Association of sociodemographic factors with needle sharing and number of sex partners among people who inject drugs in Egypt

ABSTRACT

People who inject drugs (PWID) are at a high risk for HIV. We conducted an evaluation of socio-demographic factors associated with injecting and sexual behaviour among PWID who had two or more visits at a drug outreach clinic in Cairo, Egypt from 2013 to 2017. Routinely collected information on socio-demographics and HIV risk behaviours were abstracted from client records. Bivariate analysis and logistic regression were conducted to evaluate associations between socio-demographics and HIV risk factors. All PWID who tested HIV-positive at the initial visit were excluded from analyses. PWID who were married were more likely to share needles or syringes in the last month of their baseline visit [adjusted odds ratio (aOR) = 4.3, 95% confidence interval (CI) = 1.4-13.1] as were unemployed PWID [aOR = 3.9, 95% CI = 1.5-10.3]. Married PWID were less likely to discontinue sharing needles/syringes [aOR = 0.4, 95% CI = 0.2-0.8] as were those living outside of the Shobra, downtown, and Imbabah districts within Greater Cairo [aOR = 0.2, 95% CI = 0.1-0.5]. No significant associations were found between socio-demographics and number of sex partners in the six months prior to the initial visit. At follow-up visit, 4.4% tested HIV-positive for an incidence rate of 3.9 per 100 person years. Sociodemographic factors should be considered when designing preventive services for PWID.

KEYWORDS:

• Intravenous substance abuse
• health risk behaviours
• HIV
• people who inject drugs
• socio-demographics

Introduction

In seven out of the 10 Joint United Nations Programme on HIV/AIDS (UNAIDS) regions, the use of contaminated drug injecting paraphernalia is a major contributor to transmission of HIV with 5-10% of all new HIV infections directly due to risky injecting behaviour (Aceijas et al., 2006). There is an estimated global HIV prevalence of 18% among people who inject drugs (PWID) (Larney et al., 2017). Studies have also found a high prevalence of sexual activity between PWID and female sex workers (FSW), which may increase the risk of HIV transmission (Zhong et al., 2018). There is also overlap in sexual behaviour between PWID and men who have sex with men (MSM) in Egypt (Mumtaz et al., 2014). The potential overlap of the HIV epidemics among key populations increases the risk of HIV transmission among PWID and may facilitate bridging of HIV from one key population at risk to another (Mumtaz et al., 2014). Criminalisation of injection drug use and stigmatisation of PWID also increase the risk of HIV and are barriers to receiving HIV prevention and treatment services (Henderson, 2014).

Drug use is a large and growing problem in Egypt. It has been estimated that 2.8% of all Egyptians (around 2.4 million people) have significant problems with drug use and dependence (Freedom Drugs and HIV Programme, n.d.). The geographic location of Egypt may be a contributor to its increasing drug problem as it is a transit point between major illicit drug production areas in Europe and Asia (El-Kouny, 2015). According to UNAIDS 2019 estimates, Egypt has a low general adult population HIV prevalence of less than 0.1% (UNAIDS, 2021). However, there is evidence for a growing HIV epidemic among PWID in the country with an increase in HIV prevalence from 1.0% in 2006 to 7.2% in 2010 (Mumtaz et al., 2014). Egypt has the fastest growing HIV epidemic in the Middle East and North Africa (MENA) region with a 76% increase in the number of cases from 2010 to 2016 (UNICEF, n.d.). The most recent 2010 HIV/AIDS Biological and Behavioral Surveillance Survey (BBSS) found that only 9.5% of male PWID in Cairo and Alexandria had ever been tested for HIV and that 28.3% of HIV in Egypt was likely due to injecting drug use (National Aids Program Egypt, 2012). FHI 360 and the Egyptian Ministry of Health (MOH) (2010) also found that 22.9% of male PWID reported sharing needles with at least one person in the 30 days prior to the 2010 BBSS compared to 32.2% from the 2006 BBSS (FHI 360 & Egyptian MOH, 2006). Of those who had sex in the 12 months preceding the survey, 13.1% exchanged sex for money and condom use was low for all partner types (FHI 360 & Egyptian MOH, 2010). In addition, 14.3% of male PWID reported ever having sex with a male partner (FHI 360 & Egyptian MOH, 2010). Prevention and treatment services for HIV have been expanding in Egypt; however, substantial unmet needs remain (Elgharably et al., 2017; National AIDS Programme (NAP) Egypt, 2015). Needle and syringe programmes in Egypt exist, but there is no estimate on the extent of coverage among PWID (Larney et al., 2017). Most people living with HIV (PLHIV) in Egypt are diagnosed late and there is low retention in the first year of treatment due to both personal and structural reasons such as lack of treatment knowledge and support (UNICEF, n.d.).

To better understand the risk behaviours among PWID in Egypt, we performed an evaluation to assess whether sociodemographic factors were associated with injecting and sexual behaviour at baseline among those receiving services at the Freedom Programme’s Outreach Clinic, a free walk-in centre available to PWID for HIV-related information, voluntary counselling and testing (VCT) and other supportive services, and whether certain sociodemographic groups were more likely to have a positive change in HIV risk behaviours over time, after VCT. We also estimated the incidence of HIV among PWID who attended the outreach clinic. In addition, we estimated the reduction in injecting risk behaviour as a measure of the impact of the services received at the clinic.

Materials and methods

This evaluation was conducted at the Freedom Programme’s Outreach Clinic, which is located in the Shobra district of Cairo, Egypt. The clinic provides VCT, as well as support group services for PWID and PLHIV. As part of routine service provision at the clinic, information is collected on sociodemographic factors, HIV risk behaviours (including self-reported injection drug use), and HIV testing history using a questionnaire administered by an outreach worker. After providing consent, the client then receives VCT. If the client tests positive for HIV, the client is informed about HIV transmission, HIV diagnosis, importance of antiretroviral therapy (ART), and prevention of HIV transmission through safer sex and drug injection practices. They are also referred to Ministry of Health HIV treatment services as those are not provided at the Freedom Programme. All clients are provided with information regarding safer injection and sex practices and are offered condoms, clean syringes, and educational materials. Clients are also encouraged to bring in their partners to get tested. PWID clients who test negative are asked to return to the clinic for follow-up services, including HIV retesting, in six months.

This evaluation included PWID seen at the clinic from 1 December 2013 to 5 December 2017 and who had at least one subsequent follow-up visit during that same period. Data from the questionnaires and HIV test results were abstracted into Epi Info^TM Version 7.2. There were two different versions of the questionnaire being used during the evaluation period. Although most of the questions were the same in both versions, the latter version included five additional questions, which led to missing data for those who completed the earlier version. The completeness and accuracy of abstraction for every 10th abstracted record was verified by a second staff member. After abstraction, all data were transferred to SAS Software® 9.4 (SAS Institute Inc., Cary, NC, U.S.A.) for analysis.

Those who tested HIV-positive at baseline were excluded from all further analyses as this is a distinct population who may have different behaviours compared to those who tested negative or who did not receive a HIV test. HIV prevalence at the follow-up was calculated among all included PWID who received a HIV test. To calculate the HIV incidence rate between the two visits, the number who had a positive HIV test at the second visit among PWID who tested HIV negative at the baseline visit was divided by sum of total time between the two visits among those who were HIV negative at baseline and received a HIV test at the second visit.

For baseline visit analyses, outcome variables of interest were sharing needles/syringes in the past month among those who ever shared needles/syringes (yes/no), and number of sex partners (0-1, ≥2) in the past six months at the initial visit in the period. The main predictors of interest were sociodemographic factors including age, sex, education level, area of residence, marital status, and employment status. Area of residence was separated into Shobra, Downtown, Imbabah and other as these areas differ in their population density, wealth, and other factors. Residents from these different areas may have different risk behaviours.

First, bivariate analyses were conducted using unadjusted logistic regression to examine the associations between individual sociodemographic characteristics and each outcome variable. All variables were then included in a single multivariate logistic regression model; a separate model was run for each outcome. Gender was excluded from bivariate and logistic analyses for sharing needles/syringes last month due to having too few females in the study population.

For behaviour change analysis, to evaluate whether certain sociodemographic groups were more likely to have a change in HIV risk behaviour, changes in injecting practices between the initial and follow-up visit were examined. If a participant had more than one follow-up visit during the time period, the first follow-up visit was used except when there was no HIV test result for that visit, in which case, the subsequent follow-up visit was used. Additionally, if somebody had multiple follow-up visits with HIV testing, the visit closest to the six month period was used. PWID were considered to have a positive behaviour change for injecting behaviour if at the baseline visit they reported sharing needles or syringes in the last month and then at their follow-up visit reported they did not share them in the last month. The comparison group included PWID who shared needles or syringes at both visits. Because this analysis examined sharing needles or syringes in the past month it was restricted to those who reported ever reported sharing needles or syringes at both visits.

Positive behaviour change was evaluated using logistic regression analysis. First, unadjusted analyses using crude logistic regression were conducted to examine the associations between individual sociodemographic characteristics and behaviour change. Then all variables were included in a single multivariate logistic regression model. For behaviour change analysis, female PWID were excluded due to small numbers. Male clients with missing data on sharing needles/syringes at either visit were also excluded from the analysis.

Results

A total of 287 PWID had an initial and at least one follow-up visit from 1 December 2013 to 5 December 2017. At the baseline visit, 251 (87%) PWID received HIV testing, of which 11 (4.4%) tested positive and were excluded from subsequent analyses. Among the remaining 276 PWID, the median number of days between the initial visit and recorded follow-up visit was 332 days (10.9 months) (interquartile range=226-536 days or 7.4-17.6 months); 241 (88%) of PWID had at least six months (180 days) between their baseline and follow-up visit.

At baseline, among the 276 PWID, the median age was 34 years (range: 19-65), almost all (97%) were male, and almost half (45%) had attended secondary school or higher while 28% had no formal education (Table 1). Most (64%) lived in Shobra, the district where the clinic is located. Most (69%) were unmarried. More than half (55%) were unemployed. At the baseline visit, 74% PWID reported ever sharing needles or syringes, 87% reported sharing needles or syringes in the last month, and 86% reported reusing needles or syringes. Most 83% reported injecting at least once daily in the last month. Almost all (93%) reported ever having sex with a partner of the opposite sex, 5% reported ever having sex with partners of both sexes, and 2% reported never having sex. Approximately one-third (32%) reported having ≥2 sex partners in the past six months and 53% reported having ≥2 sex partners in the past 12 months. One-fifth (20%) reported ever having sex for money and almost all (94%) reported never using a condom with non-regular sex partners in the past six months (Table 1).

Table 1. Baseline sociodemographic factors and HIV risk behaviours among PWID in Cairo, Egypt.

Factor	N	Frequency (%)
Age (years)
15–24	36	13
25–34	104	38
≥35	136	49
Gender
Male	268	97
Female	8	3
Education Level
No formal education	78	28
Primary education	47	17
Preparatory education (middle school)	28	10
Secondary education (high school)	96	35
Some university education	8	3
University degree	19	7
Residential District in Greater Cairo
Shobra	174	64
Downtown	13	5
Imbabah	25	9
Other Areas	62	23
Marital Status
Currently married ^a	85	31
Not currently married	188	69
Employment Status ^b
Employed	122	45
Unemployed	147	55
Ever Shared Needles or Syringes
Yes	205	74
No	71	26
Shared Needles or Syringes in Last Month
Yes	174	87
No	27	13
Reuse Needles or Syringes
Yes	236	86
No	37	14
Frequency of Injection Last Month
Non-Daily	47	17
Daily	229	83
# of Sex Partners in the Past 6 Months
≥2	64	32
0–1	138	68
# of Sex Partners in the Past 12 Months
≥2	141	53
0–1	127	47
Ever Had Sex for Money
Yes	33	20
No	134	80
Condom Use with Irregular Partners in the Past 6 Months
Never	223	94
Sometimes	12	5
Always	2	1
Condom Use with Regular Partners in the Past 6 Months
Never	227	96
Sometimes	7	3
Always	2	1

Data from baseline visits occurred from December 2013-December 2017 at an outreach centre in Cairo, Egypt.

Variables may have different denominators due to missing data.

^a Only two PWID were married to more than one partner.

^b Does not include PWID who reported being students (n=6).

In bivariate analyses, employment status was the only factor associated with sharing needles or syringes in the last month (Table 2). At baseline, 92% of unemployed PWID reported sharing needles or syringes last month compared with 78% of PWID who were employed [unadjusted odds ratio (OR) = 3.1, 95% confidence interval (CI) = 1.3-7.2 Table 2]. In multivariate analyses, at the baseline visit, married PWID were more likely to share needles or syringes last month than PWID who were not married [adjusted odds ratio (aOR) = 4.3, 95% CI=1.4-13.1] after adjusting for age, education, residential district, and employment status. The odds of sharing needles or syringes last month among PWID who were unemployed were almost four times the odds among PWID who were employed [aOR=3.9, 95% CI=1.5-10.3]. Age, education and residential district were not significantly associated with sharing needles or syringes last month in the adjusted model. There were some cases where a PWID didn’t share needles/syringes at baseline but did so at subsequent visit. There were 29 PWID who reported never sharing needles/syringes at baseline but did report ever sharing at the subsequent visit. There were 10 PWID who reported at baseline not sharing needles/syringes in the last month and then reported sharing needles/syringes in the last month at the subsequent visit.

Table 2. Sociodemographic factors and sharing needles/syringes in the month prior to the baseline visit among PWID in Egypt.

	Shared needles or syringes last month (N = 175)	Did not share needles or syringes last month (N = 27)	Crude OR (95% Cl)	Adjusted OR (aOR) (95% CI)^a
Age (years)
15–24	18 (95%)	1 (5%)	-	-
25–34	66 (87%)	10 (13%)	0.4 (0.0-3.1)	0.3 (0.0-2.5)
≥35	91 (85%)	16 (15%)	0.3 (0.0-2.5)	0.2 (0.0-2.2)
Education Level^b
Preparatory or less education	93 (85%)	16 (15%)	-	-
Secondary or more education	82 (88%)	11 (12%)	1.3 (0.6-2.9)	1.5 (0.6-3.7)
Residential District in Greater Cairo
Shobra	104 (90%)	12 (10%)	-	-
Downtown	11 (92%)	1 (8%)	1.3 (0.2-10.7)	2.2 (0.2-22.4)
Imbabah	17 (85%)	3 (15%)	0.7 (0.2-2.6)	1.0 (0.2-4.5)
Other	41 (79%)	11 (21%)	0.4 (0.2-1.1)	0.5 (0.2-1.3)
Marital Status
Currently married ^c	66 (93%)	5 (7%)	2.6 (0.9-7.1)	4.3 (1.4-13.1)
Not currently married	108 (84%)	21 (16%)	-	-
Employment Status ^d
Employed	61 (78%)	17 (22%)	-	-
Unemployed	111 (92%)	10 (8%)	3.1 (1.3-7.2)	3.9 (1.5-10.3)

CI = confidence interval, OR = odds ratio.

Data from baseline visits occurred from December 2013-December 2017 in Cairo, Egypt.

^a Adjusted odds ratio (aOR) values were adjusted for the other variables included in the multivariate model (age, education level, residential district, marital status, employment status) and presented in the table.

^b Clients with ‘preparatory or less education’ include those who either had not received formal education, had a primary education or preparatory education. Clients with ‘secondary or more education’ included those who had a secondary education, university education or held a university degree. Education level was dichotomised from Table 1.

^c Only two PWID were married to more than one partner.

^d Student PWID (n=3) were excluded.

None of the examined sociodemographic factors were significantly associated with having ≥2 sex partners in the past six months at baseline visit in bivariate or adjusted logistic regression analyses (Table 3).

Table 3. Sociodemographic factors and baseline number of sex partners in the past six months among PWID in Egypt.

	≥2 Sex partners in past 6 months (N = 64)	0–1 Sex partner in past 6 months (N = 138)	≥2 vs 0–1 Sex partner in past 6 months crude OR (95% Cl)	≥2 vs 0–1 sex partner in past 6 months aOR (95% CI)^a
Age (years)
15–24	9 (53%)	8 (47%)	-	-
25–34	25 (30%)	58 (70%)	0.4 (0.1-1.1)	0.5 (0.2-1.6)
≥35	30 (29%)	72 (71%)	0.4 (0.1-1.1)	0.6 (0.2-1.8)
Gender
Male	61 (31%)	137 (69%)	-	-
Female	3 (75%)	1 (25%)	6.7 (0.7-66.1)	8.3 (0.7-93.3)
Education Level
Preparatory or less education	44 (36%)	79 (64%)	-	-
Secondary or more education	20 (25%)	59 (75%)	0.6 (0.3-1.1)	0.6 (0.3-1.1)
Residential District in Greater Cairo
Shobra	38 (29%)	93 (71%)	-	-
Downtown	3 (27%)	8 (73%)	0.9 (0.2-3.6)	0.8 (0.2-3.4)
Imbabah	5 (28%)	13 (72%)	0.9 (0.3-2.8)	0.7 (0.2-2.4)
Other	18 (44%)	23 (56%)	1.9 (0.9-3.9)	1.8 (0.8-4.0)
Marital Status
Currently married^b	16 (25%)	47 (75%)	0.6 (0.3-1.3)	0.6 (0.3-1.3)
Not currently married	48 (35%)	91 (65%)	-	-
Employment Status^c
Employed	29 (33%)	59 (67%)	-	-
Unemployed	33 (29%)	79 (71%)	0.9 (0.5-1.6)	0.8 (0.4-1.5)

CI = confidence interval, OR = odds ratio.

Data from baseline visits occurred from December 2013-December 2017 in Cairo, Egypt.

^a Adjusted odds ratio (aOR) values were adjusted for the other variables included in the multivariate model (age, gender, education level, residential district, marital status, employment status) and presented in the table.

^b Only two PWID were married to more than one partner.

^c Student PWID (n=1) were excluded.

Among the 278 male clients included in this analysis, 174 (86%) reported sharing needles or syringes in the past month at the baseline visit versus 78 (39%) at the follow-up visit; this represented a 47% reduction in the percentage of clients reporting sharing needles or syringes. Among PWID living in Shobra, 72% stopped sharing needles or syringes compared to 57% in Imbabah, 50% in Downtown and 35% in other residential districts of Greater Cairo. Among PWID who were not married at the time of baseline visit, 67% stopped sharing needles or syringes compared to 50% of PWID who were married (Table 4). In the unadjusted analyses, only residence and marital status were significantly associated with discontinuing sharing needles or syringes from the baseline to follow-up visit (Table 4). In the adjusted analyses, PWID living in districts other than Imbabah and Downtown in Greater Cairo were less likely to report discontinuing sharing needles or syringes compared to those living in Shobra (aOR=0.2, 95% CI=0.1-0.5) (Table 4). Married PWID were also less likely to stop sharing needles or syringes compared to PWID who were unmarried (aOR=0.4, 95% CI=0.2-0.8). Among the 240 PWID who initially tested HIV-negative at the baseline visit (excluding missing tests), 124 (52%) received a HIV test at the follow-up visit and five (4%) tested positive for an incidence rate of 3.9 HIV-positive cases per 100 person years. Of these five PWID, three reported sharing needles or syringes in the past month at baseline and that they did not share in the past month of the follow up visit. One PWID reported sharing needles or syringes at both visits and one reported never sharing at both visits.

Table 4. Sociodemographic factors and stopping sharing needles/syringes from baseline to follow-up among PWID in Egypt.

Sociodemographic factors at baseline visit	Stopped sharing needles or syringes after VCT (N = 90)	Continued sharing needles or syringes after VCT (N = 58)	Unadjusted (crude) Odds Ratio (OR) (95% CI)^a	Adjusted Odds Ratio (aOR) (95% CI)^b
Age
15–24	5 (38%)	8 (62%)	-	-
25–34	40 (68%)	19 (32%)	3.4 (0.97-11.7)	3.2 (0.7-13.9)
≥35	45 (59%)	31 (41%)	2.3 (0.7-7.8)	2.5 (0.6-11.1)
Education Level
Preparatory or less education	43 (55%)	35 (45%)	-	-
Secondary or more education	47 (67%)	23 (33%)	1.7 (0.9-3.2)	1.6 (0.8-3.5)
Residential District in Greater Cairo
Shobra	63 (72%)	25 (28%)	-	-
Downtown	5 (50%)	5 (50%)	0.4 (0.1-1.5)	0.4 (0.1-1.9)
Imbabah	8 (57%)	6 (43%)	0.5 (0.2-1.7)	0.5 (0.1-1.7)
Other	12 (35%)	22 (65%)	0.2 (0.1-0.5)	0.2 (0.1-0.5)
Marital Status
Currently married^c	28 (50%)	28 (50%)	0.5 (0.2-0.96)	0.4 (0.2-0.8)
Not currently married	62 (67%)	30 (33%)	-	-
Employment Status^d
Employed	27 (53%)	24 (47%)	-	-
Unemployed	62 (65%)	33 (35%)	1.7 (0.8-3.3)	0.8 (0.4-2.0)

CI = confidence interval, OR = odds ratio.

Data from baseline and follow-up visits occurred from December 2013-December 2017 among male PWID in Cairo, Egypt.

^a The odds ratio represents positive behaviour change where PWID shared needles/syringes last month at baseline visit but did not share needles/syringes last month at follow-up visit. The comparison group included PWID who shared needles/syringes at both visits.

^b Adjusted odds ratio (aOR) values were adjusted for the other variables included in the multivariate model (age, education level, residential district, marital status, employment status) and presented in the table.

^c Only one PWID was married to more than one partner.

^d Student PWID (n=2) were excluded.

Discussion

The findings from this evaluation conducted among PWID in Egypt suggest that certain sociodemographic factors may be significantly associated with a key HIV risk behaviour: sharing needles or syringes. These same sociodemographic factors may also be associated with behaviour change in discontinuing sharing needles or syringes after VCT among those attending subsequent visit(s). PWID who were unemployed or married were more likely to share needles or syringes in the past month of their baseline visit. Unemployed PWID may have also been more likely to share needles or syringes due to having fewer resources to buy clean injecting equipment. No significant associations were found between socio-demographics and baseline number of sex partners in the past six months. This may indicate that socio-demographic factors are not associated with sexual behaviours among PWID in Cairo.

A 2006 survey in Cairo found that more than half (53%) of male PWID reported injecting drugs with used needles or syringes and approximately one-third (32.4%) shared needles or syringes with one or more people in the previous month (Soliman et al., 2010). This is lower than what we observed in our evaluation, where at the baseline visit, 86% reported reusing needles or syringes and 74% of PWID reported ever sharing needles or syringes, indicating that risky injecting practices among PWID in Cairo continue to be high and may even be rising. The 2006 survey also found that reported condom use was low (range: 11.8-34.1% for ever use) for all partner types (Soliman et al., 2010). These results are similar to our findings where 32% reported having ≥2 sex partners in the past 6 months and 94% reported never using a condom with non-regular partners in the past six months.

HIV testing and counselling seemed to have a positive effect on behaviour change in sharing needles or syringes as more than half of male clients (60.8%) discontinued sharing needles or syringes. Residence area and marital status were significantly associated with discontinuing the practice of sharing needles/syringes. However, residence in Imbabah, an area known to have more residents of lower socio-economic status, was not found to be significantly associated with greater odds of sharing needles or syringes in the last month of baseline visit or positive behaviour change in discontinuing the practice of sharing needles or syringes. The estimate of 3.9 HIV-positive cases per 100 person years is a relatively high incidence rate, especially among PWID engaged in harm reduction services. This further reiterates the vulnerability of this population to HIV infection and the need to expand services and interventions tailored toward PWID. This evaluation has several limitations. It relied on abstracted data that was originally collected for routine service provision and not research purposes, which was sometimes incomplete. Additionally, participant reporting may have been affected by recall bias and social desirability bias. The Freedom Programme makes extensive efforts to ensure that its clients feel comfortable, including having staff who are former PWID, to increase the likelihood clients will answer questions and answer them truthfully. Larger studies with prospective data collection are needed to better determine how to design and target HIV prevention programmes for PWID.

As these data were collected among PWID living in Greater Cairo and as the majority were men, the results may not be generalisable to other locations in Egypt or to females who inject drugs. Furthermore, this evaluation was conducted on PWID who chose to come to Freedom’s Outreach Clinic for services and who had also returned for at least one follow-up visit. PWID are highly stigmatised in Egypt, so PWID who willingly came to the clinic may differ compared to the broader PWID population. This may partially explain the difference in the HIV prevalence of 4.4% observed among PWID in this evaluation compared to the prevalence of 2.5% found in 2016 biobehavioral survey among PWID in Egypt (UNAIDS, n.d.). Furthermore, 50% of PWID did not get retested for HIV during their follow-up visit, resulting in a smaller population sample to effectively gauge the true incidence of HIV after receiving VCT.

This evaluation also had several strengths. It is one of the few studies that focus on PWID in Egypt or from the Middle East and North Africa Region, a region that lags behind in terms of the HIV response. The Freedom Drugs and HIV Programme outreach centre provides free services and the outreach workers are all ex-PWID, making it more likely that our analyses included a more diverse population of PWID, from various socio-economic backgrounds, who answered the questionnaire more truthfully compared to PWID patients who received services at government-run facilities or private facilities that charged for services.

Although implementation of interventions to prevent and treat HIV and HCV infections among PWID are increasingly available, important information on interventions, such as their cost effectiveness and accessibility, is rarely available, and when available, usually suggests poor coverage in many countries (Larney et al., 2017). Poor quality data on PWID prevalence is also a major barrier in determining the current level of service coverage and what services are still needed (Larney et al., 2017).

Conclusions

The findings from this evaluation demonstrate that PWID in Egypt are at substantial risk for HIV infection. More research and surveillance are needed to determine the true prevalence and incidence of HIV among PWID in Egypt, as well as their sociodemographic characteristics, injecting and sexual behaviours in order to inform the design and implementation of services for this population. Future work should address structural factors such as criminalisation, stigma and discrimination that create barriers to PWID accessing HIV and substance use services (Henderson, 2014). Addressing such barriers is fundamental to preventing HIV in this population. The persistence of high-risk HIV behaviours is worrisome and highlights the need for more comprehensive packages of interventions tailored to the unique needs of PWID.

Declarations

Ethics approval and consent to participate

This evaluation received approval from the institutional review board (IRB) at Columbia University Irving Medical Center (#AAAR4434) and the local Ethics Committee at the Freedom Programme. A waiver of informed consent was received because there was no more than minimal risk to participants as all data used was previously collected for routine service provision and no direct identifiers were abstracted; additionally, obtaining consent would not have been feasible.

Acknowledgements

A special thanks goes to Sara Mahmoud, MD for helping with translation of the questionnaires and verifying the completeness and accuracy of abstraction; Terry Helmy for coordination and translation support; and Joseph Nabil, Medhat Maher, Iklas Yacoub, and Sameh Fayez for translation support. We would also like to acknowledge Farah Girgis for helping with translating questionnaires from Arabic to English. Gratitude is also due to the participants and the staff at the Freedom Programme for their commitment to serving people who inject drugs with care and respect. We also especially wish to thank Matthew R. Lamb, PhD for providing statistical advice.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data can be made available to other researchers with appropriate approvals in place. Interested parties should contact Emad Helmy ([email protected]), member of the Ethics Committee at the Freedom Programme for more information.

Additional information

Funding

There was no grant funding for this project. This work was conducted as part of Ms. Anwar’s MPH practicum and she received a stipend from ICAP at Columbia University.