Prevalence and factors associated with use of khat: a survey of patients entering HIV treatment programs in Ethiopia
Among HIV patients newly enrolled in care at two large Ethiopian hospitals, we found a high prevalence of khat use, with 75% reporting lifetime use and 65% reporting use within the previous year. Among those using khat, over half reported chewing khat every day, and almost two-thirds used khat ?5 h/day. Use of khat in the past year was also associated with poorer self-reported health status, a lower BMI, and a greater number of chronic symptoms. Heavy users (?180 h in a typical month) reported all of these undesirable clinical outcomes, as well as a greater number of negative physical QOL statements.
Our study found that most persons who ever used khat had used it during the year prior to enrollment in care; future analyses in this prospective study will compare khat use in the year before and after enrollment. Studies of khat have used different time frames to estimate recent use, such as past month [11] or past year [12]. Although we used past year, data from the 2011 Ethiopian Demographic and Health Survey using a 30 day time frame are consistent with our conclusions that most persons ever using khat have used it recently. Among men and women from the Harari region who ever used khat, 91 and 88% respectively had used one or more times it in the last 30 days; among men and women from Dire Dawa, corresponding rates were 85 and 96% [19].
HIV patients who reported khat use in the past year, especially heavy use, reported a greater number of chronic symptoms and a more negative physical QOL. Whether khat users who have such symptoms are more likely to use khat to help alleviate them, or whether chronic and habitual use causes increased symptomatology is unclear. However, other studies also report greater physical illness in khat users [6] and habitual khat use has been shown to be associated with a wide variety of physical and mental health harms, including cognitive impairment that may affect daily life activities [1–5, 24].
Khat users in our study were also significantly more likely to both use tobacco and drink alcohol. The association of khat use with both smoking and alcohol use has been reported from other studies as well [10, 11, 25]. We cannot say whether khat consumption predisposes users to use of these other substances (for example, use of alcohol to counteract stimulant properties of khat), or whether this association reflects underlying stressors or psychological factors that cause people to use multiple substances. Since both alcohol abuse and smoking can have negative health outcomes for HIV patients [14, 15], use of multiple substances may add to the adverse health effects potentially associated with khat.
Although khat is legal in Ethiopia and may be considered part of the lifestyle in some countries, it also has a potential for development of dependence [1, 3, 26, 27]. Although most respondents believed khat use (especially every day) was dangerous for health of HIV-infected individuals, use on a daily basis was common; 21% of current users reported that they felt a need to cut down or control their khat use but had difficulty doing so.
Our results have several implications for strategies to prevent or reduce khat use. Over half (54%) of khat users reported first use at age 18 years or younger. Given the prevalence of khat use in some populations of young people [8, 9], this supports the importance of drug education programs in schools and other settings where youth congregate. In addition to being a major cash crop, in certain communities khat has a social and cultural significance and acceptance [26, 28]. Rather than advocating for abstinence in all populations, a more balanced harm reduction approach that discourages excessive khat use or onset early in life may be more reasonable and favorable received [28].
Our study has several limitations. First, we chose for this study two cities where khat use is especially common; persons in different geographic areas may have a different prevalence and correlates of use. Second, khat use was self-reported, and some persons may have underreported their frequency of use. Third, associations between khat use and other factors in this survey do not necessarily imply temporality or causality. Finally, during khat sessions, leaves are kept in the mouth and typically chewed over several hours to release active components, and different khat plants may contain different concentrations of active cathinone products; therefore, the number of hours chewed may not strictly correspond with number of leaves ingested. As a statistical threshold, we chose the top quartile of hours khat was used in a typical month as the cut-point for heavy use. However, future studies, ideally in correlation to cathinone blood levels, can help to clarify how frequency and amount of use is associated with drug absorption and specific biological harms.