A.Agha ( Department of Community Health Sciences,The Aga Khan University, Karachi and Section of Infectious Diseases,West Virginia University*, WV 26505, United States. )
S. Parviz ( Department of Community Health Sciences,The Aga Khan University, Karachi and Section of Infectious Diseases,West Virginia University*, WV 26505, United States. )
M. Younus ( Department of Community Health Sciences,The Aga Khan University, Karachi and Section of Infectious Diseases,West Virginia University*, WV 26505, United States. )
Z. Fatmi ( Department of Community Health Sciences,The Aga Khan University, Karachi and Section of Infectious Diseases,West Virginia University*, WV 26505, United States. )
Pakistan, along with Iran and Afghanistan, falls in the golden crescent, a region notorious for drug production and trafficking.1 According to the United Nations International Narcotic Control Board, the illicit cultivation, production and trafficking of narcotic drugs almost always result in drug use amongst local population. In this regard, Pakistan is quoted as a classic example.2 The National Health Survey of Pakistan 1993, reported approximately 2.7 million drug users in Pakistan.3
The morbidity and mortality associated with psychoactive drug use have been recognized worldwide. Nevertheless, the statistics regarding the extent and prevalence of drug use are difficult to obtain, as drug users are mostly under-sampled in surveys.4 Globally, drug use poses significant health risk to an estimated 15 million people.4,5
Injecting is considered the worst route of drug use, accounted for 100,000 to 200,000 deaths per year worldwide. Studies have shown that drug users inject drugs in "shooting galleries"; a communal injection site located beside "Nalahs" (sewage water streams), on footpaths, or in abandoned buildings, where needles are usually borrowed for injections.6 In many countries such as Russia, Ukraine and India, the increasing scales of injecting drug use creates a potentially massive group of individuals at risk of acquiring blood borne pathogens such as Human Immunodeficiency Virus (HIV), and Hepatitis B and C.5,7
In Pakistan, injecting drug use was not common until after the Afghan war, when a variety of drugs flooded from Afghanistan for transit.8 In 1993, 1.8% drug users were injecting drugs, however, in 1995 the proportion of drug users rose alarmingly to 25%. Moreover, a study by Baqi et al reported that about 52% IDUs were sharing needles to inject drugs.9 Further, half of those (1.52 million) IDUs were injecting heroin as narcotic drug.1,3,10
The United Nations International Drug Control Programme (UNDCP) has indicated an increasing prevalence of IDUs in developing countries during the past decade.5 Studies have shown socio-economic and demographic factors, such as inadequate education11, homelessness12, depression13, and low income11, associated with injecting drug use in the developed world. However, there is a general dearth of scientific literature, especially regarding modes and determinants of drug use, in developing countries.
As injecting drug use is associated with number of morbidities, therefore, exploring associated factors will help understand the nature of the problem and eventually address the hazards encountered by this high-risk group. Therefore, the objective of this study was to identify the socio-economic and demographic factors associated with the Injecting Drug Use among drug users in Karachi, Pakistan.
Subjects and Methods
This cross-sectional study was conducted from February through June 1996 in Karachi- the largest city of Pakistan, with a population of 9.9 million. Karachi is divided in four administrative districts: East, Central, West and South. The economic dominance in Karachi has led, in part, to massive in-migration and inhabitation by a wide variety of communities belonging to diverse ethnic, religious and linguistic backgrounds.14
Prior to data collection, the key informants mostly resource persons in drug treatment centers from each district were interviewed to identify habitats of drug users. Drug users were then traced and interviewed. In addition to streets, drug users were also recruited form the Central Prison, Karachi and major drug-treatment centers; namely Edhi Village, Azam Village, Al-midway Rehabilitation Center, Asghar Hospital, Karachi Addiction Clinic and Saadat Clinic.
We defined drug users as subjects taking drugs for recreational purposes. Among them, IDUs were those who took drug/drugs through sub-dermal route at least once during the past two months, with or without use of drugs from other routes. While non-IDUs were those who were taking drugs by routes other than sub-dermal injection.
After explaining the purpose of the study, verbal consent was taken and a structured questionnaire (adapted from prototype questionnaire of World Health Organization) was administered through trained staff. Subjects who were disoriented or were unable to respond to the questions asked were excluded. Drug users were interviewed with regard to socio-demographic factors (age, ethnicity, religion, city born, number of children, household members, education) social network (marital status, living with spouse, history of alcohol intake, place of residence) and economic condition (total income, employment status, source of income). In addition, information regarding district where the drug user was recruited from and current history of sexually transmitted diseases (syphilis, genital herpes, gonorrhea) were also gathered. Moreover, blood samples were also obtained for Human Immunodeficiency Virus (HIV) testing.
We divided ethnicity into five major groups (Mohajir, Punjabi, Pathan, Balochi, and Sindhi) on the basis of mother tongue. Having assessed the source of income generation, we categorized those into legal and illegal. We labeled robbery, stealing and other illegitimate ways of earnings as illegal means. The history of alcohol intake was explored by asking whether the individual had taken alcohol in his life. Similarly, subjects reported living on streets and/or having no fixed residence were categorized as "no fixed address" group. Presence of suicidal thoughts was elicited by asking whether the subject had suicidal feelings or not. We assessed the past illness of sexually transmitted diseases (STDs) by inquiring about the clinical signs and symptoms of STDs.
The study complied with the human subjects' protection requirements of the institution review board of The Aga Khan University Hospital, Karachi.
Laboratory procedures were carried out at the Department of Pathology, The Aga Khan University Hospital, Karachi. Serological testing was done for HIV-1 and HIV-2 using dipstick method (PATH; Dipstick-HIV+2). Positive samples were double tested with the same test and reconfirmation was done with Enzyme Linked Immunosorbant Assay, ELISA-11 (Enzygnosy Anti HIV-1/HIV-2; Behring).15 We also performed anonymous linked testing of the seras, provided pre-test HIV counseling, and post-test counseling to those seeking results.
Descriptive analysis was done by calculating means (+ standard deviation) for continuous and proportions for categorical variables. Univariate analysis was performed by applying chi-square and Fisher exact tests for categorical variables. To observe the independent effect of individual factors, the potential confounders were controlled by means of logistic regression analysis and adjusted odds ratios (AOR) with their 95% confidence interval (CIs) were obtained.16 All variables with p-value of <0.2 in univariate analysis were included in the multivariate analysis. Statistical program Epi-Info 6 was used to enter the data and analysis was performed using Statistical Package for Social Sciences.17,18
We interviewed 473 drug users, among them 389 (82.2%) were found on streets and 84 (17.4%) were recruited from rehabilitation centers or prison. Among drug users, 242 were IDUs and 231 were non-IDUs. All subjects were males with mean age of 30.95 ± SD 8.4 years. The majority 215 (45.5%) were recruited from district Central of Karachi. About 50% of the participants had no formal education and 83% were working as temporary employees. We also found that 312 (66%), 141 (29.8%) and 20 (4.2%) subjects were single, currently married and separated or divorced respectively (Table 1).
Factors associated with Injecting drug use
Table 2 shows results of univariate analysis with socio-demographic, economic and social network related factors taken as exposures against mode of drug use as outcome.
The multiple logistic regression analysis (Table 3) showed source of income generation [Illegal vs legal; AOR 1.6, 95% CI 1.0-2.6], sharing of income with family [No vs Yes; AOR 1.7, 95% CI 1.1-2.7] and having suicidal thoughts [Yes vs No; AOR 2.0, 95% CI 1.1-3.8] as factors significantly associated with injecting drug use. In addition, subjects living in district Central, East and West were more likely to inject the drug compared to individuals living in district South. Similarly, genital herpes was more common in IDUs [Yes vs No; AOR 4.0, 95% CI 2.0-8.0)]. One injecting drug user (IDU) was found seropositive for HIV.
Injecting drug use has long been a focus of epidemiological research and a target for pubic health interventions, especially because of the impending threat of blood-borne infections spread. Studies have been conducted among drug users in developed and developing countries, however, to the best of authors' knowledge no study is conducted to look at factors associated with injecting drug use in the local context.
In the present study, drug users generating income from illegal sources were more likely to use drugs through injections. Literature has indicated that IDUs dependence on drug is more as compared to non-IDUs, therefore they indulge themselves in illegitimate ways of earning.19 Studies also revealed that injecting drug use increases with the rise in narcotic drug prices, as required quantity of same drug, to produce desired effect, is less through injection as compared to other routes.20
Sharing of income with family members depicts cohesion of the drug users with the family. We found significant association between injecting drug use and non-sharing of income with other family members.21 This perhaps shows isolated lifestyle of drug users opting injections as mode of drug use. The close family network may help drug users in keeping themselves away from injecting drug use. Similarly, finding that injecting drug users were more likely to have suicidal thoughts compared to non-IDUs, reflects frustration and isolation among IDUs. Furthermore, suicidal thoughts or mental illness are associated with erratic behavior and use of harmful route of drug administration.22
Our data showed that subjects belonging to district East, Central and West were more likely to inject drugs compared to those belonging to district South. This association indicates that drug users in some localities were more prone to injecting drug use. This implies easy availability of injection equipment, peers, and localities for this mode of drug use. We also found strong association between the history of current genital herpes and injecting drug use. This suggests involment of IDUs in sexual risk behaviors.
The low prevalence of HIV among drug users in our study is consistent with other studies conducted in Pakistan.23-26 This may partly be explained by the relative political isolation of Pakistan from India and other HIV endemic zones.
Certain limitations of the study should be considered in interpreting the results. The hidden and scattered nature of drug users leaves us to use pragmatic ways of sampling subjects. Through this strategy, we recruited drug users from both streets and rehabilitation center/prison, however, our sample does not represent drug users taking drugs in homes. Although, through key informants, we tried our best to reach out all the streets, major rehabilitation centers, we might have missed few habitats of drug users.
Primary prevention activities focusing on improving socio-economic conditions and social network of drug users would help change IDUs behaviors towards non-injecting mode of drug use or even prevent them from indulging in injecting drug use. There are districts which need especial attention, as injecting drug use is more prevalent in few districts of city than others. Both non-sharing of income with other family members and presence of suicidal thoughts among injecting drug users show that these individuals are more isolated from social network. The community-based interventions focusing on social networking may help drug users with injecting drug use.
The authors sincerely thank the participants. We acknowledge Drs Sharaf Ali Shah and Qamar Abbas of Sindh AIDS Control Program for their continued support. We are also greatly indebted to Mr. Tariq Malik and Mr. Sheper Mirza of The Aga Khan University Hospital Laboratory for serological testing.
1. PANOS. HIV and injecting drug use in developing countries. AIDS information Fact sheet-21, 1998, p. 1.
2. Ahmad B, Mufti KA, Farooq S. Psychiatric comorbidity in substance abuse (opiods). J Pak Med Assoc 2001;51:183-6.
3. Pakistan Narcotics Control Board. National Survey on drug abuse in Pakistan. Islamabad, 1986, p. iii.
4. World Health Organization. Fact sheet No. 127: Trends in substance use and associated health problems. [Online] 1996, [cited 2003, January 10] Available from: URL: http://www.who.int/inffs/en/fact127.html. (WHO/1996/127).
5. UNAIDS. YOUANDAIDS: The HIV/AIDS portal for Asia Pacific, UNDP. [Online] 2003, [Cited 2003, February 22]. Available from: URL: http://www.youandaids.org/Themes/InjectingDrugUse.asp
6. Jarlais, D.C., Hagan, H., Friedman, S.R. et al. Maintaining low HIV seroprevalence in populations of injecting drug users. JAMA 1995;274:1226-31.
7. World Health Organization. Statement from the consultation for HIV infection, Geneva: WHO 1992.
8. UNDCP. Law Enforcement: Central Asia CIRUS - Combined Interdiction Unified Strategy for Iran. [Online] 2003, [Cited 2003, January 01]. Available from: URL: http://www.unodc.org/unodc/law_enforcement_centralasia.html
9. Baqi S, Nabi N, Hasan SN, et al. HIV antibody seroprevalence and associated risk factors in sex workers, drug users, and prisoners in Sindh. Pakistan. J Acquir Immune Defic Syndr Hum Retrovirol 1998;18:73-9.
10. Gillis JS, Mubbashar MH. Risk factors for drug abuse in Pakistan: a replication. Psychol Rep 1995;76:99-108.
11. Strathdee SA, Patrick DM, Curries SL, et al. Needle exchange is not enough lessons from the Vancouver injecting drug user study. AIDS 1997;11: F59-65.
12. Song JY, Safaeian M, Strathdee SA, et al. The prevalence of homelessness among injecting drug users with and without HIV infection. J. Urban Health 2000;77:678-87.
13. Strathdee SA, Patrick DM, Archibald CP. Social determinants predict needle-sharing behaviour among injection drug users in Vancouver, Canada. Addiction 1997;92:1339-47.
14. Government of Sindh. Development Statistics of Sindh, Pakistan 1994.
15. World Health Organization. Statement from the consultation for HIV infection, Geneva: WHO, 1992.
16. Barker DJ, Hall AJ. Practical epidemiology, 4th ed. Edinburgh: Churchill Livingstone, 1991, p. 38.
17. Statistical Package for Social Sciences. Release 10.0 1989-1999, Copyright @ SPSS Inc, Chicago, IL, USA.
18. Dean AG, Dean JA, Coulombier D, et al. Epi Info Version 6: a Word-Processing, Database and statistics program for public health on IBM-compatible microcomputers. Atlanta, Georgia: Centers for Disease Control and Prevention, USA, 1995.
19. Altaf A. Reducing the risk of injecting related harm in Karachi: a pilot project. Department of Community Health Sciences, The Aga Khan University, Karachi, [Unpublished] 2001.
20. UNDCP, HIV and development programme. HIV and injecting drug use: a challenge to sustainable human development. [Online] 2000, [Cited 2003, April 01]. Available from: URL: http://www.undp.org/hiv/ publications/deany.htm
21. Gillis JS, Tareen IA, Chaudhry HR., et al. Risk factors for drug misuse in Pakistan. Int J Addict 1994;29:215-23.
22. Rao AV, Vasudevan PM. The course and outcome of drug addiction: a follow-up study of 178 cases in Madurai, South India. Drug Alcohol Depend 1980;6:351-7.
23. Shah SA, Khan OA, Kristensen S, et al. HIV infected workers deported from the Gulf States: impact on Southern Pakistan. Int J STD AIDS 1999;10:812-14.
24. Hyder AA, Khan OA. HIV/AIDS in Pakistan: the context and magnitude of an emerging threat. J Epidemiol Community Health 1998;52:579-85.
25. Kakepoto GN, Bhally HS, Khaliq G, et al. Epidemiology of blood borne viruses: a study of healthy blood donors in Southern Pakistan. Southeast Asian J Trop Med Public Health 1996; 27):703-6.
26. Baqi S, Kayani N, Khan, J.A. Epidemiology and clinical profile of HIV/AIDS in Pakistan. Trop Doct 1999;29:144-8.
Objective: To identify the socio-economic and demographic factors associated with injecting drug users (IDUs) in Karachi.
Methods: We recruited 242 IDUs (taking drugs through sub-dermal routes) and 231 non-IDUs (taking drugs other than sub-dermal routes) from February through June 1996. IDUs were interviewed regarding socio-demographic factors, economic condition, and social network (marital status, living with spouse). In addition, information regarding location of drug users within the city (districts of Karachi) and current history of sexually transmitted diseases (STDs) were gathered. Moreover, blood samples were also obtained for HIV testing.
Results: Multivariate analysis showed that the income generation via illegal modes [AOR 1.6, 95% CI 1.0-2.6], non-sharing of income with family [AOR 1.7, 95% CI 1.1-2.7] and presence of suicidal thoughts [AOR 2.0, 95% CI 1.1-3.8] were associated with the use of drugs through injections. Further, drug users from districts West, East and Central were more likely to use drug through injection as compared to drug users from district South. The history of genital herpes was also found to be associated with injecting drug use. One IDU was found seropositive for HIV.
Conclusion: The high-risk behaviors, such as illegal modes of earning and presence of suicidal thoughts, among IDUs suggest that the group needs rehabilitation programme. Moreover, non-sharing of income suggest that IDUs are isolated from social network, therefore primary prevention activities with focus on improving socio-economic conditions and social networking can reduce drug use through injections. Focused interventions on target districts would be helpful in reducing IDU (JPMA 53:511;2003).