The Policy-Driven HIV Epidemic Among Opioid Users in the Russian Federation

HIV knowledge, self-perception of HIV risk, and sexual risk behaviors among male Tajik labor migrants who inject drugs in Moscow

BACKGROUND

The interplay of human immunodeficiency virus (HIV) knowledge and self-perception of risk for HIV among people who inject drugs is complex and understudied, especially among temporary migrant workers who inject drugs (MWID) while in a host country. In Russia, Tajik migrants make up the largest proportion of Moscow's foreign labor. Yet, HIV knowledge and self-perceived risk in association with sexual risk behavior among male Tajik MWID in Moscow remains unknown.

OBJECTIVE

This research examines knowledge about HIV transmission, self-perception of HIV risk, and key psychosocial factors that possibly contribute to sexual risk behaviors among male Tajik labor MWID living in Moscow.

METHODS

Structured interviews were conducted with 420 male Tajik labor MWID. Modified Poisson regression models investigated possible associations between major risk factors and HIV sexual risk behavior.

RESULTS

Of the 420 MWID, 255 men (61%) reported sexual activity in the last 30 days. Level of HIV knowledge was not associated in either direction with condom use or risky sexual partnering, as measured by sex with multiple partners or female sex workers (FSW). Lower self-perceived HIV risk was associated with a greater likelihood of sex with multiple partners (aPR: 1.79, 95% CI: 1.34, 2.40) and FSW (aPR: 1.28, 95% CI: 1.04, 1.59), but was not associated with condom use. Police-enacted stigma was associated with sex with multiple partners (aPR: 1.22, 95% CI: 1.01, 1.49) and FSW (aPR: 1.32, 95% CI: 1.13, 1.54). While depression and lower levels of loneliness were associated with condomless sex (aPR: 1.14, 95% CI: 1.05, 1.24; aPR: 0.79, 95% CI: 0.68, 0.92, respectively), only depression was associated with condomless sex with FSW (aPR: 1.26, 95% CI: 1.03, 1.54).

CONCLUSIONS

HIV prevention programing for male Tajik MWID must go beyond solely educating about factors associated with HIV transmission to include increased awareness of personal risk based on engaging in these behaviors. Additionally, psychological services to counter depression and police-enacted stigma are needed.

Stigma and other correlates of sharing injection equipment among people with HIV in St. Petersburg, Russia

Stigma that people with HIV who inject drugs experience negatively impacts HIV and substance use care, but stigma's association with sharing injection equipment is not known. This is a cross-sectional analysis of data from two studies of people with HIV reporting drug injection (N = 319) in St. Petersburg, Russia (September 2018-December 2020). We used logistic regression to examine associations between HIV stigma and substance use stigma scores (categorised into quartiles) and past 30-day equipment sharing, adjusting for demographic and clinical characteristics. Secondary analyses examined associations of arrest history and social support with sharing equipment. Almost half (48.6%) of participants reported sharing injection equipment. Among groups who did and did not share, mean HIV stigma (2.3 vs 2.2) and substance use stigma (32 vs 31) scores were similar. Adjusted analyses detected no significant associations between HIV stigma quartiles (global p-value = 0.85) or substance use stigma quartiles (global p-value = 0.51) and sharing equipment. Neither arrest history nor social support were significantly associated with sharing equipment. In this cohort, sharing injection equipment was common and did not vary based on stigma, arrest history, or social support. To reduce equipment sharing, investments in sterile injection equipment access in Russia should be prioritised over interventions to address stigma.

HIV Knowledge, Self-Perception of HIV Risk, and Sexual Risk Behaviors among Male Tajik Labor Migrants who inject Drugs in Moscow

Background

The interplay of HIV knowledge and self-perception of risk for HIV among people who inject drugs is complex and understudied, especially among temporary migrant workers (MWID) who inject drugs while in a host country. In Russia, Tajik migrants make up the largest proportion of Moscow's foreign labor. Yet, HIV knowledge and self-perceived risk in association with sexual risk behavior among Tajik MWID in Moscow remains unknown.

Objective

This research examines knowledge about HIV transmission, self-perception of HIV risk, and key psychosocial factors that possibly contribute to sexual risk behaviors among male Tajik MWIDs living in Moscow.

Methods

Structured interviews were conducted with 420 male Tajik MWIDs. Modified Poisson regression models investigated possible associations between major risk factors and HIV sexual risk behavior.

Results

Of the 420 MWIDs, 255 men (61%) reported sexual activity in the last 30 days. Level of HIV knowledge was not associated in either direction with condom use or risky sexual partnering, as measured by sex with multiple partners or female sex workers. Higher self-perceived HIV risk predicted less risky sexual partnering, but not condom use. Depression and police-enacted societal stigma were positively associated with risky sexual partnering, while loneliness and depression were associated with condomless sex.

Conclusions

HIV prevention programing for male Tajik MWIDs must go beyond solely educating about factors associated with HIV transmission to include increased awareness of personal risk based on engaging in these behaviors. Additionally, psychological services to counter loneliness, depression, and societal stigma through police harassment are needed.

The impacts of COVID-19 on structural inequities faced by people living with HIV who inject drugs: A qualitative study in St. Petersburg, Russia

BACKGROUND

People who inject drugs (PWID) living with HIV may be disproportionately impacted by pandemic restrictions. This study qualitatively explored the impacts of the SARS-CoV-2 pandemic on PWID with HIV in St. Petersburg, Russia.

METHODS

In March and April 2021, we conducted remote, semi-structured interviews with PWID with HIV, health care providers, and harm reductionists.

RESULTS

We interviewed 25 PWID with HIV (aged 28-56 years, 46% female) and 11 providers. The pandemic exacerbated economic and psychological challenges experienced by PWID with HIV. Simultaneously, barriers to HIV care access, ART prescription refill and dispensing and police violence, which hindered the health and safety of PWID with HIV, were themselves hindered from normal operations by the pandemic, significantly reducing these burdens.

CONCLUSION

Pandemic responses should account for the unique vulnerabilities of PWID with HIV to avoid worsening the structural violence they already experience. Wherever the pandemic decreased structural barriers, such as institutional, administrative, and bureaucratic challenges and state violence enacted by police and other elements of the criminal justice system, such changes should be protected.

Addressing intersectional stigma as a care barrier for HIV-positive people who inject drugs: Design of an RCT in St. Petersburg, Russia

Background

HIV-positive people who inject drugs (PWID) experience stigma related to their substance use and HIV, with adverse consequences to their health care utilization and mental health. To help affected individuals cope with their intersectional stigma and reduce its negative impact on health and health care, we adapted a behavioral stigma coping intervention for this HIV key population.

Objective

To conduct a randomized controlled trial (RCT) testing the ‘Stigma Coping to Reduce HIV risks and Improve substance use Prevention and Treatment’ (SCRIPT) intervention, a community-based, adapted form of Acceptance and Commitment Therapy (ACT), for PWID living with HIV in St. Petersburg, Russia.

Methods

We recruited 100 PWID living with HIV from civil society organizations (CSO) delivering harm reduction and HIV prevention services in St. Petersburg, Russia. We randomized participants 2:1 to receive either the intervention (three adapted ACT sessions in a group format over one month and usual CSO care) or usual CSO care alone. ACT aims to help affected individuals cope with stigma by increasing their psychological flexibility to handle stigma-related negative expectations, emotions and experiences. The primary outcomes were satisfaction with the intervention, and changes in HIV and substance use stigma scores.

Conclusions

Stigma coping interventions targeting HIV-positive PWID outside of formal health care settings may help them confront negativities in their lives originating from intersectional stigma and reduce stigma's impact as a health care barrier.

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HIV-positive people who inject drugs face stigma due to both substance use and HIV.

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Interventions are scarce to help this population reduce stigma as care barrier.

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We recruited participants outside of the formal health care setting in Russia.

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We partnered with multiple organizations to recruit and retain stigmatized people.

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We evaluated the intervention's effects on stigma, health care, & health outcomes.

Linking HIV-positive people in addiction care to HIV services in St. Petersburg, Russia - Mixed-methods implementation study of strengths-based case management

Access to HIV services for HIV-positive patients in addiction care is challenging in Russia, because both care systems are organised independently from each other. Strengths-based case management is an effective strategy to connect people with HIV (PHIV) to HIV care. This mixed-methods study's objective was to investigate implementation of a case management intervention in St. Petersburg, Russia, designed to connect PHIV who inject drugs to HIV care. We analysed survey data from 118 HIV-positive patients in addiction care and conducted six focus groups (n=38). Quantitative analyses of fidelity and satisfaction outcomes and qualitative text analysis assessed intervention implementation. Participants who linked to HIV services embraced empowerment and motivation resulting from case management as supporting self-efficacy and linkage to services. Among participants who did not link to care, drug use impeded their care engagement. Main levers to implementation were empowerment to cope with challenges of a fragmented health system and persistent stigma. Those who connected to HIV services credited case managers for facilitating linkage; those who did not link attributed it to personal issues. Implementation of case management for HIV care in Russia should focus on effective substance use treatment and empowerment, motivation and support in addressing personal and system factors.

HIV and Substance Use Stigma, Intersectional Stigma and Healthcare Among HIV-Positive PWID in Russia

Little is known about the intersection of HIV stigma and substance use stigma. Using data from 188 HIV-positive people who inject drugs (PWID) in Russia, we examined the associations of these stigmas and their interaction with access and utilization of healthcare. While substance use stigma was significantly associated with poor access to care (AOR 2.31, 95%CI 1.50-3.57), HIV stigma was not. HIV stigma was associated with lower inpatient care utilization (AOR 0.32, 95%CI 0.14-0.65), while substance use stigma was not. We did not detect a significant interaction between the two forms of stigma for either of the primary outcomes. However, those with high levels of both substance use stigma and HIV stigma had higher odds of poor general access to healthcare (AOR 1.86, 95%CI 1.19-2.92), and lower odds of recent general outpatient (AOR 0.52, 95%CI 0.32-0.85) and any inpatient (AOR 0.48, 95%CI 0.22-0.99) care utilization compared to those with low levels of both types of stigma. Interventions addressing both substance use and HIV stigma in general healthcare settings might improve care in this HIV key population.

Decisional considerations for methadone uptake in Kyrgyz prisons: The importance of understanding context and providing accurate information

BACKGROUND

The Kyrgyz Republic (Kyrgyzstan) is one of few countries in Eastern Europe and Central Asia to provide methadone within its prisons, but uptake of this program has been suboptimal, in part because methadone uptake may have personal or social risks and consequences. Decision aids are evidence-based strategies that are designed to inform the patient's choice by objectively providing information that incorporates patient preferences.

METHODS

We conducted qualitative interviews in Kyrgyz and Russian with currently and formerly incarcerated people (n = 36) in Kyrgyzstan from October 2016 to September 2018. Interviews explored factors influencing methadone utilization in prisons. Transcripts were coded by five researchers using content analysis. A secondary thematic analysis was conducted to determine factors specific to initiation or continuation of methadone treatment in prisons.

RESULTS

We identified six interrelated themes affecting an individual's decision to initiate or continue methadone treatment: 1) informal prison governance (incarcerated people governing themselves); 2) informal prison economy; 3) perceived and objective benefits of methadone treatment; 4) perceived and objective side effects of methadone treatment; 5) distrust of formal prison administration (medical and correctional staff); and 6) desire for a "cure" from addiction.

CONCLUSION

Respondents' perceptions about benefits, side effects, and addiction as a curable disease are not consistent with the available evidence. An evidence-based, informed decision-making aid would need to address the six themes identified here, of which several are specific to the Kyrgyz prison context. Unlike decision aids elsewhere, the unique aspects of incarceration itself alongside the informal governance system strongly present within Kyrgyz prisons will need to be incorporated into decisional processes to promote HIV prevention and treatment in a region with high rates of HIV transmission and mortality.

The protective effect of trusted dealers against opioid overdose in the U.S

BACKGROUND

Opioid overdose has become the leading cause of death among adults between 25 and 54 years old in the U.S. The purpose of this study is to explore the social and relational factors that shape the current opioid overdose epidemic.

METHODS

Between January 2016 and February 2017, adults in Providence, Rhode Island, who use opioids were recruited to complete structured survey and semi-structured interview about the social context of their substance use.

RESULTS

A total of 92 individuals completed a survey and an interview. Of those, 51 individuals (68.6% male, 49.0% white) discussed their relationships with drug suppliers in their interview and were included in this sub-study. Many of these participants indicated that long-term relationships with trusted dealers represent a key strategy for reducing the risk of substance use-related harm due to suppliers' alleged adoption of consumer protection strategies (e.g. refusing to sell fentanyl) and quality assurance measures (e.g. testing batches of drugs for fentanyl prior to sale).

CONCLUSION

Interpersonal relationships between individuals who use drugs and their suppliers strongly influence the risk and protective factors experienced by people who use drugs in today's opioid overdose epidemic. Evidence-based prevention strategies that are based on an awareness of-or even designed to harness-those positive and/or protective relationships that people who use drugs have already constructed for themselves are likely merited.

Policing Practices and Risk of HIV Infection Among People Who Inject Drugs

Drug-law enforcement constitutes a structural determinant of health among people who inject drugs (PWID). Street encounters between police and PWID (e.g., syringe confiscation, physical assault) have been associated with health harms, but these relationships have not been systematically assessed. We conducted a systematic literature review to evaluate the contribution of policing to risk of human immunodeficiency virus (HIV) infection among PWID. We screened MEDLINE, sociological databases, and gray literature for studies published from 1981 to November 2018 that included estimates of HIV infection/risk behaviors and street policing encounters. We extracted and summarized quantitative findings from all eligible studies. We screened 8,201 abstracts, reviewed 175 full-text articles, and included 27 eligible analyses from 9 countries (Canada, China, India, Malaysia, Mexico, Russia, Thailand, Ukraine, and the United States). Heterogeneity in variable and endpoint selection precluded meta-analyses. In 5 (19%) studies, HIV infection among PWID was significantly associated with syringe confiscation, reluctance to buy/carry syringes for fear of police, rushed injection due to a police presence, fear of arrest, being arrested for planted drugs, and physical abuse. Twenty-one (78%) studies identified policing practices to be associated with HIV risk behaviors related to injection drug use (e.g., syringe-sharing, using a "shooting gallery"). In 9 (33%) studies, policing was associated with PWID avoidance of harm reduction services, including syringe exchange, methadone maintenance, and safe consumption facilities. Evidence suggests that policing shapes HIV risk among PWID, but lower-income settings are underrepresented. Curbing injection-related HIV risk necessitates additional structural interventions. Methodological harmonization could facilitate knowledge generation on the role of police as a determinant of population health.

HIV PREVALENCE AMONG VULNERABLE GROUPS IN RUSSIA - RESULTS OF AN INTEGRATED BIO-BEHAVIORAL SURVEY

Aim. Of the study is to assess HIV prevalence in the vulnerable groups namely injecting drug users (IDU), sex workers (SW), and men who have sex with men (MSM) in some of the largest Russian regiоnal capitals mostly affected by HIV infection. Materials and methods. The study involved 3744 persons from vulnerable groups enrolled by respondent-driven sampling (RDS) or time-location sampling (TLS). The study was undertaken in seven regions of the Russian Federation: Moscow, St.-Petersburg, Yekaterinburg, Krasnoyarsk, Kemerovo, Tomsk and Perm. All participants were interviewed using specially designed questionnaire and then tested for HIV. The retrospective cohort method was applied to evaluate the number of new HIV cases among respondents. Results. HIV prevalence in IDUs ranged from 48.10% [95% confidence interval (CI)=42.20.54.10%] in Krasnoyarsk and 75.20% [95%CI=69.90.80.60%] in Kemerovo. HIV prevalence among sex workers varied from 2.32% [95%CI=0.49.4.17%] in St. Petersburg to 15.01% [95%CI=11.46.18.56%] in Perm. HIV prevalence among MSM ranged from 7.10% [95%CI=4.10.10.10%] in Moscow to 22.80% [95%CI=17.90.27.70%] in St.-Petersburg. Conclusion. The number of new HIV infections estimated by the retrospective cohort method indicated rapid spread of HIV infection among IDUs in all cities except St.-Petersburg, relatively high HIV growth rates among MSM ranging from 1.6% per year [95%CI=0.1... 3.1%] to 4.6% per year [95%CI=0.0... 11%] and 12.3% annual HIV growth rate [95%CI=0.0... 28.3%] among sex workers. Generally, the situation in the studied groups remained adverse and called for more intensive prevention activities in vulnerable populations.

Potential impact of implementing and scaling up harm reduction and antiretroviral therapy on HIV prevalence and mortality and overdose deaths among people who inject drugs in two Russian cities: a modelling study

BACKGROUND

Most new HIV infections among people who inject drugs (PWID) in eastern Europe and central Asia occur in Russia, where PWID have a high risk of overdose. In Russia, use of opioid agonist therapy (OAT) is prohibited, and coverage of needle and syringe programmes (NSPs) and antiretroviral therapy (ART) is poor. We aimed to assess the effects that scaling up harm reduction (ie, use of OAT and coverage of NSPs) and use of ART might have on HIV incidence and the frequency of fatal overdoses among PWID in two cities in the Ural Federal District and Siberian Federal District, where the prevalence of HIV is high or increasing in PWID.

METHODS

In this modelling study, we developed a dynamic deterministic model that simulated transmission of HIV through injection drug use and sex among PWID. We calibrated this model to HIV prevalence data among PWID in two Russian cities: Omsk (which has high but increasing prevalence of HIV among PWID) and Ekaterinburg (which has very high but stable prevalence of HIV). The source data were from research studies supported by the Global Fund to Fight AIDS, Tuberculosis, and Malaria and US Centers for Disease Control and Prevention and surveillance studies from WHO and regional AIDS centres. We modelled the effects of no intervention scale-up (no use of harm reduction measures and 30% of HIV-positive PWID receiving ART) versus combinations of scaling up of OAT, receipt of high coverage of NSPs, and use of ART on the incidence of HIV infections, mortality from HIV, and the frequency of fatal overdoses from 2018 to 2028.

FINDINGS

Without intervention, HIV prevalence among PWID in Omsk could increase from 30% in 2018 to 36% (2·5-97·5 percentile interval 22-52) in 2028 and remain high in Ekaterinburg, estimated at 60% (57-67) in 2028. Scaling up OAT to 50% coverage for a duration of 2 years could prevent 35% of HIV infections and 19% of deaths associated with HIV in Omsk and 20% (11-29) of HIV infections and 10% (4-14) of deaths associated with HIV in Ekaterinburg. Further, this scaling up could prevent 33% of overdose deaths over the next 10 years. Scaling up of NSPs and OAT to 50% coverage and tripling recruitment to ART (reaching about 65% of HIV-positive PWID) could prevent 58% (46-69) of HIV infections and 45% (36-54) of deaths associated with HIV in Omsk and 38% (26-50) of HIV infections and 32% (23-41) of deaths associated with HIV in Ekaterinburg by 2028.

INTERPRETATION

Legalisation of OAT and increased use of ART and NSPs for PWID are urgently needed to prevent HIV and fatal overdose among PWID in Russia.

FUNDING

National Institutes of Health and Elton John AIDS Foundation.