Prevalence and

Predictors

Olivia Chang, MPHResearch and Program Manager

Pangaea Global AIDS

Presentation Outline

• Background• Methods• Results• Conclusions

Emergence of Injection Drug Use in East Africa

UNODC Data

Drivers of the Epidemic in Tanzania

• 30,000-50,000 PWID– 15,000-20,000 in Dar es Salaam

Reported Heroin Use in Tanzania

PWID General

HIV 35%-50% 6.9%

HCV 28%-76% 1.5%

Williams (2009) Nyandindi (2011), Lambdin (2013), Bowring (2013), Matee (2006), TACAIDS (2011), NACP (2014)

Prevalence Estimates (Dar)

Roll-out of Methadone in Dar es Salaam

* Community-based outreach begins (2010)

MNH Muhimbili National HospitalMRH Mwananyamala Regional HospitalTRH Temeke Regional Hospital

*

J an 2010 Aug 2014J an 2011 J an 2012 J an 2013 J an 2014

MNH TRH

1,100

MRH

1,600430

Methods: Prevalence and Predictors

• Study Design: Cross-sectional• Data Sources: Routine programmatic and

clinical monitoring data• Study Population: Clients enrolled in

methadone between February 2011 to January 2013 at Muhimbili National Hospital– Provider-initiated testing and counseling for HIV

and HCV is provided (rapid tests).

– Linkage to care and treatment for PLHIV; supportive care for PLHCV

Methods: Prevalence and Predictors

• Covariates: demographics, sexual risk factors, injection risk factors, mental health history, legal/criminal history and history of abuse

• Outcomes: 1) HCV+ and 2) HIV+/HCV+

• Prevalence Estimates: Percentages with 95% confidence intervals

• Statistical Analysis: Binomial regression to estimate adjusted risk ratios with 95% confidence intervals

Results

• Median Age (years) 33 (30,37)

• Female 7%

• Median Years of Heroin Use 10 (6, 15)

• Primary Education or Lower 67%

• Methadone clients enrolled: 629• Clients HCV-screened: 494 (79%)

Results

• Sexual Risk Behaviors (last 6 months)• Multiple Sex Partners 20%• No or Inconsistent Condom Use 40%

• Ever Practiced Flashblood* 7%• Share Needles and/or other

Equipment at Last Injection 17%

• Polysubstance Use (alcohol, cocaine, and/or benzodiazepine)

34%

• Injection-related Risk Behaviors

* Practice of injecting oneself with blood from another person who has recently injected heroin.

Results: Prevalence and Predictors of HCV

• HCV+: 57% (95% CI: 53%-61%)

 Adjusted Risk Ratio (95% CI) p-value

Ever Practiced Flashblood 1.27 (1.13, 1.44) <0.001Share Needles and/or other Equipment at Last Injection

1.35 (1.17, 1.55) <0.001

Ever Been Arrested 1.21 (1.04, 1.41) <0.001

Adjusted Risk Ratios for HCV Seropositivity

Results: HIV/HCV Co-infection

Overall:

36% (95% CI: 31% – 40%)

Total HIV and HCV Screened: 413 (66%)

HIV+ HCV+

142 (34%)

24 (6%)

99(24%)

148(36% )

HIV- and HCV -

Results: HIV/HCV Co-infection

Overall:

36% (95% CI: 31% – 40%)

Among HIV+:

86% (95% CI: 81%-91%)

Total HIV and HCV Screened: 413 (66%)

HIV+ HCV+

142 (34%)

24 (6%)

99(24%)

148(36% )

HIV- and HCV -

86%

Results: Predictors of HIV/HCV Co-infection

 Adjusted Risk Ratio (95% CI) p-value

Female 1.81 (1.60, 2.04) <0.001

Ever Practiced Flashblood 1.41 (1.25, 1.59) <0.001

Share Needles and/or other Equipment at Last Injection 1.36 (1.21, 1.53) <0.001

Adjusted Risk Ratios for HIV/HCV Co-infection

Results: Predictors of HIV/HCV Co-infection

 Adjusted Risk Ratio (95% CI) p-value

Female 1.81 (1.60, 2.04) <0.001

Ever Practiced Flashblood 1.41 (1.25, 1.59) <0.001

Share Needles and/or other Equipment at Last Injection 1.36 (1.21, 1.53) <0.001

Adjusted Risk Ratios for HIV/HCV Co-infection

Conclusions

• Risky injection practices drive transmission.

• PWID, particularly women, have a disproportionate burden of disease and are also harder to reach.

• Current coverage is inadequate, scale-up of harm reduction is urgently needed.

How do we Respond?

How do we Respond?

Scale-up NSP and OST

Testing and counselingCondom distribution

IEC & BCC

Hep A/B immunization

HCV VL Monitoring

Care for PWID

Reach female PWID

How do we Respond?

Scale-up NSP and OST

Testing and counselingCondom distribution

IEC & BCC

Prevalence Estimates

Genotyping

Hep A/B immunization

HCV VL Monitoring

Simplify/optimize tx regimen

Research/ PolicyCare for PWID

Drug interaction studies

Affordable and equal access to tx

Reach female PWID

How do we Respond?

Scale-up NSP and OST

Testing and counselingCondom distribution

IEC & BCC

Prevalence Estimates

Genotyping

Hep A/B immunization

HCV VL Monitoring

Simplify/optimize tx regimen

Research/ PolicyCare for PWID

Drug interaction studies

Affordable and equal access to tx

Reach female PWID

Strengthen M&E systemsTrain Health Care Workers

Decentralize and Integrate ServicesAdvocacy

Systems

Acknowledgements