A cross-sectional assessment of utilization of addiction treatment among injection drug users in Kabul, Afghanistan

Barriers and facilitators to accessing inpatient and community substance use treatment and harm reduction services for people who use drugs in the Muslim communities: A systematic narrative review of studies on the experiences of people who receive services and service providers

BACKGROUND

The prevalence of drug use in Muslim communities is difficult to estimate due to religious, social, and cultural prohibition toward drug use. With Islam affecting all aspects of life in the Muslim world, people who use drugs do it clandestinely to avoid stigma and exclusion from the community, leading to a low number of them seeking treatment for their drug use. This review explored the barriers and facilitators to accessing inpatient and community substance use treatment and harm reduction services for people who use drugs in Muslim communities.

METHODS

This review was in accordance with PRISMA. Seven databases were systematically searched for qualitative, quantitative, and mixed methods studies conducted in countries where at least 70% of the population were Muslim or where data were presented separately for Muslim communities in other countries. Eligible articles were reviewed, and key qualitative themes were abstracted and compared across studies and settings.

RESULTS

Twenty-four studies were included from Iran, Bangladesh, Afghanistan, Tajikistan, Kazakhstan, Kyrgyzstan, Egypt, Lebanon, and UAE. Two themes were identified: a psychosocial theme included denial of the problem severity, lack of trust in the treatment system, fear of breach in confidentiality and privacy, the need for community support, religion and women who use drugs. Additionally, an organizational theme included affordability, treatment Service characteristics, lack of Awareness, service providers' Attitudes, drug use registration and fear of legal consequences of drug use. Stigma was also identified as an over-arching theme. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of the included studies with where 12 of the studies met all 5 the quality criteria. No studies were excluded for having lower quality scores.

CONCLUSION

This review reflected how diverse the Muslim world is in drug use. It is important to use mosques to raise awareness on people who use drugs and reduce stigma. Providing holistic services for people who use drugs specially women will improve their access to treatment and harm reduction services in the Muslim world.

Understanding injecting drug use in Afghanistan: A scoping review

Background

Several reports have described a growing prevalence of illicit drug use in Afghanistan, with recognition of a recent shift from traditional modes of consumption involving inhalation and oral ingestion to injecting drug use.

Objective

Conduct a comprehensive review of existing literature to map the injecting drug use situation in Afghanistan. The review intends to describe risk factors and impacts of injecting drug use, drug use characteristics and risk behaviours among people who inject drugs (PWID), and access to harm reduction and treatment.

Methods

We searched Embase, Global Health, Medline, PsycINFO, Web of Science, and grey literature to identify English language publications up to March 26^th, 2022. Studies were eligible for inclusion if they explicitly targeted PWID or injecting drug use in Afghanistan and provided information relevant to the review questions. Two reviewers independently screened titles and abstracts for inclusion and extracted information based on the review objectives.

Results

A total of 25 articles were identified representing 15 studies (11 quantitative, 2 qualitative, 2 mixed methods). All but one studies were cross-sectional. In majority of the studies, over 95% of the participants were male and most were conducted over a decade ago, in urban settings, mainly Kabul. Only one study examined risk factors of injecting drug use. Eleven studies described drug use characteristics and 9 reported risk behaviours among PWID. Health and social burden of injecting drug use were reported by 8 and 5 studies, respectively. Nine studies described access to harm reduction and treatment. Afghan PWID had high levels of injecting and sexual risk behaviours compared to global estimates. They reported high prevalence of incarceration and displacement. Access to harm reduction and treatment was very limited. This scoping review revealed important knowledge gaps including a gender gap in research with serious implications for drug policy and substance use care.

Conclusions

Development of a national public health-oriented drug policy and substance use care programme is warranted along with efforts to develop health research capacity to address the need for epidemiological data. The current humanitarian crisis necessitates continued access to evidence-based harm reduction and treatment in Afghanistan.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-022-00491-1.

Determinants of health among people who use illicit drugs in the conflict-affected countries of Afghanistan, Colombia and Myanmar: a systematic review of epidemiological evidence

BACKGROUND

Afghanistan, Colombia and Myanmar are the world's leading heroin and cocaine producers and have also experienced prolonged periods of armed conflict. The link between armed conflict and drug markets is well established but how conflict impacts on the health and social determinants of people who use drugs is less clear. The aim was to investigate health outcomes and associated factors among people who use illicit drugs in Afghanistan, Colombia and Myanmar.

METHODS

We conducted a systematic review searching Medline, EMBASE, PsychINFO and Global Health databases using terms relating to Afghanistan, Colombia and Myanmar; illicit drug use (all modes of drug administration); health and influencing factors. Quality assessment was assessed with the Newcastle-Ottawa-Scale and papers were analysed narratively.

RESULTS

35 studies were included in Afghanistan (n = 15), Colombia (n = 9) and Myanmar (n = 11). Health outcomes focused predominantly on HIV, Hepatitis C (HCV), Hepatitis B and sexually transmitted infections (STIs), with one study looking at human rights violations (defined as maltreatment, abuse and gender inequality). Drug use was predominantly injection of heroin, often alongside use of amphetamines (Myanmar), cocaine and cocaine-based derivatives (Colombia). Only one study measured the effect of a period of conflict suggesting this was linked to increased reporting of symptoms of STIs and sharing of needles/syringes among people who inject drugs. Findings show high levels of external and internal migration, alongside low-income and unemployment across the samples. External displacement was linked to injecting drugs and reduced access to needle/syringe programmes in Afghanistan, while initiation into injecting abroad was associated with increased risk of HCV infection. Few studies focused on gender-based differences or recruited women. Living in more impoverished rural areas was associated with increased risk of HIV infection.

CONCLUSIONS

More research is needed to understand the impact of armed-conflict and drug production on the health of people who use drugs. The immediate scale-up of harm reduction services in these countries is imperative to minimize transmission of HIV/HCV and address harms associated with amphetamine use and other linked health and social care needs that people who use drugs may face.

Factors Associated with HIV Risk and Vulnerability Among Injecting Drug Users in Afghanistan: A Narrative Review

The number of human immunodeficiency virus (HIV) cases in Afghanistan is increasing mainly associated with injecting drug use (IDU). This study aimed to explore the risk and vulnerability factors associated with HIV infection among injecting drug users (IDUs) in Afghanistan in order to contribute to improving the response and reversing the concentrated HIV epidemic among this group. A narrative review of the literature was conducted to reach the objective. The modified social ecological model was used as conceptual framework for analysis of the HIV risk and vulnerability factors among IDUs at five levels. At the “individual level”, the injecting risk behaviors among IDUs such as sharing the injecting equipment and their sexual risk behaviors like unprotected sexual contact with multiple partners identified as immediate factors that put them at risk of HIV infection. At the “network level”, lack of HIV knowledge and low uptake of the harm reduction services were identified as the factors that increase their vulnerability. At the “community level”, massive drug production and easy access to illicit drugs, armed conflicts, massive internal and external migration, unemployment and poverty, high stigma and discrimination against IDUs, unsafe injecting locations such as under the bridges; and at the “public policy level”, punitive drug laws, and weak national political response to HIV and IDU were identified as determinants that add to the IDUs vulnerability to HIV. At the “stage of epidemic level”, the concentrated HIV epidemic among IDUs in the country poses a potential risk to uninfected IDUs and beyond. In conclusion, the IDUs in Afghanistan are highly at risk and vulnerable to HIV. An informed and multisectoral response is required to control the epidemic. A rapid expansion of the harm reduction interventions is urgently needed.

Determination of epidemiological characteristics of addicts treated in drug addiction clinics in Kabul

According to the Afghanistan Ministry of Health, 3.5 million people use drugs, 2.4 million of which are regular users. In this cross-sectional study, it was aimed to determine epidemiological characteristics of addicts in a treatment center in Kabul. Eight hundred people were included. Statistical analysis was done with SPSS 22.0. The average age was 30.74 years, 88.9% were male, and 50.6% were married. Further, 35.9% have never been trained, 60.5% of participants were living in urban areas, 62.8% were refugees, 17.5% were unemployed, and 30.3% of them had monthly income below 147.1 USD. The average age of starting substance use was 19.9 years. "Friendship environment" was the leading reason to start (36.6%), followed by "reduce troubles" with 22.3%. The most preferred substance was cannabis (46.0%), followed by opium (25.3%) and heroin (17.0%). Heroin was the most commonly used substance lifelong (87.1%), followed by cannabis (66.3%) and opium (65.5%). When compared to individuals younger than 18, heroin use rates were 3.52 times higher in the 18-to-30 age range, 5.49 times higher in the 31-to-45 age range, and 1.86 times higher in urban residents than rural. Cannabis use was 12.24 times more among men than women, 2.79 times higher among divorced or widowed individuals than singles, 1.68 times higher among refugees than non-refugees, and 2.26 times higher among drug traffickers than non-traffickers. Opium use was 1.63 times higher for refugees than non-refugees and 3.24 times higher in those who worked in drug fields than those who did not. Periodic assessment of prevalence of drug use and the establishment of drug use monitoring systems are recommended.

The epidemiology of hepatitis C virus in Afghanistan: systematic review and meta-analysis

OBJECTIVES

To characterize hepatitis C virus (HCV) epidemiology and inform public health research, policy, and programming priorities in Afghanistan.

METHODS

Records of HCV incidence and prevalence were reviewed systematically and synthesized following PRISMA guidelines. Meta-analyses were implemented using a DerSimonian-Laird random effects model with inverse variance weighting to estimate HCV prevalence among various at risk populations. A risk of bias assessment was incorporated.

RESULTS

The search identified one HCV incidence and 76 HCV prevalence measures. HCV incidence was only assessed among people who inject drugs (PWID), and was reported at 66.7 per 100 person-years. Meta-analyses estimated HCV prevalence at 0.7% among the general population (range 0-9.1%, 95% confidence interval (CI) 0.5-0.9%), 32.6% among PWID (range 9.5-70.0%, 95% CI 24.5-41.3%), and 2.3% among populations at intermediate risk (range 0.0-8.3%, 95% CI 1.3-3.7%). No data were available for other high risk populations such as hemodialysis, thalassemia, and hemophilia patients.

CONCLUSIONS

HCV prevalence among the general population in Afghanistan is comparable to global levels. Data are needed for the level of infection among key clinical populations at high risk of infection. There is also an immediate need for expansion of harm reduction programs among PWID and prisoners.

Prevalence and correlates of HIV, syphilis, and hepatitis B and C infection and harm reduction program use among male injecting drug users in Kabul, Afghanistan: A cross-sectional assessment

Background

A nascent HIV epidemic and high prevalence of risky drug practices were detected among injecting drug users (IDUs) in Kabul, Afghanistan from 2005-2006. We assessed prevalence of HIV, hepatitis C virus (HCV), hepatitis B surface antigen (HBsAg), syphilis, and needle and syringe program (NSP) use among this population.

Methods

IDUs were recruited between June, 2007 and March, 2009 and completed questionnaires and rapid testing for HIV, HCV, HBsAg, and syphilis; positive samples received confirmatory testing. Logistic regression was used to identify correlates of HIV, HCV, and current NSP use.

Results

Of 483 participants, all were male and median age, age at first injection, and duration of injection were 28, 24, and 2.0 years, respectively. One-fifth (23.0%) had initiated injecting within the last year. Reported risky injecting practices included ever sharing needles/syringes (16.9%) or other injecting equipment (38.4%). Prevalence of HIV, HCV Ab, HBSAg, and syphilis was 2.1% (95% CI: 1.0-3.8), 36.1% (95% CI: 31.8-40.4), 4.6% (95% CI: 2.9-6.9), and 1.2% (95% CI: 0.5-2.7), respectively. HIV and HCV infection were both independently associated with sharing needles/syringes (AOR = 5.96, 95% CI: 1.58 - 22.38 and AOR = 2.33, 95% CI: 1.38 - 3.95, respectively). Approximately half (53.8%) of the participants were using NSP services at time of enrollment and 51.3% reported receiving syringes from NSPs in the last three months. Current NSP use was associated with initiating drug use with injecting (AOR = 2.58, 95% CI: 1.22 - 5.44), sharing injecting equipment in the last three months (AOR = 1.79, 95% CI: 1.16 - 2.77), prior incarceration (AOR = 1.57, 95% CI: 1.06 - 2.32), and greater daily frequency of injecting (AOR = 1.40 injections daily, 95% CI: 1.08 - 1.82).

Conclusions

HIV and HCV prevalence appear stable among Kabul IDUs, though the substantial number having recently initiated injecting raises concern that transmission risk may increase over time. Harm reduction programming appears to be reaching high-risk drug user populations; however, monitoring is warranted to determine efficacy of prevention programming in this dynamic environment.

Opium trade, insurgency, and HIV/AIDS in Afghanistan: relationships and regional consequences

Global health and conflict studies share key linkages that have important research and policy implications but for which data are currently lacking. This analytical review examines the ongoing conflict in Afghanistan, using it as a basis to develop a conceptual framework that integrates security and public health concepts. The analysis draws on recent peer-reviewed and gray literature to assess the interrelationship among 3 variable clusters and their impact on the emergence of the HIV epidemic in Afghanistan. The evidence suggests that there is a complex indirect relationship linking illicit opium trade, the ongoing insurgency, and forced and spontaneous migration to the emergence of an injection drug use-driven HIV epidemic in Afghanistan. These findings demonstrate a clear need for an integrated cross-disciplinary and regional approach to the emerging threat of HIV/AIDS in Afghanistan, to inform more balanced and effective policy making in this and other regions of strategic global import.