1. VULNERABILITY FACTORS OF SEXUALLY TRANSMISSIBLE INFECTIONS (STIs) AMONG INJECTABLE DRUG USERS (IDUs) IN MALI Dr. BORE Djibril Oral session 3 - Abstract N° 0159

2. INTRODUCTION

3. Justification of the survey Lack of sufficient information about IDU in Mali (population of difficult access ) Not enough or no targeted interventions in terms of HIV and other STI among IDUs No representative study for this population Consequence : No HIV (and hepatitis) prevalence data among IDUs Ignorance about risky practices among IDUs (risks related to consumption and sexual practices No description for drugs consumption (products, frequency, method of consumption, context and practices

4. Objectives of the survey Estimate the HIV, HBV and HCV prevalence among Injectable Drug Users Describe the socio-demographic characteristics of Injectable Drug Users as well as their at-risk practices Identify behaviors at risk related to the method of use and the sexual behaviors of drug users. Identify the needs of drug users in terms of HIV, HBV, HCV prevention and the treatment and care for problematic use of drugs

5. METHODOLOGY

6. Methodology (1) A methodology adapted to hidden population / difficult access : RDS (Respondent Driven Sampling) Example of waves from a seed :

7. Methodology (2) Two steps: – Interviews: Socio-demographic characteristic Table of consumption Practices with risk of infection (drug use and sexuality) Knowledge about HIV and the hepatitises ( including HIV status ) Access to care and treatment Incarcerations Social Networks for drug users – Biological Sampling HIV, HBV, HCV (Quick tests)

8. Methodology (3) Announcement National Committee for Ethics (NCE) Agreement form Inclusion criteria – Consumption of at least an injectable drug (heroin, cocaine) or crack, No matter how the person uses them – 18 years old – Permanent Resident in Bamako – Agreeing to sign the agreement form Objective: include 500 participants Place: – Clinic des Halles de Bamako, District 6 – Allocated space, allocated hours

9. Operationnal Aspects (1) Preliminary diagnostic, Mapping and preparation (between October 2014 and February 2015) Submission of the protocol to CNE (February 2015) Training of interviewers: February 2015 Identification of seeds: February 2015 Conducting the survey: from march 5 to 27, 2015 Inputting questionnaires : April - May 2015 Preliminary analysis and debriefing of interviewers: June 2015 July 1st, 2015 : Presentation of preliminary results April 15, 2016 : Presentation of final results

10. RESULTS

11. Inclusions 500 persons: – 491 men (98,2 %) – 9 women Coming from all the districts of Bamako but with a high representation of district 6 (47%) Average AgeMin AgeMax Age.Median Age Men29,4 years old18 years old58 years old27 years old Women23,7 years old18 years old34 years old21 years old Total29,3 years old18 years old58 years old27 years old

12. General Characteristics (1) Almost all IDUs are schooled (93,4%) – Level < to lycee: 56,4% (same level Men /women – Level => to lycee: 34,3% (level 3 times higher among men /women) – Vocational training : 8,8% (men only) They are well accommodated [fixed accommodation= in their own house or in the family ]

13. General Characteristics(2) On the other hand, their family situation shows an isolation:  80% live alone (Single + Widowers + divorced)

14. General Characteristics(3) The big majority (>90%) does a professional activity to have incomes, may it be a formal or an informal activity. But: – 15% are doing illegal activities (as their main activity or as complementary to legal activities) – 15% are beggars Finally, a fifth declares to be benefiting from a family support – situation concerning the youngests : 31% among =<25 years old against 10% among the oldests

15. Drugs use(1) Profile-type of IDU in Bamako – Men – 27 years old – Poly-consumer (heroin, crack, cannabis) – Method of consumption: inhalation/smoking – Consuming at a regular basis (every day ) – 2 times more infected by HIV than the general population, While 1 of 2 IDUs has never got tested – Having 1 « chance » out of 3 to be in prison – For more than one IDU out of 2, ignore hepatitis C And 5 times more infected by HCV when he is an injector – And having a « chance » out of 2 to be a commercial Sex worker if she is a woman

16. Drugs use(2) The 3 products that are the most consumed : heroin (consumed by 98% of interviewees) cannabis (consumed by 87% of interviewees) crack (consumed by 70% % of interviewees)

17. Drugs use(3) The three quarter use at least 3 different products at the time They use at a regular basis. They may begin at a very young age their career in the consumption (the youngest age of beginning consumption is : 10 years old )

18. Drugs use(4) The major using method is " inhale / smoke " – Crack and cannabis – Heroin (95% of heroin users ) – Cocaine (61% of Cocaine users ) Minority injection: – During their life : 7,8% (n = 39) – During the last 30 days : 4,6% (n = 23) Heroin (100% of injectors)

19. Drug use and their associated risks 24% have already experienced an overdose 10 HIV+ (8 Men and 2 women) 2 co-infections HIV-HCV Incarceration: 30,3% have already been sent to jail – 12% of those sent to prison have consumed while being in prison PrevalenceTotal (n=500) Men (n=491) Men (n=9) HIV2%1,6%22,2% HBV15%15,3%0% HCV3%2,9%11,1%

20. Focus on injectors Oldest: 32,2 years old (median: 28 years old) Median Age of starting injection: 21 years old [12-38 years old ] More or less the same social characteristics Actives Injectors are more poly-consumers : median 4 products Most often incarcerated : 45%, – and most often consumers at prison : 77% Prevalence higher: PrevalenceInjectors during their lifeActive Injectors (During the last 30 days ) VIH5,1%4,3% VHC15,4%21,7%  The 2 co-infected HIV-HCV are part of the injectors group

21. Prise de risque sexuel Close to a third have exchanged money or drug against sex. 30% declare that they not having used condom during their last sexual intercourse due to the following reasons: Did not think it was useful / necessary Do not like them Did not think about it Partner refusal Not available Too expensive Use another contraceptive method

22. Knowledge on HIV and Hepatitises General knowledge: – 96% know HIV… – … But close to the half (42,6%) does not no HCV. Knowing the HIV status : more than the half have never done an HIV Test

23. CONCLUSION

24. Conclusion : This survey has enabled to draw up an inventory of the needs of this population and justifies the establishment of responses and services tailored to the issues encountered by IDUs - including access to sterile equipment for consumption, screening consultations and care tailored to their profile as well as access to specialized treatments, including opium scented substitution treatment.

25. Thank to the participants, the team that conducted the survey and the team that organized the conference !