Profile of risk factors for injecting drug use among the sample at high risk of HIV/AIDS in Kigali, Rwanda

doi:10.21203/rs.3.rs-5278497/v1

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Profile of risk factors for injecting drug use among the sample at high risk of HIV/AIDS in Kigali, Rwanda

https://doi.org/10.21203/rs.3.rs-5278497/v1

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Background

The increasing prevalence of injection drug use (IDU) among populations at high risk for human immunodeficiency virus (HIV) has become a critical public health concern, particularly in Africa. This issue significantly exacerbates health-related effects among those at high risk of HIV/AIDS. Hence, our study aimed to scrutinize the associations between sociodemographic characteristics, alcohol and substance dependence, depression, and psychosocial behaviors among intravenous drug users within this high-risk HIV population.

Methods

We conducted a cross-sectional study design with 480 respondents self-identifying as being at high risk of HIV/AIDS [males having sex with males (MSM), female sex workers (FSW), and injecting drug users (IDU)] living in Kigali, Rwanda, via snowball sampling. Chi-square bivariate analysis was used to explore factors associated with IDUs. Significant variables from these bivariable analyses were included in multivariate logistic regression models, in which odds ratios were used to determine the risk factors linked to IDU. Our study adhered to a 95% confidence interval and a 5% significance level to validate the statistical associations.

Results

Over 86.25% of the 480 respondents reported symptoms of depression, and 31.5% of the respondents identified as injection drug users (IDUs). Notably, 78% were male and fell within the age range of 18 to 45. The use of alcohol (wine, hard alcohol, or liquor), smoking cigarettes, marijuana, or heroin was significantly associated with IDU. Multiple regression analysis revealed that those with alcohol dependence [aOR = 3.547; 95% CI (1.59–10.857)] and marijuana use [aOR = 3.261; 95% CI (1.380–7.708)] were more likely to be IDUs than other risk group members (MSMs, FSWs). Furthermore, individuals with symptoms of depression [(aOR = 4.50; 95% CI (2.55–7.96), p = 0.018)] were more likely to be IDUs than their counterparts were.

Conclusion

The results of the present study indicated that substance and alcohol abuse behaviors, as well as mental health issues such as depression symptoms, were significantly associated with injecting drug use. The findings support the promotion of harm reduction prevention strategies that utilize mental health programs for this population at high risk for HIV.

Injection

Drugs

Depression

HIV/AIDS

MSM

FSW

Worldwide, drug use and drug dependence are increasing significantly, with 296 million people using drugs worldwide (United Nations office on Drugs and Crime (UNODC; World Drug report, 2023)). This represents an increase of 23% over the past decade. Most drug users (78%) reside in low- and middle-income countries and gravitate to urban settings (Degenhardt et al., 2017; Opheim et al., 2024). Moreover, among those using drugs, the number of people with a drug use disorder has also skyrocketed by 45–39.5% (Hajarizadeh et al., 2023). Clearly, substance use and drug dependence pose significant global challenges, especially as they are often associated with crime and burden already-stretched thin public health services. Globally, approximately 11 million people have injected drugs, and the prevalence of IDU has exhibited a consistent upward trend since 2017 across various regions. In Latin America, estimates range from 1,392,000 to 2,380,000; in Central Asia, the figures range from 400,000 to 510,000 (Hickman et al., 2018). Similarly, South Asia has a prevalence ranging from 783,500 to 1,263,000. These growing numbers underscore the expanding impact of addictive behaviors across all countries, with low- and middle-income countries being especially affected (Hickman et al., 2018). Moreover, approximately 1 in 8 (or 1.4 million) IDUs are living with HIV (UNODC World Drug Report, 2020), while 39.4% have viremic HCV infection (Grebely et al., Addiction, 2019). The growing number of IDUs at risk for HIV/AIDS are men who have sex with men (M.S.M.) and female sex workers (FSW), all of which represent risk that continues to contribute to the ongoing burdetn of VIV/AIDS, emphasizing the critical requirement for immediate, targeted interventions for each of these diverse groups to address this pressing public health issue (Hickman et al., 2018).

Geographically, the prevalence of IDUs is relatively high in towns and urban areas (Degenhardt et al., 2017). While African countries currently have low rates of IDUs, this trend has shifted over the past 25 years, with heroin injection use increasing in large towns in Kenya, Uganda, and Tanzania since 2009 (Mwangi et al., 2019). The prevalence of IDUs has notably increased in East African countries, particularly in Tanzania, Kenya, and Rwanda. This surge in IDU has had detrimental effects on quality of life and increased the risk of blood-borne diseases and sexually transmitted infections, including HIV (Asher et al., 2013; Beckerleg et al., 2005; Savanna R Reid, 2009; Twahirwa Rwema et al., 2021). Notably, vulnerability to HIV is pronounced in groups such as men who have sex with men (M.S.M.), female sex workers (FSW), and IDUs, who currently exhibit the highest HIV prevalence (Ahaneku et al., 2016; Guichard et al., 2015; S. R. Reid, 2009).

The interplay between IDU and HIV/AIDS is not a recent revelation, as evidenced by surveys in India and China indicating a link between HIV/AIDS and drug use, including alcohol and other substances (Bouscaillou et al., 2016; Degenhardt et al., 2017; Palareti et al., 2016; Sutton et al., 2012). Currently, the association between HIV/AIDS and injection drug use is a pertinent public health concern, especially with high HIV prevalence in MSM, FSW, and IDU groups (Ahaneku et al., 2016; Guichard et al., 2015; S. R. Reid, 2009). The practice of sharing drugs among the majority of injecting drug users in communities serves as a significant conduit for the transmission of HIV and other blood-borne diseases. A comprehensive systematic review encompassing the analysis of 55,671 papers and reports, with data extracted from 1,147 eligible records, revealed substantial evidence of injecting drug use (IDU) (Degenhardt et al., 2017; Hickman et al., 2018). This phenomenon was documented in 179 out of 206 countries or territories, covering 99% of the population aged 15 to 64. According to the Centers for Disease Control and Prevention (CDC, 2021), each new HIV infection can be attributed to injecting drugs in 1 of 10 instances. These findings underscore the global impact of IDUs on the transmission of HIV and emphasize the urgent need for targeted interventions and public health initiatives (CDC, 2022).

According to the preceding literature, injecting drug use can be influenced by a multitude of interconnected factors (Degenhardt et al., 2017). Factors associated with injection drug use encompass a range of experiences, from engagement in sex work and a history of sexual abuse to exposure to trauma and violence, social disadvantage, family history of drug use, and incarceration (Latkin et al., 2011; Knowlton et al., 2005; McLaughlin et al., 2012). Social environments play a significant role, as peer pressure and the prevalence of drug use within communities can sway individuals toward injecting drugs. Mental health also plays a pivotal role, with conditions such as depression, previous substance use, trauma, adverse childhood experiences, anxiety, or trauma leading some to seek solace in substances (Cornford & Close,2016). Genetics may contribute, as certain individuals might be more genetically predisposed to addiction (NIDA, 2023). Access to drugs, whether through social circles or easy availability in illegal markets, can increase the likelihood of drug use. Socioeconomic factors, including poverty and a lack of opportunities, might drive individuals toward substances as a means of escape (Latkin et al., 2011; Knowlton et al., 2005). Additionally, cultural influences and media representations can normalize or glamorize drug use, potentially influencing individuals’ ability to experiment with or resort to injecting drugs (McLaughlin et al., 2012).

Depression has emerged as a widespread public health issue globally (Haro et al., 2006). However, depression rates vary among different communities, with a rising trend observed among IDUs in various countries in eastern Africa, including Kenya (Paquette et al., 2018). In the Rwandan context, depression affects 35% of genocide survivors and 20% of the general population (Kayiteshonga, 2022). Additionally, individuals living with HIV/AIDS in Rwanda experience depression, which is often linked to stigma and medication nonadherence (Cohen et al., 2009). Some of these individuals who experienced depression or other mental health issues might turn to substance use, including injecting drugs, as a way to cope with their emotional distress or to self-medicate (Okonkwo et al., 2021).

In Rwanda, while depression rates among genocide survivors and the general population have been extensively studied, an unexplored realm concerning the prevalence of depression among adolescents engaged in drug use exists. Despite remarkable progress across multiple sectors after genocide, the persistent issue of injecting drug use (IDU) remains a significant driver of the HIV epidemic, particularly affecting hard-to-reach populations such as female sex workers and sexual and gender minorities (Twahirwa Rwema et al. 2021) and individuals whose biological sex, sexuality, gender identity, and gender expression differ from majority norms (Holzinger, 2018).

Harm reduction or minimization strategies for the behaviors of injecting drug users in Rwanda have received limited exploration and promotion. Recent research conducted by Twahirwa Rwema et al. (2021) on injecting drug practices and HIV infection in Kigali revealed that bisexuality and initial needle sharing were significant risk factors for the necessity of sharing needles and the transmission of bloodborne diseases in Rwanda, then, the study advocates for the increased implementation of harm reduction practices (Twahirwa Rwema et al. 2021).To our knowledge, there is a shortage of research on the determinants of IDUs in Rwanda. One difficulty in studying IDUs within the context of local culture is that in most countries, IDUs are considered illegal, making it difficult for users to reach the local population (Degenhardt et al., 2017).

This study aims to explore the relationships among sociodemographics, substance and alcohol dependence, and depression symptoms among intravenous drug users and then examine the risk factors for IDU within a high-risk sample for HIV/AIDS in Kigali, Rwanda. This research aims to fill critical gaps in understanding the complexities surrounding drug use behaviors and their psychosocial-related implications within this context.

Design and Procedures

This cross-sectional study focused on various correlated variables, such as sociodemographics, substance and alcohol dependence, and depression symptoms. among hard-to-reach populations who are engaged in risky behaviors for HIV/AIDS, such as female sex workers (FSWs), sexual and gender minorities, and IDUs, and those who interact within the social networks of these risk groups (e.g., clients of sex workers, men who have sex with men [M.S.M.]) in Kigali, Rwanda.

The Rwanda National Ethics Committee (RNEC) reviewed and approved the study for the ethical protection of research participants. This study was conducted between November 2018 and February 2019 in accordance with the principles and regulations of the World Medical Association (WMA.) Declaration of Helsinki Declaration. The surveys were distributed to 480 people who were classified into one of three groups: MSMs, FSWs, and IDUs. Among the 480 individuals who participated in this study, 151 were IDUs, whereas 329 were noninjecting drug users. The participants were informed of the risks and benefits of study participation and provided written informed consent before enrollment.

The following inclusion criteria were used for participation in this study: individuals had to be 18 years or older; live in Kigali; identify as either MSM, FSWs, or IDUs; and not have an existing diagnosis of depression. Given the official illegality of these behaviors in Rwanda, all groups were identified as “hard to reach”, and nonprobability sampling, known as snowball, chain-referral, or referral sampling, was used to recruit participants from among their acquaintances once a group was identified through trusted outreach workers.

Data collection and measures

Research assistants and nurses from the Rwandan Health Development Initiative (HDI) at two sites, the HDI headquarters and the Nyakabanda health clinic, both in Kigali, were trained to administer a structured questionnaire in the Kinyarwanda language to the study participants. Each study participant was assigned a unique identification number to protect confidentiality. The participants received 5 $ US in compensation for their time and travel expenses. The time needed to complete the questionnaire ranged between 15 and 30 minutes.

Self-demographic Questionnaire (SDQ)

The demographic variables examined in this study included age, marital status, gender, sexual orientation and behavior, relationship status, a history of sex work, education, and employment status. Other variables included the type of injecting drug used, frequency of drug injection, HIV/AIDS status, and use of other substances. In total, 25 variables were identified.

Beck Depression Inventory Scale, second version (BDI-II)

The BDI-II is the psychometric instrument used to assess the severity of depressive symptoms, as it has previously shown strong psychometric properties in both the general population and in clinical settings in the Rwandan context. It is an effective tool that has high predictive value. The BDI-II presents 21 items rated on a Likert scale from 0 to 3, with a maximum achievable score of 63 (Levintow et al., 2018). A score less than 14 indicates minimal symptoms of depression, a score ranging from 14 to 19 indicates mild depressive symptoms, a score ranging from 20 to 28 indicates moderate depressive symptoms, and a score ≥ 29 indicates severe depressive symptoms (Toledano-Toledano et al., 2020). The Cronbach's alpha (α) in this study was 0.898.

The Mini-International Neuropsychiatric Interview (MINI): The MINI is a short structured diagnostic interview developed jointly by psychiatrists and other US and European clinicians for DSM-IV and ICD-10 psychiatric disorders. With an administration time of approximately 15 minutes, it was designed to meet the need for a short but accurate structured psychiatric interview for multicenter clinical trials and epidemiology studies and be used as the first step in outcome tracking in nonresearch clinical settings (Sheehan et al., 1998). The MINI is divided into eight modules identified by letters, each corresponding to a diagnostic category. For this study, we used two such categories: alcohol dependence or abuse, with 21 items, and substance dependence or abuse, with 12 items. Each question asked about activities performed over 12 months, with response options being true or false, with true items indicating that a participant has symptoms of either alcohol or substance dependence and abuse or both. The Cronbach's alpha (α) values for the alcohol and substance dependence scales were 0.915 and 0.793, respectively.

HIV testing

During the informed consent process, participants were informed that the study would include a rapid HIV test. The study participants underwent pretest and posttest counseling by research assistants trained in HIV counseling, testing, and referrals. Participants who received an initial positive result on the rapid HIV test were confirmed with a second rapid test. Two positive results were required for subjects to be classified as HIV positive. The participants who had discordant results between the two tests were classified as HIV negative. Those who had a previous HIV/AIDS diagnosis and were receiving treatment were only tested for HIV once.

Data analyses

Since the primary focus of this paper is to characterize the correlates of IDUs, once the overall population was described, subsequent statistical analyses focused on IDUs as a marginalized population at heightened risk of HIV transmission in Rwanda. Initially, descriptive statistics were employed to examine the sociodemographic characteristics of the overall sample and then to explore correlates of injection drug use. Further descriptive analyses explored substance types, alcohol and drug usage patterns, associated symptoms, and HIV prevalence within this cohort. Pearson's chi-square tests (χ2) were used to compare demographic factors and substance use patterns with the primary outcome variable (IDU). A significance level of 0.05 was applied for statistical significance. All significant factors for IDU identified in the bivariate analyses were subsequently used in multivariate logistic regression analyses, and adjusted odds ratios (aORs) were calculated to identify factors associated with IDU. A confidence interval of 95% and a significance level of 5% were considered during the analyses. Statistical computations were performed via the Statistical Package for Social Sciences (SPSS) software version 28 (IBM SPSS Corporation).

Descriptive analysis by sociodemographic variables

Table (1) shows a total of 480 participants, among whom 151 individuals (31.5%) were identified as intravenous drug users (IDUs). A segment of the participants, constituting 12%, reported engagement in work as Female Sex Workers (FSW), whereas 57.9% were classified as Men who have Sex with Men (MSMs). Notably, 72.3% of non-IDU drug users, compared with 89.4% of IDUs, are single.

Among IDUs, a significant majority (52.3%) fell within the age range of 18–25 years, and a notable proportion (84.1%) were identified as males. Bivariate logistic regression analyses revealed statistically significant associations between injection drug use and various demographic factors, including age (χ2 = 7.7, p < 0.05), sex (χ2 = 16.35, p < 0.001), MSM status (χ2 = 24.2, p < 0.001), FSW status (χ2 = 6.56, p < 0.006), marital status (χ2 = 19.38, p < 0.001), and education (χ2 = 8.2, p < 0.01). However, employment status (χ2 = 3.51, p = 0.30) was not significantly associated with injecting drug use.

Table 1

Description of the sociodemographic characteristics of IDUs and bivariate associations of variables of interest with IDU. (n = 480)
	Descriptive Analysis		Bivariate analysis
Variables	IV Drug Users		Chi-square	p value
Variables	Yes, N (%)	No, N (%)
Age (in years)			7.70	0.050*
18–25 years	79 (52.3)	140 (42.6)
26–35 years	59 (39.1)	132 (40.1)
36–45 years	11 (7.3)	45 (13.7)
45 + years	2 (1.3)	12 (3.6)
Gender			16.35	< 0.001***
Male	141 (93.4)	280 (85.1)
Female	10 (6.6)	49 (14.9)
Relationship Status			19.38	< 0.001***
Single	135 (89.4)	238 (72.3)
Married	9 (6.0)	41 (12.4)
Divorced/Widower	7(4.6)	50(15.2)
FSW			6.56	0.006**
Yes	10(6.6)	49(14.4)
No	141(93.4)	280(85.6)
MSM			24.2	< 0.010**
Yes	110(72.8)	160(47.1)
No	41(27.2)	169(52.9)
Education			8.20	< 0.010**
None	4 (2.6)	12 (3.6)
Primary	28 (18.5)	100 (30.4)
Secondary	119 (78.8)	217 (66.0)
Employment Status			3.51	0.30
Unemployed	54 (35.8)	93 (28.3)
Student	24 (15.9)	48 (14.6)
Employed	15(9.9)	37(11.2)
Other	58 (38.4)	151 (45.9)
Notes: statistical significance at p < 0.05; * statistical significance at p < 0.01; *** statistical significance at p < 0.001, Yes: Number of injecting drug users; No: Number of non -injecting drug users

Description of substance and alcohol use and their associations with IDU.

Table (2) shows that among the intravenous drug users (IDUs), a significant majority of the respondents (73.5%) reported the use of alcohol, and 61.6% reported the use of marijuana. Notably, over 96.02% of the IDUs exhibited symptoms of drug dependence, whereas 43.04% met the criteria for alcohol dependence or abuse. Furthermore, nearly 86.25% of the IDUs and non-IDUs presented depressive symptoms. Comparatively, both IDUs and non-IDUs presented 2.6% and 5.7% prevalence rates of HIV/AIDS, respectively. In terms of seeking substance abuse treatment in the past, 29.1% of IDUs, as opposed to 14.3% of non-IDUs, reported having pursued such treatment. Regarding depressive symptoms, a substantial 81.5% of IDUs acknowledged experiencing such manifestations.

Bivariate logistic regression analyses revealed statistically significant associations between injection drug use and alcohol consumption (wine, hard alcohol, and liquor) (χ2 = 25.07, p < 0.001), smoking cigarettes (χ2 = 5.8, p < 0.01), smoking marijuana (χ2 = 3.77, p < 0.05), and using diazepam (χ2 = 11.9, p < 0.001). Moreover, individuals engaged in injection drug use were more likely to seek treatment for substance use (χ2 = 14.86, p < 0.001) and exhibit depressive symptoms (χ2 = 17.76, p < 0.001). Although 4.7% of the samples tested positive for HIV, there was no statistically significant association between HIV status and IDU. (χ2 = 2.21, p = 0.136). Similarly, a family history of substance abuse was not significantly associated with IDU in the sample (χ2 = 0.98, p = 0.320).

Table 2

Description of the substance use variables comparing IDUs and other high-risk groups for HIV/AIDS and bivariate associations of drug use variables with IDU.
	Descriptive Analysis		Bivariate association analysis
Variables	IV Drug Users		Chi-square	p value
Variables	Yes, N (%)	No, N (%)
Used alcohol			25.07	< 0.001***
Ever	111 (73.5)	299 (90.9)
Never	40 (26.5)	30 (9.1)
Alcohol dependence			24.06	<0.001***
Yes	65(44.5)	208(68.6)
No	81(45.5)	95(31.4)
Drug dependence			13.00	< 0.001***
Yes	145(96.0)	262(84.5)
No	6(4.0)	48(15.5)
Used cigarettes			5.80	< 0.001**
Ever	125 (82.8)	239 (72.6)
Never	26 (17.2)	90 (27.4)
Marijuana			3.77	0.050
Ever	93 (61.6)	232 (70.5)
Never	58 (38.4)	97 (29.5)
Diazepam			11.90	< 0.001***
Ever	28 (22.2)	31 (9.8)
Never	98 (77.8)	284 (90.2)
Cocaine			2.97	0.080
Ever	7 (6)	8 (2.6)
Never	110 (94)	305 (97.4)
Sought treatment
Yes	44 (29.1)	47 (14.3)	14.86	< 0.001***
No	107 (70.9)	282 (85.7)
Family history			0.98	0.320
Yes	94 (62.3)	191 (58.1)
No	57 (37.7)	138 (41.9)
Depression Status			17.76	< 0.001***
Yes	142 (94.0)	271(82.3)
No	9(6.0)	57 (11.7)
H.I.V. status			2.21	0.136
Yes	4(2.6)	19(5.7)
No	147(97.4)	310(94.2)
Notes: statistically significant at p < 0.05; statistically significant at p < 0.01; **statistically significant at p < 0.001; Yes: number of injecting drug users; No: number of noninjecting drug users.

Multivariate logistic regression model analyses for the risk factors for injecting drug use

The multivariate logistic regression analysis indicated that participants with substance dependence disorders were almost four times more likely to be IDUs (aOR = 3.547; 95% CI (1.59–10.857), p = 0.028) than their counterparts were. Conversely, those with alcohol dependence presented decreased odds (aOR = 0.511; 95% CI (0.285–0.918), p = 0.024) of being an IDU. MSM status was significantly associated with an increase in IDU (aOR = 3.2; 95% CI (1.816–5.64), p < .001). Furthermore, females presented a lower likelihood of being an IDU (aOR = 0.698; 95% CI (0.248–0.967), p = 0.031) than males did. Additionally, marijuana users were more likely to be IDUs (aOR = 3.26; 95% CI (1.38–7.708), p = 0.007) than nonusers were. However, cocaine users were less likely to be IDUs (aOR = 0.404; 95% CI (0.184–0.887), p = 0.024) than their counterparts were. Our results revealed that participants with depressive symptoms were more likely to be IDUs (aOR = 4.50; 95% CI (2.55–7.96), p = 0.018) than high-risk groups for HOV/AIDS (MSMs and FSWs). Notably, variables such as age, cigarette use, education level, family history of substance use, and marital status were not associated with the likelihood of engaging in IDU. These findings provide essential insights into the intricate interplay of mental health, substance dependencies, and demographic aspects shaping IDU—behaviors within this specific context.

Table 3

Multivariate logistic regression model analyses for the risk factors for injection Document
		95% Confidence intervals
Variables	Adjusted Odds ratio	Lower	Upper	P Values
Age
18–25 years	1
26–35 years	0.635	0.282	1.431	0.273
36–45 years	0.996	0.416	2.384	0.994
45 + years	0.766	0.281	2.09	0.603
Education
None	1
Primary	1.327	0.236	7.47	0.748
Secondary and above	0.961	0.172	5.356	0.964
Gender
Male	1
Female	0.698	0.248	0.967	0.031*
Use of alcohol
No	1
Yes	0.487	0.275	0.862	0.014*
M.S.M.
No	1
Yes	3.2	1.816	5.64	< .001**
Heroin users
No	1
Yes	0.697	0.377	1.291	0.479
Cigarette
No	1
Yes	0.892	0.406	1.963	0.777
Marijuana
No	1
Yes	3.261	1.38	7.708	0.007*
Diazepam
No	1
Yes	1.277	0.649	2.515	0.777
Cocaine
No	1
Yes	0.404	0.184	0.887	0.024*
Alcohol dependence
No	1
Yes	0.511	0.285	0.918	0.028*
Substance dependence
No	1
Yes	3.547	1.159	10.857	0.027*
Sought treatment
No	1
Yes	1.798	0.916	3.529	0.088
Family history
No	1
Yes	0.728	0.41	1.292	0.278
Depression
No	1
Yes	4.50	2.55	07.95	0.018*
Notes: statistical significance at p < 0.05; * statistical significance at p < 0.01; *** statistical significance at p < 0.001, Yes: Number of injecting drug users; No: Number of non -injecting drug users

The findings of this study revealed that depression is an exceedingly prevalent high risk factor for HIV/AIDS in Kigali, Rwanda. Just over 86.25% of the participants reported depression. We found that most IDUs have moderate to severe symptoms of depression. A 2015 study by Li et al. in China confirmed our results, showing that IDU is closely associated with depression and other mental health problems. Depression disorders are mostly associated with any type of addiction. Many people inject drugs because they are depressed, and others report that the experience of injecting drugs makes them depressed (Hamzeh et al., 2018; Jia et al., 2018; Lemstra et al., 2011; Levintow et al., 2018). The high number of people with symptoms of depression in Rwanda is not a new phenomenon. The postgenocide period in Rwanda was characterized by a high prevalence of depression in the Rwanda community. Recent studies have shown that poor mental health has doubled in Rwanda and that depression has been found to be high in all demographics (Ng & Harerimana, 2016, Kayiteshonga et al., 2022). Nevertheless, the rates of 94% of IDUs presenting with depressive symptoms and 82.3% of those in the other groups at risk for HIV/AIDS far exceed the noted rates of depression of 35% in individuals who are genocide survivors and 20% in the general population (Kayiteshonga, 2022).

Our study revealed that participants' age and sexual orientation are factors associated with IDU. For example, being a younger participant and a sexual minority, especially an MSM or FSW, was associated with increased odds of being an IDU. Regarding mental health, our results showed that participants with depressive symptoms were more likely to be IDUs than their counterparts were. This was because the coexistence of depression and limited access to mental health resources in rural settings often creates a scenario where individuals might resort to substances, including injection drugs, as a way to self-medicate or cope with their mental health challenges. Moreover, the illegality of IDU discourages those who may have initiated the behavior as a result of depression (self-medication) to even attempt to seek assistance for their underlying depression. This interplay between depression and the scarcity of mental health support in Rwanda can significantly heighten the vulnerability of individuals to engaging in injecting drug use as a means of coping. These findings are relevant to previous studies (Cody et al., 2021).

Additionally, while this was a cross-sectional study and we cannot ensure which behavior came first, it is most often assumed that persons using other drugs graduate to injection drug use over time. Thus, it is not surprising that behaviors such as alcohol use, especially marijuana use, were more likely to be IDU than their counterparts were. These findings align with those of an earlier study conducted in China that focused on female IDUs who also engaged in sex work (IDUFSW). Those studies highlighted that these women faced a greater likelihood of experiencing thoughts of suicide, engaging in risky behaviors, and being involved in alcohol and substance use (Lau et al., 2018; Lemstra et al., 2011). The customers of the sex workers provided them with drugs and frequently shared injecting equipment. Corroborating these findings, a survey conducted in the Saskatoon Health Region (SHR) in Canada, as outlined by Gu et al. (2014), revealed that the initiation of substance use often commences in childhood and is influenced by networks of injecting users, including friends and schoolmates. Notably, the Rwandan population is characterized by a predominantly young demographic, with up to 65% of individuals, even from our current study, under 25. These results underscore the prevalence of substance use initiation during younger years among a significant majority, although this particular aspect was not explicitly explored in our research.

A recent study conducted on practice and HIV/AIDS among IDUs revealed that 99% of people who inject drugs (PWID) primarily used heroin, with 91% having shared needles in their lifetime and 31% in the past six months. The prevalence of HIV was 9.5%, with needle sharing and risky behaviors such as reusing needles and sharing drug paraphernalia significantly increasing the risk, particularly among females in Rwanda (Rwema et al., 2022).

We also found that having depression symptoms, alcohol, and substance dependence disorders, and having sought substance abuse treatment in the past, are significantly correlated risk factors for injection drug use, suggesting that the IDU is an excellent predictor of non-IDU risk patterns. These outcomes endorse previous studies conducted on fisher-folk in China and other groups in Vietnam, Tanzania, and Kenya, which showed that adolescents of both sexes and sexual minorities (female sex workers and males who have sex with males) are more likely to become injection drug users (Lau et al., 2018; Lemstra et al., 2011; Li et al., 2015). A recent study on injecting drug use in Rwanda, as documented by Rwema et al. (2022), established a correlation between injecting drug use and HIV/AIDS. However, the investigation did not delve into the examination of how depression symptoms are linked to individuals involved in intravenous drug use. Our findings affirm that a considerable portion of Rwandan youth who engage in drug injection present with a high prevalence of depression symptoms. Such behavior may serve as a coping mechanism, potentially utilized as a means to escape or alleviate the effects of a person’s depressive mood.

While substance use was high overall, our results confirmed that the people who were injected with drugs in our sample were more likely to be drug dependent than alcohol dependent. Nevertheless, both drug and alcohol dependence are risk factors for injecting drug use. Drug use tends to be progressive, from alcohol drinkers or non-IDUs graduating to injection drug use over time. IDUs use other types of drugs in different ways, including sniffing (cocaine) and chewing (marijuana), rather than drinking alcohol (Bouscaillou et al., 2016; Jia et al., 2018).

Finally, in our study, 5% of the participants were HIV/AIDS positive. These results prove that our sample, which was recruited because it included individuals at greater risk for HIV/AIDS, was indeed at higher risk of HIV/AIDS than the 3% among adults from 15–49 years of age in the total Rwandan population (Nsanzimana et al.,2022). However, the somewhat unexpected finding that the HIV/AIDS prevalence in IDUs was lower (2.6%) than that in the other risk groups in the study (5.7%) is somewhat reassuring and suggests that with intervention and tailored programs, including mental health programs and drug treatment, their progression to being HIV/AIDS positive could still be averted, which makes sense since this group is overall younger and most likely has less lifetime risk exposure than the other groups.

Two previous studies of HIV-positive individuals who were injected with drugs reported that the prevalence of depression is high in this group, ranging from 42–44% (Levintow et al., 2018; Noroozi et al., 2016), which we have exceeded. Both studies revealed that depression is a factor of IDU among HIV-positive individuals (Levintow et al., 2018; Noroozi et al., 2016). Depression symptoms and mental health disorders are not new to illicit drug users; however, the types of substances used can affect the severity of symptoms. The preceding example is based on research conducted in Mwanza, Tanzania, which revealed that heroin users are more likely to engage in unprotected sex, thus becoming exposed to HIV/AIDS and other blood-borne diseases, which can lead to depression (Tan et al., 2015).

Our findings contradict the prevailing literature, indicating that family background is not statistically correlated with injecting drug use. This contradicts European research findings where more than half of frequent domestic conflicts were associated with a history of substance use in the family and three-fourths had peers engaged in IDU. (Williams et al., 2017). The absence of such associations in our results can be attributed to the relatively underexplored nature of IDU, which represents a rapidly evolving trend in African countries, including Rwanda. Unlike other forms of substance consumption, IDU is a new phenomenon, and familial influences on this specific method of drug intake are not yet well understood.

In contrast to established patterns in other forms of substance use, family members in Rwanda significantly influence their offspring in matters related to drug consumption (Kanyoni et al.2014). Substance use in a family member may affect a child through mechanisms such as an increased genetic predisposition or negative role modeling, heightening a child's susceptibility to substance use (Kuppens et al, 2020)In Rwandan culture, as in many other societies, children tend to emulate the behaviors and activities demonstrated by their parents, and the consumption of drugs, including drinking and smoking, can reflect a familial culture of substance use.

Strengths and limitations

This study has crucial strengths, as it is the first-ever investigation into the influence of mental health on injecting drug use (IDU) in Kigali, Rwanda. Notably, this study revealed a substantial prevalence of depression among those at risk of HIV/AIDS, highlighting a significant association between moderate to severe depression and IDU. Additionally, it effectively identifies vulnerable populations, such as younger individuals and sexual minorities, shedding light on their increased likelihood of engaging in IDU. The study's focus on behavioral influences, particularly alcohol and substance use, extends our understanding of these factors in relation to IDU patterns. Furthermore, these findings carry substantial implications for tailored interventions and public health strategies, emphasizing the urgent need for expanded mental health services, especially among vulnerable groups. These insights pave the way for targeted interventions to mitigate the risks associated with IDU and enhance mental health outcomes in Rwanda and analogous contexts within Sub-Saharan Africa."

Despite the strengths of this study, we acknowledge several limitations. First, owing to the cross-sectional study design, we were unable to determine a causal relationship between various types of drug and alcohol exposure and IDU. Did depression lead to drug use and then escalate to the IDU? Clearly, further studies using a longitudinal study design are essential for allowing us to assess the progression of risk factors, including depression, among IDUs. Second, the sample size was somewhat limited, as it was derived through nonrandom, snowball sampling because the study population is hard to reach because of the hidden and illegal nature of the behavior. This could result in an overestimation or underestimation of our results, which prevents us from generalizing. Future studies should employ larger sample sizes and some type of more systematic recruitment, as randomization is clearly never possible.

Moreover, as we decided to limit the line of questioning, to keep the survey brief and optimize responses, the exploration of most likely crucial sociocultural and belief-related factors could not be performed, and of course, the use of self-reported measures introduces potential recall bias, impacting data reliability. Therefore, at the very least, mixed methods could be important for exploring all possible factors of IDUs. This could then be followed by a longer survey aligned with the contextual findings.

Finally, in the process of gathering data on alcohol and substance use, we utilized the MINI, which employs DSM-IV criteria. However, certain criteria were modified and consolidated in the updated DSM-V version, potentially leading to misunderstandings in data concerning alcohol and substance dependence. These acknowledged limitations highlight the need for further research employing various methodologies to capture the complex interplay of IDU factors comprehensively.

Public health implications

The study outcomes highlight the staggering prevalence of depression among our sample of individuals at high risk of HIV/AIDS in Kigali, Rwanda, with more than 86.25% of participants exhibiting symptoms of depression. Moreover, depression was even more common among IDUs (94%). An intricate relationship between injecting drug use (IDU) and moderate to severe depressive symptoms is established, which aligns with previous global research findings that closely link depression disorders with alcohol and substance use disorders. These findings emphasize the critical need for tailored interventions addressing depression symptoms, especially among vulnerable populations such as sexual minorities (MSMs and FSWs) and individuals engaging in substance abuse, particularly hard alcohol and marijuana users. The finding that family background does not exhibit a statistical association with IDU contradicts established patterns in other substance use forms, indicating the evolving nature of injecting drug use in Rwanda and the limited exploration of the familial influence of this specific drug intake method.

Future directions

Moving forward, addressing the mental health challenges posed by depression and substance dependence among youth engaging in intravenous drug use becomes important. It is essential to prioritize mental health services that address depression, alcohol, and substance abuse by seeking treatment together, especially considering that only a small fraction of Rwandans seek help for mental health concerns. Given the limitations of this study, future research directions should include mixed methods studies to further explore the context and progression of IDU, followed by larger powered longitudinal studies that allow the determination of causality. Moreover, our study focused on the urban environment of Kigali. We need to explore other geographical areas beyond Kigali to better understand whether IDU occurs mostly in urban environments or begins in rural seetings, with people then migrating to the urban environment with more access to drugs. Furthermore, larger-scale studies with varied populations would enhance the understanding and generalizability of the findings. The use of representative, comprehensive and frequent assessments of substance use, mental health, and health risk behaviors within Rwanda overall could further elucidate the complex interplay between depression, substance use, and health-risk behaviors among individuals engaged in intravenous drug use in Rwanda and neighboring Sub-Saharan African countries.

The findings of this study highlight a significant association between injecting drug users (IDUs) and various factors, including the types of substances used, such as cocaine, marijuana, hard alcohol, cigarettes, simple beer, diazepam, substance dependence, and prior treatment for substance use. Furthermore, a strong correlation was observed between depression and IDUs, suggesting that mental health is a critical driver of increasing drug use. It is essential to implement harm reduction practices, particularly through mental health-based interventions, not only at the government level but also among partners and stakeholders, to enhance the well-being of the population. These factors related to IDUs must be addressed by a comprehensive range of psychosocial and behavioral healthcare providers. Effective interventions should focus on individual IDUs and their families, taking into account the deeply rooted social factors within Rwandan culture. Consequently, mental health policies and strategies that integrate rehabilitation practices with Community Resilience Model (CRM) skills training (Freeman et al., 2021; Grabbe et al., 2021; Habimana et al., 2021) could be implemented to reduce and minimize harm for participants, thereby improving their quality of life and enhancing the resilience and mental well-being of individuals at high risk for HIV/AIDS in Rwanda

CRM

Community resilience model

FSW

Female sex worker

HDI

Health development initiatives

HIV/AIDS

Human immunodeficiency virus

MSM

Males having sex with Males

RRGO

Rwanda Resilience and Grounding Organization

Availability of data and materials

The datasets generated and analyzed during the current study are available to the Health Development Initiative (HDI) upon reasonable request.

Funding

The authors declare that they are not funding this study.

Authors' contributions

SH, SM, LZ,ER and EB contributed to the study conceptualization, design, data acquisition, and study administration and searchedthe literature. EB SM and SH drafted the manuscript, conception, data curation, analysis and interpretation of data, visualization, and validation. ER and KA contributed to the acquisition of data and conceptualization, edited the manuscript, and revised the manuscript critically for important intellectual content. AN,ER,SJ had a supervisory contribution to the study and KA substantially contributed to resource availability. All authors critically revised the manuscript and approved the final version of this manuscript.

Ethics approval and consent to participate

The Rwanda National Ethics Committee (RNEC) obtained ethical clearance under the Rwanda Ministry of Health. Verbal and written informed consent forms were received from all research participants.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no conflicts of interest. The authors reported no financial interest or personal relationship that could influence the performance of this research.

Acknowledgments

The authors thank the Health Development Initiatives (HDIs) for facilitating data collection. The participants are acknowledged for their participation.

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Profile of risk factors for injecting drug use among the sample at high risk of HIV/AIDS in Kigali, Rwanda

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Conclusion

Background

Methods

Design and Procedures

Data collection and measures

Data analyses

Results

Descriptive analysis by sociodemographic variables

Multivariate logistic regression model analyses for the risk factors for injecting drug use

Discussion

Strengths and limitations

Public health implications

Future directions

Conclusion

Abbreviations

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