With regard to sexual risk behaviors, those who were abstinent were more likely to be HIV positive than those who were sexually active. Those who had an HIV-positive sex partner, however, were twice as likely to be HIV positive themselves as those who did not have an HIV-positive partner or who did not know the status of their partner. When data from those who did not know the status of their partner were combined with data from those who knew their partners were positive, they were much more likely to be HIV positive than those who knew that their sex partners were negative.
A logistic regression model was built using all of the variables above, including age and years injecting. The resulting model produced seven significant variables, with a –2LL of 730.15 and an R2 of 0.16. The significant variables, their adjusted odds ratios, confidence intervals and P-values are shown in Table 3. Variables are listed in the order in which they were entered into the model. Injecting a sedative/opiate mix, female sex, having had sex with a person who was HIV positive or whose HIV status was unknown, and injecting daily indicated an increased likelihood of being HIV positive. Variables that reflect a lower likelihood of HIV infection include being younger, from Makeevka/Donetsk and having had sex in the prior 30 days.
Rates of HIV infection are high throughout Ukraine as evidenced from this investigation, although there is also variation across cities. Government figures on HIV prevalence also indicate large regional differences [4,18]. Our findings show HIV infection among drug injectors ranging from 17.4% in Makeevka/Donetsk to 32.6% in Kiev and 50.5% in Odessa. Further investigation into a possible explanation revealed that IDU in Odessa were older than those in the other sites (33.2 versus 26.2 in Makeevka/ Donetsk and 27.4 in Kiev, P < 0.0001) and they had been injecting longer (14.0 years versus 8.3 in Makeevka/ Donetsk and 8.4 in Kiev, P < 0.0001). Since age and years injecting were controlled for in the model this provides only a partial clarification. Studies in the US have shown mixed results regarding these factors, with some reporting newer injectors had lower HIV rates [19,20], whereas others suggest the opposite [21,22]. Regional differences in HIV-related risk factors, as well as drug preferences, have been observed in the US as well, with calls for further examination of social and environmental factors that may account for these differences [23,24]. Another explanation may be that the first reported HIV cases were from Odessa, allowing more time for the virus to spread. Some researchers believe that once the virus reaches a prevalence of 10–20% in an area, the incidence increases exponentially . If correct, this suggests the potential for a rapid increase in HIV rates in Kiev and Makeevka/Donetsk without the help of interventions to reduce risk behaviors.
Several other noteworthy findings were also observed. First, females were more likely to be infected with HIV than males. Prior investigations with IDU have also noted the significance of female sex in accounting for higher rates of both HIV incidence [26,27] and prevalence . Second, two drug-related variables were significantly, and independently, associated with HIV infection. These included injecting daily and injecting a sedative/opiate mixture. Others have reported that injection frequency among IDU, including daily injection , independently predicted HIV infection [30,31]. The relationship between injecting a sedative/opiate mixture and HIV may be explained by several inter-related factors. According to the staff involved in the study, this drug combination is extremely strong. IDU have experienced very negative consequences associated with its use, including seizures and dementia, and thus they neglect to practice safer behaviors. In addition, the mixture is usually prepared in a common container used by several injectors.
Finally, two sex-related variables were associated with HIV serostatus. Those who were sexually active were less likely to be infected than those who did not have sex. This suggests the possibility that those who tested positive may have been suspicious that they might be infected and therefore refrained from sexual contact. On the other hand, participants who were HIV positive were more likely to report sex with another HIV-infected individual or sex with someone whose HIV status was unknown, thus increasing the likelihood of re-infection.
Although we hesitate to infer too much from null findings, we were somewhat surprised to find that using a used needle was not related to HIV status. A possible explanation is that only 4.5% reported engaging in this risk behavior without cleaning their needle first (data not shown). Other needle-related risk factors (e.g., front/back loading with a dealer, injecting sedatives/opiates) appear more threatening to drug injectors in Ukraine.
There are several limitations that should be considered when drawing conclusions from this study. First, the sampling plan was designed to access IDU from areas throughout each city so that findings could be representative of street-based drug injectors in those locations. Although this approach is preferable to convenience sampling, it is not known how representative the three samples were of IDU in each city. As reported by outreach workers, there were few refusals to participate. However, it is not possible to know the number or characteristics of those who refused to participate. It is likely that the sample over-represents IDU willing to spend the time necessary to participate in a research study and motivated by the modest stipend. Thus, this study does not purport to generalize to all IDU, but to a relatively representative sample of street-recruited IDU, who were probably more impoverished and in worse health than other drug users in Ukraine. Second, the majority of the data reported here were based on self-reports, which potentially could be biased due to recall errors and social desirability. Recall error should have been diminished by the relatively brief time period respondents were asked to remember (i.e., 30 days). As IDU in Ukraine are less familiar with research practices than IDU in the US and elsewhere, it is unclear what influence social desirability might have played. Although social desirability cannot be ruled out, it is unlikely that the main findings were influenced by this factor. In addition, prior studies have shown that drug users' self-reports are sufficiently valid for this type of research [32,33].
The rapid increase in injection drug use and HIV in Ukraine following the collapse of the Soviet Union was remarkable but perhaps not surprising. The resulting deterioration of the economic and social fabric of the country created a vacuum in which illicit drug use flourished. As this study revealed, HIV is at extremely high levels in Ukraine, due in large measure to drug injection. There is, unfortunately, increasing evidence that the epidemic is now moving to non-injectors through sexual transmission . Behavioral interventions, along with antiretroviral medications, are urgently needed.
The authors would like to acknowledge the dedicated NGO staff and directors who participated in this project. These include Elena Teryayeva with Health of Nation in Makeevka/Donetsk, Olga Kostyuk with Faith, Hope and Love in Odessa and Natalya Podlesnaya with the Substance Abuse and AIDS Prevention Foundation in Kiev. Their commitment to preventing the further spread of HIV in their country is nothing less than heroic. We are also indebted to the drug users who agreed to participate and gave their time to provide the data-base for this study.
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