Co-morbidities among injecting drug users with HIV in India

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Co-morbidities among injecting drug users with HIV in India -

challenges in clinical management

Kamalesh Sarkar & Sekhar Chakrabarti

Indian J Med Res 127 (5) , May 2008, pp 428-430

Asia currently faces an escalating HIV/AIDS epidemic with more than

8.3 million people living with HIV. In many parts of Asia, HIV

epidemics have been largely driven by injection drug use. HIV rates

greater than 20 per cent among injecting drug users (IDUs) have been

reported in many countries, including Indonesia, Malaysia, Myanmar,

Thailand, and Vietnam.

Globally, the number of IDUs was estimated to be approximately 13.2

million and over ten million (78%) live in developing and

transitional countries (Eastern Europe and Central Asia, 3.1 million;

South and South-east Asia, 3.3 million; East Asia and Pacific, 2.3

million)1.

India is estimated to have approximately 1.1 million IDUs with HIV

prevalence as high as 64 per cent in them in certain cities 2. India

recognized injecting drug use as a problem of public health

importance following detection of HIV epidemic in IDUs of north-

eastern states during 1990-19913,4.

Metropolitan cities like Kolkata, Chennai, Mumbai and Delhi also

reported injecting drug use problem since 1990s that witnessed

growing impure heroin (brown sugar) addiction throughout the 1980s.

Apart from HIV, two other blood borne infections, hepatitis B and

hepatitis C were widely prevalent in IDUs and many of them were found

to be suffering chronically. The opportunistic infections and AIDS

indicator conditions that were observed in HIV- infected IDUs were

herpes zoster, tuberculosis, cryptosporidial diarrhoea, oropharyngeal

candidiasis, Kaposi's, sarcoma as evident by several studies5.

A community-based serosurveillance of IDUs of Kolkata showed a

continuous increment of hepatitis C infection from 17 to 80 per cent

within a span of seven year despite their ongoing needle exchange

intervention programme.

The study also showed that the prevalence HIV increased from 1 to 2

per cent and that of HBV increased from 2 to 18 per cent in them during the same

period6.

Moreover, the study showed that there were a number of items other

than the injecting equipment (earthen pot containing water for

cleaning, cotton swab, etc.) shared by the IDUs that might play some

role in transmitting blood borne infections particularly that of HCV.

In 2004, another epidemic investigation was carried out in IDUs of

Darjeeling district of West Bengal. The investigation explored an

epidemic of HIV coupled with HCV in IDUs of Darjeeling district.

The seroprevalence of HIV was found to be 12 per cent and that of HCV

was 48 per cent in IDUs7,8. The finding of this kind generally

indicates that the transmission of such blood borne infections in the said IDU

community was not very old. Had it been for longer duration, more would have

been the seroprevalence of HIV and HCV as unsafe injection practices were found

to be rampant in them.

The transmission potential of HCV appears to be much higher compared

to HIV or HBV. This is supported by the fact that seroprevalence of

HCV in IDUs usually remains very high (80% or more) after few years

following initiation of unsafe injection practices as observed by

several studies6.

Chennai, Tamil Nadu has also reported a high prevalence of HIV in

IDUs with an estimated 10,000 to 15,000 IDUs9. HIV prevalence among

IDUs in Chennai ranged from 30 to 40 per cent10. et al11 in

this issue have reported that the prevalence of HBV and HCV in IDUs

were 11.9 and 94.1 per cent respectively.

This clinic-based study also showed that 13 out of 118 study

participants (11%) were co-infected with HIV, HBV and HCV. Oral

candidiasis, tuberculosis, anaemia, lower respiratory tract

infections, herpes zoster, etc., were other common co-morbidities

reported11.

These are similar to those observed earlier among the IDUs in other

parts of India. A recent study has also shown that there is an

increase of injecting drug users in Punjab, Haryana and other parts

of northern India and drugs come from nearby `Golden Crescent'12.

Like other places, many of them are expected to develop HIV, HBV and

HCV in varying combinations in due course, which would be revealed

only after careful investigation.

It was observed that recombination of HIV-1 virus in IDUs takes place

at a higher rate in north-eastern region. Circulation of such

recombinant forms accounted for as much as 25-30 per cent in north-

eastern region (Chakrabarti S, personal communication).

This form of genetic diversity is hardly known from other parts of

the country, where heterosexual act is the primary mode of

transmission for HIV-1.

The presence of intersubtype recombinants of HIV in context to gag,

and env genes among the IDUs in Manipur has been reported13,14.

Whether these recombinants will be circulating recombinant is yet to

be established. It might pose problem in clinical management of these

patients in future.

It is evident that the IDUs are on increased risk of developing

hepatitis in addition to acquiring HIV. The development of hepatitis

could be induced by abusing drugs including their over dosage

(chemical hepatitis) or by infection with HCV or HBV or both

(infective hepatitis).

There is a need to assess their hepatic function along with

evaluation of HCV and HBV infections to rationalize the treatment for

HIV-infected IDUs. HCV is highly transmissible through blood-borne

exposure. Chronic HCV and HIV co-infection results in an accelerated

progression to end-stage liver disease and death compared with

individuals infected with HCV alone15.

When considering treatment for IDUs with HCV, particular attention

must be paid to mental health conditions, which are associated with

both hepatitis C and substance use. As a group, IDUs exhibit higher

rates of co-morbid psychiatric disorders than do the general

population. Interferon (IFN)-based regimens for hepatitis C are often

complicated by neuropsychiatric adverse effects, including

depression, insomnia, and irritability.

Poverty, homelessness, addiction, mental health disorders, social

marginalization, fear of arrest and prosecution, mistrust on the

health care system and limited involvement in stable primary care

relationships represent challenges to effective hepatitis C care

among IDUs.

Other barriers may include the social instability and comorbidities

associated with drug use, insufficient access to expertise about HCV,

and the high cost of comprehensive care and treatment.

Physicians rarely receive meaningful training in addiction medicine

or effective strategies for managing the difficulties often

encountered in providing care for the drug users. Consequently,

unrealistic expectations, coupled with judgemental attitudes, can

lead to frustration and resentment for both physician and patient.

Better education of physicians and health care providers about

substance use and addiction, and exposure to models of compassionate

care, are needed to improve their understanding of problematic

substance use as a treatable disorder.

Expanding the capacity of hepatitis specialists to manage care for

substance users, and of addiction specialists to manage treatment of

hepatitis C, will be necessary to overcome these challenges.

It is well documented that IDUs with HIV infection are at risk of TB

and in some settings, multidrugresistant TB. Considering TB as the

commonest opportunistic infection in HIV-infected individuals, an HIV

infected IDU really poses a challenge while requiring treatment for

opportunistic infection like TB with or without anti-retroviral

therapy.

As rightly pointed out by et al11, a combination of

stavudine, lamivudine and nevirapine is the most commonly used first-

line regimen in India. However, studies have found increased levels

of nevirapine induced hepatotoxicity among patients co-infected with

HCV or HBV.

Long-term nevirapine use in co-infected patients has also been shown

to accelerate progression to liver cirrhosis16. The co-administration of

rifampin, an anti-tuberculous drug, and nevirapine can result in lower

nevirapine concentrations.

Thus, the currently favoured regimens for the management of HIV in

India may not be optimal for IDUs, especially for those with HBV

and/or HCV coinfection or in those who also abuse alcohol.

This might be complicated further by the hepatotoxicity induced by

anti-tubercular drugs like isoniazid, rifampicin, when given to IDUs

with already compromised liver function.

So, there is a need to develop a rational treatment protocol of

tuberculosis for the IDU population with deranged liver function.

Considering above, physicians are expected to face higher degree of

challenges while dealing with management of an HIV-infected IDUs in

general. This would be compounded further in IDUs of north-eastern

region particularly in the event of dual/multiple infections with HIV-

1 of diverse genetic nature.

Kamalesh Sarkar & Sekhar Chakrabarti*

HIV/AIDS Unit

National Institute of Cholera & Enteric Diseases

P-33, CIT Road, Scheme XM, P.O. Beliaghata

Kolkata 700 010, India

*For correspondence:

drsekharchakrabarti@...

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