Sex work, drug use, HIV infection, and spread of sexually transmitted infections in Moscow, Russian Federation

The Global Distribution and Epidemiology of Psychoactive Substance Use and Injection Drug Use Among Street-Involved Children and Youth: A Meta-Analysis

Background: Globally, street-involved children and youth (SICY) who work and live on/of the streets are at higher risk of increased psychoactive substances and injecting drug use. Objectives: The present study aimed to identify the prevalence, distribution, sociodemographic factors, and risk-taking behaviors associated with psychoactive substances and injecting drug use among SICY. Methods: Studies in English published from December 1 1985 to July 1 2022, were searched for on PubMed, Scopus, Cochrane, and Web of Science to identify primary studies on psychoactive substances and injecting drug use among SICY. The pooled-prevalence estimates were obtained using a robust fixed-effects model. Results: The most commonly reported life-time and current psychoactive substance was tobacco followed by cannabis, LSD/ecstasy, cocaine, methamphetamine, heroin and injection drug use. The results showed that life-time and current prevalence of methamphetamine and cannabis use, as well as life-time prevalence of cocaine, LSD/ecstasy, heroin, tobacco, and injecting drug use increased as age rose while current prevalence of cocaine and tobacco use decreased as age rose. SICY who were male, homeless, had parents who had died, had history of substance use among family members or best friends, had experienced violence, had casual sex partners, had a history of working in the sex trade, and had unprotected sex were all related to psychoactive substance use and injecting drug use. Conclusions: Research examining this population suffers from lack of studies, therefore, improving the knowledge for interventions aimed at reducing risk behaviors, particularly those related to the transmission of sexually transmitted infections such as HIV is of great importance.

Sex work stigma and non-disclosure to health care providers: data from a large RDS study among FSW in Brazil

Background

Stigma in health services may be detrimental to health seeking attitudes and practices. This study investigates non-disclosure of sex work to health care providers among female sex workers (FSW) in Brazil and its association with the utilization of health care services.

Methods

This study used cross-sectional respondent-driven sampling, carried out in 12 Brazilian cities to identify HIV risk behaviors among FSW. We first assessed statistical associations of sociodemographic, human right violations, health service access and utilization, and discrimination variables with non-disclosure of FSW status to health care providers as outcome. Secondly, we investigated the association of non-disclosure of FSW status with selected preventive health care outcomes: HIV testing, PAP smear exam, and post-exposure prophylaxis (PEP). Adjusted odds ratio with 95% confidence intervals were calculated by multivariable logistic regressions.

Results

Among 4245 recruited FSW, a high percentage received free condoms (82%) but only 24.4% were counseled on STI. Most FSW used non-specialized public healthcare routinely (62.6%), but only 51.5% had a Pap smear exam in the last two years and less than 40% were tested for HIV in the last 12 months. Among FSW who engaged in risky behavior (49.6%), only 8.3% used PEP. Regarding human rights violations, approximately 15% were required to give part of their earnings to owners of workplace establishments, 38% started sex work under 18 years old and 6% were required to periodically present their HIV test results. 21.3% reported having faced discrimination in health services, and 24.3% always disclosed their FSW status. Multivariable logistic models indicated significant associations of non-disclosure on the four healthcare outcomes, with lower odds of using preventive health services among women who did not disclose their sex work status, even after controlling for age, educational level, NGO affiliation, and type of health care routinely used.

Conclusions

Our results indicate that sex work stigmatization within health services may be one of the main barriers to STI control and HIV response among FSW. It is essential to combat stigmatization and discrimination against FSW in health services to guarantee the appropriate uptake of preventive services available in the public health system in Brazil.

Heterogeneity in geographical trends of HIV epidemics among key populations in Pakistan: a mathematical modeling study of survey data

BACKGROUND

Assessing patterns and trends in new infections is key to better understanding of HIV epidemics, and is best done through monitoring changes in incidence over time. In this study, we examined disparities in geographical trends of HIV epidemics among people who inject drugs (PWIDs), female sex workers (FSWs) and hijra/transgender/male sex workers (H/MSWs), in Pakistan.

METHODS

The UNAIDS Estimation and Projection Package (EPP) mathematical model was used to explore geographical trends in HIV epidemics. Four rounds of mapping and surveillance data collected among key populations (KPs) across 20 cities in Pakistan between 2005-2011 was used for modeling. Empirical estimates of HIV prevalence of each KP in each city were used to fit the model to estimate prevalence and incidence over time.

RESULTS

HIV incidence among PWIDs in Pakistan reached its peak in 2011, estimated at 45.3 per 1000 person-years. Incidence was projected to continue to rise from 18.9 in 2015 to 24.3 in 2020 among H/MSWs and from 3.2 in 2015 to 6.3 in 2020 among FSWs. The number of people living with HIV in Pakistan was estimated to steadily increase through at least 2020. HIV incidence peak among PWIDs ranged from 16.2 in 1997 in Quetta to 71.0 in 2010 in Faisalabad (per 1000 person-years). Incidence among H/MSWs may continue to rise through 2020 in all the cities, except in Larkana where it peaked in the early 2000s. In 2015, model estimated incidence among FSWs was 8.1 in Karachi, 6.6 in Larkana, 2.0 in Sukkur and 1.2 in Lahore (per 1000 person-years).

CONCLUSIONS

There exists significant geographical heterogeneity in patterns and trends of HIV sub-epidemics in Pakistan. Focused interventions and service delivery approaches, different by KP and city, are recommended.

Factors associated with HIV infection among female sex workers in Brazil

BACKGROUND

Female sex workers (FSWs) are one of the most-at-risk population groups for human immunodeficiency virus (HIV) infection. This paper aims at identifying the main predictors of HIV infection among FSW recruited in the 2nd Biological and Behavioral Surveillance Survey in 12 Brazilian cities in 2016.

METHOD

Data were collected on 4245 FSW recruited by respondent driven sampling (RDS). Weights were inversely proportional to participants' network sizes. To establish the correlates of HIV infection, we used logistic regression models taking into account the dependence of observations resultant from the recruitment chains. The analysis included socio-demographic sex work characteristics, sexual behavior, history of violence, alcohol and drug use, utilization of health services, and occurrence of other sexually transmitted infections (STIs).

RESULTS

HIV prevalence was estimated as 5.3% (4.4%-6.2%). The odds ratio (OR) of an HIV-positive recruiter choosing an HIV-positive participant was 3.9 times higher than that of an HIV-negative recruiter (P < .001). Regarding socio-demographic and sex work characteristics, low educational level, street as the main work venue, low price per sexual encounter, and longer exposure time as a sex worker were found to be associated with HIV infection, even after controlling for the homophily effect. The OR of being HIV infected among FSW who had been exposed to sexual violence at least once in a lifetime (OR = 1.5, P = .028) and the use of illicit drugs at least once a week were highly significant as well, particularly for frequent crack use (OR = 3.6, P < .001). Among the sexual behavior indicators, not using condoms in some circumstances were significantly associated with HIV infection (OR = 1.8, P = .016). Regarding the occurrence of other STI, the odds of being HIV infected was significantly higher among FSW with a reactive treponemal test for syphilis (OR = 4.6, P < .001).

CONCLUSIONS

The main factors associated with HIV infection identified in our study characterize a specific type of street-based sex work in Brazil and provided valuable information for developing interventions. However, there is a further need of addressing social and contextual factors, including illicit drug use, violence, exploitation, as well as stigma and discrimination, which can influence sexual behavior.

A systematic review of the state of the literature on sexually exploited boys internationally

This systematic review assessed the current state of the literature on sexually exploited boys internationally. We aimed to describe what is known about sexual exploitation of boys, identify gaps in the literature, provide implications for practice, and make recommendations for future research. Multiple database searches were conducted using a combination of controlled vocabulary and keywords to capture child and adolescent sexual exploitation. Our search identified 11,099 unique references and excluded studies that did not include male participants less than 18 years old or disaggregate results by relevant age groups and/or by sex. This review identified 42 studies from 23 countries, providing evidence that sexual exploitation of boys is an issue in both high- and low-income countries. Seventeen articles had sexual exploitation as their primary variable of interest, the majority of which sampled boys who accessed services (i.e., shelters, health care, social, and justice services). Boys' experiences of sexual exploitation varied in terms of venue, exploiters, and compensation. Compared to their non-sexually exploited peers, sexually exploited boys more commonly reported experiences of child abuse, substance use, conduct problems, and mental health problems such as anxiety, depression, and self-harm. Despite increasing evidence that boys are sexually exploited around the world, the current literature provides limited data about the antecedents, sequelae, and the specific features of sexual exploitation experiences among boys. Further research is needed to inform, policy, social services and health care delivery specific to the needs of sexually exploited boys.

The association between substance use and sub-optimal HIV treatment engagement among HIV-infected female sex workers in Lilongwe, Malawi

Female sex workers (FSW) have a high prevalence of substance use and HIV, but the impact of substance use on HIV treatment engagement is not well established. We evaluated the association between alcohol and marijuana use and sub-optimal HIV treatment engagement outcomes among HIV-infected FSW in Lilongwe, Malawi. We enroled FSW using venue-based recruitment into a cross-sectional evaluation assessing substance use and HIV treatment engagement. Seropositive FSW, identified through HIV rapid testing, received rapid CD4 count and viral load testing. We used Poisson regression with robust variance estimates to ascertain associations of alcohol and marijuana use with sub-optimal HIV treatment outcomes: (1) lack of ART use among previously diagnosed, ART-eligible FSW and (2) viral nonsuppression among FSW on ART. Of previously diagnosed, ART-eligible FSW (n = 96), 29% were not using ART. Patterns of hazardous drinking were identified in 30%, harmful drinking in 10%, and alcohol dependence in 12%. ART-eligible FSW with harmful drinking or alcohol dependency were 1.9 (95% CI: 1.0, 3.8) times as likely to not use ART compared to FSW without harmful or dependent drinking. Among those on ART, 14% were virally nonsuppressed. The prevalence ratio for viral nonsuppression was 2.0 (95% CI: 0.6, 6.5) for harmful drinkers and alcohol-dependent FSW. Over 30% of ART-eligible FSW reported using marijuana. Marijuana-using FSW were 1.9 (95% CI: 0.8, 4.6) times as likely to not use ART compared to FSW who were not using marijuana. Given the high prevalence of alcohol use and its association with lack of ART use, ART uptake and alcohol reduction strategies should be tailored for alcohol-using FSW in Malawi.

Victimization and HIV Risks Among Croatian Female Sex Workers: Exploring the Mediation Role of Depressiveness and the Moderation Role of Social Support

To assess the association between victimization and HIV vulnerability among Croatian female sex workers (FSWs), a survey involving 157 FSWs recruited from Croatia's two largest urban areas was conducted in 2014. A majority of participants reported direct and indirect victimization, which was found to be significantly associated with condom use at most recent noncommercial sexual intercourse and sexually transmitted infection (STI) diagnosis in the past 12 months. The association between victimization and STI diagnosis was partially mediated by depressiveness and moderated by social support. The buffering role of social support points to the importance of including counseling services in HIV prevention programs in Croatia.

Heterogeneity Among Sex Workers in Overlapping HIV Risk Interactions With People Who Inject Drugs: A Cross-Sectional Study From 8 Major Cities in Pakistan

Concerns remain regarding the heterogeneity in overlapping human immunodeficiency virus (HIV) risk behaviors among sex workers (SWs) in Pakistan; specifically, the degree to which SWs interact with people who inject drugs (PWID) through sex and/or needle sharing.Following an in-depth mapping performed in 2011 to determine the size and distribution of key populations at highest risk of HIV acquisition in Pakistan, a cross-sectional biological and behavioral survey was conducted among PWID, female (FSWs), male (MSWs), and hijra/transgender (HSWs) sex workers, and data from 8 major cities were used for analyses. Logistic regression was used to identify factors, including city of residence and mode of SW-client solicitation, contributing to the overlapping risks of drug injection and sexual interaction with PWID.The study comprised 8483 SWs (34.5% FSWs, 32.4% HSWs, and 33.1% MSWs). Among SWs who had sex with PWID, HSWs were 2.61 (95% confidence interval [CI], 1.19-5.74) and 1.99 (95% CI, 0.94-4.22) times more likely to inject drugs than MSWs and FSWs, respectively. There was up to a 3-fold difference in drug injecting probability, dependent on where and/or how the SW solicited clients. Compared with SWs in Larkana, the highest likelihood of drug injection use was among SWs in Multan (OR = 4.52; 95% CI: 3.27-6.26), followed by those in Lahore, Quetta, and Faisalabad.Heterogeneity exists in the overlapping patterns of HIV risk behaviors of SWs. The risk of drug injection among SWs also varies by city. Some means of sexual client solicitation may be along the pathway to overlapping HIV risk vulnerability due to increased likelihood of drug injection among SWs. There is a need to closely to monitor the mixing patterns between SWs and PWID and underlying structural factors, such as means of sexual client solicitation, that mediate HIV risk, and implement prevention programs customized to local subepidemics.

HIV sexual risk behaviors and multilevel determinants among male labor migrants from Tajikistan

The purpose of this study was to investigate HIV risk behaviors and their multilevel determinants in male labor migrants from Tajikistan to Moscow. In Russia and Central Asia, where AIDS rates are amongst the world's highest, conditions in both sending and receiving countries pose serious challenges to HIV prevention. A survey of Tajik married male seasonal labor migrants in Moscow was completed by 200 workers from 4 bazaars and 200 workers from 18 construction sites as part of a mixed method study. The quantitative results indicated that male labor migrants were at risk for HIV due to higher sexual behaviors including sexual relations with sex workers (92 %), multiple partnering in the past month (86 %), unprotected sex with sex workers (33 %), and reduced frequency of condom use while drinking alcohol (57 %). Multivariate tests indicated the multilevel factors that increased HIV sexual risks including: pre-migration factors (e.g. used sex workers in Tajikistan); migrant work and lifestyle factors (e.g. greater number of times visited Moscow); migrant sexual and relational factors (e.g. regular partner in Moscow); and migrant health and mental health factors (e.g. increased frequency of alcohol use). Qualitative findings from longitudinal ethnographic interviews and observations of a subset of 40 purposively sampled Tajik male migrants demonstrated how these multilevel pre-migration and migration factors account for HIV risk and protective behaviors in context. These findings underscore the seriousness of HIV risk for labor migrants and call both for multilevel approaches to prevention and for further study.

Female sex workers in three cities in Russia: HIV prevalence, risk factors and experience with targeted HIV prevention

Within Eastern Europe/Central Asia's expanding HIV epidemic, relatively little is known about female sex workers (FSWs). Using mixed methods, we report on sex work context, HIV prevalence and contextual risk factors, and exposure to FSW-targeted prevention services among FSWs in Kazan, Krasnoyarsk, and Tomsk, Russia. Following a qualitative phase, FSWs (n = 754) were recruited via respondent-driven sampling for a cross-sectional survey with HIV screening in 2011. HIV was prevalent (3.9 %). In adjusted analyses, significant risk factors included injection drug use (IDU; AOR 5.85, 95 % CI 2.47, 14.43), client-perpetrated physical violence (AOR 2.52, 95 % CI 1.41, 4.51), and client-perpetrated sexual violence (vaginal AOR 3.77, 95 % CI 1.73, 8.22; anal AOR 4.80, 95 % CI 1.89, 12.19). FSW-targeted programming (reported by 75 %) was described as highly valuable, providing free, anonymous, and non-stigmatizing care. Findings confirm FSWs as a core HIV risk population in Russia, and demonstrate the need to support FSW-oriented HIV services. Such efforts should address violence against FSWs.

Sexually transmitted infections among HIV-infected heavy drinkers in St Petersburg, Russia

The objective of this study was to estimate the prevalence and identify correlates of four sexually transmitted infections (STIs) among HIV-infected Russians reporting heavy alcohol use and recent unprotected sex, we conducted a cross-sectional analysis of baseline data from the HERMITAGE study. The primary outcome was any current STI, based on urine tests for Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis and serological testing for infection with Treponema pallidum. Data on potential demographic and behavioural predictors of STI were obtained from surveys administered at study entry. Of 682 participants, 12.8% (95% confidence interval [CI] 10.3, 15.3) tested positive for at least one STI. In a multivariable model adjusted for gender, age and marital status, only sex trade involvement over the last three months was significantly associated with an increased odds of STI (adjusted odds ratio [AOR] 2.00, 95% CI 1.13, 3.55). Given that STIs were common in this HIV-infected cohort, and that few patient characteristics predicted STI, the current practice of screening HIV-infected Russians for syphilis alone merits re-evaluation.

The health status of street children and youth in low- and middle-income countries: a systematic review of the literature

The health of the tens of millions of street children globally is understudied. We undertook a systematic review of the existing quantitative literature regarding the health status of street children and youth in low- and middle-income countries to summarize available knowledge, identify underexplored areas of research, and inform the future research agenda regarding the health of this population. A total of 108 articles met our inclusion criteria. Demographic data and structural factors associated with street life are summarized. Although data in specific regions or diseases are sparse, the literature review illustrates that youth's survival behaviors and the exposures associated with poor shelter have resulted in disproportionate morbidity in the areas of infectious illness, psychiatric disease, reproductive health, and perhaps to a lesser extent, growth. Vast areas of health that may disproportionately affect street children in childhood or later on as adults have not been investigated, including chronic diseases and cognitive deficits. Studies of specific diseases or conditions vary considerably by region. Strengths and limitations of the literature are discussed and principles for future research in this area are proposed.

Patterns and trends in Pakistan's heterogeneous HIV epidemic

BACKGROUND

Considerable HIV transmission occurs among injection drug users (IDUs) in Pakistan and recently the HIV prevalence has been increasing among male (MSW), hijra (transgender; HSW) and female (FSW) sex workers. We describe past and estimate future patterns of HIV emergence among these populations in several cities in Pakistan.

METHODS

The density of these key populations per 1000 adult men was calculated using 2011 mapping data from Karachi, Lahore, Faisalabad, Larkana, Peshawar and Quetta, and surveillance data were used to assess bridging between these key populations. We used the UNAIDS Estimation and Projection Package model to estimate and project HIV epidemics among these key populations in Karachi, Lahore, Faisalabad and Larkana.

RESULTS

The density and bridging of key populations varied across cities. Lahore had the largest FSW population (11.5/1000 adult men) and the smallest IDU population (1.7/1000 adult men). Quetta had the most sexual and drug injection bridging between sex workers and IDUs (6.7%, 7.0% and 3.8% of FSW, MSW and HSW, respectively, reported injecting drugs). Model evidence suggests that by 2015 HIV prevalence is likely to reach 17-22% among MSWs/HSWs in Karachi, 44-49% among IDUs in Lahore and 46-66% among IDUs in Karachi. Projection suggests the prevalence may reach as high as 65-75% among IDUs in Faisalabad by 2025. HIV prevalence is also estimated to increase among FSWs, particularly in Karachi and Larkana.

CONCLUSIONS

There is a need to closely monitor regional and subpopulation epidemic patterns and implement prevention programmes customised to local epidemics.

Female migrant sex workers in Moscow: gender and power factors and HIV risk

This study aimed to build formative knowledge regarding HIV risks in female migrant sex workers in Moscow, focusing on gender and power. This was a collaborative ethnographic study, informed by the theory of gender and power, in which researchers conducted minimally structured interviews with 24 female sex workers who were migrants to Moscow and who provided sexual services to male migrant laborers. Overall, the female migrant sex workers engaged in HIV risk behaviors and practiced inadequate HIV protection with their clients. These behaviors were shaped by gender and power factors in the realms of labor, behavior, and cathexis. In the labor realm, because some female migrants were unable to earn enough money to support their families, they were pushed or pulled into sex work providing service to male migrants. In the behavior realm, many female migrant sex workers were intimidated by their male clients, feared violence, and lacked access to women's health care and prevention. In the cathexis realm, many had a sense of shame, social isolation, emotional distress, and lacked basic HIV knowledge and prevention skills. To prevent HIV transmission requires addressing the gender and power factors that shape HIV/AIDS risks among female migrant sex workers through multilevel intervention strategies.

Factors mediating HIV risk among female sex workers in Europe: a systematic review and ecological analysis

OBJECTIVES

We reviewed the epidemiology of HIV and selected sexually transmitted infections (STIs) among female sex workers (FSWs) in WHO-defined Europe. There were three objectives: (1) to assess the prevalence of HIV and STIs (chlamydia, syphilis and gonorrhoea); (2) to describe structural and individual-level risk factors associated with prevalence and (3) to examine the relationship between structural-level factors and national estimates of HIV prevalence among FSWs.

DESIGN

A systematic search of published and unpublished literature measuring HIV/STIs and risk factors among FSWs, identified through electronic databases published since 2005. 'Best' estimates of HIV prevalence were calculated from the systematic review to provide national level estimates of HIV. Associations between HIV prevalence and selected structural-level indicators were assessed using linear regression models.

STUDIES REVIEWED

Of the 1993 papers identified in the search, 73 peer-reviewed and grey literature documents were identified as meeting our criteria of which 63 papers provided unique estimates of HIV and STI prevalence and nine reported multivariate risk factors for HIV/STI among FSWs.

RESULTS

HIV in Europe remains low among FSWs who do not inject drugs (<1%), but STIs are high, particularly syphilis in the East and gonorrhoea. FSWs experience high levels of violence and structural risk factors associated with HIV, including lack of access to services and working on the street. Linear regression models showed HIV among FSWs to link with injecting drug use and imprisonment.

CONCLUSIONS

Findings show that HIV prevention interventions should be nested inside strategies that address the social welfare of sex workers, highlighting in turn the need to target the social determinants of health and inequality, including regarding access to services, experience of violence and migration. Future epidemiological and intervention studies of HIV among vulnerable populations need to better systematically delineate how microenvironmental and macroenvironmental factors combine to increase or reduce HIV/STI risk.

Trauma exposure, PTSD, and HIV sexual risk behaviors among labor migrants from Tajikistan

Little is known about the role of trauma and PTSD symptoms in the context of migration-associated HIV risk behaviors. A survey of Tajik married male seasonal labor migrants in Moscow was completed by 200 workers from 4 bazaars and 200 workers from 18 construction sites as part of a mixed method (quantitative and qualitative) study. The mean PC-PTSD score was 1.2 with one-quarter of migrants scoring at or above the cutoff of 3 indicating likely PTSD diagnosis. PC-PTSD score was directly correlated with both direct and indirect trauma exposure, but PC-PTSD score did not predict either HIV sexual risk behaviors or HIV protective behaviors. HIV sexual risk behavior was associated with higher indirect trauma exposure. PC-PTSD score was associated with some indicators of increased caution (e.g., more talking with partners about HIV and condoms; more use of condom when drinking). Qualitative findings were used to illustrate the differences between direct and indirect traumas in terms of HIV sexual risk. The study findings call for future efforts to address labor migrant's mental health needs and to integrate trauma dimensions into HIV prevention.

Sexual behaviours, knowledge and attitudes regarding safe sex, and prevalence of non-viral sexually transmitted infections among attendees of youth clinics in St. Petersburg, Russia

BACKGROUND

Adolescents and young adults are at increased risk of sexually transmitted infections (STIs). Knowledge of STI prevalence and risk factors are essential tools to elaborate preventive strategies. However, internationally reported studies on epidemiology of STIs among the youth in Russia are mainly lacking.

OBJECTIVES

To ascertain sexual behaviours, knowledge and attitudes about safe sex and prevalence and correlates with STIs in attendees of youth clinics in St. Petersburg, Russia.

METHODS

A total of 301 women and 131 men, who self-referred for STI testing, completed a questionnaire and were screened for Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and Trichomonas vaginalis using nucleic acid amplification tests.

RESULTS

The overall STI prevalence was 16.9%, and similar in the female patients and male patients (15.6% and 19.8% respectively). C. trachomatis, N. gonorrhoeae, M. genitalium and T. vaginalis were detected in 13%, 2.5%, 4.6% and 1.2% of the attendees respectively. The men displayed riskier sexual behaviours and worse knowledge and attitudes regarding safe sex compared to the women, with the most distinguishing features being younger age at first intercourse (P < 0.0005), higher numbers of sex partners during lifetime (P = 0.001) and latest 6 months (P < 0.0005), more frequently consuming alcohol (P < 0.0005), poorer knowledge of STI/HIV prevention measures (P < 0.0005), and less positive attitudes towards safe sex (P = 0.001). However, no significant predictors of STI positivity were found in the men. In the women, the strongest predictors of STI positivity were young age (15-19 years) and multiple sex partners (≥ 2) during latest 6 months.

CONCLUSIONS

The overall prevalence of STIs among users of STI services at youth clinics in St. Petersburg was high. Comprehensive epidemiological data on STI prevalence and sexual behaviour correlates are necessary to initiate new and strengthen existing STI prevention programmes for the youth, in Russia as well as in many other settings.

Injection drug use, sexual risk, violence and STI/HIV among Moscow female sex workers

BACKGROUND/OBJECTIVES

The HIV prevalence in Eastern Europe and Central Asia continues to increase. While injection drug use (IDU) is leading factor, heterosexual transmission is on the rise. Little is known about female sex workers (FSWs) in the region despite the central role of commercial sex in heterosexual sexually transmitted infection (STI)/HIV transmission globally. The authors evaluated the prevalence of STI/HIV among Moscow-based FSWs and potential risk factors including IDU, sexual risks and violence victimisation.

METHODS

Moscow-based FSWs (n=147) completed a clinic-based survey and STI/HIV testing over an 8-month period in 2005.

RESULTS

HIV prevalence was 4.8%, and 31.3% were infected with at least one STI including HIV. Sexual behaviours significantly associated with STI/HIV included anal sex (adjusted odds ratio (AOR) 3.48), high client volume (three or more clients daily, AOR 2.71), recent subbotnik (sex demanded by police; AOR 2.50) and regularly being presented with more clients than initially agreed to (AOR 2.45). Past year experiences of physical violence from clients and threats of violence from pimps were associated with STI/HIV (AOR 3.14 and AOR 3.65, respectively). IDU was not significantly associated with STI/HIV. Anal sex and high client volume partially mediated the associations of abuse with STI/HIV.

CONCLUSIONS

Findings illustrate substantial potential for heterosexual STI/HIV transmission in a setting better known for IDU-related risk. Many of the STI/HIV risks observed are not modifiable by FSWs alone. STI/HIV prevention efforts for this vulnerable population will benefit from reducing coercion and abuse perpetrated by pimps and clients.

Does Powerlessness Explain Elevated HIV Risk Amongst Tajik Labor Migrants? An Ethnographic Study

To investigate the role of powerlessness in elevated HIV risk among labor migrants, we compared internal verses external male migrant workers from Tajikistan using minimally structured interviews and focused field observations. The sample included 30 male labor migrants who traveled to work in Regar, Tajikistan (internal labor migrants), and 30 who traveled to work in Moscow, Russia (external labor migrants). Though powerlessness did not appear to account for whether labor migrants engaged in more HIV risk behaviors, the harsh living and working conditions of external labor migration impacted how the migrants manifested these HIV risks by amplifying group masculine norms and behaviors. Progress in preventing HIV infection amid the difficult social conditions of labor migration is contingent upon adequate conceptualization of how such conditions impact HIV risk behaviors.

HEPATITIS C VIRUS GENOTYPES IN INJECTING DRUG USERS FROM ROMANIA

Due to the increasing number of infections related to injecting drug use, both the pattern of hepatitis C virus (HCV) transmission, and the circulating genotypes in Europe have changed. As there are little available data in this respect for Romania, the aim of our study was a preliminary analysis of the distribution of HCV genotypes circulating among injecting drug users (IDUs). Of the 45 IDUs evaluated (86.7% men, mean age - 27.6±3.7 years, mean age at first drug use - 17.5±3.9 years), 88.9% presented anti-HCV antibodies, with higher rates in those with an injecting history of more than 10 years; 57.8% of the subjects had detectable HCV viral load. Only 6.7% had markers of chronic hepatitis B infection, and none had anti-HIV antibodies. While HCV subtype 1b is still prevalent (in 50% of the viraemic subjects), other subtypes begin to emerge, especially in younger patients (1a - in 23.1%, 4 - in 11.5%, 3a - in 7.7% of the cases). These data indicate the possibility of major shifts in the distribution of the dominant subtype, underlining the need for close surveillance of HCV infections in IDUs, who can act as a bridging group toward the general population.

Prevalence and assessment of clinical management of sexually transmitted infections among female sex workers in two cities of India

Objective. Control of sexually transmitted infections (STIs) among female sex workers (FSWs) is an important strategy to reduce HIV transmission. A study was conducted to determine the prevalence and assess the current clinical management of STIs in India. Methods. FSWs attending three clinics for regular checkups or symptoms were screened for study eligibility. A behavioral questionnaire was administered, clinical examination performed, and laboratory samples collected. Results. 417 study participants reported a mean number of 4.9 (SD 3.5) commercial clients in the last week. 14.6% reported anal sex in the last three months. Consistent condom use with commercial and regular partners was 70.1% and 17.5%, respectively. The prevalence of gonorrhea was 14.1%, chlamydia 16.1%, and trichomoniasis 31.1% with a third of all infections being asymptomatic. Syphilis seropositivity was 10.1%. Conclusions. At study sites, presumptive treatment for gonorrhea, chlamydia, and syphilis screening should continue. Presumptive treatment for trichomoniasis should be considered. Consistent condom use and partner treatment need to be reemphasized.

HIV prevention for migrants in transit: developing and testing TRAIN

This study was a pilot investigation of the feasibility, acceptability, and effects of TRAIN (Transit to Russia AIDS Intervention with Newcomers) a three-session HIV preventive intervention for Tajik male labor migrants performed in transit. Sixty adult Tajik male labor migrants on the 5-day train ride from Dushanbe to Moscow were randomly assigned to either the intervention or a control condition. Each initially completed an in-person survey then another 3 days later (immediately postintervention), and participated in a cell phone survey three months later. All participants came to all intervention sessions, were satisfied with the program, and completed all postassessments. In comparison with the controls, the TRAIN group reported significant increases in condom use with sex workers and non-sex workers, condom knowledge, worry about HIV/AIDS, talking with persons about HIV/AIDS, talking with wife about HIV/AIDS, community activities, and religious activities. HIV/AIDS prevention performed in transit is feasible, accceptable, and potentially efficacious in diminishing HIV risk behaviors in labor migrants.

HIV risk perceptions, knowledge and behaviours among female sex workers in two cities in Turkmenistan

This paper describes HIV risk behaviour patterns among street- and bar-based female sex workers in the Turkmenistan cities of Ashgabat and Mary. Street-based sex workers had little to no knowledge of HIV and primarily used condoms when condom use was initiated by clients. Bar-based sex workers had HIV knowledge and reported regularly using condoms mainly with first-time clients. While sex workers perceived themselves to be at low risk for acquiring HIV, they were aware of other sexually transmitted infections (STI) and expressed a strong desire for free STI testing and treatment services.

Implementation of respondent-driven sampling among female sex workers in Brazil, 2009

Female sex workers are known in Brazil and elsewhere in the world as one of the most-at-risk populations for risk of HIV infection, due to their social vulnerability and factors related to their work. However, the use of conventional sampling strategies in studies on most-at-risk subgroups for HIV is generally problematic, since such subgroups are small in size and are associated with stigmatized behaviors and/or illegal activities. In 1997, a probabilistic sampling technique was proposed for hard-to-reach populations, called Respondent-Driven Sampling (RDS). The method is considered a variant of chain sampling and allows the statistical estimation of target variables. This article describes some assumptions of RDS and all the implementation stages in a study of 2,523 female sex workers in 10 Brazilian cities. RDS proved appropriate for recruiting sex workers, allowing the selection of a probabilistic sample and the collection of previously missing information on this group in Brazil.

Gender and age disparities in the prevalence of Chlamydia infection among sexually active adults in the United States

BACKGROUND

Chlamydia trachomatis (CT) causes a costly and potentially recurrent bacterial infection that accounts for a considerable proportion of sexually transmitted infections (STIs) in the United States. Disparities by gender and age group in CT prevalence have been reported previously. The current study evaluates demographic, socioeconomic, and behavioral risk and protective factors that may account for gender/age disparities in CT infections among sexually active young adults in the United States.

METHODS

Secondary analyses were performing using the 1999-2006 National Health and Nutrition Examination Survey (NHANES) data.

RESULTS

A total sample of 5611 adults, 20-39 years of age, who participated in the 1999-2006 NHANES, reported lifetime sexual experience, and had valid laboratory-based CT status, was analyzed. CT prevalence did not differ significantly by gender and was estimated to be 1.6%. It was slightly higher for people <25 years vs. those ≥25 years of age; age disparities were reduced after controlling for demographic, socioeconomic, and behavioral characteristics. Among those <25 years, non-Hispanic blacks had a higher odds of CT infection compared with other groups. Among those ≥25 years of age, not having had unprotected sex in the past month reduced the odds for CT infection, whereas non-Hispanic black race and never married status increased the odds for CT infection.

CONCLUSIONS

Among sexually active adults, no gender disparities were observed in CT prevalence. Age group disparities were partly explained by personal characteristics associated with risk of STIs.

Male sex workers in Moscow, Russia: a pilot study of demographics, substance use patterns, and prevalence of HIV-1 and sexually transmitted infections

The Russian federation has been undergoing a concentrated epidemic of HIV-1 with high rates of infection among injecting drug users. Less is known about the relative risk and contribution to the country's HIV epidemic by other at-risk populations including sex workers and men who have sex with men. The goals of this project were to explore demographic characteristics, substance use patterns, and estimate the prevalence of sexually transmitted infections (STIs) and high-risk behaviors among male sex workers (MSW) in Moscow and to assess the feasibility of prospective cohort recruitment and retention among this population. Research design was a longitudinal study of 50 men with a six-month follow-up period. Participants were recruited through venue-based and snowball sampling methods. Results revealed an HIV prevalence at baseline of 16%; one MSW seroconverted during the follow-up period, yielding an incidence estimate of 4.8/100PY (95%CI 0.0-11.2). Twenty-four percentage were diagnosed with at least one STI: 12% had syphilis; 8% had Human Papilloma Virus (HPV); and 4% had Herpes Simplex Virus (HSV)-2. Three (6%) of the study participants had evidence of previous Hepatitis C Virus (HCV) exposure at baseline. Retention rates were poor with higher retention significantly associated with older men (OR: 13.1, 95% CI 3.3-52.5). This was the first study to evaluate baseline demographics, substance use patterns, and prevalence of infectious disease among MSW in Moscow. Identification and recruitment of this population appears to be feasible, but retention a challenge. While the sample size in the current study was small, the results also suggested that this is a population at considerable high risk for HIV. MSW in Moscow may be an important at-risk population in the Russian HIV epidemic and further research is urgently required to address their needs and explore prevention strategies.

The health of Italian prison inmates today: a critical approach

Despite declarations about health and social inequalities by the World Health Organization (WHO) and the Italian Constitution, the Italian penitentiary health system often does not meet the needs of the prisoners. This article summarizes the findings concerning contextual and structural reasons for these deficiencies (in part as reported by a prisoner rights association) and describes an Italian Ministry of Justice project to promote health by creating homogeneous groups of comorbidity for epidemiological study. Data and analysis on certain pathologies in the prison population are presented with special regard to addictions, hepatitis C virus, and cardiovascular problems. One etiological hypothesis focuses on the factors of promiscuity, excessive smoking, sedentary life, and stress. The conclusion is that prisoner health is a problem not only of inmates but for society.

Evaluating recruitment among female sex workers and injecting drug users at risk for HIV using respondent-driven sampling in Estonia

Few recent publications have highlighted theoretical and methodological challenges using respondent-driven sampling (RDS). To explore why recruitment with RDS may work in some populations and not in others, we assess the implementation of RDS to recruit female sex workers (FSWs) and injection drug users (IDUs) into a human immunodeficiency virus biological and risk behavior survey in Tallinn, Estonia. Recruitment of FSWs was slower and more challenging than that of IDUs. The IDU study recruited 350 participants within 7 weeks, while the FSW study recruited 227 participants over 28 weeks. Implementation modifications that did not negatively impact key RDS theoretical and methodological requirements were used to improve recruitment during the FSW study. We recommend that all RDS studies include a formative research process to involve the participation of target populations and key persons associated with these populations in the study planning and throughout the implementation processes to improve recruitment from the outset and to respond to poor recruitment during data collection.

Injection drug use among street-involved youth in a Canadian setting

Background

Street-involved youth contend with an array of health and social challenges, including elevated rates of blood-borne infections and mortality. In addition, there has been growing concern regarding high-risk drug use among street-involved youth, in particular injection drug use. We undertook this study to examine the prevalence of injection drug use and associated risks among street-involved youth in Vancouver, Canada.

Methods

From September 2005 to November 2007, baseline data were collected for the At-Risk Youth Study (ARYS), a prospective cohort of street-recruited youth aged 14 to 26 in Vancouver, Canada. Using multiple logistic regression, we compared youth with and without a history of injection.

Results

The sample included 560 youth among whom the median age was 21.9 years, 179 (32%) were female, and 230 (41.1%) reported prior injection drug use. Factors associated with injection drug use in multivariate analyses included age ≥ 22 years (adjusted odds ratio [AOR] = 1.18, 95% CI: 1.10–1.28); sex work involvement (AOR = 2.17, 95% CI: 1.35–3.50); non-fatal overdose (AOR = 2.10, 95% CI: 1.38–3.20); and hepatitis C (HCV) infection (AOR = 22.61, 95% CI: 7.78–65.70).

Conclusion

These findings highlight an alarmingly high prevalence of injection drug use among street-involved youth and demonstrate its association with an array of risks and harms, including sex work involvement, overdose, and HCV infection. These findings point to the need for a broad set of policies and interventions to prevent the initiation of injection drug use and address the risks faced by street-involved youth who are actively injecting.

Prevalence and risk factors of the whole spectrum of sexually transmitted diseases in male incoming prisoners in France

Sexually transmitted diseases (STD) are a public health issue in prison. As inmates are eventually released, it is also a community concern. There are very few data on the entire spectrum of STDs, particularly condyloma among prisoners. To determine the prevalence of all STDs: infection with human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), herpes simplex virus (HSV), Chlamydia trachomatis, Neisseria gonorrhoea, syphilis, and condyloma among entering inmates. A cross-sectional study was conducted in France from November 2000 to June 2003. Male adults entering a prison remand center in Caen had a medical consultation and physical examination including external genital organs and perianal area for condyloma and herpes infection, a urethral swab for Chlamydia trachomatis and Neisseria gonorrhoea detection, and a blood sample for HBV, HCV, HIV, and syphilis serology. Five hundred and ninety-seven inmates agreed to participate in the study. Sixteen percent had at least one STD: 4.0% had condyloma, 4.0% chlamydia infection, and 4.9% were positive for HCV antibodies. Two had early syphilis and 1 had acute HBV, but no HIV infection, neither genital herpes nor gonorrhea. The analysis of the STD risk behaviors did not show any difference between the infected and uninfected participants, except that HCV-positive participants were more likely to be intravenous drug users. Results suggest that a systematic screening of all STDs should be at least proposed to every entering inmate since no demographic or sexual characteristics are consistently associated with STDs.

Unprotected Tajik male migrant workers in Moscow at risk for HIV/AIDS

This paper focuses on Tajik male migrant workers in Moscow and seeks to address the global public health problem of HIV prevention amongst male migrant workers. To develop feasible and effective preventive interventions for reducing HIV risk behaviors amongst Tajik male migrant workers in Moscow, this study aimed to characterize their HIV/AIDS risk and protective knowledge, attitudes, and behaviors, as well as key contextual factors that would likely impede or facilitate a preventive intervention. This was a collaborative multi-sited ethnography in Moscow that included minimally structured interviews with 16 participants and focus group discussions with an additional 14 participants. The results suggest that many Tajik male migrant workers in Moscow are having unprotected sex with commercial sex workers. Although some of the migrants have basic knowledge about HIV, the migrants' ability to protect themselves from acquiring HIV is compromised by harsh living and working conditions as a consequence of being unprotected by law in Russia. To respond to HIV/AIDS risks amongst Tajik male migrant workers in Moscow, preventive interventions must be developed that respond to their sense of being unprotected in the midst of harsh living and working conditions and that draw upon existing sources of religious, community, and family support.

Assessment of the routine, occupation-based gonorrhea and syphilis screening program in Moscow, Russia: an analysis of sexually transmitted infection prevalence and cost-effectiveness

OBJECTIVES

In the Russian Federation, large sectors of the population regularly undergo mandatory occupational screening for sexually transmitted infections (STIs). Objectives of our study were to determine the prevalence of syphilis and gonorrhea in the screened occupational groups in Moscow and to conduct a cost-effectiveness evaluation of the occupational screening program.

STUDY DESIGN

Serum samples from 4 main occupational groups (food handlers and other food industry workers, market salespersons, education and health care providers, and hotel and other public utility workers) were tested for syphilis and gonorrhea. We conducted a cost-effectiveness analysis (in 2003 rubles) of the screening program using decision analysis models.

RESULTS

In the total sample of 1000 study participants, overall prevalence for syphilis was 1.2% with the highest rate in market salespersons (4.4%) and for gonorrhea 0.3%. The incremental cost per case of STI treated was 8409 rubles ($252) for syphilis screening (compared with no screening) with higher incremental costs associated with expanding the program to include gonorrhea screening. The relatively low STI prevalence in the screened groups and the poor performance of the diagnostic tests used were important factors in the estimated cost-effectiveness of occupation-based screening.

CONCLUSIONS

Modifications to occupation-based screening, including an increased focus on higher risk population and the adoption of more current diagnostic technologies, could help to use prevention resources more effectively.

Not all injection drug users are created equal: heterogeneity of HIV, hepatitis C virus, and hepatitis B virus infection in Georgia

Injection drug users (IDU) are widely believed to have accelerated the looming HIV/AIDS epidemic now faced by the Russian Federation and countries of the former Soviet Union. However, IDUs may be heterogeneous with regard to risk behaviors, and a subpopulation may be responsible for the majority of blood-borne pathogen transmission. We studied 926 adult injection drug users (IDU) from the cities of Tbilisi, Batumi, and Poti in Georgia, a small country in the Caucuses region between the Black and Caspian Seas, between 1997 and 1998. Study participants were administered a confidential questionnaire and were tested for antibody to HIV, hepatitis C virus (HCV), hepatitis B virus surface antigen (HBsAg), and hepatitis B core antibody (anti-HBc). Five (0.5%) individuals were positive for HIV; 539 (58.2%), for HCV; 67 (7.2%), for HBsAg; and 475, for (51.3%) anti-HBc. Surveyed individuals, 88.7%, reported sharing needles with others, and needle sharing with more than 10 other individuals versus no sharing was a highly significant predictor (OR: 278.12, 95% CI: 77.57, 997.20) of HCV seropositivity. In adjusted analysis, individuals who usually injected stolen medical/synthetic drugs had significantly lower odds of HCV (OR: 0.38, 95% CI: 0.22, 0.68) and HBV (OR: 0.58, 95% CI: 0.37, 0.90) than individuals most commonly injecting opium. Despite some limitations, these results suggest the presence of substantial heterogeneity between different injection drug-using groups in Georgia. Identification of high-risk IDU subpopulations is vital to efficiently target risk reduction programs and to prevent confounding by risk status in large HIV/AIDS behavioral intervention and vaccine trials.

Health systems' responses to 25 years of HIV in Europe: inequities persist and challenges remain

Europe is currently experiencing the fastest rate of growth of HIV of any region of the world. An analysis of policy and health system responses to the HIV epidemic in Europe and central Asia (hereafter referred to as Europe) over the last 25 years reveals considerable heterogeneity. In general, while noting hazards of broad generalisations and the differences that exist across countries in a particular grouping, effective policies to control HIV have been implemented more widely in western than in central and eastern Europe. However, the evidence suggests persistence of inequalities in access to preventive and treatment services, with those at highest risk, such as commercial sex workers, prisoners, intravenous drug users, and migrants often particularly disadvantaged, despite many targeted programmes. Responses in individual countries, especially in the early stages of the epidemic, were influenced by specific cultural and political factors. Strong leadership and active involvement by civil society organisations emerge as important factors for success but also a limiting factor to the response observed in eastern Europe, where civil society or NGO culture is weak as compared to western Europe. Scaling up of effective responses in many countries in eastern Europe will be challenging-where increased financial resources will have to be accompanied by broader changes to health system organization with greater involvement of the civil society in planning and delivery of client-focused services.

HIV seroprevalence in street youth, St. Petersburg, Russia

BACKGROUND

Reliable data on HIV infection among Russian street youth are unavailable. The purpose of this study was to assess HIV seroprevalence among street youth in St Petersburg and to describe social, sexual, and behavioral characteristics associated with HIV infection.

METHODS

A cross-sectional assessment conducted during January-May 2006 included city-wide mapping of 41 street youth locations, random selection of 22 sites, rapid HIV testing for all consenting 15-19-year-old male and female street youth at these sites, and an interviewer-administered survey. Adjusted odds ratios (AOR) were calculated using logistic regression, accounting for intracluster homogeneity.

RESULTS

Of 313 participants, 117 (37.4%, 95% confidence interval 26.1-50.2%) were HIV infected. Subgroups with the highest seroprevalences included double orphans (64.3%), those with no place to live (68.1%), those previously diagnosed with a sexually transmitted infection (STI; 70.5%), those currently sharing needles (86.4%), and those currently using inhalants (60.5%) or injection drugs (78.6%), including Stadol (82.3%) or heroin (78.1%). Characteristics independently associated with HIV infection included injecting drugs (AOR 23.0), sharing needles (AOR 13.3), being a double or single orphan (AOR 3.3 and 1.8), having no place to live (AOR 2.4), and being diagnosed with a STI (AOR 2.1). Most HIV-infected street youth were sexually active (96.6%), had multiple partners (65.0%), and used condoms inconsistently (80.3%).

DISCUSSION

Street youth aged 15-19 years in St Petersburg, Russia, have an extraordinarily high HIV seroprevalence. In street youth who are injection drug users, HIV seroprevalence is the highest ever reported for eastern Europe and is among the highest in the world.

High prevalence of blood-borne virus infections and high-risk behaviour among injecting drug users in Tallinn, Estonia

The HIV epidemic in Estonia is rapidly expanding, and injection drug users (IDUs) are the major risk group contributing to the expansion. A convenience sample of 159 IDUs visiting syringe-exchange programmes (SEPs) was selected to quantify the association of HIV-risk behaviours and blood-borne infections. A high prevalence of HIV, hepatitis B core antibody (HBVcore), hepatitis B surface antigen (HbsAg) and hepatitis C virus antibodies (56, 85.1, 21.3, and 96.2%, respectively) was associated with high-risk injections, unsafe sexual behaviour and alcohol abuse. These findings emphasize the importance of evidence-based secondary prevention among the HIV-infected, especially given the uncertain sustainability of antiretroviral and substance abuse treatments.

Prospective, multi-centre clinic-based evaluation of four rapid diagnostic tests for syphilis

OBJECTIVES

To evaluate prospectively four rapid, point-of-care serological tests for syphilis in prenatal or high risk populations in four countries.

METHODS

Tests were performed on consecutive clinic attenders, using whole blood in the clinic, and whole blood and serum in the laboratory. The sensitivity and specificity of each test was evaluated, using a standard treponemal test (Treponema pallidum haemagglutination assay (TPHA) or fluorescent treponemal antibody, absorbed (FTA-ABS) as gold standard. Non-treponemal tests (rapid plasma reagin (RPR) or venereal diseases research laboratory (VDRL) tests) were also performed on all subjects at three sites.

RESULTS

The specificity of each rapid test was >95% at each site. Sensitivities varied from 64-100% and, in most cases, were lower when whole blood was used rather than serum.

CONCLUSIONS

Rapid serological tests for syphilis are an acceptable alternative to conventional laboratory tests. Since they do not require equipment or electricity, they could increase coverage of syphilis screening, and enable treatment to be given at the first clinic visit.

Adherence to HIV treatment among IDUs and the role of opioid substitution treatment (OST)

In the era of highly effective anti-retroviral therapy (ART), data show a significant difference in treatment outcomes between injecting drug users (IDUs) and non-IDUs. Factors that may contribute to suboptimal treatment outcomes in IDUs include delayed access to ART, competing comorbid diseases, psychosocial barriers and poor long-term adherence to ART. This review describes and compares several studies on adherence to ART and its correlates in HIV-infected individuals in general, then IDUs and finally those IDUs on opioid substitution treatment (OST). It highlights how ongoing drug use or OST can modify the pattern of these correlates. The aim is to extend all the experience acquired from these studies in order to optimise both access to care and adherence in those countries where HIV infection is mainly driven by IDUs and where ART and OST are only starting to be scaled up. The role of OST in fostering access to care and adherence to ART together with the promising results achieved to date using modified directly observed therapy (DOT) programs for patients taking methadone, allow us to emphasize the efficacy of a comprehensive care model which integrates substance dependence treatment, psychiatric treatment, social services, and medical treatment. The review concludes by suggesting areas of future research targeted at improving the understanding of both the role of perceived toxicity and patient-provider relationship for patients on ART and OST.

Buprenorphine Use: The International Experience

The confluence of the heroin injection epidemic and the human immunodeficiency virus (HIV) infection epidemic has increased the call for expanded access to effective treatments for both conditions. Buprenorphine and methadone are now listed on the World Health Organization's Model Essential Drugs List. In France, which has the most extensive experience, buprenorphine has been associated with a dramatic decrease in deaths due to overdose, and buprenorphine diversion appears to be associated with inadequate dosage, social vulnerability, and prescriptions from multiple providers. Other treatment models (in the United States, Australia, Germany, and Italy) and buprenorphine use in specific populations are also reviewed in the present article. In countries experiencing a dual epidemic of heroin use and HIV infection, such as former states of the Soviet Union and other eastern European and Asian countries, access to buprenorphine and methadone may be one potential tool for reducing the spread of HIV infection among injection drug users and for better engaging them in medical care.

Drug injecting and syringe use in the HIV risk environment of Russian penitentiary institutions: Qualitative study

BACKGROUND

Evidence highlights the prison as a high risk environment in relation to human immunodeficiency virus (HIV) and hepatitis C virus (HCV) transmission associated with injecting drug use.

METHODS

We undertook qualitative studies among 209 injecting drug users (IDUs) in three Russian cities: Moscow (n = 56), Volgograd (n = 83) and Barnaul in western Siberia (n = 70).

RESULTS

Over three-quarters (77%) reported experience of police arrest related to their drug use, and 35% (55% of men) a history of imprisonment or detention. Findings emphasize the critical role that penitentiary institutions may play as a structural factor in the diffusion of HIV associated with drug injection in the Russian Federation. While drugs were perceived to be generally available in penitentiary institutions, sterile injection equipment was scarce and as a consequence routinely shared, including within large groups. Attempts to clean borrowed needles or syringes were inadequate, and risk reduction was severely constrained by a combination of lack of injecting equipment availability and punishment for its possession. Perceptions of relative safety were also found to be associated with assumptions of HIV negativity, resulting from a perception that all prisoners are HIV tested upon entry with those found HIV positive segregated.

CONCLUSION

This study shows an urgent need for HIV prevention interventions in the Russian penitentiary system.

An analysis of respondent driven sampling with Injection Drug Users (IDU) in Albania and the Russian Federation

Injection drug users in Tirana, Albania and St. Petersburg, Russia were recruited into a study assessing HIV-related behaviors and HIV serostatus using Respondent Driven Sampling (RDS), a peer-driven recruitment sampling strategy that results in a probability sample. (Salganik M, Heckathorn DD. Sampling and estimation in hidden populations using respondent-driven sampling. Sociol Method. 2004;34:193-239). This paper presents a comparison of RDS implementation, findings on network and recruitment characteristics, and lessons learned. Initiated with 13 to 15 seeds, approximately 200 IDUs were recruited within 8 weeks. Information resulting from RDS indicates that social network patterns from the two studies differ greatly. Female IDUs in Tirana had smaller network sizes than male IDUs, unlike in St. Petersburg where female IDUs had larger network sizes than male IDUs. Recruitment patterns in each country also differed by demographic categories. Recruitment analyses indicate that IDUs form socially distinct groups by sex in Tirana, whereas there was a greater degree of gender mixing patterns in St. Petersburg. RDS proved to be an effective means of surveying these hard-to-reach populations.

Barriers to effective STI screening in a post-Soviet society: results from a qualitative study

OBJECTIVE

This qualitative study assesses knowledge about sexually transmitted infections (STI), identifies perceived barriers to STI testing, and recommends strategies to optimise participation in a home based STI testing programme.

METHODS

Five focus groups composed of 29 total participants were recruited using convenience sampling methods based on age (18-40 years), gender (male and female), and residency (Tartu region, Estonia).

RESULTS

The focus groups revealed significant knowledge deficits and a widespread attitude of denial. However, participants acknowledged that STIs are a serious problem and recommended strategies for increasing participation in an STI testing and treatment programme. Successful STI prevention programmes must address a number of challenges, including disease stigmatisation and privacy protection.

CONCLUSION

The fear of enforced disease control methods coupled with the current stigmatisation of STIs creates a serious challenge for Estonian STI prevention and treatment efforts. This qualitative study provides a good contextual reference for STI control programmes in eastern Europe.

Behavior change and health-related interventions for heterosexual risk reduction among drug users

Prevention of heterosexual transmission of HIV between and from drug users is important for controlling the local and global HIV heterosexual epidemic. Sex risk reduction interventions and health-related interventions are important for reducing the sex risk behaviors of drug users. Sex risk reduction interventions address individual-level, peer-level, and structural-level determinants of risk reduction. Health-related interventions include HIV counseling and testing, prevention and treatment of sexually transmitted diseases, and delivery of highly active antiretroviral therapy. It is important to adapt effective interventions implemented in resource-rich countries to the realities of the resource-constrained settings and to address relevant contextual factors.