A New Generation of Drug Users in St. Petersburg, Russia? HIV, HCV, and Overdose Risks in a Mixed-Methods Pilot Study of Young Hard Drug Users

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

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

Food Insecurity and Transmission Risks Among People with HIV Who Use Substances

Food insecurity (FI) impacts people with HIV (PWH) and those who use substances (i.e. drugs and alcohol). We evaluated the longitudinal association between FI and HIV transmission risks (unprotected sexual contacts and shared needles/syringes). Among 351 PWH who use substances in Russia, 51.6% reported FI and 37.0% past month injection drug use. The mean number of unprotected sexual contacts in the past 90 days was 13.4 (SD 30.1); 9.7% reported sharing needles/syringes in the past month. We did not find a significant association between mild/moderate FI (adjusted IRR = 0.87, 95% CI 0.47, 1.61) or severe FI (aIRR = 0.84, 95% CI 0.46, 1.54; global p = 0.85) and unprotected sexual contacts. We observed a significant association between severe FI and sharing needles/syringes in the past month (adjusted OR = 3.27, 95% CI 1.45, 7.39; p = 0.004), but not between mild/moderate FI and sharing needles/syringes in the past month (aOR = 1.40,95% CI 0.58, 3.38; p = 0.45). These findings suggest that severe FI could be a potential target for interventions to lower HIV transmission.

Reconstructing the Temporal Origin and the Transmission Dynamics of the HIV Subtype B Epidemic in St. Petersburg, Russia

The HIV/AIDS epidemic in Russia is among the fastest growing in the world. HIV epidemic burden is non-uniform in different Russian regions and diverse key populations. An explosive epidemic has been documented among people who inject drugs (PWID) starting from the mid-1990s, whereas presently, the majority of new infections are linked to sexual transmission. Nationwide, HIV sub-subtype A6 (previously called A_FSU) predominates, with the increasing presence of other subtypes, namely subtype B and CRF063_02A. This study explores HIV subtype B sequences from St. Petersburg, collected from 2006 to 2020, in order to phylogenetically investigate and characterize transmission clusters, focusing on their evolutionary dynamics and potential for further growth, along with a socio-demographic analysis of the available metadata. In total, 54% (107/198) of analyzed subtype B sequences were found grouped in 17 clusters, with four transmission clusters with the number of sequences above 10. Using Bayesian MCMC inference, tMRCA of HIV-1 subtype B was estimated to be around 1986 (95% HPD 1984-1991), whereas the estimated temporal origin for the four large clusters was found to be more recent, between 2001 and 2005. The results of our study imply a complex pattern of the epidemic spread of HIV subtype B in St. Petersburg, Russia, still in the exponential growth phase, and in connection to the men who have sex with men (MSM) transmission, providing a useful insight needed for the design of public health priorities and interventions.

Behavioral patterns of people who use synthetic psychostimulants: Results of a qualitative study in St. Petersburg, Russia

BACKGROUND

Russia, like many other places, is currently experiencing a proliferation of new psychoactive substances, many of which are psychostimulants. In St. Petersburg, these appear to be mostly congeners of cathinone. We sought to obtain qualitative data to better understand the impact on the health and behaviors of people who use drugs (PWUD) by recruiting individuals who reported recent use of psychostimulants.

METHODS

In-depth qualitative data on current drug use and its effects were collected through thirty interviews (n=30) and two focus groups (n=10: five male, five female). The interviews and focus groups also provided data on the social contexts of drug use including sexual behaviors and associated medical issues. Secondary data about online drug purchases were obtained from a source that accesses and analyzes darknet purchases. Qualitative data were initially coded using a priori codes developed on the basis of the interview guide, and then data were coded again inductively based on emergent findings from the data. Thematic analysis was carried out using OpenCode 4.0 qualitative data analysis software.

RESULTS

Thematic analysis of the interviews and focus groups identified distinct differences in behavior patterns between older, more experienced PWUD and a "new generation" of PWUD. Routes of initiation of drug use and sexual behaviors associated with drug use differed, but both groups reported high levels of unsafe injection and sexual behaviors. In interpreting the texts and purchasing data, we have attempted to anticipate how the drug use patterns can influence HIV transmission.

CONCLUSIONS

The emergence of a new class of psychostimulant drugs presents new threats to the health of drug users and new opportunities to intervene to reduce those risks. The information obtained may assist HIV/AIDS prevention specialists and drug user support groups in their efforts to decrease unsafe drug use and sexual behaviors.

Computer-based alcohol reduction intervention for alcohol-using HIV/HCV co-infected Russian women in clinical care: study protocol for a randomized controlled trial

BACKGROUND

Russia has a high prevalence of human immunodeficiency virus (HIV) infections. In 2018, over one million persons were living with HIV (PLWH); over a third were women. A high proportion of HIV-infected women are co-infected with hepatitis C virus (HCV), and many consume alcohol, which adversely affects HIV and HCV treatment and prognosis. Despite the triple epidemics of alcohol use, HIV and HCV, and the need for interventions to reduce alcohol use among HIV/HCV co-infected women, evidence-based alcohol reduction interventions for this vulnerable population are limited. To address this gap, we developed a clinical trial to evaluate the efficacy of a computer-based intervention to reduce alcohol consumption among HIV/HCV co-infected women in clinical care.

METHODS

In this two-arm parallel randomized controlled trial, we propose to evaluate the efficacy of a culturally adapted alcohol reduction intervention delivered via a computer for HIV/HCV co-infected Russian women. The study population consists of women 21-45 years old with confirmed HIV/HCV co-infection who currently use alcohol. Intervention efficacy is assessed by a novel alcohol biomarker, ethyl glucuronide (EtG), and biomarkers of HIV and HCV disease progression. Women are randomized to trial conditions in a 1:1 allocation ratio, using a computer-generated algorithm to develop the assignment sequence and concealment of allocation techniques to minimize assignment bias. Women are randomized to either (1) the computer-based alcohol reduction intervention or (2) the standard-of-care control condition. We will use an intent-to-treat analysis and logistic and linear generalized estimating equations to evaluate intervention efficacy, relative to the standard of care, in enhancing the proportion of women with a laboratory-confirmed negative EtG at each research study visit over the 9-month follow-up period. Additional analyses will evaluate intervention effects on HIV (viral load and CD4+ levels) and HCV markers of disease progression (FibroScan).

DISCUSSION

The proposed trial design and analysis provides an appropriate conceptual and methodological framework to assess the efficacy of the computer-based intervention. We propose to recruit 200 participants. The intervention, if efficacious, may be an efficient and cost-effective alcohol reduction strategy that is scalable and can be readily disseminated and integrated into clinical care in Russia to reduce women's alcohol consumption and enhance HIV/HCV prognosis.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03362476 . Registered on 5 December 2017.

Chemiluminescent-microparticle-immunoassay-based detection and prevalence of human immunodeficiency virus infection in Islamabad, Pakistan

An advanced detection assay is important for clinical diagnosis of human immunodeficiency virus (HIV) infection in asymptomatic individuals. The first step in timely treatment and management of the infection is the early detection of HIV. In this study, we determined the prevalence of HIV in Islamabad for the first time using a chemiluminescent microparticle immunoassay (CMIA), which is an advanced serological diagnostic technique. A total of 3659 samples were obtained from the general public in Islamabad, Pakistan, and 85 of them were found to be positive for HIV infection (2.32% prevalence). Of the positive subjects, 78.82% (67/85) were male, 10.6% (9/85) were female, and 10.6% (9/85) were of unidentified gender. The results revealed a significant relationship between age groups and HIV status. The age group of 21- to 30-year-olds was found to have the highest rate of HIV infection, and the rate of HIV infection in males was higher than in females.

Harm reduction via online platforms for people who use drugs in Russia: a qualitative analysis of web outreach work

Background

Harm reduction services to people who use drugs (PWUD) in Russia are insufficient in terms of quantity, government endorsement, and accessibility. The situation has recently deteriorated even further because of social distancing measures of the COVID-19 pandemic. Several organizations have started to provide some harm reduction services via online platforms by web outreach. However, little is known on how online outreach services are organized and implemented. Drawing on the example of St. Petersburg-based NGO “Humanitarian Action,” we explored web outreach work in Telegram instant messenger.

Methods

Our data were comprised of 4 semi-structured interviews with the NGO staff and 301 cases of web outreach work with PWUD. We used thematic analysis to study the process of web outreach, harm reduction service provision, and needs of PWUD.

Results

Three stages of the process of web outreach work were identified: clients initiating communication, NGO workers addressing clients’ needs, and NGO workers receiving clients’ feedback. Communication proceeded in group chat or direct messages. Challenges in addressing clients’ needs happened when clients turned for help after hours, sent recorded voice messages, sent unclear messages, and/or were unwilling to transition to telephone communication. All web outreach workers reported receiving only positive feedback on their work. The needs of PWUD were categorized into two major themes, depending on whether they can be addressed fully or partially online. In cases of online only provision of services, web outreach workers helped PWUD treat minor injection drug use complications, obtain verified harm reduction information and receive general psychological support. In instances of partial online services provision, PWUD were assisted in getting treatment of severe injection drug use complications, overdoses, and in accessing offline medical, psychological, social, legal and harm reduction services.

Conclusions

Our research demonstrated that web outreach work is a convenient tool for delivering some harm reduction services to PWUD either partially or completely online and for recruiting new clients (including hard-to-reach PWUD that avoid attending brick-and-mortar facilities). Harm reduction organizations should consider incorporating online harm reduction services into their activities. However, further research is needed to explore relative advantages and disadvantages of online harm reduction services.

Harm reduction via online platforms for people who use drugs in Russia: A qualitative analysis of web outreach work

Background Harm reduction services to people who use drugs (PWUD) in Russia are insufficient in terms of quantity, government endorsement, and accessibility. The situation has recently deteriorated even further because of social distancing measures of the COVID-19 pandemic. Recently several harm reduction organizations have started to provide some harm reduction services via online platforms by web outreach. However, little is known on how online outreach services are organized and implemented. Drawing on the example of St. Petersburg-based NGO "Humanitarian Action" we explored web outreach work in Telegram instant messenger. Methods 4 semi-structured interviews with the NGO staff and 301 cases of web outreach work with PWUD comprised the dataset. The process of web outreach, service provision to PWUD, and PWUD's needs were thematically analyzed. Results Three stages of the process of web outreach work were determined: clients initiating communication, NGO workers addressing clients' needs, and NGO workers receiving clients' feedback. Communication proceeded either in group chat or in direct messages. Challenges in addressing clients' needs happened when clients turned for help in nighttime, sent recorded voice messages, sent unclear messages, and/or were unwilling to transition to telephone communication. All web outreach workers reported receiving only positive feedback on their work. PWUD's needs were categorized into two major themes, depending on whether they can be addressed fully or partially online. In cases of online only provision of services, web outreach workers helped PWUD treat minor injection drug use complications, obtain verified harm reduction information and receive general psychological support. In instances of partial online services provision, PWUD were assisted in getting treatment of severe injection drug use complications, overdoses, and in accessing offline medical, psychological, social, legal and harm reduction services. Conclusions Our research demonstrated that web outreach work is a convenient tool for delivering some harm reduction services to PWUD either partially or completely online and recruiting new clients (including hard-to-reach PWUD that avoid attending brick-and-mortar facilities). It indicates that harm reduction organizations should consider incorporating online harm reduction services into their activities. However, more research is needed to explore relative advantages and disadvantages of online harm reduction services delivery.

Epidemics of HIV Infection among Heavy Drug Users of Depressants Only, Stimulants Only, and Both Depressants and Stimulants in Mainland China: A Series, Cross-Sectional Studies

Background: Heavy drug users was a global consensus high-risk population of HIV infection. However, the specific impact of drug on HIV infection has not yet been established. Depressants and stimulants were most widely used drugs in mainland China, and mix use of the two drugs was also serious. We assessed the HIV infection rate and trends in heavy drug users by analyzing data from the National Dynamic Management and Control Database for Drug Users (NDMCDDU). Methods: All heavy drug users with HIV test results in NDMCDDU from 2008 to 2016 were grouped into depressants only group (DOG), stimulants only group (SOG), and both depressants and stimulants group (DSG). We used joinpoint regression to examine trends of HIV infection rates. Multivariable logistic regression was used to examine factors related to HIV infection. Results: A total of 466,033 heavy drug users with 9522 cases of HIV infection were included in this analysis. HIV infection rate was estimated at 2.97% (95% CI 2.91–3.04%) of 265,774 users in DOG, 0.45% (95% CI 0.42–0.49%) of 140,895 users in SOG, and 1.65% (95% CI 1.55–1.76%) of 59,364 users in DSG. In DOG, a U-shaped curve of HIV infection rate decreased from 3.85% in 2008 to 2.19% in 2010 (annual percent change (APC) −12.9, 95% CI −19.3–−6.0, p < 0.05), then increased to 4.64% in 2016 (APC 8.3, 95% CI 6.1–10.4, p < 0.05) was observed. However, SOG and DSG showed consistent increases from 0.15% in 2008 to 0.54% in 2016 (APC 8.2, 95% CI 4.8–11.8, p < 0.05) and from 0.78% in 2008 to 2.72% in 2016 (APC 13.5, 95% CI 10.7–16.4, p < 0.05), respectively. HIV infection rate of DOG in the southwest region presented a U-shaped trend. All groups showed significant increases in HIV infection in east and central regions. Conclusions: The U-shaped curve for HIV infection rate among DOG users and consistent increases among SOG and DSG users implies drug abuse is still a critical focus of HIV infection in China. It is urgently needed to reassess the effectiveness of current strategies on HIV prevention and control among drug users.

The fentanyl epidemic in Estonia: factors in its evolution and opportunities for a comprehensive public health response, a scoping review

BACKGROUND

The spread of illicitly manufactured fentanyl has the potential to greatly increase the fatal overdoses in many places in the world. The purpose of this paper is to analyse the evolution of fentanyl use epidemic in Estonia.

METHODS

this scoping review is based on extensive review and synthesis of broad range of literature: research reports, newspaper, magazine, coverage of illicit fentanyl use; policy documents, position papers, reports released by government agencies, and surveillance data.

RESULTS

For an over a decade up to 2017, Estonia has had the highest overdose death mortality in Europe. The use of (injected) fentanyl is a major contributor to the Estonian overdose death epidemic. Shutting down a major producer and distributor of illicit fentanyl has been extremely effective in curbing the number of overdose deaths. Unfortunately, this supply-side intervention came ten years into the epidemic, and might be difficult to replicate in settings with decentralized production. In areas faced by fentanyl we would recommend large-scale implementation of opiate substitution treatment and naloxone distribution, syringe service programs to provide for safer injecting and link to other services (high frequencies of fentanyl injection create high risk for HIV and HCV transmission), and programs, such as "Break the Cycle," to reduce initiation into injecting drug use. Further, the means of responding to emerging substances should match the world in which different substances can be rapidly introduced, and where people who use drugs can change preferences based on market availability.

CONCLUSION

Addressing illicitly manufactured fentanyl may serve as a public health learning experience for developing early detection and rapid response programs in rapidly changing drug use environments.