Correlates of Intersectional HIV and Substance Use Stigma Affecting People with HIV and Substance Use in St. Petersburg, Russia.

People with HIV (PWH) who inject drugs often experience coexisting HIV- and substance use-related stigma manifestations. We assessed correlates of HIV stigma (Berger HIV stigma scale), substance use stigma (Substance Abuse Self-stigma scale) and intersectional HIV and substance use stigma in a cohort of PWH with a lifetime history of drug use in St. Petersburg, Russia. Intersectional stigma was defined as having a score greater than the median for both forms of stigma. Of the 208 participants, 56 (27%) had intersectional stigma. Depressive symptoms and alcohol dependence were significantly associated with a higher HIV and substance stigma score, but not with intersectional stigma. Individual and community interventions to reduce the impact of HIV stigma and substance use stigma affecting PWH who inject drugs should consider assessing and addressing mental health and unhealthy substance use. Further work with longitudinal data is needed to understand mechanisms leading to intersectional stigma.

RESUMEN: Las personas infectadas por el VIH que se inyectan drogas a menudo experimentan manifestaciones de estigma relacionadas con el uso de sustancias y el propio VIH. En este estudio evaluamos los correlatos de estigma asociado al VIH (escala de estigma asociado al VIH de Berger), el estigma asociado al uso de sustancias ("Substance Abuse Self-stigma Scale") y el estigma interseccional del VIH y el uso de sustancias en una cohorte de personas infectadas por el VIH con antecedente de uso de drogas en San Petersburgo, Rusia. El estigma interseccional se definió como una puntuación superior a la mediana para ambas formas de estigma. De los 208 participantes, 56 (27%) tenían estigma interseccional. Los síntomas depresivos y la dependencia del alcohol se asociaron significativamente con una puntuación más alta de estigma relacionado con el VIH y las sustancias, pero no con el estigma interseccional. Las intervenciones individuales y comunitarias para reducir el impacto del estigma asociado al VIH y al uso de sustancias que afectan a las personas con VIH que se inyectan drogas deben tener en cuenta la salud mental y el uso nocivo de sustancias. Se necesitan estudios con datos longitudinales para comprender mejor los mecanismos que conducen al estigma interseccional.

Provider-patient experiences and HIV care utilization among people living with HIV who inject drugs in St. Petersburg, Russia.

Providers' disrespect and abuse of patients is a recognized but understudied issue affecting quality of care and likely affecting healthcare utilization. Little research has examined this issue among people living with HIV (PWH) who inject drugs, despite high stigmatization of this population. No research has examined this issue in the context of Russia. This study assesses patients' reports of disrespect and abuse from providers as a barrier to healthcare and examines the association between these reports and HIV care outcomes.We conducted a cross-sectional analysis of the associations between disrespect/abuse from health providers as a barrier to care and the following HIV care outcomes: (i) anti-retroviral treatment (ART) uptake ever, (ii) past 6-month visit to HIV provider, and (iii) CD4 count. Participants (N = 221) were people living with HIV who injected drugs and were not on ART at enrollment.Two in five participants (42%) reported a history disrespect/abuse from a healthcare provider that they cited as a barrier to care. Those reporting this concern had lower odds of ever use of ART (adjusted odds ratio 0.46 [95% CI 0.22, 0.95]); we found no significant associations for the other HIV outcomes. We additionally found higher representation of women among those reporting prevalence of disrespect/abuse from provider as a barrier to care compared to those not reporting this barrier (58.1% versus 27.3%).Almost half of this sample of PWH who inject drugs report disrespect/abuse from a provider as a barrier to healthcare, and this is associated with lower odds of receipt of ART but not with other HIV outcomes studied. There is need for improved focus on quality of respectful and dignified care from providers for PWH who inject drugs, and such focus may improve ART uptake in Russia.

Contraceptive Use Among HIV-Infected Females with History of Injection Drug Use in St. Petersburg, Russia.

Limited research examines family planning for HIV-infected women with a history of injection drug use. We describe modern contraceptive use and its association with heavy drinking and recent injection for HIV-infected females in St. Petersburg, Russia (N = 49): 22.4% (n = 11) used traditional methods and 30.6% (n = 15) reported modern contraceptive use, which consisted primarily of condoms (26.5%, n = 13). Over 63% (n = 31) had an abortion. Observed associations for heavy alcohol use (AOR = 2.36, CI = 0.53, 12.41) and recent injection drug use (AOR = 2.88, CI = 0.60, 16.92) were clinically notable, but not statistically significant. Prioritizing family planning for HIV-infected women with a history of substance use is urgently needed.

Female Gender and HIV Transmission Risk Behaviors Among People Living with HIV Who Have Ever Used Injection Drugs in St. Petersburg, Russia.

Among persons who inject drugs, women have a higher HIV prevalence (than men) in many settings. Understanding how gender affects risk for infection among HIV-negative, and transmission among HIV-positive people who currently or previously injected drugs is key to designing effective prevention and treatment programs. We analyzed data from 291 persons living with HIV who had ever injected drugs. Participants were drawn from the Russia Alcohol Research Collaboration on HIV/AIDS cohort (2012-2015) to examine associations between female gender and HIV transmission risk. Primary outcomes were sharing drug injecting equipment (e.g., needle/syringes) and condomless sex. Secondary outcomes were alcohol use before sharing drug injecting equipment; before condomless sex; and both sharing drug injecting equipment and condomless sex. Logistic regression models assessed associations between gender and outcomes, controlling for demographics, partner HIV status and use of antiretroviral treatment. Female gender was not significantly associated with sharing drug injecting equipment [aOR = 1.45, 95% confidence interval (CI) 0.85-2.46, p value = 0.18] but was associated with condomless sex (aOR = 1.91, 95% CI 1.12-3.23, p = 0.02) in adjusted models. Female gender was not significantly associated with any secondary outcomes. Better understanding of risky sex and drug use behaviors among people who currently or previously injected drugs can support the design of effective gender-tailored HIV prevention interventions.

Effects of Opioid Withdrawal on Psychobiology in People Living with HIV.

OBJECTIVE: Many persons with opioid use disorders (OUDs) have HIV disease and experience clinically significant stress after they enroll in abstinence-based treatment and undergo medically assisted withdrawal. We examined whether opioid withdrawal affects virologic control, inflammatory markers, cognition, and mood in persons with an OUD and HIV, and explored whether measures of withdrawal stress, such as activation of the HPA axis, contribute to alterations in immune function, cognition, and mood. METHOD AND PARTICIPANTS: Study participants were 53 persons with HIV who were admitted for OUD treatment at the City Addiction Hospital in Saint Petersburg, Russian Federation. Participants were examined at admission, at the anticipated peak of withdrawal 3 to 7 days after the last day of a clonidine-based withdrawal process lasting 7 to 14 days, and 3 to 4 weeks after completing withdrawal. At these times, participants received medical exams and were evaluated for symptoms of withdrawal, as well as cognition and mood. Viral load, plasma cortisol, DHEA sulfate ester (DHEA-S), interleukin-6 (IL-6), and soluble CD14 (sCD14) were determined. Multivariable models examined the relationships between markers of HPA activation and the other parameters over time. RESULTS: HPA activation as indexed by cortisol/DHEA-S ratio increased during withdrawal, as did markers of immune activation, IL-6 and sCD14. There were no significant associations between viral load and indicators of HPA activation. In longitudinal analyses, higher cortisol/DHEA sulfate was related to worse cognition overall, and more mood disturbance. Increase in IL-6 was associated with worse cognitive performance on a learning task. There were no significant associations with sCD14. CONCLUSIONS: Worsening of cognition and measures of mood disturbance during withdrawal were associated with activation of the HPA axis and some measures of inflammation. Whether repeated episodes of opioid withdrawal have a cumulative impact on long-term HIV outcomes and neurocognition is a topic for further investigation.

Correlates of unprotected sexual intercourse among women who inject drugs or who have sexual partners who inject drugs in St Petersburg, Russia.

OBJECTIVES: To assess risk for unintended pregnancy, this study describes the correlates of unprotected sexual intercourse (UPSI) among women who inject illicit drugs or who have sexual partners who inject drugs in St Petersburg, Russia. METHODS: Data from a cross-sectional survey and biological test results collected between 2005 and 2008 from 202 Russian women (143 drug injectors and 59 non-drug injectors) were analysed. Multivariate regression was used to investigate the correlates of UPSI occurring at the women's last sexual act. Independent variables included socio-demographics, age at sexual debut, first sexual encounter perceived as involuntary, number of pregnancies and number of children for which the participant is the primary caretaker, heavy sporadic drinking (i.e. consuming more than five drinks in 2 hours at least twice a month), at-risk drinking per the Alcohol Use Disorder Identification Test (AUDIT-C) score, and sexually transmitted infections (HIV-1, syphilis serology, Chlamydia trachomatis and Neisseria gonorrheae). RESULTS: Sixty-seven percent of women reported UPSI at last intercourse. UPSI was independently associated with heavy sporadic drinking [odds ratio (OR) 2.8, 95% CI 1.2-6.6] and having been pregnant (OR 2.25, 95% CI 1.1-4.6). CONCLUSIONS: Despite the high risk for HIV acquisition or transmission and unintended pregnancy, condom use among the study population is low. Programmes to investigate and improve contraceptive use, including condom use, among this vulnerable group of women are needed. Such programmes may require identifying and targeting female reproductive health concerns and problem drinking, particularly heavy sporadic drinking, rather than conventional measures of alcohol misuse.

An acceptance-based, intersectional stigma coping intervention for people with HIV who inject drugs-a randomized clinical trial.

Background: People with HIV who inject drugs experience intersecting forms of stigma that adversely impact care access. This RCT aimed to evaluate effects of a behavioral intersectional stigma coping intervention on stigma and care utilization. Methods: We recruited 100 participants with HIV and past-30-day injection drug use at a non-governmental harm reduction organization in St. Petersburg, Russia, and randomized them 1:2 to receive usual services only or an additional intervention of three weekly 2-h group sessions. Primary outcomes were change in HIV and substance use stigma scores at one month after randomization. Secondary outcomes were initiation of antiretroviral treatment (ART), substance use care utilization, and changes in frequency of past-30-days drug injection at six months. The trial was registered as NCT03695393 at clinicaltrials.gov. Findings: Participant median age was 38.1 years, 49% were female. Comparing 67 intervention and 33 control group participants recruited October 2019-September 2020, the adjusted mean difference (AMD) in change in HIV and substance use stigma scores one month after baseline were 0.40, (95% CI: -0.14 to 0.93, p = 0.14) and -2.18 (95% CI: -4.87 to 0.52, p = 0.11), respectively. More intervention participants than control participants initiated ART (n = 13, 20% vs n = 1, 3%, proportion difference 0.17, 95% CI: 0.05-0.29, p = 0.01) and utilized substance use care (n = 15, 23% vs n = 2, 6%, proportion difference 0.17, 95% CI: 0.03-0.31, p = 0.02). The adjusted median difference in change in injecting drug use frequency 6 months after baseline was -3.33, 95% CI: -8.51 to 1.84, p = 0.21). Five not intervention-related serious adverse events (7.5%) occurred in the intervention group, one (3.0%) serious adverse event in the control group. Interpretation: This brief stigma-coping intervention did not change stigma manifestations or drug use behaviors in people with HIV and injection drug use. However, it seemed to reduce stigma's impact as an HIV and substance use care barrier. Funding: R00DA041245, K99DA041245, P30AI042853.

Age at first alcoholic drink as predictor of current HIV sexual risk behaviors among a sample of injection drug users (IDUs) and non-IDUs who are sexual partners of IDUs, in St. Petersburg, Russia.

This study investigates whether age at first alcoholic drink is associated with sexual risk behaviors among injection drug users (IDUs) and non-IDUs who are sexual partners of IDUs in St. Petersburg, Russia. A path analysis was used to test a model of age at first drink, age at sexual debut, age at first drug use, current substance use patterns and current sexual risk behaviors among 558 participants. Results revealed that age at first drink had an effect on multiple sex partners through age at sexual debut and injection drug use, but no effect on unprotected sex. Age at first drug use was not related to sexual risk behaviors. Investigation of age of drinking onset may provide useful information for programs to reduce sexual risk behaviors and injection drug use. Different paths leading to unprotected sex and multiple sexual partners call for different approaches to reduce sexual risk behaviors among this population.

Stigma and ART initiation among people with HIV and a lifetime history of illicit drug use in Saint-Petersburg, Russia-A prospective cohort analysis.

BACKGROUND: HIV-positive people who inject drugs (PWID) are stigmatized and face more challenges in accessing ART. The natural course of stigma and its role on ART initiation in this population is unclear. We examined 1] whether HIV stigma changes over time and 2] whether HIV and substance use stigma are associated with ART initiation in a prospective cohort of HIV-positive PWID in St. Petersburg, Russia. METHODS: We used data from 165 HIV-positive PWID who were ART-naïve at enrollment andgeneralized estimating equations to assess changes in HIV stigma between baseline, 12- and 24-month study visits. Logistic regression estimated associations of HIV stigma and substance use stigma with ART initiation. All models were adjusted for gender, age, CD4 count, duration of HIV diagnosis, recent (past 30-day) drug use and depressive symptoms. RESULTS: Participants characteristics were the following: median age of 34 (Q1; Q3: 30; 37) years; 30% female; 28% with CD4 count <350; 44% reported recent drug use. During the study period, 31% initiated ART and the median time between HIV diagnosis and ART initiation was 8.5 years (Q1; Q3: 4.68; 13.61). HIV stigma scores decreased yearly by 0.57 (95% CI -1.36, 0.22). More than half (27/47 [57.4%]) of participants who were eligible for ART initiation per local ART guidelines did not initiate therapy. Total HIV stigma and substance use stigma scores were not associated with ART initiation (AOR 0.99, 95%CI 0.94-1.04; AOR 1.01, 95%CI 0.96-1.05, respectively). CONCLUSION: In this Russian cohort of HIV-positive, ART-naïve PWID, stigma did not change over time and was not associated with ART initiation. Addressing stigma alone is unlikely to increase ART initiation rates in this population. Reducing further existing structural barriers, e.g., by promoting equal access to ART and the value of substance-use treatment for ART treatment success should complement stigma-reduction approaches.

HIV disclosure, condom use, and awareness of HIV infection among HIV-positive, heterosexual drug injectors in St. Petersburg, Russian Federation.

We examined the prevalence of HIV disclosure to sexual partners by HIV-positive drug injectors (IDUs) in St. Petersburg, Russia and compared the magnitude and direction of associations of condom use with awareness of one's HIV infection and disclosure to partners. Among 157 HIV-infected participants, awareness of infection at time of last intercourse was associated with condom use with partners perceived to be HIV-negative (aOR 6.68, 95% CI 1.60-27.88). Among the 70 participants aware of their infection prior to enrolment, disclosure to potentially uninfected sexual partners was independently and negatively associated with condom use (aOR 0.13, 95% CI 0.02-0.66). Disclosure was independently associated with having injected ≥ 9 years (aOR 6.04, 95% CI 1.53-23.77) and partnership with another IDU (aOR 3.61, 95% CI 1.44-9.06) or HIV-seropositive (aOR 45.12, 95% CI 2.79-730.46). Scaling up HIV testing services and interventions that increase the likelihood of individuals receiving their test results is recommended.

Estimates of HIV incidence among drug users in St. Petersburg, Russia: continued growth of a rapidly expanding epidemic.

BACKGROUND: Russia has one of the world's fastest growing HIV epidemics and it has been largely concentrated among injection drug users (IDU). St Petersburg, Russia's second largest city, is one of the country's regions that has been most affected by the HIV epidemic. To monitor the current epidemic situation, we sought to estimate recent HIV incidence among IDU in St Petersburg. METHODS: In a cross-sectional study of 691 IDU recruited during 2005-08, HIV incidence was estimated by two methods: a retrospective cohort analysis and BED capture enzyme immunoassay (EIA) results. Socio-demographic and behavioural correlates of incident infections and spatial patterns were examined. RESULTS: In the retrospective cohort analysis, the incidence rate was estimated to be 14.1/100 person-years [95% confidence interval (CI) 10.7-17.6]. Using results of BED EIA and two correction formulas for known misclassification, incidence estimates were 23.9 (95% CI 17.8-30.1) and 25.5 (95% CI 18.9-32.0) per 100 person-years. Independent correlates of being recently infected included current unemployment (P = 0.004) and not having injected drugs in the past 30 days (P = 0.03). HIV incident cases were detected in all but one district in the city, with focal areas of transmission observed to be expanding. CONCLUSIONS: High HIV incidence among IDU in St Petersburg attests to continued growth of the epidemic. The need for expansion of HIV prevention interventions targeted to vulnerable populations throughout the city is urgent. These results also suggest that the BED EIA may over-estimate incidence even after correction for low specificity.

A substantial transmission bottleneck among newly and recently HIV-1-infected injection drug users in St Petersburg, Russia.

There are limited data on the genetic complexity of human immunodeficiency virus type 1 (HIV-1) after transmission among a cohort of injection drug users (IDUs). We used single-genome amplification of HIV-1 env to determine the genotypic characteristics of virus among IDUs with acute infection in St Petersburg, Russia. Our results indicate that a single variant was transmitted in a majority of cases (9 of 13 participants), which is analogous to what is observed in sexual transmission. These data are most consistent with a genetic bottleneck during transmission by injection drug use that is due to a small inoculum, which most often results in the transmission of a low-complexity viral population.

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.

High HIV prevalence, suboptimal HIV testing, and low knowledge of HIV-positive serostatus among injection drug users in St. Petersburg, Russia.

The purpose of this analysis was to estimate human immunodeficiency virus (HIV) prevalence and testing patterns among injection drug users (IDUs) in St. Petersburg, Russia. HIV prevalence among 387 IDUs in the sample was 50%. Correlates of HIV-positive serostatus included unemployment, recent unsafe injections, and history/current sexually transmitted infection. Seventy-six percent had been HIV tested, but only 22% of those who did not report HIV-positive serostatus had been tested in the past 12 months and received their test result. Correlates of this measure included recent doctor visit and having been in prison or jail among men. Among the 193 HIV-infected participants, 36% were aware of their HIV-positive serostatus. HIV prevalence is high and continuing to increase in this population. Adequate coverage of HIV testing has not been achieved, resulting in poor knowledge of positive serostatus. Efforts are needed to better understand motivating and deterring factors for HIV testing in this setting.

Comparing sexual risks and patterns of alcohol and drug use between injection drug users (IDUs) and non-IDUs who report sexual partnerships with IDUs in St. Petersburg, Russia.

BACKGROUND: To date, the great majority of Russian HIV infections have been diagnosed among IDUs and concerns about the potential for a sexual transmission of HIV beyond the IDU population have increased. This study investigated differences in the prevalence of sexual risk behaviors between IDUs and non-IDUs in St. Petersburg, Russia and assessed associations between substance use patterns and sexual risks within and between those two groups. METHODS: Cross-sectional survey data and biological test results from 331 IDUs and 65 non-IDUs who have IDU sex partners were analyzed. Multivariate regression was employed to calculate measures of associations. RESULTS: IDUs were less likely than non-IDUs to report multiple sexual partners and unprotected sex with casual partners. The quantity, frequency and intensity of alcohol use did not differ between IDUs and non-IDUs, but non-IDUs were more likely to engage in alcohol use categorized as risky per the alcohol use disorders identification test (AUDIT-C). Risky sexual practices were independently associated with monthly methamphetamine injection among IDUs and with risky alcohol use among non-IDUs. Having sex when high on alcohol or drugs was associated with unprotected sex only among IDUs. CONCLUSIONS: Greater prevalence of sexual risk among non-IDUs who have IDU sex partners compared to IDUs suggests the potential for sexual transmission of HIV from the high-prevalence IDU population into the general population. HIV prevention programs among IDUs in St. Petersburg owe special attention to risky alcohol use among non-IDUs who have IDU sex partners and the propensity of IDUs to have sex when high on alcohol or drugs and forgo condoms.

Design of a randomized controlled trial to Link Infectious and Narcology Care (LINC-II) in St. Petersburg, Russia.

BACKGROUND: If Russia is to achieve the UNAIDS 90-90-90 HIV targets, better approaches to engage, effectively treat, and retain patients in care are needed. This paper describes the protocol of a randomized controlled trial (RCT) testing the effectiveness of LINC-II, a strength-based case management program for HIV-positive people who inject drugs (PWID) to increase rates of HIV viral suppression, ART initiation, and opioid abstinence. METHODS: This RCT will enroll and randomize 240 participants, recruited from a narcology (addiction care) hospital in St. Petersburg, Russia. Participants are randomized to the intervention or control arms. Those in the intervention arm receive: (1) strengths-based HIV case management supporting coordinated care; (2) rapid ART initiation; and (3) pharmacotherapy for opioid use disorder. We will evaluate the intervention's effectiveness compared to standard of care on the following outcomes: (1) undetectable HIV viral load at 12 months (primary); (2) initiation of ART within 28 days of randomization; (3) change in CD4 count from baseline to 12 months; (4) retention in HIV care (i.e., ≥ 1 visit to medical care in 2 consecutive 6 month periods); (5) undetectable HIV viral load at 6 months; and (6) past 30-day opioid abstinence (at 6 and at 12 months). DISCUSSION: This RCT will assess the LINC-II intervention in an urban Russian setting. If effective, it will offer a new approach for increasing the uptake of both HIV and opioid use disorder treatment and coordination of these modalities in standard Eastern European clinical settings. Trial registration This study was registered with ClinicalTrials.gov through the National Institutes of Health, NCT03290391. Registered 19 September 2017, https://clinicaltrials.gov/ct2/show/NCT03290391.

The potential for bridging of HIV transmission in the Russian Federation: sex risk behaviors and HIV prevalence among drug users (DUs) and their non-DU sex partners.

The HIV epidemic that began in Russia in the mid-1990s has been concentrated mostly among drug users (DUs). Recent evidence of increasing HIV cases among non-DUs attributed to sexual behavior raises potential concern about a more generalized epidemic. The purpose of this analysis is to examine the potential for HIV transmission from DUs to their non-DU sex partners. Analyses are conducted using data collected during 2005-2008 in St. Petersburg, Russia. A total of 631 DUs were recruited into the sample with an HIV prevalence of 45%. A majority (84%) of DUs reported being sexually active in the past 6 months, and the DU status of their sex partners was reported as follows: 54% DU, 40% non-DU, and 6% unknown DU status. In 41% of partnerships with an HIV-negative or unknown status partner not known to be DU (potential bridging partnerships), the last reported intercourse was unprotected. Female DUs with potential bridging partnerships were more likely than male DUs to be younger and report homelessness and to have multiple or new sex partners. Many non-DU sex partners of DUs enrolled in the study reported new sex partners in the past 6 months (66%), unprotected intercourse at last sex (60%), and multiple sex partners in the past 6 months (48%). HIV prevalence in this group was 15% (eight out of 53). The high prevalence of HIV among DUs, their sexual contact with non-DUs, and the high-risk sexual behaviors of this potential bridging population together indicate the real potential for an increasingly generalized epidemic. The degree to which there will be further transmission from non-DU sex partners of DUs who exhibit high levels of sex risk behaviors to other non-DU sex partners deserves further study.

Potential bridges of heterosexual HIV transmission from drug users to the general population in St. Petersburg, Russia: is it easy to be a young female?

The epidemic of HIV in St. Petersburg, which is currently concentrated among injection drug users (IDUs), may be penetrating into the general population. Non-IDUs who have IDU sex partners (SP) could be potential bridges in an expanding epidemic. To investigate potential bridges, we accrued a convenience sample of 288 non-IDUs whose HIV diagnosis was attributed to sexual transmission and we determined the proportion that had IDUs among their SP. Having IDU SP ever (lifetime) and IDU SP in the last year were the key variables for the analysis of potential bridges in this study. The interaction of gender and age was found to be a significant predictor of having lifetime IDU SP (p = 0.006, chi (2) test) and IDU SP in the last year (p = 0.05, chi (2) test): females aged 26 and younger were more likely to have both lifetime IDU SP and IDU SP in the last year. Among the group of young females, 46% reported ever having an IDU SP. Out of young women reporting ever having an IDU SP, 85% also reported at least one lifetime non-IDU SP. Among the females aged 26 or younger, a lower level of education (odds ratio [OR] = 2.7, confidence interval [CI] = 1.1-6.7), being born in St. Petersburg (OR = 2.9, CI = 1.2-7.2), and alcohol use in the last 30 days (OR = 3.5, CI = 1.3-9.6) were significant correlates for ever having had an IDU SP. Urgent efforts are necessary to expand HIV prevention to target the potential bridging population to prevent further transmission.

Drug choice, spatial distribution, HIV risk, and HIV prevalence among injection drug users in St. Petersburg, Russia.

BACKGROUND: The HIV epidemic in Russia has been driven by the unsafe injection of drugs, predominantly heroin and the ephedrine derived psychostimulants. Understanding differences in HIV risk behaviors among injectors associated with different substances has important implications for prevention programs. METHODS: We examined behaviors associated with HIV risk among 900 IDUs who inject heroin, psychostimulants, or multiple substances in 2002. Study participants completed screening questionnaires that provided data on sociodemographics, drug use, place of residence and injection- and sex-related HIV risk behaviors. HIV testing was performed and prevalence was modeled using general estimating equation (GEE) analysis. Individuals were clustered by neighborhood and disaggregated into three drug use categories: Heroin Only Users, Stimulant Only Users, and Mixed Drug Users. RESULTS: Among Heroin Only Users, younger age, front/backloading of syringes, sharing cotton and cookers were all significant predictors of HIV infection. In contrast, sharing needles and rinse water were significant among the Stimulant Only Users. The Mixed Drug Use group was similar to the Heroin Only Users with age, front/back loading, and sharing cotton significantly associated with HIV infection. These differences became apparent only when neighborhood of residence was included in models run using GEE. CONCLUSION: The type of drug injected was associated with distinct behavioral risks. Risks specific to Stimulant Only Users appeared related to direct syringe sharing. The risks specific to the other two groups are common to the process of sharing drugs in preparation to injecting. Across the board, IDUs could profit from prevention education that emphasizes both access to clean syringes and preparing and apportioning drug with these clean syringes. However, attention to neighborhood differences might improve the intervention impact for injectors who favor different drugs.

A strengths-based case management intervention to link HIV-positive people who inject drugs in Russia to HIV care.

OBJECTIVE: To determine whether the Linking Infectious and Narcology Care strengths-based case management intervention was more effective than usual care for linking people who inject drugs (PWID) to HIV care and improving HIV outcomes. DESIGN: Two-armed randomized controlled trial. SETTING: Participants recruited from a narcology hospital in St. Petersburg, Russia. PARTICIPANTS: A total of 349 HIV-positive PWID not on antiretroviral therapy (ART). INTERVENTION: Strengths-based case management over 6 months. MAIN OUTCOME MEASURES: Primary outcomes were linkage to HIV care and improved CD4 cell count. We performed adjusted logistic and linear regression analyses controlling for past HIV care using the intention-to-treat approach. RESULTS: Participants (N = 349) had the following baseline characteristics: 73% male, 12% any past ART use, and median values of 34.0 years of age and CD4 cell count 311 cells/µl. Within 6 months of enrollment 51% of the intervention group and 31% of controls linked to HIV care (adjusted odds ratio 2.34; 95% confidence interval: 1.49-3.67; P < 0.001). Mean CD4 cell count at 12 months was 343 and 354 cells/µl in the intervention and control groups, respectively (adjusted ratio of means 1.14; 95% confidence interval: 0.91, 1.42, P = 0.25). CONCLUSION: The Linking Infectious and Narcology Care strengths-based case management intervention was more effective than usual care in linking Russian PWID to HIV care, but did not improve CD4 cell count, likely due to low overall ART initiation. Although case management can improve linkage to HIV care, specific approaches to initiate and adhere to ART are needed to improve clinical outcomes (e.g., increased CD4 cell count) in this population.