Research paperHIV and hepatitis C prevalence, and related risk behaviours among people who inject drugs in three cities in Croatia: Findings from respondent-driven sampling surveys
Introduction
Drug injecting practices using non-sterile injecting equipment are a well-known risk factor for acquiring numerous blood born viral and bacterial infections (MacArthur et al., 2014). However, representative data on the spread of Human immunodeficiency virus (HIV), hepatitis C virus (HCV) and other blood borne infections among people who inject drugs (PWID) are difficult to obtain, mainly due to the fact that drug use is criminalized in most countries of the world.
Estimations of the size of the population of problematic drug users (defined as injecting drug use or regular and/or long-term use of opiates, cocaine and/or amphetamines) (PDU) (European Monitoring Centre for Drugs and Drug Addiction, 2013) and PWID were done in Croatia in 2006 and 2012 using the multiplier method. In 2006, it was found that there might be 1370 (95% CI 760–3423) PWID in Rijeka, 2805 (95% CI: 1515–9313) in Zagreb and 3347 (95% CI 1320–16,716) in Split (Kolaric, Stajduhar, Gajnik, Rukavina, & Wiessing, 2010) while in 2012 it was estimated that 10,012 (95% CI 7842–13,723) PDU lived in the entire Croatia (OCDAGRC, 2013).
Needle and syringe exchange programmes (NSEP) for PWID were established in Croatia in 1996. They are run by non-governmental organizations (NGOs), and are currently available at 102 locations. NSEP also provide free condoms and voluntary, anonymous and free-of-charge counselling and testing for HIV, HCV and other blood-borne infections (European Monitoring Centre for Drugs and Drug Addiction, 2015b). Needles and syringes can be bought at pharmacies at a price of 0.2 USD per needle with a syringe. NSEPs are not available in prisons.
Free-of-charge methadone treatment for those insured by the Croatian Health Insurance Fund was introduced in Croatia in 1991, while the treatment with buprenorphine was introduced in 2004. In 2009, a combination of buprenorphine and naloxone (Suboxone®) was approved as an alternative substitution substance. Opioid substitution therapy (OST) is predominantly administered by general practitioners and is available in prisons as well. In 2014, a total of 5067 clients were receiving OST out of which 51.4% were taking buprenorphine (Croatian Institute of Public Health, 2015b).
The highest HIV prevalence of 2.8% and 4.5% in key populations for HIV assessed in integrated bio-behavioural surveys (IBBS) in Croatia was found among men who have sex with men (MSM) in 2010 (Bozicevic et al., 2012) and 2006 (Bozicevic et al., 2009), respectively. In 2007, a study based on the snowball sampling among PWID recorded HCV antibody prevalence of 29% in Rijeka, 51% in Zagreb and 65% in Split (Kolaric et al., 2010). No HIV cases were found in this study. Since beginning of reporting until end of 2014, 1208 HIV cases were reported in Croatia and 5.9% of these were reported as being due to injecting drug use. Among 92 persons newly diagnosed with HIV in 2014 there were no cases attributed to injecting drug use (Croatian Institute of Public Health, 2015a).
The aim of this paper is to describe the results of the first IBBS using respondent-driven sampling (RDS) among PWID in Split, Rijeka and Zagreb and to assess correlates of never being tested for HIV and HCV in Split and Rijeka.
Section snippets
Participants and procedures
We used RDS, a chain referral sampling method that collects data on social network sizes and recruitment patterns (Heckathorn, 1997, Heckathorn, 2002) and is widely used to sample hard-to-reach populations at risk for HIV (Malekinejad et al., 2008, White et al., 2015), to recruit PWID in the cities of Zagreb, Split and Rijeka. To be eligible for the study, participants needed to be 18 years of age or older, injected drugs for non-medical reasons in a month prior to enrolment into the study
Recruitment patterns
Data collection lasted from November 2014 to February 2015. In total, 830 PWID were enrolled in the study – 399 in Split, 255 in Rijeka and 176 in Zagreb. A sample size determined prior to the beginning of the surveys was reached only in Split. In Zagreb and Rijeka, only 44.0% and 72.9%, respectively, of the planned sample size was reached. The maximum chain length ranged from 11 in Zagreb to 16 in Rijeka. Proportion of the coupons returned to the study site ranged from 34.1% in Rijeka to 48.8%
Discussion
We found the HIV prevalence of 0.2% among PWID in Zagreb and Rijeka and 0.3% in Split, respectively, which is comparable to the other countries of Central and South Europe (such as Hungary, Slovakia, Czech Republic, Montenegro, Bosnia and Herzegovina, Macedonia, Albania) where injecting drug use is rarely reported as a mode of HIV transmission (Bozicevic, Handanagic, Lepej, & Begovac, 2013) and HIV prevalence in PWID is mainly below 1.0% (European Monitoring Centre for Drugs and Drug Addiction,
Conclusion
Key findings of this study point to a low-level HIV epidemic, a sizable HCV epidemic and low recent testing rate for HIV and HCV among PWID across three largest cities in Croatia. Development of a more comprehensive approach to harm reduction in PWID should enable better coverage with NSEP, OST, HIV and HCV testing services, prevention of overdose and reduction of injecting behaviours among those on OST. There is an urgent need to enable NSEP in prisons and strengthen the access to both OST and
Funding
The core funding for the study was provided by the Office for Combating Drug Abuse of the Government of the Republic of Croatia and Croatian Ministry of Health.
Contributors
All authors participated in the planning and conception of the research questions and the study design. SH, IB, MC, ZD and JBg conceptualised the study design and coordinated the study implementation. ODR did the laboratory analysis of the samples. SH, SS, ZD and JB were responsible for analysing the data. SH drafted the article, and all authors participated in interpreting the data and critically revising the manuscript. All authors read and approved the revised manuscript.
Acknowledgments
We would like to thank the study participants and the staff of the University Hospital for Infectious Disease ‘Dr Fran Mihaljevic’, the NGOs Let, Terra, Help and Croatian Red Cross, and Institutes of Public Health Splitsko-Dalmatinska and Primorsko-Goranska County.
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