Thesis on Perceived Susceptibility of Hepatitis C Infection among the Injecting Drug Users of Dhaka City

This formative study examined the perceived susceptibility of hepatitis C among the injecting drug users of Dhaka city. A total of 384 currently injecting drug users were interviewed with structured questionnaire in the statistically metropolitan area of Dhaka. The structured questionnaire included their socio-demographic information, knowledge about hepatitis C; hepatitis C related risk practices and health care seeking practices. Both qualitative and quantitative data were collected from IDUs. Majority of the respondents (53.60 percent) had a low level of knowledge about hepatitis C and about 40 percent were thought themselves at risk of contracting hepatitis C. About 61 percent respondents share needles and syringes in unavoidable circumstances. Results of the logistic regression indicate the importance of socio-demographic characteristics (R2= 0.16, p= p<0.005) in determining respondents’ risk practices related to hepatitis C. Structural vulnerability, deeply constructed by respondents’ socio-demographic characteristics are indicating potential hepatitis C epidemic in the population.

“Living with risk, therefore, may involve the acceptance of some degree of uncertainty and instability, however controversial this may seem to we late moderns who are obsessed with control and certainty”
(Lupton, 1999:10)
Hepatitis C is a major global health problem (WHO, 2010). Although its means of transmission are well documented, the hepatitis C virus itself still remains an enigma. The hepatitis C virus (HCV) is a widespread, easily transmissible, blood-borne virus with serious and potentially fatal health consequences for the infected individual (Ryder and Beckingham, 2001). Furthermore, hepatitis C positive individuals are of extremely high transmission risk to others and are likely to be so for a substantially long period of time (MacDonald, Wodak and Dolan, 2000). In this context, it is widely recommended that the planning and implementation of health strategies to prevent hepatitis C transmission must be informed by theoretically developed models of behavior. There are widely used public health models for changing the risk practices of hepatitis C. As the transmission of hepatitis C is affected significantly by individual behavior, individual behavior change theories have remained the theoretical anchor for most preventive efforts (UNAIDS, 1999; WHO, 2010). These strategies were largely inspired by the Health Belief Model (HBM) (Rosenstock, 1974), which establishes a direct and rational connection between knowledge and practice when an individual feels truly concerned by a health threat (Paicheler, 1999). The risk of practicing these public health strategies based on assumptions rather than validated models is evident in poorly planned, early AIDS prevention campaigns (O'Brien, 1989; Fee and Krieger, 1993; Lupton, 1993; Bloor, 1995a, 1995b; Gabe, 1995; Fishbein and Guinan, 1996; Anwar and Kabir, 1998; Foss et al, 2007; Amanullah, 2002). Moreover hepatitis C transmission is inextricably intertwined with the social behaviors which are the construction of socio-cultural context of a particular society (Connel and Dowsett, 1992; Petersen and Lupton, 1992; Rhodes, 1995, Rhodes, Davis and Judd, 2004; Lawless, Kippax and Crawford, 1996; Douglas, 1992, 1996; Lupton, 1999; MacRae and Aalto, 2000; Loxely, Bolleter and Carruthers, 2001; Jenkins et al, 2001:452-461; Habib, 2002, 2003; Southgate et al, 2005:5; Lakon, Ennet and Norton, 2006; Paterson et al, 2007; Roy et al, 2007; Brener, Hippel and Kippax, 2007; Rhodes and Treloar, 2008:1593-1603; Neale, 2008:429-435; Lowe, 2008:229-238). However, a few studies had acknowledged this socio-cultural construction of hepatitis C related risk behavior in the world (as far as I know) which provides this study to explore the relatively unobserved/overlooked area of hepatitis C research.

Since its identification in 1990, WHO estimates that about 200 million people, 3 percent of the world's population, are infected with hepatitis C and 3 to 4 million persons are newly infected in each year with a global 170 million chronic carriers at risk of developing liver cirrhosis and liver cancer (WHO, 1997; Limburg, 2004; Alter et al., 1999:556–62). The high prevalence of hepatitis C in the world as well as in South Asian countries like Malaysia (3 percent), Pakistan (2.40 percent), India (1.85 percent) and Bangladesh (2.40 percent) warrant global surveillance of the disease in order to determine specific health care measures for prevention and control (WHO, 1997; GoB, 2009; Khan et al., 2010:37–39).

Injecting drug use and hepatitis c
The risk factors for hepatitis C are injectable drug use (Bellentani et al, 1999:874-80; Farrell et al, 1993:32–6), paraphernalia sharing (Hagan et al, 2001), blood transfusions and organ transplantation (Alter, 1995:5–14) , unsafe injections and other healthcare related procedures ( Alter et al, 1989:1201–5), occupational exposure (Alter et al, 1989:1201–5) and unsafe sexual practices (Khan et al, 2010:37–39). While a number of risk factors have been identified, injecting drug use being the primary route of transmission in most countries (Roy et al, 2002; WHO, 2000) because between 30 percent and 60 percent of people who inject drugs (IDUs) have hepatitis C (Aceijas and Rhodes 2007; Hagan et al, 2007; NIH, 2002:341-351l; Jarlais and Schuchat 2001:21-22). In other words, drug-related infectious diseases, most notably HIV, hepatitis B (HBV) and xhepatitis C, are among the gravest health consequences of injection drug use (Ráczab et al, 2007:59-66).

In Bangladesh, it is widely acknowledged that drug use is increasing and accompanied with this are various risk practices (GoB, 2008). It has shown particular concern to injecting drug use and adverse health consequences of HIV/AIDS and hepatitis C virus. The estimates of total drug users vary with figures ranging from 500,000 to 4.6 million in Bangladesh (GoB, 2008:3).

There are an estimated 20,000-40,000 IDUs in Bangladesh (Mathers et al, 2008; Azim et al, 2009; Reddy, Hoque and Kelly, 2008) with the largest concentration estimated to be in Dhaka city (approximately 7,400). Serological surveillance for HIV in Bangladesh, Round VIII, 2007 and other studies in Bangladesh have identified Injecting Drug Users (IDU) as the most at-risk population for hepatitis C (Amanullah, 2002; GoB, 2009, 2010).
Higher hepatitis c prevalence among IDUs in a low HIV prevalence setting

Hepatitis C prevalence is the most common among the injecting drug users where up to 98percent of the population can be infected despite a low prevalence of HIV (Nat and Tompkins 2006:27). In low HIV prevalence countries, surrogates of HIV, such as hepatitis C and B, which are mostly attributed to sharing of needles in these settings, have been reported with alarming sero-prevalence rates (Sarkar, Chatterjee and Bergenström 2003:277). In central European states, rates of HIV among injection drug users (IDUs) have been low although hepatitis C is widespread (Ráczab, Gyarmathycd and Neaigusde, 2007:59-66). In Japan hepatitis C antibodies were found among 75 per cent of the 47 IDUs tested (Ichimura et al, 1995). Today, around 4.87 million people are living with HIV in South, East and South-east Asia (UNAIDS, 2010).Pakistan is also an example where 89 per cent of IDUs to be infected with hepatitis C, while none of them tested positive for HIV (UNDCP and UNAIDS, 1999). Now the HIV prevalence among IDUs in Pakistan has already significantly increased to 21 percent in 2008 (UNAIDS, 2010).
Although the largest concentration in Bangladesh, Dhaka city is still a low prevalence, a 7 percent HIV prevalence level has been reported among IDUs (GoB, 2009) and hepatitis C prevalence rates have been reported at 54 percent in the same city (GoB, 2009), indicating considerable hepatitis C vulnerability among IDUs. No behavioral or other studies which could have provided insights into protective behaviors that could be promoted in harm reduction programs have been conducted in Bangladesh.
Multiple factors contribute to high levels of hepatitis C incidence and prevalence among IDUs, including the efficiency of transmission through the shared use of contaminated injecting equipment such as needles, syringes, and other items used to prepare and administer drugs (De et al, 2008; Maher et al, 2007). However, the impact of needle and paraphernalia sharing is far greater for hepatitis C transmission than HIV (Murray et al, 2003: 708-714). Clearly people who share injection drug equipment may introduce HIV and hepatitis C into their drug communities where these diseases have the ability to spread rapidly and infect large proportions of individuals who inject and share drugs (GoB, 2008; Amanullah, 2002; Habib, 2002, 2003).

Challenges in preventing hepatitis C transmission among injection drug users (IDUs) are it is more infectious than HIV, more prevalent among IDUs, greater transmission risk linked to sharing drugs and paraphernalia (e.g. cookers, cotton) , weaker cultural norms around hepatitis C prevention, lack of vaccine and behavioral interventions (Raymond, 2009).
Hepatitis c prevalence as an independent risk factor for HIV/AIDS

The near saturation of hepatitis C among IDUs is considered as a signal of looming HIV epidemic and a window of opportunity in which to prevent that from occurring (White et al, 2007:172). Hepatitis C infection has been found to be a significant independent risk factor for HIV seroconversion among IDUs (Backmund, 2005). In many studies, over 90 percent of HIV-infected IDUs are co-infected with hepatitis C (Maier and Wu, 2002; Miller et al, 2004). Among the HIV positive IDUs in Bangladesh, 84.3 percent were found to be hepatitis C positive. Without large scale efforts to contain the spread of hepatitis C and treat infected populations, the death rate from hepatitis C will surpass that of AIDS by the turn of the century and will only get worse.

Hepatitis c prevention and intervention programs
Primary prevention interventions have led to a reduction in HIV incidence; have been less effective at reducing hepatitis C incidence (Nat and Tompkins, 2006:27). Global prevalence of hepatitis C remains disturbingly high in injecting drug users. A robust response to the global health problem of hepatitis C will require provision of new interventions including sociological approach (Nat and Tompkins, 2006:27).

The picture for hepatitis C and the success of harm reduction (Wodak, 1997:275-284; Loxley, 2000:407-16; Habib, 2001, 2004) interventions in preventing hepatitis C transmission among IDUs is less clear; this is also the case internationally (ACMD, 2009). It is possible, and even likely, that HIV prevention programs have contributed to decreasing hepatitis C risk and infection (Page-Shafer, Hahn and Lum 2007). Still, the incidence of hepatitis C remains extremely high, even in settings where HIV incidence is low, and further decreases in hepatitis C are unlikely to continue in the absence of large-scale and effective behavior change interventions. This contrast of high hepatitis C incidence and low HIV incidence highlights the high infectiousness of hepatitis C; even infrequent injecting poses too great a risk to prevention of hepatitis C transmission (Page-Shafer, Hahn and Lum 2007:1967–1969). In Uganda, Thailand, and many high-income countries, early prevention successes have been followed years later by marked increases in risk behavior, which underscores the difficulty of sustaining prevention gains (GHPWG, 2008). It can be particularly difficult to preserve prevention achievements in the face of changes in the underlying social or physical environment that make hepatitis C seem less threatening (GHPWG, 2008).

In sub-Saharan Africa, where the HIV burden is heaviest, programs focusing on individual risk behavior are unlikely on their own to achieve the level of success needed to reverse the epidemic (UNAIDS and WHO, 2007). Although individual behavior change programs and initiatives that target groups at highest risk retain an important place in the region’s HIV prevention continuum, meaningful reductions in HIV prevention levels will require major population-wide changes in social norms with regard to sexual and relationship norms and gender equity (U.N. Secretary-General 2008).
HIV intervention programs restricted to awareness and information, education and communication (IEC) in South Asia to promote knowledge on modes of HIV transmission combined with awareness raising on methods of cleaning injecting equipment and promotion of non-sharing of needles are of limited effectiveness (Sarkar et al, 1995; Sarkar, Chatterjee and Bergenström, 2003:277). Moreover, favorable behavior changes seen in individuals during the first year following exposure to a prevention intervention can fade over time (Epstein, 2007). Frequently, the first HIV intervention drug users are subject to is an awareness program including information on the transmission modes with the assumption that IEC will lead to behavior change (Sarkar, Chatterjee and Bergenström, 2003:277). In spite of considerable literature on behavior change theories and findings from India (Sarkar et al, 1995), Bangladesh (Jenkins et al, 2001), Nepal (FHI) and Pakistan (UNDCP and UNAIDS, 1999) that awareness alone does not result in behavior change among drug users, most interventions for this population in South Asia continue to be awareness focused. South-East Asia is no exception as the majority of the countries are implementing HIV interventions focused on drug users mostly through IEC and awareness without provision of effective services using rational actor theories as a basic framework for understanding social responses to risk and to design policies that fit the needs of risk managers. Majority of the stated researches and programs followed the Health Belief Model (HBM) (Rosenstock, 1974) which is a widely used psychological model to the prevention programs of developing countries to address the risk behavior of hepatitis C among the injecting drug users.

Hepatitis C among IDUs is a much neglected aspect of the harm reduction program in Bangladesh (GoB, 2008). However, behavior change intervention is a major component to prevent hepatitis C among the Injecting Drug Users (IDUs) of Bangladesh (GoB, 2008). It has been newly addressed in the field of hepatitis C related risk behavior aiming to provide harm reduction services and knowledge about hepatitis C as a part of HIV intervention structure, specialized for IDUs, the most at risk group of hepatitis C Virus (HCV) transmission (GoB, 2009). In Bangladesh, prevalence and incidence of hepatitis C were 66.8 percent in 2002 among male IDUs and 16.8 percent in 2005 among the female IDUs which has increased to 74.9 percent and 25 percent in 2006 respectively (ICDDRB, 2007). The national response in Bangladesh through Drop in Centers (DICs) has traditionally been based on a service provider approach. Behavior Change Communication (BCC) in relation to minimizing hepatitis C related risk behavior is part of an integrated, multilevel, interactive process with communities aimed at providing tailored messages about hepatitis C transmission and change IDUs’ attitude and practice regarding hepatitis C risk behavior. It aims to foster positive behavior, promote and sustain individual, community and social behavior change and maintain appropriate behavior.

The percentage of IDU populations covered with HIV/AIDS prevention in 2009 in Bangladesh is 2.1 percent (GoB, 2009; UNGASS, 2010). Harm reduction services for IDUs were initiated in Dhaka, Bangladesh in 1998, and later expanded to other cities and 20000 IDUs were covered through the Government’s HIV/ IDS Targeted Intervention (HATI) program and GFATM round 6 HIV Prevention project which finished in June 2009. The package of services includes: needle/syringe exchange programs (NEP), condom promotion and distribution, BCC, STI treatment, abscess management, advocacy, referrals to detoxification and rehabilitation programs, and in some instances short term community based detoxification camps. The needle/syringe exchange program (NEP) in Dhaka was initiated early, before the HIV epidemic started (UNAIDS, 2010). The NEP also provides knowledge on hepatitis C and harm reduction services. This is the only structure for reducing hepatitis C related risk behavior in Bangladesh. However, now that there is a concentrated HIV epidemic in Dhaka it is time to reassess these programs.