Background
UNAIDS targets are for 95-95-95% for testing, treatment and viral suppression for people living with HIV (PWH) by 2030. People who inject drugs (PWID) face persistent barriers to engaging in consistent care for HIV. We explored temporal trends in UNAIDS indicators over 10 years in two Indian cities in Punjab, which has an unabating drug use epidemic.
Methods
5315 PWID were recruited from 2 Indian cities (Amritsar-2622,Ludhiana-2693) across 3 cross-sectional surveys (2013,2016,2023) using respondent driven sampling (RDS). PWID ≥18 years and who injected drugs in past 2 years were eligible. Participants completed behavioral surveys and laboratory testing (onsite HIV antibody;HIV RNA on stored sample). Among PWH, we estimated in each survey RDS-II weighted HIV prevalence and UNAIDS treatment indicators:1) awareness of HIV status 2) ART use among those aware and 3) viral suppression among those on ART.
Results
Over the decade,HIV prevalence increased in both cities;from 21% to 20% to 35% in Amritsar and from 18% to 22% to 43% in Ludhiana. Median age for PWH across surveys was 30 years and 28 years in Amritsar and Ludhiana, respectively. Almost all were male. Proportion of daily injectors increased from 32% to 87% in Amritsar;13% to 27% in Ludhiana. In Amritsar, needle-syringe sharing decreased from 33%(2013) to 14% (2016) but increased to 48% in 2023;while sharing increased from 10% to 20% to 42% in Ludhiana. Proportion reporting heroin injection more than doubled in both cities (5% to 97% in Ludhiana;32% to 99% in Amritsar) while buprenorphine injection declined (90% to 3% at Amritsar;77% to 8% in Ludhiana). As seen in the Figure, awareness of HIV status was stable or increasing between 2013-2016 but declined by >50% in both cities by 2023. Among those aware, percentage on ART increased and remained stable in Amritsar;in Ludhiana ART use increased initially (2013-2016) but then decreased. Among those on ART, viral suppression increased between 2013-2016 but decreased by 2023.
Conclusions
Despite initial gains in these two Indian cities that are experiencing a shift in the epidemiology of drug use, from prescription opioid injection to near universal heroin injection and an increase in high risk injecting practices; levels of awareness of HIV status and viral suppression were lower among PWID in 2023 than they were a decade ago and HIV prevalence is increasing. Novel approaches will be required to engage this vulnerable group in prevention and treatment services that address changing needs.
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