After adjustment, 5 variables remained associated with anti-HIV in the multivariable model. Decreased odds of anti-HIV remained associated with IDUs recruited in 2004 compared with 2001 (OR = 0.1, 95% CI: 0.05 to 0.25). Odds of HIV increased per year of injection (OR = 1.4, 95% CI: 1.01 to 2.0) and were higher among IDUs who reported frontloading in the past 4 weeks compared with those who had not (OR = 3.1, 95% CI: 1.44 to 6.79). Increased odds of anti-HIV were higher among IDUs who reported exchanging sex in the past 4 weeks compared with those who had not (OR = 2.5, 95% CI: 1.01 to 6.28). Decreased odds of anti-HIV were associated with IDUs who reported ever experiencing drug treatment compared with those with no experience (OR = 0.4, 95% CI: −0.14 to 0.95). There was no evidence of an interaction between time and any covariates.
Togliatti City is a setting characterized historically by an explosive outbreak of HIV and high HIV prevalence among injectors.3 Our findings indicate a large decrease in HIV prevalence among new injectors between 2001 and 2004, from 55% to 11.5% prevalence. These findings are indicative of a reduction in HIV prevalence among new injectors. This is supported by city HIV case reports, which show a decrease in the absolute number of new HIV cases in the same time frame and a decrease in the proportion of new cases associated with injection drug use.
In the multivariable analysis, new injectors reporting frontloading had 3 times the odds of HIV infection. There is evidence of HIV transmission linked to paraphernalia and indirect sharing practices, such as frontloading and backloading, but this remains limited.39,40 We also interpret the association between frontloading and increased odds of HIV as important because such a measure may be acting as a proxy of risk for injecting risk behavior, including direct needle and syringe sharing. Surveys of IDUs may be underreporting direct needle and syringe sharing.41 Qualitative studies have also emphasized that user interpretations of what constitutes “sharing” in relation to injecting risk may be different from that assumed by survey measures.42
We found elevated odds of HIV associated with sex work across the 2 samples. Studies among IDU sex workers suggest that the primary route of HIV transmission remains drug injecting and not sexual transmission and that IDU sex workers have a greater risk of infection related to injection than nonsex workers because of higher rates of borrowing injecting equipment and injecting in higher risk environments.25,43,44 It is nonetheless important to note recent evidence indicative of HIV seroconversion associated with sexual behavior among community-recruited IDU sex workers.45,46 City HIV case report data presented here show an increase since 2001 in the proportion of new HIV cases among women compared with men and a shift in the main attributed risk factor from injecting to sexual transmission. IDUs, and IDUs involved in sex work specifically, should be targets for sexual risk reduction interventions. After adjustment by sex work and duration of injection, new injectors engaged in drug treatment had decreased odds of HIV.
A reduction in injecting risk behaviors was observed across the 2 time frames, providing some evidence to support the supposition that the observed decline in HIV prevalence between 2001 and 2004 is real. IDUs in 2004 were less likely to inject daily or with used needles or syringes and were less likely to practice frontloading or to inject using a communal filter. They were, however, more likely to inject drugs from a prefilled syringe. The explanation for this is unclear. Purchasing drugs in prefilled syringes is most likely associated with the distribution of home-produced drug solutes (eg, the opiate “mak,” the methamphetamine “vint”), and there were only nonsignificant increases in mak or vint being injected as primary drugs in 2004 compared with 2001. Taken together, our findings suggest that new injectors in 2004 were engaging in less injecting risk behavior than new injectors in 2001. New injectors in 2004 would have started injecting at a time when there was generalized awareness among injectors in Togliatti City that explosive HIV spread had occurred, reaching a high prevalence among injectors, including new injectors.3,25,47 Patterns of injecting may therefore have changed in the intervening period, and for those new to injection after 2001, involved much less frequent injection and related risk exposure despite a high background HIV prevalence among established injectors. Evidence from other Russian cities suggests that the frequency of injection may have decreased in recent years, with studies undertaken between 1999 and 2001 reporting higher proportions of IDUs injecting daily of up to 68%,48,49 whereas later studies indicated lower proportions of approximately 18%.36
We found decreases in the proportions of new injectors reached by the city needle and syringe exchange program (NSEP), outreach, and drug treatment. The decline in attendance at the state-provided drug treatment services is most likely attributable to an increase in the availability of private treatment centers over the period. There is also an increasing reluctance on the part of drug users to use these services because of their emphasis on detoxification and maintaining abstinence, lack of emphasis on confidentiality, and tendency to exchange patient information with police services for surveillance purposes; in addition, drug treatment attendance leads to official registration as an addict, which affects the ability to find employment.38,50
In both time periods, most IDUs (near 90% in 2001 and more than 90% in 2004) relied on pharmacies as their main source of sterile injecting equipment. The coverage achieved through dedicated needle and syringe exchange or outreach projects in the city is clearly limited relative to the potential role played by pharmacies. The low coverage achieved by the NSEP relative to pharmacies is not unusual for projects in the Russian Federation. Evidence from other cities has shown that the geographic location of outlets and strict program regulations, such as demand for 1-for-1 exchange rather than unconditional provision of syringes, make pharmacies a far more accessible source of new needles/syringes than NSEPs, especially given their ubiquity and more accessible opening times.51 The observed decline in HIV prevalence among new injectors is therefore unlikely to be directly linked to the introduction of needle and syringe or outreach projects in 2001 but is more likely to be a consequence of more generalized shifts in risk awareness and patterns of injection. A higher proportion of IDUs in 2004 reported ever having been tested for HIV in 2004 than in 2001, and this was associated with decreased odds of anti-HIV univariably. We emphasize the need for increasing access to voluntary and confidential HIV testing in combination with increasing the accessibility of sterile injecting equipment through pharmacies, including through pilot pharmacy-based exchange schemes.
Aside from some difference in geographic distribution of injectors across the 3 districts, the demographic and environmental indicators of the populations sampled in the 2 time frames are similar and suggest that the observed decline is unlikely to be an artifact of sampling bias alone. In the 2001 survey, however, increased odds of anti-HIV were associated with injectors residing in Komsomolskii, raising the possibility that this sample had tapped into a network of HIV-positive IDUs from this district. The implementation of future repeat community-recruited cross-sectional surveys would substantiate the validity of the observed differences in HIV risk factors and shifts in HIV transmission case reports reported here and the extent to which sampling variation or misclassification of behavioral data may play a role.
We must recognize that any inferences made about the underlying risk factors driving HIV transmission and changes since 2001 are limited by the fact that the behavioral data are drawn from self-reports, although the potential bias associated with socially desirable responses was limited by the use of a field work team involving current or former drug users.52 Newer evidence suggests that risk behavior reported to indigenous field workers may be of poorer quality than that collected through computer-assisted survey interviewing (CASI) programs, however.41 Any inferences about causality between risk factors and anti-HIV is unavoidably limited by the cross-sectional nature of the study, and in respect to sexual risk behavior, this was compounded by the lack of standardized sexual risk indicators collected between 2001 and 2004.
Our analysis was predicated on the assumption that our sample of new injectors was HIV-negative before initiation into injection. This assumption is plausible considering other international evidence, but the ability to test this assumption explicitly was limited by 3 factors: first, by lack of biologic indicators on other sexually transmitted infections; second, by lack of use of detuned assays to verify that the HIV infections were new infections; and third, by lack of standardized data on sexual risk behaviors collected from the 2 time points. Additionally, data on the extent to which the population size of IDUs had changed by 2004 would have enabled us to explore whether the decline in HIV prevalence among new injectors was influenced by changes in the size of the IDU population.
These studies highlight the potential role of cross-sectional surveys as a method of second-generation surveillance in conjunction with HIV case reporting for monitoring trends in HIV and in pinpointing key intervention targets of risk and behavior change. Our findings also highlight the importance of sampling recent initiates into injecting to predict changing incidence.9,10 Findings suggest a reduction in HIV prevalence among populations of new injectors in a city having witnessed explosive HIV spread and high HIV prevalence. Despite this, HIV remains of epidemic proportions among new injectors in Togliatti City. Findings emphasized the importance of HIV testing in maximizing risk awareness and opportunities for behavior change and of piloting pharmacy-based needle and syringe exchange, given low levels of coverage linked to expanding dedicating needle and syringe exchange. These findings have relevance for other cities in Russia and Eastern Europe, which were witness to rapid or explosive HIV outbreaks occurring among IDUs in the past decade.
The authors are grateful for the support of the UK Department for International Development, which supported this study through program grants, and to the UK Department of Health, which provided core funding to the Centre for Research on Drugs and Health Behaviour. They also thank the study participants and the following individuals: Sergei Belikh, Irina Berezhnova, Dimitry Blagov, Natalia Bobrova, Elvira Demyanyenko, Alexander Fillipov, Nadezhda Gorshkhova, Elena Kudravtseva, Peter Madden, Olga Mikhailova, Adrian Renton, Nelly Savelevna, Lenar Sultanov, Grigoryev Svyatoslav, Mikhail Tichonov, Venyamin Volnov, Konstantin Vyshinsky, and Martin Wall. This article is dedicated to the memories of our colleagues and friends, Andrei Rylkov and Nadezhda Zabotina.
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