Tattoing associated HIV Risk in Chennai

[Guest guest]

Around 30% of the intravenous drug users (IVDUs) in Chennai, India, are infected

with HIV, and around one out of six of these has passed the infection onto their

regular sex partners, according to a cross-sectional study published in the May

1st edition of the Journal of Acquired Immune Deficiency Syndrome.

Once HIV prevalence among a high-risk IVDU population becomes so high, the paper

says “HIV epidemics can become self-perpetuating, with even modest levels of

risk behaviour leading to substantial rates of infection. And yet very few of

the participants in this study, including those who were infected, thought that

they were at any risk of contracting HIV.”

Furthermore, sharing needles was not the only risky behaviour this study

population engaged in. Many of the participants had risky sex with multiple

partners (including sex workers), although this was not significantly associated

with a greater risk of being infected in this population. However, there was one

factor unrelated to injection-related risks that was significantly associated

with participants being infected: getting a street-corner tattoo.

HIV and injection drug use in India

No one really knows exactly how many people in India are HIV-infected. UNAIDS

estimates in 2004 put the number up to around 5.1 million, but the number could

in fact be much higher. It is believed that the epidemic is primary spread by

unprotected heterosexual intercourse, but Indian epidemiology research tends to

focus on individual risk factors and does not analyse the lifestyles of Indians

at risk too deeply.

A good example of this is injection drug use. IV drug use is a common means of

HIV transmission in parts of Asia, including parts of India bordering Myanmar

(although lately there has been a diffusion of IV drug use to other parts of

India). HIV outbreaks among IVDUs in the northeastern states of India led the

country to adopt targeted prevention interventions focused on safer injection

practices. However, a number of studies in other Asian countries have reported

that IVDUs also engage in a variety of risk behaviours that put themselves, and

others, at risk of infection. For example, despite a popular misconception that

injection drug use decreases libido, several studies find IVDUs are far more

likely to have unprotected sex with multiple partners.

A study in Chennai

To learn more about the lives and risk behaviours of IVDUs in India,

researchers decided to conduct a cross-sectional study (a one-time assessment)

of risk-taking and HIV prevalence among IVDUs and their regular sex partners in

Chennai, India. In the past ten years, injection drug use has become

increasingly common in Chennai (India's third largest city, which is on the

southeast coast of the country), but there have been no studies in this

population.

The study employed peer outreach workers and field researchers to recruit 260

IVDUs and their wives or live-in sex partners living in central Chennai over a

period of three months in 2003. After obtaining the participants’ informed

consent, researchers used a questionnaire to gather information on the subjects’

socio-demographic profile, initiation of drug use, switching to injection drug,

injection equipment sharing practices, sexual practices in and

outside marriage, risk perception, and knowledge of HIV/AIDS. Each study

participant also donated blood for anonymous HIV testing.

Complete data were available for 226 IVDUs and their regular sex partners. The

HIV seroprevalence was 30% (68/226) in IDUs and 16% of these passed HIV onto

their wives or live-in partners (11/226). This rate of onward transmission is

low compared to some studies, and may reflect a rapid turnover of regular

partners. Women who had been with their IVDU partners for more than six years

were significantly more likely to be HIV-positive (p = 0.02).

Fifty-seven percent of the HIV-positive IVDUs and 45% of the HIV-infected women

thought that they had “no chance” or “very little chance” of becoming infected.

Since such a low number of female partners in the study were infected, the

researchers focused on the risk-taking behaviours among IVDUs.

Nearly 60% of the IVDUs (137/226) reported ever having sex with female

commercial sex workers, however this was not associated with an increased risk

of being HIV-positive. Neither was condom use. However, the IVDUs could have put

the sex workers or other irregular sex partners at risk of infection, although

the study did not address this.

Most of the risk factors that were most likely to be associated with

HIV-infection were related to injection drug use, not surprising since more than

20% IVDUs reported borrowing or lending of injection equipment. In a univariate

analyses, more than twice-a-day injecting frequency, and ever-injecting drugs in

drug-selling places had a significant association with HIV-infection, together

with a history of incarceration and recruitment from the northern part of the

city.

However, researchers tied both of these factors to injection drug

use. Living in the northern part of the city was associated with worse economic

status. Consequently, IVDUs living there are more likely to be forced to reuse

needles. The researchers made the same association (a higher rate of

needle-sharing) for those with a history of incarceration; unprotected sex in

prison with other men did not appear to be addressed in the questionnaire.

Tattoos

Another interesting factor was associated with being HIV-infected in the

univariate analysis: having a tattoo. This prompted a subsequent investigation

into tattooing in Chennai. The researchers wrote: “Persons applying tattoos

carry out their business from roadside pavements or by roaming the streets in

Chennai. They also display their wares in festivals and weekly bazaars. Instead

of battery-operated machines used by male tattoo makers, women belonging to

nomadic tribes, who are also in such businesses, manually prick the skin

repeatedly with solid sharp needles dipped in green dye or ink along the lines

of the design drawn on the chosen part of the body. The time taken to complete a

tattoo varies from 15 minutes to one hour, depending on the size of the design.

Some wipe off the oozing blood with a strip of cloth, which has seen

many usages. Some even advise not to wipe off the blood and let the wound heal

by itself.”

The investigators continue “Talking with an injector revealed more details about

tattooing in the city. He recalled being the fifth person in the line.

Everyone took their turn and once the above-mentioned process was completed, the

person applying the tattoo did not change the needle or clean it at all. The

needle was in fact not even kept immersed in any kind of solution. This appeared

to be the common practice in this business followed by most of the tattoo

makers.”

In an adjusted analysis, having a tattoo still tended toward being

significantly associated with HIV-infection (p=0.07) which suggests that HIV is

probably being transmitted via this root. If so, then IVDUs are not likely to be

the only group being infected this way.

Conclusion

However, in the adjusted model, the odds of HIV-infection were twice higher

among IDUs who had ever injected drugs in drug-selling places and six times

higher in those who were recruited from the northern part of central Chennai.

This suggests that sharing needles is still the most significant risk factor for

transmission. Nonetheless, the researchers conclude that “reducing the sharing

of injection equipment and unsafe tattooing through targeted and environmental

interventions, increasing HIV risk perception, and promoting safer sex practices

among IDUs and their sex partners are urgent program needs.”

Reference

Panda S et al. Risk factors for HIV infection in injection drug users and

evidence for Onward transmission of HIV to their sexual partners in Chennai,

India. J Acquir Immune Defic Syndr 39: 9 - 15, 2005.

http://www.aidsmap.com/en/news/9C786221-5D9F-496C-91C4-1A5659ACC5EA.asp?hp=1

[Guest guest]

All--

As a well-tattooed HIV+ person, this news is alarming and reflects a huge public

health issue, as so many blood-borne illnesses can come

through unsanitary tattooing.

I have had my tattoos done under full disclosure and with standard precautions,

taken with every person receiving tattoos in many countries, from Brazil to

the Netherlands.

I do disclose, not only to ensure that the artist is well-informed,

but also to make sure I am cared for in that situation. Simple

precautions reduce the risk, but translating such strategies to

street corners is a huge challenge.

This seems like a place for some creative thinking about how to work with

these tattoo artists, who themselves are at risk, to develop some methodologies

for introducing some standards for sterile tattooing methodologies.

I would gladly get a new tattoo in Chennai in such a situation and do not want

to limit people's economic means, just the public health risk.

This is sentinel work and needs to be incorporated in regional and national

public health strategies on HIV and hepatitis.

Stuart Flavell, Advisor

The Global Network of People Living with HIV/AIDS

P.O. Box 11726

1001GS Amsterdam

The Netherlands

+31 20 423-4114 phone

+31 20 423-4224 fax

+31 62 157-2520

www.gnpplus.net

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