Alisher Latypov

HIV among people who inject drugs in Central and Eastern Europe and Central Asia: a systematic review with implications for policy

Background and objectives HIV among people who inject drugs (PWID) is a major public health concern in Eastern and Central Europe and Central Asia. HIV transmission in this group is growing and over 27 000 HIV cases were diagnosed among PWID in 2010 alone. The objective of this systematic review was to examine risk factors associated with HIV prevalence among PWID in Central and Eastern Europe and Central Asia and to describe the response to HIV in this population and the policy environments in which they live. Design A systematic review of peer-reviewed and grey literature addressing HIV prevalence and risk factors for HIV prevalence among PWID and a synthesis of key resources describing the response to HIV in this population. We used a comprehensive search strategy across multiple electronic databases to collect original research papers addressing HIV prevalence and risk factors among PWID since 2005. We summarised the extent of key harm reduction interventions, and using a simple index of ‘enabling’ environment described the policy environments in which they are implemented. Studies reviewed Of the 5644 research papers identified from electronic databases and 40 documents collected from our grey literature search, 70 documents provided unique estimates of HIV and 14 provided multivariate risk factors for HIV among PWID. Results HIV prevalence varies widely, with generally low or medium (<5%) prevalence in Central Europe and high (>10%) prevalence in Eastern Europe. We found evidence for a number of structural factors associated with HIV including gender, socio-economic position and contact with law enforcement agencies. Conclusions The HIV epidemic among PWID in the region is varied, with the greatest burden generally in Eastern Europe. Data suggest that the current response to HIV among PWID is insufficient, and hindered by multiple environmental barriers including restricted access to services and unsupportive policy or social environments.

Factors mediating HIV risk among female sex workers in Europe: a systematic review and ecological analysis

Objectives We reviewed the epidemiology of HIV and selected sexually transmitted infections (STIs) among female sex workers (FSWs) in WHO-defined Europe. There were three objectives: (1) to assess the prevalence of HIV and STIs (chlamydia, syphilis and gonorrhoea); (2) to describe structural and individual-level risk factors associated with prevalence and (3) to examine the relationship between structural-level factors and national estimates of HIV prevalence among FSWs. Design A systematic search of published and unpublished literature measuring HIV/STIs and risk factors among FSWs, identified through electronic databases published since 2005. ‘Best’ estimates of HIV prevalence were calculated from the systematic review to provide national level estimates of HIV. Associations between HIV prevalence and selected structural-level indicators were assessed using linear regression models. Studies reviewed Of the 1993 papers identified in the search, 73 peer-reviewed and grey literature documents were identified as meeting our criteria of which 63 papers provided unique estimates of HIV and STI prevalence and nine reported multivariate risk factors for HIV/STI among FSWs. Results HIV in Europe remains low among FSWs who do not inject drugs (<1%), but STIs are high, particularly syphilis in the East and gonorrhoea. FSWs experience high levels of violence and structural risk factors associated with HIV, including lack of access to services and working on the street. Linear regression models showed HIV among FSWs to link with injecting drug use and imprisonment. Conclusions Findings show that HIV prevention interventions should be nested inside strategies that address the social welfare of sex workers, highlighting in turn the need to target the social determinants of health and inequality, including regarding access to services, experience of violence and migration. Future epidemiological and intervention studies of HIV among vulnerable populations need to better systematically delineate how microenvironmental and macroenvironmental factors combine to increase or reduce HIV/STI risk.

Characterization of the emerging HIV type 1 and HCV epidemics among injecting drug users in Dushanbe, Tajikistan.

This study aimed to determine HIV, HCV, and syphilis prevalence and correlates, and to characterize the molecular epidemiology of HIV-1 among injecting drug users (IDUs) in Dushanbe, Tajikistan. A cross-sectional study assessing risk factors for HIV and HCV through an interview administered survey was conducted. A total of 491 active adult IDUs were recruited from May to November 2004 in Dushanbe, Tajikistan. HIV-1 antibody status was determined with rapid testing and confirmed with ELISA. HCV antibody testing was conducted using a BIOELISA HCV kit. HIV-1 subtyping was done on a subset with full-length sequencing. Correlates of HIV and HCV infection were assessed using logistic regression. Overall prevalence of HIV was 12.1%, HCV was 61.3%, and syphilis was 15.7%. In a multivariate logistic regression model controlling for gender and ethnicity, daily injection of narcotics [odds ratio (OR) OR 3.22] and Tajik nationality (OR 7.06) were significantly associated with HIV status. Tajik nationality (OR 1.91), history of arrest (OR 2.37), living/working outside Tajikistan in the past 10 years (OR 2.43), and daily injection of narcotics (OR 3.26) were significantly associated with HCV infection whereas being female (OR 0.53) and always using a sterile needle (OR 0.47) were inversely associated with HCV infection. Among 20 HIV-1-positive IDU with specimens available for typing, 10 were subtype A, 9 were CRF02_AG, and one was an A-CRF02_AG recombinant. Epidemics of HIV-1, HCV, and drug use are underway in Dushanbe. The molecular epidemiology is distinctive, with West African variants accounting for roughly 50% of prevalent infections. Targeted prevention programs offering both needle exchange programs and opiate substitution therapies are urgently called for to prevent the further spread of HIV and HCV in Tajikistan.

HIV Epidemics in the European Region : Vulnerability and Response

This report aims to describe the dynamics of HIV epidemics among vulnerable and key populations at high risk in the European region, focusing specifically on people who inject drugs (PWID), sex workers (SWs) and men who have sex with men (MSM). This report covers 54 countries of the WHO European Region and Lichtenstein. It does so in order to inform future HIV prevention, treatment and care responses as well as to guide future HIV prevention surveillance and research. In addition to a description of methods (below), the report comprises three main sections. Chapter 2 synthesizes evidence drawn from European HIV surveillance data (chapter 2.1) and targeted HIV prevalence studies (chapter 2.2). Chapter 3 synthesizes evidence drawn from systematic reviews of epidemiological studies among PWID, SWs, and MSM. Chapter 4 draws on the evidence reviewed in chapter 3 as well as the international literature more broadly to consider implications for strengthening responses, including in relation to HIV surveillance and HIV prevention for PWID, SWs, and MSM. In chapter 5, we draw conclusions. This report confirms that these populations are disproportionately affected by the growing HIV epidemic in Europe.

Effective use of naloxone among people who inject drugs in Kyrgyzstan and Tajikistan using pharmacy- and community-based distribution approaches

BACKGROUND Opioid overdose (OD) is a major cause of mortality among people who inject drugs (PWID) in Central Asia, and distribution of naloxone, an opioid antagonist, can effectively prevent these deaths. However, little is known about the use and wastage of distributed naloxone ampoules. Having reliable data on wastage rates is critical for accurately calculating the health impact of naloxone distribution projects targeting PWID. METHODS In 2011, Population Services International (PSI) launched two pilot naloxone distribution programs in Kyrgyzstan (pharmacy-based approach) and Tajikistan (community-based approach). PWID were trained on OD prevention and naloxone use. Upon returning for more ampoules, the PWID completed a brief survey on their OD experience and naloxone use. 158 respondents in Kyrgyzstan and 59 in Tajikistan completed the questionnaire. Usage and wastage rates were calculated based on responses. A four-year model wastage rate that takes into account the shelf life of naloxone for both countries was then calculated. RESULTS 51.3% of respondents in Kyrgyzstan and 91.5% in Tajikistan reported having ever experienced an OD. 82.9% of respondents in Kyrgyzstan and all respondents in Tajikistan had ever witnessed an OD. Out of these PWID who experienced or witnessed OD, 81.5% in Kyrgyzstan and 59.3% in Tajikistan reported having been injected with naloxone, and 83.2% in Kyrgyzstan and 50.9% in Tajikistan reported injecting another individual with naloxone. Of ampoules received, 46.5% in Kyrgyzstan and 78.1% in Tajikistan were used. In both countries, 3.1% of these ampoules were wasted. The four-year model wastage rates for Kyrgyzstan and Tajikistan were found to be 13.8% and 3.9% respectively. CONCLUSION Findings indicate that a high proportion of naloxone distributed to PWID is used in actual OD incidents, with low wastage rates in both countries. Expanding these distribution models can potentially create more positive health outcomes for PWID in Central Asia.

Prohibition, stigma and violence against men who have sex with men: effects on HIV in Central Asia

Conscious of a paucity of evidence, and drawing upon a combination of historical documentary material, research literature and surveillance data, this paper offers a commentary on the social, historical and HIV contexts affecting men who have sex with men in Central Asia. The authors describe the history of men who have sex with men in the five Central Asian republics, before, during and after the Soviet-imposed legal prohibition, which continues in Turkmenistan and Uzbekistan, the only nations in the World Health Organization Europe region where sex between men remains illegal. This historical context frames contemporary responses to men who have sex with men. Despite long-established homoerotic traditions, modern attitudes to men who have sex with men are marked by great hostility, generating stigmatization of sex between men and discrimination against men suspected of it. The losses following public exposure can be severe: loss of employment; limited/lack of health-care access; and safety from physical and sexual assault. Such hostility creates an environment of increased HIV risk, and constrains the production of reliable HIV evidence. The authors argue that the generation of HIV risk, HIV-prevention responses and HIV evidence are products of their historical and social contexts, and call attention to the urgent need for HIV prevention and structural reforms to protect the health of men who have sex with men in Central Asia.

Introduction: Illicit drugs in Central Asia

Recently described as a “hotspot” of the worldwide HIV epiemic (Thorne, Ferencic, Malyuta, Mimica, & Niemiec, 2010), entral Asia is currently facing “the perfect storm” of the interwined epidemics of drug use, HIV, HCV and TB (El-Bassel, trathdee, & El Sadr, 2013). In contrast to the global decreases in IV transmission, the HIV epidemic in Eastern Europe and Cenral Asia continues to grow at a pace faster than anywhere else UNAIDS, 2014; The Global Fund to Fight AIDS, Tuberculosis and alaria, 2014). Overall, an estimated 1.1 million [0.98 million1.3 illion] people were living with HIV in Eastern Europe and Central sia by the end of 2013, representing 3 percent of the global numer of people living with HIV (UNAIDS, 2014). Across the region, the pidemic is concentrated among key populations at higher risk of IV exposure, including people who inject drugs and their sexual artners (Platt et al., 2013; Grund, Latypov, & Harris, 2013), with IV prevalence 20 times higher among Central Asian female sex orkers who reported injecting drug use than sex workers who id not (Baral et al., 2013). The prevalence of opiate use in Cenral Asia – 0.8 percent of the adult population – is twice the global verage (UNODC, 2014). The authors, who contributed to this special issue of the Interational Journal of Drug Policy, examine illicit drugs, their use and ssociated problems in Central Asia from a range of angles and isciplines. These include both leading and renowned experts in heir respective fields and more junior scholars whose papers were nformed by their recent or on-going doctoral research in Central sia. Together, many of these authors either come from or spent ears working in the region, and are now presenting some of their ndings on the pages of this journal. Covering geographically four out of the five former Soviet entral Asian countries (Kazakhstan, Kyrgyzstan, Tajikistan and zbekistan), the articles of this special issue offer unique insights nto the epidemiology of drug use and drug-related infectious disases and other consequences, the Central Asian drug markets nd actors, drug economies and the state-crime nexus. Imporantly, in most of the cases, these insights are based on primary ources, interviews, ethnographic observations as well as preiously unanalysed local institutional data. Whether working hrough a formal agreement with a Central Asian government or an ffiliation with a strategic research institution at a Prime Minister’s ffice, living with and observing rural communities in Kyrgyzstan r conducting focus group discussions in places as remote and difcult to reach as Tajik Badakhshan, recruiting large samples of ndividual respondents or obtaining key pieces of information from nternational partners and donors – accessing these sources, places nd people would not have been possible without trust.