title: Hepatitis C and HIV incidence and harm reduction program use in a conflict setting: an observational cohort of injecting drug users in Kabul, Afghanistan.
abstract: BACKGROUND
  Armed conflict may increase the risk of HIV and other pathogens among injecting drug users (IDUs); however, there are few prospective studies. This study aimed to measure incidence and potential predictors, including environmental events and needle and syringe distribution and collection program (NSP) use, of hepatitis C virus (HCV) and HIV among IDUs in Kabul, Afghanistan.
  
  
  METHODS
  Consenting adult IDUs completed interviews quarterly in year 1 and semi-annually in year 2 and HCV and HIV antibody testing semi-annually through the cohort period (November 2007-December 2009). Interviews detailed injecting and sexual risk behaviors, NSP service use, and conflict-associated displacement. Quarters with peak conflict or local displacement were identified based on literature review, and key events, including insurgent attacks and deaths, were reported with simple counts. Incidence and predictors of HCV and HIV were measured with Cox proportional hazards models.
  
  
  RESULTS
  Of 483 IDUs enrolled, 385 completed one or more follow-up visits (483.8 person-years (p-y)). All participants were male with a median age of 28 years and a median duration of injecting of 2 years. Reported NSP use among the participants ranged from 59.9 to 70.5 % in the first year and was 48.4 and 55.4 % at 18 and 24 months, respectively. There were 41 confirmed deaths, with a crude death rate of 93.4/1000 p-y (95 % confidence interval (CI) 67.9-125) and overdose as the most common cause. HCV and HIV incidence were 35.6/100 p-y (95 % CI 28.3-44.6) and 1.5/100 p-y (95 % CI 0.6-3.3), respectively. Changing from injecting to smoking was protective for HCV acquisition (adjusted hazard ratio (AHR) = 0.53, 95 % CI 0.31-0.92), while duration of injecting (AHR = 1.09, 95 % CI 1.01-1.18/year) and sharing syringes (AHR = 10.09, 95 % CI 1.01-100.3) independently predicted HIV infection.
  
  
  CONCLUSIONS
  There is high HCV incidence and high numbers of reported deaths among male Kabul IDUs despite relatively consistent levels of harm reduction program use; peak violence periods did not independently predict HCV and HIV risk. Programming should increase awareness of HCV transmission and overdose risks, prepare clients for harm reduction needs during conflict or other causes of displacement, and continue efforts to engage community and police force support.
authors.affiliation: Department of Obstetrics & Gynecology, College of Physicians and Surgeons, and Heilbrunn Department of Population & Family Health, Columbia University, Mailman School of Public Health, PH 16-69, 622 West 168th Street, New York, NY, 10032, USA. CTodd@fhi360.org.|Asia Pacific Business Unit and Clinical Sciences Division, FHI 360, Sindhorn Building, 130-132 Wittayu Road, Bangkok, 10330, Thailand. CTodd@fhi360.org.
authors.forename: Catherine S
authors.initials: CS
authors.lastname: Todd
authors.affiliation: Health Protection and Research Organisation, Street 4, Taimani, Kabul, Afghanistan. abdulnasir39@yahoo.com.
authors.forename: Abdul
authors.initials: A
authors.lastname: Nasir
authors.affiliation: Health Protection and Research Organisation, Street 4, Taimani, Kabul, Afghanistan. mohammad-raza.stanikzai@unodc.org.
authors.forename: Mohammad Raza
authors.initials: MR
authors.lastname: Stanekzai
authors.affiliation: Health Protection and Research Organisation, Street 4, Taimani, Kabul, Afghanistan. k.fiekert@gmail.com.
authors.forename: Katja
authors.initials: K
authors.lastname: Fiekert
authors.affiliation: Department of Epidemiology, Yale School of Public Health, 60 College Street, P.O. Box 208034, New Haven, CT, 06520-8034, USA. sipsmah@uic.edu.
authors.forename: Heather L
authors.initials: HL
authors.lastname: Sipsma
authors.affiliation: Department of Community Health Systems, University of California, San Francisco School of Nursing, 2 Koret Way, #N-319X UCSF Box 0602, San Francisco, CA, 94143-0602, USA. dvlahov@nyam.org.
authors.forename: David
authors.initials: D
authors.lastname: Vlahov
authors.affiliation: Division of Global Public Health, University of California San Diego School of Medicine, 9500 Gilman Drive, MC 0507, La Jolla, CA, 92093-0507, USA. sstrathdee@ucsd.edu.
authors.forename: Steffanie A
authors.initials: SA
authors.lastname: Strathdee
mesh_terms: D000328:Adult; D055826:Afghan Campaign 2001-; D000346:Afghanistan / Q000453:epidemiology; D015331:Cohort Studies; D015897:Comorbidity; D055030:Drug Users / Q000706:statistics & numerical data*; D015658:HIV Infections / Q000453:epidemiology* / Q000517:prevention & control; D040261:Harm Reduction; D006526:Hepatitis C / Q000453:epidemiology* / Q000517:prevention & control; D006801:Humans; D015994:Incidence; D008297:Male; D016485:Needle Sharing / Q000706:statistics & numerical data; D018671:Needle-Exchange Programs / Q000706:statistics & numerical data; D012307:Risk Factors; D012309:Risk-Taking; D015819:Substance Abuse, Intravenous / Q000453:epidemiology*