In the early 1990s, drug production in Colombia diversified to include heroin as well as cocaine, and since then the country's role in the heroin trade has substantially increased. According to the United Nations Office on Drugs and Crime, Colombia produced approximately 70 to 100 metric tons of heroin between 1998 and 2004. Studies have found an increase in local heroin use since the mid-1990s. This is a strong cause for concern, given the potential for HIV to spread through networks of injection drug users and disseminate to the general public.
In 1999 the Colombian Ministry of Health confirmed the first cases of HIV among people who inject drugs (PWID). The threat of an HIV/AIDS epidemic in Colombia may be especially pressing, as increased incidence of heroin injection has accompanied the rise in heroin use. However, despite such concerns, drug injection in Colombia remains a largely understudied practice.
A recent study by Pedro Mateu-Gelabert, PhD, principal investigator with New York University's Center for Drug Use and HIV Research (CDUHR) and NDRI, Inc., examined injection risk behaviors among heroin injectors in the Colombian cities of Medellín and Pereira to explore the implications for possible increased HIV transmission within PWID.
"The two cities were chosen because they are epicenters for street level drug sales and preliminary research indicated a sizeable number of young PWID in both cities," said Dr. Mateu-Gelabert.
Published in the journal of Substance Use and Misuse, the study, "Heroin Use and Injection Risk Behaviors in Colombia: Implications for HIV/AIDS Prevention," began with six non-randomly selected PWID "seed" participants over the age of 18, who were chosen to recruit their peers, who in turn recruited their peers. Through six to seven waves of recruitment in each city, the study accumulated a total of 540 participants. Field researchers conducted a structured hour-long interview with each participant, and collected a small blood sample via finger prick to test for HIV. On average, participants were 25 years of age, with the median age being 24. By sample design, all participants injected heroin.
For their first time injecting, most participants (60%) report they were assisted by a close friend, 12% reported they were helped by other known people, and 17% reported they self-injected. On average, participants started injecting drugs at 21 years of age. Participants reported an average of 3.2 injections per day, 73% responded one to three times a day, and the other 27% reported injecting four or more times per day.
"Syringe sharing was quite common among participants," says Dr. Mateu-Gelabert. "42% said they used previously used syringes provided by other PWID. Forty-nine percent of participants also reported sharing cookers, filters, or rinse water."
These participants gave several reasons for using shared syringes, most (59%) report doing so because they did not have their own syringe. However, 43% thought it was safe because they were selective of whom they shared syringes with, and 33% thought it was safe because they cleaned the syringe before using it. Of those participants who cleaned used syringes, 72% tended to clean them with only water, 18% with alcohol, and 7% with another cleaning agent (e.g. bleach or soap/detergent).
Sixty-two percent of participants reported giving their used syringe to a close friend for injection. Many participants also reported giving their used syringe to a stranger (27%), an associate (25%), a primary sex partner (11%), someone who paid them for help injecting (10%), or a first time injector (7%).
Notably, 55% of participants reported that the police or other authorities confiscated their injection equipment at least once in the previous six months.
Results from the blood samples collected found 2.7% of participants tested positive for HIV.
"This figure is similar to the previously reported 2% estimated prevalence rate for the population of PWID in Medellín and Pereira," said Dr. Mateu-Gelabert.
By contrast, the HIV prevalence among PWID is 11% in the United States.
"Both countries deal with a new generation of young injectors," says Dr. Mateu-Gelabert, "in Colombia, driven by heroin production, in the US, driven by the recent epidemic of prescription opioid misuse in youth which has evolved into widespread injection drug use."
While HIV prevalence in Colombia is still low, Mateu-Gelabert warns this may be "time-limited." The findings of his study indicate high rates of injection-related risk behaviors, coupled with limited knowledge of HIV prevention techniques. "Colombia has an opportunity to prevent an HIV epidemic by implementing harm reduction interventions among PWID," says Mateu-Gelabert.
By highlighting the importance of such interventions in Colombia, the study underscores issues that may have important public health implications for other countries and regions faced with similar emerging heroin markets. Dr. Mateu-Gelabert says further research on heroin consumption in Colombia and heroin distribution routes to neighboring countries could serve as an early warning regarding the spread of heroin-related HIV epidemics elsewhere in Latin America.
Researcher Affiliations: Pedro Mateu-Gelaberta, Shana Harrisb, Dedsy Berbesic, Ángela María Segura Cardonac, Liliana Patricia Montoya Vélezc, Inés Elvira Mejía Mottad, Lauren Jessella, Honoria Guarinoa, and Samuel R. Friedmana
aNational Development and Research Institutes, New York, New York, USA; bUniversity of Central Florida, Orlando, Florida, USA; cUniversidad CES, Medellín, Colombia; dUniversity of the Andes, Bogotá, Colombia
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
Funding: This study was supported by the Colombian Ministry of Health and the United Nations Office on Drug and Crime. The time of authors Mateu-Gelabert, Guarino, Jessell, and Friedman was partially supported by Grant No. R01DA035146 from the National Institute on Drug Abuse. Harris was supported as a Postdoctoral Fellow in the Behavioral Sciences Training in Drug Abuse Research Program with funding from the National Insti-tute on Drug Abuse (5T32 DA07233). Points of view, opinions, and conclusions in this paper do not necessarily represent the official position of the U.S. Government or National Develop-ment and Research Institutes, Inc.
The mission of the Center for Drug Use and HIV Research (CDUHR) is to end the HIV and HCV epidemics in drug using populations and their communities by conducting transdisciplinary research and disseminating its findings to inform programmatic, policy, and grass roots initiatives at the local, state, national and global levels. CDUHR is a Core Center of Excellence funded by the National Institute on Drug Abuse (Grant #P30 DA011041). It is the first center for the socio-behavioral study of substance use and HIV in the United States and is located at the New York University College of Nursing. For more information, visit http://www.
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