Risk behaviours for infection with HIV and hepatitis C virus among people who inject drugs in Regina, Saskatchewan

Canada Communicable Disease Report

1 March 2007

Volume 33

Number 05

M Hennink, MB, ChB, M Med (1), Z Abbas, MBBS, MPH (1), Y Choudhri, MD, MPH (2), T Diener, MB ChB, DCH, M Med, MPA (1), K Lloyd, BScN, RN (1), CP Archibald, MDCM, MHSc, FRCPC (2), S Cule, BSc (2)

  1. Population and Public Health Services, Regina Qu'Appelle Health Region, Regina, Saskatchewan

  2. Public Health Agency of Canada, Ottawa, Ontario

Introduction

The Regina Qu'Appelle Health Region (RQHR) in collaboration with the Centre for Infectious Disease Prevention and Control, Public Health Agency of Canada (PHAC), implemented an I-Track, enhanced surveillance system to monitor risk behaviours among people who inject drugs (IDU)(1). I-Track consists of repeated, cross-sectional surveys of IDU from urban and semi-urban centres across Canada and provides critical information for those involved in planning and evaluating the response to programs to combat HIV and hepatitis C (HCV) infection among IDU.

The main objective of I-Track is to monitor trends over time in high-risk behaviour associated with HIV and HCV infection among IDU, as well as their HIV and HCV testing patterns. I-Track activities are being undertaken in multiple cycles over time with data being collected from IDU periodically. It is important to know the characteristics and risk behaviours of IDU to guide community interventions, priority setting and treatment.

This publication presents information on the injecting and sexual behaviours of IDU recruited in Regina in 2005 as well as their HIV and HCV testing patterns. A report on Phase I of I-Track studies can be accessed at < http://www.phac-aspc.gc.ca/i-track/sr-re-1/index-eng.php>.

Methods

A cross-sectional study was undertaken in the city of Regina during March and April 2005 as part of an ongoing, second generation surveillance system of IDU. The sample comprised 250 self-referred IDU recruited primarily from the Needle Exchange Program (NEP) operated by the RQHR as well as through community agencies that work with persons who use injection drugs. An IDU was defined as someone who reported injecting drugs, for non-therapeutic purposes, in the 6 months preceding the interview. Verbal informed consent was obtained from all subjects for participation in the study. A person who appeared to be incapable of understanding the information provided about the survey, unable to understand English or who did not meet the lower age limit for the age of consent (16 years) was excluded. Face-to-face interviews were conducted by a trained public health nurse and community health worker using a standardized questionnaire. No identifying information was collected at any time throughout the interview.

The interviews lasted approximately 25 minutes and included questions related to socio-demographic characteristics, drug use, risk behaviours in terms of needle sharing and lending, sexual behaviours, number of sexual partners and condom use in the preceding 6 months. Questions about previous testing for HIV and HCV were also asked. Two types of biological samples were collected: capillary blood was collected on blotting paper by finger prick with single-use lancets and tested for HIV and HCV at the National HIV and Retrovirology Laboratories, and a urine sample was collected and tested for Chlamydia trachomatis and Neisseria gonorrhoeae.

Data were analyzed using the SPSS Version 13.0(2).

Results

From 14 March, 2005, to 12 April, 2005, 250 individuals (136 men and 114 women) participated in the study. For both sexes, the mean age was 34.8 years; the median age of the women was lower than that of men (31 years versus 38 years). The majority of participants (87.2%) identified themselves as aboriginal. More than two-thirds (68%) of them had less than high school education. Nearly all (98%) lived in the city of Regina.

The socio-demographic characteristics are listed in Table 1.

History of drug use and drug of choice

The mean age of initiating injection drug use was 20.9 years (range 10 to 48 years; females 20.8 years, males 21.0 years). Reported patterns of drug use among male and female IDUs were similar for most drugs (Table 1). Cocaine was the most common drug injected in the previous 6 months for both sexes, followed by Talwin and Ritalin in female IDU and Ritalin alone in male IDU. The most common locations where injection drug use took place, as identified by 233 respondents, were the participant's home/apartment (64.4%), friend's place (17.6%) and at parent(s)/ other relative's home (8%). Nearly a quarter of them (23.2%) reported injecting in public places in the previous 6 months. The drugs were reported to be injected mostly with regular sex partners (40.0%) followed by close friends (24.8%), and 16.4% reported always injecting alone.

Table 1. Socio-demographic characteristics of I-Track participants in Regina, 2005

Characteristic Female (n = 114) Male (n = 136)
Age distribution n % n %
<20 4 3.5 4 2.9
20-29 42 36.8 26 19.1
30-39 42 36.8 50 36.8
≥ 40 24 21.1 56 41.2
Missing 2 1.8 0 0.0
Ethnic origin        
Aboriginal 105 92.1 113 83.1
Canadians 5 4.4 11 8.1
Other 1 0.9 3 2.2
Missing 3 2.6 0 0.0
Education        
<Grade 12 83 72.8 87 64.0
Grade 12 22 19.3 26 19.1
>Grade 12 7 6.1 23 16.9
Missing 2 1.8 0 0.0
Current residence        
Regina 112 98.2 133 97.8
Other city 1 0.9 3 2.2
Missing 1 0.9 0 0.0
Residence within the previous 6 months        
Not lived elsewhere 88 77.2 101 74.3
Lived elsewhere 25 21.9 35 25.7
Missing 1 0.9 0 0.0

Table 2. Drug history

  Female (n = 114) Male (n = 136)
IV drug of choice n % n %
Cocaine 38 33.3 50 36.8
Talwin and Ritalin 30 26.3 26 19.1
Ritalin alone 29 25.4 30 22.1
Morphine 14 12.3 22 16.2
Others 3 2.7 8 5.8
Non-injected drug of choice        
Alcohol 31 27.2 31 22.8
Marijuana 24 21.1 37 27.2
Tylenol with codeine 10 8.8 17 12.5
Methadone 10 8.8 9 6.6
Benzodiazepines 8 7.0 8 5.9
Others 23 20.2 25 18.4
Missing 8 7.0 9 6.6
Most common site of injection        
Own house/apartment 76 66.7 85 62.5
Friend's place 19 16.7 25 18.4
Parents'/other relative's house 12 10.5 8 5.9
Other 2 1.8 6 4.4
Missing 6 4.4 12 9.6

Risk behaviours

Ten percent of the participants (25/250) reported sharing needles/syringes in the 6 months prior to the study: 23/250 respondents (9.2%) reported borrowing used needles, and 25/250 (10.0%) reported lending in the previous 6 months. Forty-one percent (102/250) reported injecting with other used equipment. Almost half (46.8%) reported lending used injection equipment (defined as sharing cookers/spoon, water or filter) to someone else in the preceding 6 months. Used needles were borrowed mostly from regular sex partners (43.5%) and family (21.7%).

Sexual risk behaviours

The majority of respondents reported being sexually active in the previous 6 months. Of 136 males, 122 (89.7%) reported having had a female sexual partner, 3 (2.2%) reported having had both male and female sexual partners, and one reported having had only male sexual partners in the preceding 6 months (Table 3). Of 114 females, 101 (88.6%) reported having had male sexual partners, three (2.6%) reported only female sexual partners, and eight (7%) reported both male and female sexual partners. Of the 122 males who reported heterosexual activity, 103 (84.4%) had had regular partners, 36 (29.5%) casual partners and two (1.6%) client partners. Eighty-nine females (88.1%) had had regular partners, 24 (23.8%) casual partners and 26 (25.7%) client partners in the preceding 6 months.

Table 3. Type of opposite sex partners, by gender

Type of sexual partner Male (n = 122)
Number (%)
Female (n = 101)
Number (%)
Regular partner 103 (84.4%) 89 (88.1%)
Casual partner 36 (29.5%) 24 (23.8%)
Client partner 2 (1.6%) 26 (25.7%)

Condom use

Table 4 shows reported frequency of condom use with sexual partners. Participants with regular sex partners were more likely to never use condoms than were those with casual and client sex partners. The largest percentage of respondents reported never using condoms with regular partners. Approximately 68% of males and 70% of females never used condoms with regular sex partners during vaginal sex. Only 14% of males and 16% of females always used condoms with regular sexual partners during vaginal sex. This rate improved with casual and client sexual partners.

HIV and HCV prevalence

Blood samples were obtained from 238 participants. Of these, seven (2.9%) tested positive for HIV, and of 237 tests carried out for HCV, 151 (63.7%) were positive. Of the seven persons whose specimens were positive for HIV, six were coinfected with HCV.

Table 4. Frequency of reported condom use during sex with partner of opposite sex

  Regular Casual Client
Vaginal
(n = 104)
n (%)
Oral
(n = 69)
n (%)
Anal
(n = 15)
n (%)
Vaginal
(n = 37)
n (%)
Oral
(n = 17)
n (%)
Anal
(n = 6)
n (%)
Vaginal
(n = 3)
n (%)
Oral
(n = 2)
n
(%)
Anal
(n
=0)
n
(%)
Males: frequency of condom use with female sex partners
Always 15 (14.4) 11 (15.9) 2 (13.3) 22 (59.5) 10 (58.8) 4 (66.7) 2 (66.7) 1 (50.0)  
Usually 2 (1.9) 0 (0.0) 0 (0.0) 3 (8.1) 1 (5.9) 1 (16.7) 0 (0.0) 0 (0.0)  
Sometimes 3 (2.9) 3 (4.4) 0 (0.0) 3 (8.1) 1 (5.9) 0 (0.0) 0 (0.0) 0 (0.0)  
Occasionally 12 (11.5) 6 (8.7) 1 (6.7) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)  
Never 71 (68.3) 47 (68.1) 10 (66.7) 9 (24.3) 3 (17.7) 0 (0.0) 0 (0.0) 0 (0.0)  
Missing/
refused
1 (1.0) 1 (1.5) 2 (13.4) 1 (2.7) 2 (11.8) 1 (16.7) 1 (33.3) 1 (50.0)  
  Vaginal
(n =90)

n (%)
Oral
(n = 67)

n (%)
Anal
(n = 22)
n (%)
Vaginal
(n = 24)
n (%)
Oral
(n = 15)

n (%)
Anal
(n =6)

n (%)
Vaginal
(n = 25)
n (%)
Oral
(n =21)
n (%)
Anal
(n =6)
n (%)
Females: frequency of condom use with male sex partners
Always 14 (15.6) 10 (14.9) 4 (18.2) 15 (62.5) 8 (53.3) 2 (100.0) 23 (92.0) 19 (90.5) 5 (83.3)
Usually 3 (3.3) 3 (4.5) 1 (4.6) 1 (4.2) 0 (0.0) 0 (0.0) 1 (4.0) 1 (4.8) 0 (0.0)
Sometimes 5 (5.6) 4 (6.0) 1 (4.6) 0 (0.0) 2 (13.3) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Occasionally 5 (5.6) 3 (4.5) 0 (0.0) 0 (0.0) 1 (6.7) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Never 63 (70.0) 46 (68.7) 15 (68.2) 8 (33.3) 4 (26.7) 0 (0.0) 0 (0.0) 1 (4.8) 0 (0.0)
Missing/
Refused
0 (0.0) 1 (1.5) 1 (4.6) 0 (0.0) 0 (0.0) 0 (0.0) 1 (4.0) 0 (0.0) 1 (16.7)

Prevalence of chlamydia and gonococcal infection

Not all participants provided urine samples. Some voiced concerns that the urine collection might be used for the purpose of drug testing. Two hundred and twenty-five participants provided urine samples, and among these the prevalence of chlamydia was 6.9% and of gonococcal infection was 0.8%. One participant had concurrent chlamydial and gonorrheal infection.

Discussion

The results of this survey showed that use of cocaine has gone up: the proportion for whom cocaine was the most commonly injected drug was higher than that found in a similar survey done in 2003 (35.6% versus 18.9%). The borrowing of needles by people who inject drugs has decreased as compared with the 2003 survey (9.2% versus 16.5%). Similarly, borrowing of other injecting equipment has gone down, from 53.5% in 2003 to 40.8% in 2005. Although borrowing of equipment and needles has shown a downward trend, a high level of sharing and lending of used injection equipment in the previous 6 months is still a concern, and the likelihood of transmission of HIV and other blood-borne infections cannot be ruled out. Sexual activity was high, the majority of IDUs being sexually active in the preceding 6 months. Condom use was low with regular partners as compared with casual or client sexual partners.

HCV is acquired relatively soon after individuals begin injecting drugs. Within 5 years of beginning to inject, 50% to 80% of IDUs are infected with HCV. As a result, many IDUs who become infected with HIV are already infected with HCV(3). This trend was also found in our study population.

The HIV prevalence in this group was 2.9%, which is higher than the figure of 1.2% obtained in a similar survey in 2003. Self selection of participants in this survey makes it difficult to say with any certainty how representative they are of the IDU population in Regina. The HIV prevalence found in this study is relatively low as compared with the reported prevalence among IDU in Edmonton (23.8%), Quebec (17.3%), Victoria (15.4%), Sudbury (12.2%), Winnipeg (13.1%) and Toronto (7.6%)(4).

There were as many women as men in this survey, in contrast to most population-based surveys of IDUs, in which the majority are male(4). As compared with the proportion of aboriginal persons making up the population in Regina, a disproportionately high number of survey participants identified themselves as aboriginal.

There is an ongoing risk of sexual transmission of HIV between IDUs and their sexual partners, since reported condom use during sexual activity with regular sexual partners was very low and sharing of syringes, needles and equipment was mostly being carried out with regular sexual partners.

The information in this report are subject to several limitations. The findings of the study may not be generalizable to other cities. Because an interviewer administered the survey, some respondents may not have reported their behaviours accurately. A number of steps were taken to minimize social desirability bias, such as providing private and confidential areas for interviewing as well as stressing the confidential nature of the survey. Participant recruitment in this survey was dependent upon selfselection and may not have represented all IDU in Regina. The current needle exchange programs do not appear to attract many users who would be considered middle-class or higher. Individuals are able to purchase injection equipment, including needles and sharps containers, without a medical prescription throughout the region. It is likely that those who can afford to do so are not accessing the current needle exchange programs.

The findings from this survey were shared with a variety of stakeholders and at an open event for IDU. The findings are being incorporated by the Health Region in its harm reduction programs.

Acknowledgments

The authors wish to thank personnel at the Regina Qu'Appelle Health Region for conducting the interviews, National HIV and Retrovirology Laboratories for doing the HIV and HCV testing, and the Saskatchewan Provincial Laboratory for conducting the chlamydia and gonorrhea testing. The authors would also like to thank all the individuals who participated in the survey and shared their time.

References

  1. Public Health Agency of Canada. I-Track - enhanced surveillance of risk behaviours among injecting drug users in Canada, pilot survey report, 2004. URL: <http://www.phac-aspc.gc.ca/i-track/index.html>. Accessed 20 August, 2006.

  2. Centres for Disease Control and Prevention. Hepatitis C virus and HIV coinfection. IDU/HIV Prevention, September 2002. URL: <http://www.cdc.gov/idu/hepatitis/hepc_and_ hiv_co.pdf>. Accessed 20 August, 2006.

  3. Public Health Agency of Canada. I-Track: enhanced surveillance of risk behaviours among people who inject drugs. Phase I report, August 2006. URL: <http://www.phac-aspc.gc.ca/ i-track/sr-re-1/index.html>. Accessed 1 September, 2006.

  4. Elliott L, Blanchard J. The Winnipeg Injection Drug Epidemiology (W.I.D.E.) Study: A study of the epidemiology of injection drug use and HIV infection in Winnipeg, Manitoba: Final report. Winnipeg: Epidemiology Unit, Manitoba Health, 1999.

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