When and how do individuals transition from regular drug use to injection drug use in Uganda? Findings from a rapid assessment

Estimation of the Population Size of Street- and Venue-Based Female Sex Workers and Sexually Exploited Minors in Rwanda in 2022: 3-Source Capture-Recapture

BACKGROUND

HIV surveillance among key populations is a priority in all epidemic settings. Female sex workers (FSWs) globally as well as in Rwanda are disproportionately affected by the HIV epidemic; hence, the Rwanda HIV and AIDS National Strategic Plan (2018-2024) has adopted regular surveillance of population size estimation (PSE) of FSWs every 2-3 years.

OBJECTIVE

We aimed at estimating, for the fourth time, the population size of street- and venue-based FSWs and sexually exploited minors aged ≥15 years in Rwanda.

METHODS

In August 2022, the 3-source capture-recapture method was used to estimate the population size of FSWs and sexually exploited minors in Rwanda. The field work took 3 weeks to complete, with each capture occasion lasting for a week. The sample size for each capture was calculated using shinyrecap with inputs drawn from previously conducted estimation exercises. In each capture round, a stratified multistage sampling process was used, with administrative provinces as strata and FSW hotspots as the primary sampling unit. Different unique objects were distributed to FSWs in each capture round; acceptance of the unique object was marked as successful capture. Sampled FSWs for the subsequent capture occasions were asked if they had received the previously distributed unique object in order to determine recaptures. Statistical analysis was performed in R (version 4.0.5), and Bayesian Model Averaging was performed to produce the final PSE with a 95% credibility set (CS).

RESULTS

We sampled 1766, 1848, and 1865 FSWs and sexually exploited minors in each capture round. There were 169 recaptures strictly between captures 1 and 2, 210 recaptures exclusively between captures 2 and 3, and 65 recaptures between captures 1 and 3 only. In all 3 captures, 61 FSWs were captured. The median PSE of street- and venue-based FSWs and sexually exploited minors in Rwanda was 37,647 (95% CS 31,873-43,354), corresponding to 1.1% (95% CI 0.9%-1.3%) of the total adult females in the general population. Relative to the adult females in the general population, the western and northern provinces ranked first and second with a higher concentration of FSWs, respectively. The cities of Kigali and eastern province ranked third and fourth, respectively. The southern province was identified as having a low concentration of FSWs.

CONCLUSIONS

We provide, for the first time, both the national and provincial level population size estimate of street- and venue-based FSWs in Rwanda. Compared with the previous 2 rounds of FSW PSEs at the national level, we observed differences in the street- and venue-based FSW population size in Rwanda. Our study might not have considered FSWs who do not want anyone to know they are FSWs due to several reasons, leading to a possible underestimation of the true PSE.

Population Size Estimation of Men Who Have Sex With Men in Rwanda: Three-Source Capture-Recapture Method

BACKGROUND

Globally, men who have sex with men (MSM) continue to bear a disproportionately high burden of HIV infection. Rwanda experiences a mixed HIV epidemic, which is generalized in the adult population, with aspects of a concentrated epidemic among certain key populations at higher risk of HIV infection, including MSM. Limited data exist to estimate the population size of MSM at a national scale; hence, an important piece is missing in determining the denominators to use in estimates for policy makers, program managers, and planners to effectively monitor HIV epidemic control.

OBJECTIVE

The aims of this study were to provide the first national population size estimate (PSE) and geographic distribution of MSM in Rwanda.

METHODS

Between October and December 2021, a three-source capture-recapture method was used to estimate the MSM population size in Rwanda. Unique objects were distributed to MSM through their networks (first capture), who were then tagged according to MSM-friendly service provision (second capture), and a respondent-driven sampling survey was used as the third capture. Capture histories were aggregated in a 2k-1 contingency table, where k indicates the number of capture occasions and "1" and "0" indicate captured and not captured, respectively. Statistical analysis was performed in R (version 4.0.5) and the Bayesian nonparametric latent-class capture-recapture package was used to produce the final PSE with 95% credibility sets (CS).

RESULTS

We sampled 2465, 1314, and 2211 MSM in capture one, two, and three, respectively. There were 721 recaptures between captures one and two, 415 recaptures between captures two and three, and 422 recaptures between captures one and three. There were 210 MSM captured in all three captures. The total estimated population size of MSM above 18 years old in Rwanda was 18,100 (95% CS 11,300-29,700), corresponding to 0.70% (95% CI 0.4%-1.1%) of total adult males. Most MSM reside in the city of Kigali (7842, 95% CS 4587-13,153), followed by the Western province (2469, 95% CS 1994-3518), Northern province (2375, 95% CS 842-4239), Eastern province (2287, 95% CS 1927-3014), and Southern province (2109, 95% CS 1681-3418).

CONCLUSIONS

Our study provides, for the first time, a PSE of MSM aged 18 years or older in Rwanda. MSM are concentrated in the city of Kigali and are almost evenly distributed across the other 4 provinces. The national proportion estimate bounds of MSM out of the total adult males includes the World Health Organization's minimum recommended proportion (at least 1.0%) based on 2012 census population projections for 2021. These results will inform denominators to be used for estimating service coverage and fill existing information gaps to enable policy makers and planners to monitor the HIV epidemic among MSM nationally. There is an opportunity for conducting small-area MSM PSEs for subnational-level HIV treatment and prevention interventions.

A Pilot Study of Polysubstance Use Sequences across the Lifespan among Assiniboine and Sioux People Who Use Injection Drugs

Compared with other racial/ethnic groups in the United States, American Indians/Alaska Natives have the highest rates of acute Hepatitis C Virus (HCV) infection, the highest HCV-related mortality, and one of the fastest climbing rates of drug overdose deaths involving stimulants. In this pilot study, a life history calendar was administered to Indigenous people who use injection drugs (IPWIDs) to understand sequences of polysubstance use across the lifespan. 40 IPWIDs completed a questionnaire and life history calendar. Social sequence analysis was used to examine patterns in sequential phenomena among substances reported over years of the lifespan. Most participants (55%) began injecting substances before the age of 21, 62.5% shared syringes with others, and 45% had ever been diagnosed with HCV. An appreciably large increase in the use of stimulants occurred between the year prior to and following injection initiation (33% to 82%). A three-cluster solution distinguished younger IPWIDs transitioning into polysubstance use involving stimulants and/or narcotic analgesics from adults using narcotic analgesics with stimulants over longer periods of time, and adults most focused on stimulant use over time. Findings from this pilot study contribute to an understanding of how methamphetamine injection plays a role in the HCV epidemic among IPWIDs.

Factors associated with smoking and transitioning to nyaope injection amongst women in the City of Tshwane Municipality: A self-report by women

Background

Substance use disorder has emerged as a key health and social challenge in South Africa (SA). It is projected that about 15% of South African youth, especially young women are prone to engage in drug use and the prospects of coming into contact with nyaope, a highly addictive drug, are higher. Nyaope is mainly smoked, but the prevalence of injecting it is increasing in most regions.

Aim

This study aimed to explore and describe the perception of women, who use nyaope, about the factors contributing to nyaope smoking and transitioning to injecting nyaope amongst women in the City of Tshwane Municipality (CoT), Gauteng.

Setting

The research was conducted within Community Oriented Substance Use Programme sites across the CoT Municipality.

Methods

Qualitative research methods were utilised to explore and describe the perceptions of the participants on factors contributing to the use of nyaope amongst women residing in the CoT. Data were collected through face-to-face interviews and thematically analysed.

Results

Intimate partner influence (IPI), peer pressure, being misled by friends, weight loss, lack of effective coping mechanisms and counteracting other drugs contributed to women smoking nyaope. Additionally, a need for an intense high, IPI, influence by the social network, curiosity and cost-effectiveness contributed to women transitioning from smoking to injecting nyaope.

Conclusion

The study has established factors contributing to smoking and transition to injecting nyaope as viewed by women residing in the CoT.

Contribution

This research affirms that women are influenced by different factors to use and transition to injecting Nyaope.

Associations between alexithymia, parental rearing styles, and frequency of drug use in male methamphetamine dependence patients

BACKGROUND

Alexithymia, which is characterized by difficulty identifying and describing feelings, is a stable personality trait and it has been associated with early life experiences. Methamphetamine dependence patients with high level of alexithymia may be particularly vulnerable to engaging in more frequent methamphetamine use. Therefore, we aimed to evaluate whether alexithymia was associated with frequency of methamphetamine use. Additionally, the current study sought to examine early-life factors associated with the development of alexithymia, i.e., parental rearing styles.

METHOD

Participants were 108 non-injecting methamphetamine dependent patients from a male compulsory detoxification center. The level of alexithymia was assessed by Toronto Alexithymia Scale-20(TAS-20). In addition, we applied Egna Minneu av. Bardndosnauppforstran (EMBU) to assess the parental rearing styles, including the dimensions of warmth, rejection, punishment/strictness, overinvolvement, overprotection, and favoring.

RESULTS

The total score of TAS-20 was positively correlated with frequency of methamphetamine use (r = 0.26, p < 0.01). Specifically, except for externally oriented thinking, difficulty identifying feelings (r = 0.23, p < 0.05) and difficulty describing feelings (r = 0.25, p < 0.05) were positively correlated with frequency of methamphetamine use. Multiple linear regression showed that more maternal rejection (B = 0.59, p = 0.002), or less maternal warmth (B = -0.22, p = 0.004) was associated with higher levels of alexithymia. Ordinal logistic regression showed that for every 1 score increase in the total score of TAS-20, there was a 1.06 times risk of a one level increase in the level of methamphetamine use frequency (OR = 1.06, p = 0.01).

CONCLUSIONS

These results have major implications for understanding the role of alexithymia in craving and addiction, while providing a further and explicit entry point for addiction treatment. Moreover, more attention should be focused on parenting in relation to early experiences.

Perceived and misperceived norms about khat and/or cannabis use among adults in southwest Uganda

BACKGROUND

Studies from high-income contexts have found evidence that norms about substance use are misperceived. The accuracy of perceived norms about khat and cannabis use in Uganda have not previously been described.

METHODS

We conducted a population-based study targeting all resident adults across eight villages in southwestern Uganda. Personal khat and/or cannabis use frequency was based on self-report. We measured perceived norms about substance use by eliciting individuals' perceptions about how often most other adult men and most other adult women in their villages used these substances. We compared perceived norms to aggregated village rates of use to assess the extent to which norms were misperceived. We used multivariable Poisson regression to estimate correlates of misperceived norms.

RESULTS

Among 1626 participants (91% response rate), only 29 men (4%) and 9 women (1%) reported any lifetime use of khat and/or cannabis. However, 695 participants (43%) did not think lifetime abstinence was the norm among men in their villages, and 256 participants (16%) did not think lifetime abstinence was the norm among women. Moreover, 219 participants (13%) incorrectly believed most men in their village regularly used khat and/or cannabis (≥4 times per week). Misperceived norms were present across subgroups and were correlated with larger social networks, symptoms of depression, loneliness, and younger age.

CONCLUSION

In this study of all adults across 8 villages in rural Uganda, many participants misperceived norms about khat and/or cannabis use. Providing accurate information about prevailing norms in the local population may help prevent initiation of khat and/or cannabis use among adults in this context.

Characterization of Acute HCV Infection and Transmission Networks in People Who Currently Inject Drugs in Catalonia: Usefulness of Dried Blood Spots

BACKGROUND AND AIMS

Accurate identification of recent HCV infections is critical for tracing the extent and mechanisms of ongoing transmission. We aimed to validate dried blood spot (DBS) samples for the assessment of Hepatitis C virus (HCV) genetic diversity and to determine epidemiological parameters including incidence, determinants of acute infection, and phylogenetic clustering in people who inject drugs (PWID).

APPROACH AND RESULTS

HCV nonstructural protein 5B next-generation sequencing was performed from plasma and/or DBS in 220 viremic PWID from the HepCdetect II study. No significant differences were found in consensus sequences or Shannon entropy (SE) intrahost diversity estimate between paired plasma/DBS specimens. SE values were used to identify acute infections with 93.3% sensitivity (95% CI, 0.81-1.06) and 95.0% specificity (95% CI, 0.88-1.02) in a set of well-defined controls. An acute HCV infection (either primary infection or reinfection) was detected in 13.5% of viremic participants and was associated with age ≤30 years (OR, 8.09), injecting less than daily (OR, 4.35), ≤5 years of injected drug use (OR, 3.43), sharing cocaine snorting straws (OR, 2.89), and being unaware of their HCV status (OR, 3.62). Annualized HCV incidence was estimated between 31 and 59/100 person-years. On phylogenetic analysis, 46.8% of viremic cases were part of a transmission pair or cluster; age ≤30 years (OR, 6.16), acute infection (OR, 5.73), and infection with subtype 1a (OR, 4.78) were independently associated with this condition.

CONCLUSIONS

The results obtained from plasma and DBS characterize PWID with acute infection and those involved in ongoing HCV transmission and allow estimating incidence from cross-sectional data. This information is critical for the design and assessment of targeted harm reduction programs and test-and-treat interventions and to facilitate monitoring of HCV elimination in this key population.

Associations Between Childhood Trauma and the Age of First-Time Drug Use in Methamphetamine-Dependent Patients

Childhood trauma is related to substance use disorder; however, few studies have examined the relationship between childhood trauma and the age at which the drug was first used. The aim of this study was to investigate the relationship between childhood trauma and the age of first-time drug use among methamphetamine-dependent patients. Moreover, we analyzed the characteristics of adverse family environment associated with severe childhood trauma and the risk factors for starting drugs in minors. A baseline interview was conducted with 110 participants who were in detoxification, including demographic information, past substance use, and age of first-time drug use. The participants' childhood trauma experience before 18 years of age was evaluated using the simplified version of the Childhood Trauma Questionnaire (CTQ-SF). The Chinese version of the Family Environment Scale (FES-CV) was used to assess the family environment of methamphetamine-dependent patients. Among 110 non-injecting methamphetamine-dependent patients, nearly half (n = 48, 43.6%) had moderate and severe childhood trauma. Correlation analysis showed that the age of first-time drug use negatively correlated with emotional abuse (r = -0.32, p < 0.01) and physical abuse (r = -0.27, p < 0.01). The age of first-time drug use negatively correlated with conflict (r = -0.20, p < 0.05) and independence (r = -0.22, p < 0.05) of family environment, but positively correlated with intellectual-cultural orientation (r = 0.28, p < 0.01). Additionally, childhood trauma factors significantly correlated with many indexes of family environment, especially cohesion (r = -0.45, p < 0.01), conflict (r = 0.49, p < 0.01), and independence (r = 0.33, p < 0.01). Additionally, the regression model showed that when emotional abuse increased by one point, the age of first-time drug use was 0.69 years earlier. These findings suggest that a detrimental family environment can aggravate childhood trauma, and the experience of childhood emotional or physical abuse may be an effective predictor of early drug use among methamphetamine-dependent patients.