This study examined all known HIV positive women in Georgia and found that the HIV epidemic remains closely tied to the IDU community. The majority of HIV positive women (70%) have a documented connection to the IDU community through either their own IDU (n = 10) or a partner with IDU (n = 163) or HCV (a proxy for IDU among men in the region, n = 152).
While few women reported IDU, HCV in women is common for those with partners who are HCV seropositive. The fact that most women reported no risk behavior related to HCV does not necessarily mean that the infection was transmitted through heterosexual exposure. Although sexual transmission of HCV may occur [15
], the overwhelming evidence suggests that the efficiency of transmission by the sexual route is very low. Longitudinal studies among monogamous heterosexual couples indicate no or low risk associated with acquisition of HCV through sexual intercourse. Vandelli and colleagues reported an incidence rate of 0.37/1,000 person-years (py) among monogamous heterosexual couples with over 10 years of follow-up [17
]. In another follow-up study, incidence of HCV acquisition was estimated at 2.33/1,000py [18
]. Two other studies reported an absence of seroconversion among spouses [19
On the other hand, previous studies have shown that those with risky sexual behavior, STIs (particularly genital ulcerative diseases), and co-infection with HIV have an increased risk of HCV acquisition [21
]. Consistent with these reports our study suggests that having sexual contact with HCV positive partners is an important co-factor for being HCV positive among HIV infected women in Georgia. However, it is unlikely that the high prevalence of HCV in our study was solely due to the sexual exposure to the virus.
Evidence suggests that IDU is one of the most efficient modes of HCV transmission,[27
] which can occur shortly after initiation of IDU [28
]. Within the ALIVE Study, 65% of participants with brief IDU were positive for HCV antibodies [29
]. And HCV seroprevalence exceeding 70% was reported in a similar study in Southern China [30
]. Cohort studies among persons with IDU showed that the incidence of HCV was greatest within the first year of follow-up and ranged from 16.1/100py to 41.8/100py [31
]. The same studies reported significantly lower rates for HIV seroconversion over the same time of observation: 0.8/100py to 7.2/100py, likely due to the difference in baseline prevalence [31
]. The greater transmissibility of HCV through percutaneous blood exposures compared to HIV suggests that even a single instance of sharing injection equipment or accidental intrafamilial transmission by sharing razors or needles for medicine could be sufficient [34
]. This circumstance might have been overlooked in our study as such data has not been collected.
Relatively limited education and intervention has been targeted at the IDU community in Georgia. Primary prevention of IDU in the country has been implemented on a small scale by Non-Governmental Organizations (NGO) as fragmentary programs. Although harm reduction interventions (syringe exchange and substitution therapy) are carried out on a more systematic scale, the current coverage does not meet existing demand [35
]. More regular, coordinated prevention interventions at the school, community and family level are needed. An important component may be educating women about household exposures to HIV and HCV.
As with all studies, caveats require mention. First, the study was based on chart review and data collected by physicians as part of clinical intake interviews. While all physicians at the IDACIRC are trained to work with risk groups, some patients may not feel comfortable in revealing IDU [36
]. Second, injection-related exposure is associated with deeply ingrained cultural attitudes about IDU that highly stigmatize women, potentially increasing the likelihood of non-disclosure of IDU, especially if use is occasional. Third, measurement of exposures to HCV through medical and dental care was nonspecific. However, the relatively small risk related to medical care cannot explain the HCV distribution seen. Fourth, while majority of women with multiple sexual partners were divorced, partner information was available only on the last regular partner. Finally, 21 women were missing data either on their own HCV status or partner-related information, and were excluded from analysis.
An explosive increase in the size of the IDU population in NIS has placed drug abusers at the core of the HIV epidemic in the region, as well as a parallel HCV epidemic [4
]. It is estimated that more than 1% of the population in Eastern Europe abuses injection opiates [39
]. Our study suggests that the HIV epidemic in Georgia remains largely concentrated around the IDU community. Of the almost 80,000 pregnant women screened for HIV in Georgia, 32 women were HIV infected,[40
] 66% of whom had a documented connection with the IDU community. Given the potential for undocumented IDU, some of the remaining 11 women also may be connected to this high-risk community or represent further transmission of HIV into the general community. There is a clear need for evidence-based interventions targeting persons with IDU and their partners, especially educational activities for young women. Mercifully, Georgia still has the chance to halt the spread of the HIV epidemic.