1. Hepatitis C: A hidden epidemic among People Who Inject Drugs (PWID) in Bangladesh Workshop on SRH and HIV linkages for KAP 24 – 27 August 2015 Ezazul Islam Chowdhury, Md. Masud Reza, M. Rahman, Md. Zafrul Hasan, Chandra Nath Roy and Tasnim Azim.

2. Harm reduction services in Bangladesh: what is needed and what is available Needle and syringe programmes √ Condom programming √ Targeted information, education and communication √ Prevention and treatment of sexually transmitted infections √ Voluntary counselling and testing √ Anti-retroviral therapy √ Opioid substitution therapy (OST) √ Tuberculosis prevention, diagnosis and treatment √ X Hepatitis diagnosis, treatment and vaccination; X

3. Mainly blood-borne, infectious, viral disease that is caused by the hepatitis C virus (HCV). Hepatitis C How does it infect HCV transmission occurs when traces of blood from an infected person enters the body of a HCV-negative person. HCV is spread through sharing injection equipment i.e., needle syringe and other paraphernalia like ampoule, cotton etc. Consequences About 15 to 45 percent of infected persons spontaneously clear the virus within 6 months of infection without any treatment. The remaining 55 to 85 percent of persons will develop chronic HCV infection. Of those with chronic HCV infection, the risk of cirrhosis of the liver is 15 to 30 percent within 20 years, and 5 to 7 percent will develop liver failure or liver cancer (J Hepatol 2006; 44 (1 Suppl): S6-9)

4. Up to 80% of people with HCV usually develop no symptoms Initial symptoms: can include jaundice, fatigue, dark urine, abdominal pain, loss of appetite and nausea etc. Symptoms The treatment (Interferon is given alone or in combination with ribavirin usually for a 12-month ) for HCV is available BUT very expensive – costing on average approximately US$250 per week ( The Seoul Times, Report from Boby Ramakant, Asia correspondent), Neglect of Hepatitis C leaves with HIV vulnerable) Treatment

5. Global situation of HCV and situation in Bangladesh There are an estimated 170 million people chronically infected with the Hepatitis C virus (HCV). Every year 3 to 4 million people are newly infected and 350,000 people die ( Hepatology. 2013; 57(4): 1333-42) Approximately 67 percent of PWID are infected with HCV; representing 10 million people across 148 countries ( Lancet. 2011; 378(9791): 571-83. Bangladesh – 2.4% of total population, which is more than India (1.8%), Nepal (0.6%) (WHO, Hepatitis C, Global Infection Rate reviewed in 2006)

6. Epidemiology of HCV risk and vulnerability of PWIDs in Bangladesh Sources of data: HIV Surveillance PWID cohort study

7. Serological surveillance is conducted regularly among PWID in Bangladesh – antibodies to HIV, HCV and syphilis are measured In 2011, the 9 th round of surveillance was conducted 7529 PWID sampled from 30 cities

8. HCV prevalence among PWID and combined PWID and heroin smokers Source: Bangladesh serological surveillance, 2007: NASP, (unpublished)

9. A cohort study on male PWID was initiated in two areas of Dhaka, Bangladesh in 2002 with the collaboration of CARE Bangladesh Area A Area B PWIDs in Dhaka: HIV - 7%, HCV - 54% PWIDs who were: 15 years and older injected drugs at least once in the last two months did not change their neighbourhood where they lived in the last six months West Bengal

10. Study steps Explored the IPWID spots with CARE Bangladesh outreach workers and through their own networks Semi-structured behavioural questionnaire was administered at the spots Clinical examination and blood drawing were conducted at the DIC of CARE Bangladesh Laboratory tests for HIV, HCV and syphilis were done at the Virology Laboratory of icddr,b Results were provided by the physician except HIV positive results which were provided by the counselors of the VCT Unit of Iiddr,b 10 Procedure was repeated every six months Study conducted between 2002-2007 IDU Injecting SpotBehavioural data collection CounselingClinical examination

11. Data analysis Data collected during Oct 2003 - Feb 2004 were used to analyze risk factors for HCV (N=430) Different features associated with HCV was determined by using bivariate analysis Factors that were found to be significantly associated with being HCV positive at the 10% level in the bivariate analysis were included in a backward stepwise logistic regression model

12. Prevalence of HCV among PWIDs in the cohort study Out of 561 IDUs, 434 were HCV positive (77%) in 5 year follow-up Of 179 HCV negative, 59 (33%) seroconverted to HCV positive by the end of the study for five years suggesting an incidence rate of 11.6 infections/100 person-years

13. Demographic information

14. Injection and sharing behaviour Injection paraphernalia (drug ampoule) sharing through front loading

15. Sharing injection paraphernalia 69.5% PWIDs in Dhaka shared paraphernalia in past two months (BSS 2006-2007). Such sharing leads to spread of hepatitis C Sharing ampoule, cotton etc. previously used by others

16. Transition period between initiating drugs and injecting and injection sharing network size A network of PWIDs

17. PWIDs are not isolated 4 PWIDs sold blood in last six months and of them all were HCV positive

18. Table 1. Risk factors for HCV (Multivariate analysis) Adjusted odds ratio95% CI Location Area A Area B 2.0* 1.0 1.1-3.5 - Duration of injection (in years) ≤ 5 > 5-10 >10 1.0 2.1* 4.7** - 1.1-3.7 1.9-11.6 Age at 1 st drugs (in years) > 15-19 >1 9-24 3.6*** 1.0 1.8-7.1 - Duration of drug use (in years) ≤ 5 > 5-10 >10-20 > 20 1.0 Dropped 2.1** Dropped - 1.2-3.7 - Borrowed used needle/syringes in last week (among those who injected in last week Yes No 2.2* 1.0 1.2-4.1 - N=325, Model Chi-square=48.3, p<0.001; Significant level: *p<0.05, **p<0.01, ***p<0.001

19. Co-infection of HIV with HCV in the PWID cohort, original (n=57)

20. Sharing network of an HIV positive IDU Red circles indicate HIV positive IDU Green circles indicate HIV negative IDU Arrows show who was sharing with whom -red if both partners were HIV+, blue if one was HIV+

21. Conclusions HCV rates are high among Dhaka male PWID and higher in those living in area A The risk factors for HCV are related to both social factors and individual risk behaviours PWIDs are not isolated and HCV can potentially spread through their sexual and injection networks as well as to the general population through commercial blood donation

22. Recommendations HCV infection among PWIDs needs attention – it is a much neglected aspect of the harm reduction programme in Bangladesh Areas where high HCV is reported in surveillance including north west of Bangladesh need extra attention Younger PWIDs need to be especially targeted for safer behaviours Policy dialogue needs to be started to arrange test and treat of PWIDs for HCV and understanding the issue through research 99.6% had heard of HIV/AIDS but only 26.5% had heard HCV If they do not even know about HCV, how they will protect themselves?

23. 23 Who will be our target?

24. OUR ENVIRONMENT Drugs are not child’s play but our children are playing with drugs. Are we doing enough to save our next generation?

25. All male PWID who participated in the study NASP and IEDCR Team from icddr,b and CARE Bangladesh AusAID who funded the project Acknowledgement THANK YOU