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Ponticiello M, Azbel L, Tate MM, Bromberg DJ, Pykalo I, Kiriazova T, Saichuk N, Altice FL. Introducing methadone maintenance therapy into Ukrainian prisons: a qualitative study of criminal subculture, Russia's full-scale invasion, and contested methadone objects. Front Psychiatry 2023; 14:1227216. [PMID: 38098632 PMCID: PMC10720714 DOI: 10.3389/fpsyt.2023.1227216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/17/2023] [Indexed: 12/17/2023] Open
Abstract
Background After pilot testing, methadone was newly being introduced into Ukrainian prisons in 2021 as part of a national scale-up strategy to treat opioid use disorder and prevent transmission of HIV and HCV infections. Opioid agonist therapy (OAT) scale-up in Eastern Europe and Central Asia prisons has been hampered by varying levels of influence of criminal subculture, an extralegal informal governance by a social hierarchy that operates in parallel to formal prison authorities. This study examined the socio-environmental factors influencing the uptake of methadone treatment in Ukrainian prisons, including changes that evolved during Russia's full-scale invasion of Ukraine and the displacement of people deprived of liberty (PDL) from conflict to non-conflict regions. Methods In-depth qualitative interviews (N = 37) were conducted from January 2021 to October 2022 in the only two Ukrainian prisons where methadone was being introduced with PDL (N = 18). These two prisons continued to provide methadone after the full-scale invasion. Former PDL (N = 4) were also interviewed and prison staff (N = 15). Interviews were audio-recorded, transcribed, and translated into English. Four authors independently reviewed, coded, and applied a phenomenological framework for data analysis, delineating themes related to criminal subculture, drug use, methadone uptake, and evolving changes during the Russian invasion. Findings Criminal subculture perceptions varied, with some seeing it as strongly discouraging drug use among certain groups, while others described it as a residual and weak influence from a more distant past. The influence of the subculture on methadone treatment uptake, however, was less clear. PDL and prison staff struggled to identify and articulate differences between illicit street-bought methadone, used recreationally, and medically prescribed methadone. Thus, the meaning of "methadone" varies in interpretation as it is being introduced, making it potentially conflicting for patients to opt into this evidence-based treatment. As Russia invaded Ukraine in 2022, PDL from conflict zones were transferred to non-conflict regions where methadone was being introduced. The prison environment became more enabling for PDL to start methadone as they were segregated and not subject to the existing criminal subculture's rules and lacked the social ties necessary to procure drugs illegally. Conclusion It appears that the criminal subculture is variable and evolving in Ukrainian prisons and appears to be impacted differently by the invasion of Russia. As methadone scale-up in prisons expands, it will be important to distinguish the meaning of methadone perpetuated negatively by the prison subculture versus that in which it is intended as a medical treatment by the formal prison authorities. The current invasion of Ukraine by Russia provides a potential disruption to alter this course.
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Affiliation(s)
- Matthew Ponticiello
- Yale School of Medicine, Yale University, New Haven, CT, United States
- Department of Epidemiology of Microbial Diseases, Yale University, New Haven, CT, United States
| | - Lyu Azbel
- Department of Social and Behavioral Sciences, Yale University, New Haven, CT, United States
| | - Mary M. Tate
- Department of Epidemiology of Microbial Diseases, Yale University, New Haven, CT, United States
| | - Daniel J. Bromberg
- Department of Social and Behavioral Sciences, Yale University, New Haven, CT, United States
| | - Iryna Pykalo
- European Institute on Public Health Policy, Kyiv, Ukraine
| | | | | | - Frederick L. Altice
- Yale School of Medicine, Yale University, New Haven, CT, United States
- Department of Epidemiology of Microbial Diseases, Yale University, New Haven, CT, United States
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Bromberg DJ, Tate MM, Alaei A, Rozanova J, Karimov S, Saidi D, Alaei K, Altice FL. "Who are You and What are You Doing Here?": Social Capital and Barriers to Movement along the HIV Care Cascade among Tajikistani Migrants with HIV to Russia. AIDS Behav 2021; 25:3115-3127. [PMID: 34195912 DOI: 10.1007/s10461-021-03359-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 11/28/2022]
Abstract
Tajikistani migrants who work in Russia and acquire HIV seldom receive HIV treatment while in Russia. Barriers to engagement in the HIV care cascade were identified from in-depth, semi-structured interviews with purposefully sampled Tajikistani migrants (n = 34) with HIV who had returned from Russia. Data were analyzed using thematic analysis, drawing from Putnam's theory of social capital, showing how bridging and bonding social capital relate to poor engagement in HIV care. We identified three barriers to Tajikistani migrants' movement through the HIV care cascade: (1) Russia's migration ban on people with HIV interrupts social capital accumulation and prevents access to HIV treatment within Russia; (2) mistrust of authority figures, including healthcare providers, leads to avoiding treatment and harm-reduction services upon their return to Tajikistan; and (3) because of pervasive discrimination, Tajikistani migrants form weak social ties while in Russia, which exacerbates risk, including with Russian citizens, and deters engagement with HIV care. Deploying a treatment as prevention strategy and abolishing Russia's ban on people with HIV would improve both individual and public health.
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Affiliation(s)
- Daniel J Bromberg
- Yale School of Public Health, Yale University, New Haven, CT, USA.
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, USA.
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA.
| | - Mary M Tate
- Yale School of Public Health, Yale University, New Haven, CT, USA
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Arash Alaei
- Republican AIDS Center, Tajikistan Ministry of Health, Dushanbe, Tajikistan
- Institute for International Health and Education, Albany, NY, USA
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Julia Rozanova
- Department of Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Saifuddin Karimov
- Republican AIDS Center, Tajikistan Ministry of Health, Dushanbe, Tajikistan
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Dilshod Saidi
- Republican AIDS Center, Tajikistan Ministry of Health, Dushanbe, Tajikistan
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Kamiar Alaei
- Institute for International Health and Education, Albany, NY, USA
- Health Science Department, California State University, Long Beach, Long Beach, CA, USA
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Frederick L Altice
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, USA
- Republican AIDS Center, Tajikistan Ministry of Health, Dushanbe, Tajikistan
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA
- Centre of Excellence on Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
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Alaei A, Bromberg DJ, Tate MM, Karimov S, Saidi D, Alaei K. HIV and associated factors among female sex workers in Tajikistan: Analysis from a national bio-behavioral survey. Int J STD AIDS 2021; 32:678-686. [PMID: 33769910 PMCID: PMC9827419 DOI: 10.1177/0956462420984696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Tajikistan, a country of approximately nine million people, has a relatively small but quickly growing HIV epidemic. No peer-reviewed study has assessed factors associated with HIV, or associated risk factors, among female sex workers (FSWs) in Tajikistan. The purpose of the current study is to elucidate the factors associated with HIV status and risk factors in the Tajikistani context and add to the scant literature on risk factors among FSWs in Tajikistan and Central Asia. We used cross-sectional data from an HIV bio-behavioral survey (BBS) conducted among FSWs in the Republic of Tajikistan (n = 2174) in 2017. Using Respondent Driven Sampling Analysis Tool software, we calculated the prevalence of HIV, diagnosed cases, linkage to antiretroviral therapy (ART), and the prevalence of syphilis for FSWs in Tajikistan. Prevalence data were adjusted for network size and any clustering effects in the network. Further, using univariate and multivariable logistic regression, we determined correlates of HIV-positive status. Results were as follows: Of all FSWs in Tajikistan, 2.6% (95% CI: 1.7-3.8%) are HIV positive, 2.3% (95% CI: 1.4-3.5%) are diagnosed and aware of their status, and 2.0% (95% CI: 1.2-3.1%) are on ART. About 5.7% (95% CI: 4.5-7.4%) of FSWs in Tajikistan have ever had syphilis, and 0.8% (95% CI: 0.4-1.3%) have active syphilis infections. The epidemic of injection drug use was found to be strongly synergistic with HIV infection as having had sex with a person who injects drugs was shown to be strongly associated with HIV-positive status (OR: 5.2; 95% CI: 2.6-10.2) in the multivariable model. While this study estimates that HIV prevalence among Tajikistani FSWs is relatively low, it is likely an underestimated due to selection and social desirability biases. To curb the small, but potentially volatile, HIV epidemic among FSWs, the government should consider targeted testing and linkage-to-care efforts for FSWs who inject drugs or who have people who inject drugs partners. Services should also be prioritized in Gorno-Badakhshan, which has a higher number of FSWs per capita relative to other regions. Additionally, the link between HIV and experiences of stigma, violence, and discrimination against FSWs should motivate advocates to protect Tajikistani FSWs from these experiences.
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Affiliation(s)
- Arash Alaei
- Institute for International Health and Education, Albany, NY, USA
| | - Daniel J Bromberg
- Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, USA
| | - Mary M Tate
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Saifuddin Karimov
- Republican AIDS Centre, Tajikistan Ministry of Health, Dushanbe, Tajikistan
| | - Dilshod Saidi
- Republican AIDS Centre, Tajikistan Ministry of Health, Dushanbe, Tajikistan
| | - Kamiar Alaei
- Institute for International Health and Education, Albany, NY, USA
- Department of Health Science, California State University Long Beach, CA, USA
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Bromberg DJ, Tate MM, Alaei K, Karimov S, Saidi D, Alaei A. Association between time spent in the Russian Federation and late presentation for HIV among Tajikistani migrants. BMC Public Health 2020; 20:1379. [PMID: 32912203 PMCID: PMC7488340 DOI: 10.1186/s12889-020-09434-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/24/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Between 700 thousand and 1.2 million citizens of Tajikistan currently live in the Russian Federation, one of the only countries where the HIV epidemic continues to worsen. Given the previously reported barriers to healthcare access for migrants to the Russian Federation, and the rapidly expanding HIV epidemic in Eastern Europe and Central Asia, this present study set out to determine whether these barriers impact late presentation with HIV among Tajikistani migrants upon their return to Tajikistan. METHOD This study uses data from the Tajikistan Ministry of Health surveillance system (2006 - 2019). At time of diagnosis, patients are interviewed by staff of AIDS centers, and doctors complete routine intake forms and complete medical exams. Descriptive characteristics of migrants with HIV who had lived in the Russian Federation (n=503) were calculated and compared with those of non-migrants with HIV (n=9519). Missing data were imputed using multiple imputation (predictive means matching, logistic regression imputation, and polytomous regression imputation). Two logistic models were created to model the probability of late presentation for HIV. The first model shows unadjusted associations between predictor variables and late presentation for HIV. The second model shows multivariable associations between significant study variables identified in the univariate model, and late presentation. RESULTS Compared to non-migrants, migrants with HIV are more likely to be from Gorno-Badakhshan region, are less likely to use illicit drugs, and are more likely to have purchased the services of sex workers. The unadjusted logistic model found that for every year spent in the Russian Federation, the risk of late presentation for a Tajikistani migrant with HIV increases by 4.0% (95% CI: 0.3-7.7). The multivariate model showed that when age, sex, and region of origin are held constant, the risk of late presentation for a Tajikistani migrant with HIV increases by 4.0% (95% CI: 0.1-7.8) for each year spent in the Russian Federation. CONCLUSION The results of this paper suggest that if the Russian Federation were to loosen its restrictions on HIV care for foreign nationals, it might improve the treatment outcomes of migrant laborers. As this analysis is only correlational in nature, further research is needed to explicate the causal pathways of the associations found in the present analysis.
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Affiliation(s)
- Daniel J Bromberg
- Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS (CIRA), Yale University, New Haven, CT, USA
| | - Mary M Tate
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Kamiar Alaei
- Institute for International Health and Education, Albany, NY, USA
- Department of Health Sciences, California State University, Long Beach, USA
| | - Saifuddin Karimov
- Republican AIDS Center, Tajikistan Ministry of Health, Dushanbe, Tajikistan
| | - Dilshod Saidi
- Republican AIDS Center, Tajikistan Ministry of Health, Dushanbe, Tajikistan
| | - Arash Alaei
- Institute for International Health and Education, Albany, NY, USA.
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Bromberg DJ, Tate MM, Alaei K, Karimov S, Saidi D, Alaei A. Predictors of Late Presentation for HIV among HIV-positive Tajik Migrants to the Russian Federation. Eur J Public Health 2019. [DOI: 10.1093/eurpub/ckz187.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Between 800 thousand and 1.2 million citizens of Tajikistan currently live in the Russian Federation, one of the only countries where the HIV epidemic continues to worsen. Given the previously reported barriers to healthcare access for migrants in to the Russian Federation, and the rapidly expanding HIV epidemic in Eastern Europe and Central Asia, this present study set out to determine whether these barriers impact late presentation with HIV upon their return to Tajikistan. This study uses data from the Tajikistan Ministry of Health surveillance system. The dataset contains all new known HIV diagnoses between 2006 and 2018. At time of diagnosis, patients are interviewed by staff of AIDS centers, complete routine intake forms and complete medical exam and related forms by doctors. HIV-positive returned migrants who had lived in the Russian Federation (n = 770) were included in final data-analysis after data cleaning. Data were analyzed using three logistic (logit) models. The unadjusted logistic model found that for every year spent in the Russian Federation, the risk of late presentation for an HIV-positive Tajikistani migrant increases by 10.3% (95% CI: 5.5-15.3). The saturated multivariate model showed that when holding all study variables constant, the risk of late presentation for an HIV-positive Tajikistani migrant increases by 9.5% (95% CI: 2.6-16.9). The parsimonious multivariate model showed that when current age and region of origin are held constant, the risk of late presentation for an HIV-positive Tajikistani migrant increases by 6.3 (95% CI: 1.1-11.8). Even when other potential predictors are included in the logistic model, only age and length of time abroad remain statistically significant. The results of this paper suggest that if the Russian Federation were to adopt a reciprocal policy, it might improve treatment outcomes of migrant laborers. Further research is needed to explicate the causal pathways of the associations found in the present analysis.
Key messages
Structural factors are the strongest predictors of HIV late presentation among returned Tajik migrants to the Russian Federation. Further research is needed to explicate the causal pathways of the associations found in the present analysis.
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Affiliation(s)
- D J Bromberg
- Department of Social and Behavioral Sciences, Yale University, New Haven, Connecticut, USA
- Center for Interdisciplinary Research on AIDS (CIRA), Yale University, New Haven, Connecticut, USA
| | - M M Tate
- Yale University, New Haven, Connecticut, USA
| | - K Alaei
- Institute for International Health and Education, Albany, NY, USA
- School of Public Health, Drexel University, Philadelphia, PA, USA
| | - S Karimov
- Republican AIDS Center, Tajikistan Ministry of Health, Dushanbe, Tajikistan
| | - D Saidi
- Republican AIDS Center, Tajikistan Ministry of Health, Dushanbe, Tajikistan
| | - A Alaei
- Institute for International Health and Education, Albany, NY, USA
- Republican AIDS Center, Tajikistan Ministry of Health, Dushanbe, Tajikistan
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