Incarceration history, antiretroviral therapy, and stigma: A cross-sectional study of people with HIV who inject drugs in St. Petersburg, Russia

Highlights

• History of incarceration very common among people who inject drugs (PWID) in Russia.

• Low rates of prior antiretroviral therapy (ART) treatment among PWID.

• Prior incarceration in jail or prison did not predict prior ART treatment.

• High levels of self-stigma among people with HIV (PWH) and opioid use disorder.

Abstract

Background

The HIV epidemic is intertwined with substance use and incarceration in Russia. The relationships between incarceration history, HIV treatment history, and stigma experiences among people with HIV (PWH) who inject drugs in Russia have not been well described.

Methods

We conducted a cross-sectional study of a cohort of PWH with opioid use disorder who inject drugs (n=201) recruited at a narcology (substance use treatment) hospital in St. Petersburg, Russia from September 2018 to December 2020. The primary analysis evaluated the association between self-reported prior incarceration and prior antiretroviral therapy (ART) initiation using multivariable logistic regression to adjust for demographic, social, and clinical covariates. We used multivariable linear regression models to analyze associations between prior incarceration and two secondary outcomes: HIV stigma score (11-item abbreviated Berger scale) and substance use stigma score (21-item combination of Substance Abuse Self-Stigma Scale and Stigma-related Rejection Scale).

Results

Mean age was 37 (SD 5) years; 58.7% were male. Participants had been living with HIV for a mean of 13 (SD 6) years. Over two thirds (69.2%) of participants reported prior incarceration. One third (35.3%) of participants reported prior ART initiation. Prior incarceration was not significantly associated with prior ART initiation (AOR 1.76; 95% CI: 0.81, 3.83). Prior incarceration was associated with a lower HIV stigma score (adjusted mean difference in z-score: −0.50; 95%CI: −0.81, −0.19) but was not significantly associated with substance use stigma score (adjusted mean difference in z-score: −0.10; 95%CI: −0.42, 0.21).

Conclusion

Prior incarceration was common, and rates of prior ART initiation were low even though most participants had been living with HIV for at least a decade. We did not find an association between prior incarceration and prior ART initiation, which suggests a need to explore whether opportunities to initiate ART during or after incarceration are missed.

Clinical Trial Number

NCT03290391.

Introduction

The HIV epidemic in the Russian Federation (“Russia”), which accounts for over half of all new HIV cases in the WHO Europe region (European Centre for Disease Prevention and Control & WHO Regional Office for Europe, 2021), has been fueled by mass incarceration, opioid use disorder, and injection drug use (Altice et al., 2016)—i.e., a syndemic (Singer et al., 2017) where multiple disease entities and social vulnerabilities coincide within a population and interact synergistically. Due to punitive drug policies and weak investments in HIV prevention and treatment for key populations, people who inject drugs (PWID) in Russia experience very high rates of HIV infection, high rates of incarceration, intense stigma and marginalization, and poor access to high-quality care for HIV and drug dependency (Altice et al., 2016; Golichenko & Sarang, 2013; Jolley et al., 2012; Yasaveev, 2020). As examples of these punitive national policies, possession of small amounts of an illicit substance (e.g. for personal use) is a criminal offense punishable by incarceration; opioid agonist therapies for the treatment of opioid use disorder remain legally banned; and people with a drug dependency who seek narcology care at governmental clinics are placed on a government registry which restricts their access to drivers’ licenses and other resources (and facilitates targeting by police) (Altice et al., 2016; Golichenko & Sarang, 2013; Jolley et al., 2012).

While prior research has explored the role of police brutality and incarceration in shaping the HIV risk environment of PWID in Russia and other Eastern European countries (Lunze et al., 2014, 2015, 2016; Sarang et al., 2006, 2010), the relationship between incarceration and HIV care engagement among people with HIV (PWH) who inject drugs is not well described. If HIV care is relatively available in carceral facilities, then an incarceration—despite its potential deleterious effects on health (Brinkley-Rubinstein, 2013; Massoglia & Pridemore, 2015; Wildeman & Wang, 2017)—might serve as a touchpoint for vulnerable populations that otherwise might not be able to access care (Westergaard et al., 2013). However, in most of Russia, ART coverage is low overall (Beyrer et al., 2017; Parfitt, 2011), especially for PWID, who comprise the majority of PWH (Jolley et al., 2012). Historically carceral institutions have often had poorly resourced medical facilities (Parfitt, 2010), although a recent study of HIV in the Russian penitentiary system reported substantial improvement in ART coverage from 21.7% in 2014 to 89.6% in 2020 (Ponomarev et al., 2022). Even after release, experiences of incarceration can have immediate and lasting effects which create ongoing barriers to HIV care (Iroh et al., 2015; Rich et al., 2016; Westergaard et al., 2011), such as mistrust of medical providers (Teoharov et al., 2018), disruptions in the social resources (e.g. employment, housing) that support care engagement (Brinkley-Rubinstein & Turner, 2013; Pecoraro et al., 2013; Taweh et al., 2021), and the risk of relapse during post-incarceration reentry (Cepeda, Niccolai, et al., 2015; Cepeda, Vetrova, et al., 2015; Joudrey et al., 2019). A better understanding of the link between incarceration experiences and HIV treatment history would help gauge how well public institutions are utilizing this critical touchpoint and could illuminate challenges and opportunities for community providers seeking to better engage this population.

Moreover, in combination with criminal-legal and health system policies and practices, stigma may also be a key barrier to care for PWH who inject drugs in Russia (Jolley et al., 2012; Lunze et al., 2015). Generally, stigma refers to the social process of labeling, stereotyping, separation, discrediting, devaluing, and discrimination of individuals with stigmatized identities in a setting where power is exercised (Link & Phelan, 2001). A variety of stigma manifestations can impact targeted individuals' access to health care and health outcomes: experiences of discrimination (e.g., mistreatment by health care professionals, exclusion from housing), internalization of stigma (i.e., of negative views of self), and anticipated stigma (e.g., avoidance of settings where discrimination is expected) (Hatzenbuehler et al., 2013; Major et al., 2018; Stangl et al., 2019). In societies around the world, the stigma attached to having HIV has been identified as a key driver of access to care and health outcomes for PWH (Earnshaw et al., 2013; Sayles et al., 2009; Smith et al., 2020), and similar dynamics have been described for those who face stigma related to substance use (Earnshaw, 2020; Hammarlund et al., 2018). Many individuals in the syndemic of HIV, poor mental health and incarceration due to drug criminalization in Russia face additional forms of stigma related to mental illness or criminal legal status (e.g. prior incarceration) (Howell et al., 2022). While this study focuses on HIV and substance use stigmas due to the limited scope of our data, their intersection with other forms of stigma may affect health care utilization and health outcomes. The relationships between drug use stigma, HIV stigma, and health care utilization have previously been studied among PWID in Russia (Calabrese et al., 2016; Sereda et al., 2020; Vetrova et al., 2021), but less is known about the role, potentially positive or negative, that prior incarceration (and related stigma) has on their experiences of stigma or on ART use. Research to better understand these relationships might inform new approaches for counteracting stigma in this population.

Using cross-sectional data from a cohort of PWH who inject drugs with opioid use disorder in St. Petersburg, Russia, we sought to characterize the association between prior incarceration and whether one had ever initiated ART. Secondarily, we evaluated the associations of incarceration with measures of HIV stigma and substance use stigma.