Within Prison Drug Injection and Injection Equipment Sharing Among HIV-Infected Ukrainian Prisoners

Prevalence and Correlates of an Extremely High Risk Behavior

Jacob M. IzenbergChethan BachireddyMichael SouleJeffrey A. WickershamTetiana KiriazovaSergey DvoriakFrederick L. Altice

Source: Jon Cohen Science 2010

Background

• Ukraine is home to Europe’s worst HIV epidemic (prevalence >1%). Among 290,000 people who inject drugs (PWID) prevalence 21.5-41.8%1,2

• Incarceration rate in Ukraine = 350 / 100,000 population3 or ~110,000 people

1. Bobrovskyy 2013 2. Mathers, 2008 3. International Centre for Prison Studies

Source: Azbel PLoS ONE 2013

Source: Azbel PLoS ONE 2013

Background

• Globally, within-prison drug injection common (3-53%)1

• In Ukraine, despite high rates of HIV and large PWID population in prison, opioid substitution therapy (OST) and needle and syringe exchange programs (NSP) are not available in prison settings

• In general: less injection in prison, but more needle/syringe sharing2

• Relatively few studies in low- and middle-income countries

• Lack of studies examining only HIV-infected inmates (the only individuals who can transmit HIV)

1. R Jurgens Lancet Inf Dis 2009 2. R Jurgens J Int AIDS Soc 2011

Study aim

To describe both the prevalence and key correlates of within-prison drug injection and

injection equipment sharing among HIV-infected individuals recently released from prison

in Ukraine.

Methods

• Recruitment• Kiev (N=47) – prison-release social services agency• Odessa (N=50) – modified snowball sampling

• Eligibility criteria• HIV+• Released from prison 1 to 12 months (mean=5.8) prior

• 60-minute cross-sectional interviews • Pre-, within- and post-release time periods covered• Demographics and criminal justice history• Substance use disorder screening• Drug use and injection history• Use of OST and antiretroviral therapy (ART)

Methods (continued)

• Dependent variables:• Within-prison drug injection (WP-DI)• Within-prison sharing of injection equipment

• Data analysis:• N=95 (2 excluded because dependent variable not

answered)• Bivariate modeling of basic characteristics with WP-DI

and injection equipment sharing• Multivariate logistic regression for modeling correlates of

both dependent variables

Characteristics of the final sample (N=95)

Characteristics %Male 88.4%Mean age 35.4Stably housed 61.7%Last prison sentence from drug-related charge 76.8%Prescribed ART in prison 14.3%Active injection 30 days before prison 88.4%Illegal opioid use 30 days before prison 73.7%Opioid dependent(brief opioid dependence scale) 84.2%Alcohol use disorder (AUDIT) 60.9%Moderate to severe drug addiction (DAST-10) 92.6%

Injection before, during, and after prison

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10088.4

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42.1

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30 days Pre-Incarceration

Within Prison

30 days before interview

Perc

ent

Rep

orti

ng (

%)

N=95 N=95

Injection before, during, and after prison

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10088.4

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42.1

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30 days Pre-Incarceration

Within Prison

30 days before interview

Perc

ent

Rep

orti

ng (

%)

N=95 N=95

Injection before, during, and after prison

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10088.4

47.453.656.8

42.1

74.1

57.8

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30 days Pre-Incarceration

Within Prison

30 days before interview

Perc

ent

Rep

orti

ng (

%)

N=95 N=95N=84 N= 55 N=54

Outcome 1: Within-Prison Drug Injection

Covariate AOR 95% CI p-value

Recruitment in Kyiv 7.46 1.99 – 27.92 0.003Age 0.95 0.93 – 1.07 0.080Male gender 22.07 1.69 – 155.38 0.006Opioid use in the 30 days before prison 8.67 1.91 – 39.44 0.005

Drug injection in the 30 days before prison

 

No injection reported

Ref  -- --

  Injection no sharing 2.83 0.16 – 47.35 0.417

  Reported sharing 2.95 0.15 – 15.21 0.293

Outcome 2: Within Prison Injection Equipment Sharing

Covariate AOR 95% CI p-value

Recruitment in Kyiv 27.89 6.16 – 126.33 <0.001

Age 1.05 0.97 – 1.14 0.220Opioid use in the 30 days before prison 6.50 1.26 – 33.71 0.025Drug injection in the 30 days prior to prison No injection Ref  -- --

  Injection with no sharing 1.32 0.06 – 30.51 0.859

Injection with sharing 0.56 0.05 – 7.01 0.657

Key findings summarized

• More than half reported within-prison drug injection• About three quarters of this group shared needles or syringes

in prison, with a mean of 4.43 users per / needle• Prison term length not correlated with injection

• Correlates of within-prison drug injection• Pre-prison opioid use• Site of recruitment (Kyiv)• Gender (Male)

• Correlates of within-prison injection equipment sharing• Pre-prison opioid use• Site of recruitment (Kyiv)

Implications

• Prison-based OST and NSP are evidence-based practices that reduce within-prison drug injection and equipment sharing.1,2

OST, NSP urgent need to implement and scale

HIV testing and treatment must ensure availability within prison settings

• Need for effective transitional programs for those returning to the community OST and ART linkage

1. Larney 2010 2. Stover 2010

Acknowledgements

• Study participants who generously gave their time• Yale Center for Interdisciplinary AIDS Research staff• Ukraine Institute for Public Health Policy staff• Future Without AIDS Foundation, Odessa, Ukraine• Funding support from

• International Renaissance Foundation, Ukraine • National Institute on Drug Abuse for research (R01 DA033679

and R01 DA029910) and for career development (K24 DA017072)

• Yale University School of Medicine Office of Student Research• Yale University Global Health Initiative