Pre-incarceration police harassment, drug addiction and HIV risk behaviours among prisoners in Kyrgyzstan and Azerbaijan: results from a nationally representative cross-sectional study

Abstract

Introduction

The expanding HIV epidemic in Azerbaijan and Kyrgyzstan is concentrated among people who inject drugs (PWID), who comprise a third of prisoners there. Detention of PWID is common but its impact on health has not been previously studied in the region. We aimed to understand the relationship between official and unofficial (police harassment) detention of PWID and HIV risk behaviours.

Methods

In a nationally representative cross-sectional study, soon-to-be released prisoners in Kyrgyzstan (N=368) and Azerbaijan (N=510) completed standardized health assessment surveys. After identifying correlated variables through bivariate testing, we built multi-group path models with pre-incarceration official and unofficial detention as exogenous variables and pre-incarceration composite HIV risk as an endogenous variable, controlling for potential confounders and estimating indirect effects.

Results

Overall, 463 (51%) prisoners reported at least one detention in the year before incarceration with an average of 1.3 detentions in that period. Unofficial detentions (13%) were less common than official detentions (41%). Optimal model fit was achieved (X²=5.83, p=0.44; Goodness of Fit Index (GFI) GFI=0.99; Comparative Fit Index (CFI) CFI=1.00; Root Mean Square Error of Approximation (RMSEA) RMSEA=0.00; PCLOSE=0.98) when unofficial detention had an indirect effect on HIV risk, mediated by drug addiction severity, with more detentions associated with higher addiction severity, which in turn correlated with increased HIV risk. The final model explained 35% of the variance in the outcome. The effect was maintained for both countries, but stronger for Kyrgyzstan. The model also holds for Kyrgyzstan using unique data on within-prison drug injection as the outcome, which was frequent in prisoners there.

Conclusions

Detention by police is a strong correlate of addiction severity, which mediates its effect on HIV risk behaviour. This pattern suggests that police may target drug users and that such harassment may result in an increase in HIV risk-taking behaviours, primarily because of the continued drug use within prisons. These findings highlight the important negative role that police play in the HIV epidemic response and point to the urgent need for interventions to reduce police harassment, in parallel with interventions to reduce HIV transmission within and outside of prison.

References UNAIDS. Joint United Nations Programme on HIV/AIDS (UNAIDS) Global report: UNAIDS report on the global AIDS epidemic 2013. Geneva, Switzerland: UNAIDS; 2013. Thorne C, Ferencic N, Malyuta R, Mimica J, Niemiec T. Central Asia: hotspot in the worldwide HIV epidemic. Lancet Infect Dis. 2010;10(7): 479–88. Kvitsinadze L, Tvildiani D, Pkhakadze G. HIV/AIDS prevalence in the Southern Caucasus. Georgian Med News. 2010;12: 26–36. Altice FL, Azbel L, El-Bassel N, Dvoryak S, Stover H, Brooks-Pollard E, et al. The perfect storm: incarceration and multi-level contributors to perpetuating HIV and tuberculosis in Eastern Europe and Central Asia. Lancet. 2016. (in press). Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet. 2008;372(9651): 1733–45. Cohen J. Tracing the regional rise of HIV. Science. 2010;329(5988): 161. Jurgens R, Ball A, Verster A. Interventions to reduce HIV transmission related to injecting drug use in prison. Lancet Infect Dis. 2009;9(1): 57–66. Jürgens R, Csete J, Amon JJ, Baral S, Beyrer C. People who use drugs, HIV, and human rights. Lancet. 2010;376(9739): 475–85. Mathers BM, Degenhardt L, Ali H, Wiessing L, Hickman M, Mattick RP, et al. HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage. Lancet. 2010;375(9719): 1014–28. Strathdee SA, Beletsky L, Kerr T. HIV, drugs and the legal environment. Int J Drug Policy. 2015;26(Suppl 1): S27–32. Wood E, Kerr T, Tyndall MW, Montaner JS. A review of barriers and facilitators of HIV treatment among injection drug users. AIDS. 2008;22(11): 1247–56. Strathdee SA, Hallett TB, Bobrova N, Rhodes T, Booth R, Abdool R, et al. HIV and risk environment for injecting drug users: the past, present, and future. Lancet. 2010;376(9737): 268–84. Booth RE, Dvoryak S, Sung-Joon M, Brewster JT, Wendt WW, Corsi KF, et al. Law enforcement practices associated with HIV infection among injection drug users in Odessa, Ukraine. AIDS Behav. 2013;17(8): 2604–14. Marshall BD, Kerr T, Qi J, Montaner JS, Wood E. Public injecting and HIV risk behaviour among street-involved youth. Drug Alcohol Depend. 2010;110(3): 254–8. Bazazi AR, Zelenev A, Fu JJ, Yee I, Kamarulzaman A, Altice FL. High prevalence of non-fatal overdose among people who inject drugs in Malaysia: correlates of overdose and implications for overdose prevention from a cross-sectional study. Int J Drug Policy. 2015;26(7): 675–81. Hayashi K, Ti L, Buxton JA, Kaplan K, Suwannawong P, Kerr T. The effect of exposures to policing on syringe sharing among people who inject drugs in Bangkok, Thailand. AIDS Behav. 2013;17(8): 2615–23. Izenberg J, Bachireddy C, Soule M, Kiriazova T, Dvoryak S, Altice FL. High rates of police detention among recently released HIV-infected prisoners in Ukraine: implications for health outcomes. Drug Alcohol Depend. 2013;133(1): 154–60. Beletsky L, Thomas R, Shumskaya N, Artamonova I, Smelyanskaya M. Police education as a component of national HIV response: lessons from Kyrgyzstan. Drug Alcohol Depend. 2013;132(Suppl 1): S48–52. Cooper H, Moore L, Gruskin S, Krieger N. The impact of a police drug crackdown on drug injectors’ ability to practice harm reduction: a qualitative study. Soc Sci Med. 2005;61(3): 673–84. Cooper HL, Des Jarlais DC, Tempalski B, Bossak BH, Ross Z, Friedman SR. Drug-related arrest rates and spatial access to syringe exchange programs in New York City health districts: combined effects on the risk of injection-related infections among injectors. Health Place. 2012;18(2): 218–28. Bojko MJ, Mazhnaya A, Makarenko I, Marcus R, Dvoriak S, Islam Z, et al. “Bureaucracy & Beliefs”: assessing the barriers to accessing opioid substitution therapy by people who inject drugs in Ukraine. Drugs. 2015;22(3): 255–62. Bojko MJ, Mazhnaya A, Marcus R, Makarencko J, Fillipovich S, Islam MA, et al. The future of opioid agonist therapies in Ukraine: a qualitative assessment of multilevel barriers and ways forward to promote retention in treatment. J Subst Abuse Treat. 2016;66: 37–47. Cohen J. Law enforcement and drug treatment: a culture clash. Science. 2010;329(5988): 169. Mimiaga MJ, Safren SA, Dvoryak S, Reisner SL, Needle R, Woody G. We fear the police, and the police fear us”: structural and individual barriers and facilitators to HIV medication adherence among injection drug users in Kiev, Ukraine. AIDS Care. 2010;22(11): 1305–13. Werb D, Wood E, Small W, Strathdee S, Li K, Montaner J, et al. Effects of police confiscation of illicit drugs and syringes among injection drug users in Vancouver. Int J Drug Policy. 2008;19(4): 332–8. Ancker S, Rechel B. Policy responses to HIV/AIDS in Central Asia. Glob Public Health. 2015;10(7): 817–33. Boltaev AA, El-Bassel N, Deryabina AP, Terlikbaeva A, Gilbert L, Hunt T, et al. Scaling up HIV prevention efforts targeting people who inject drugs in Central Asia: a review of key challenges and ways forward. Drug Alcohol Depend. 2013;132(Suppl 1): S41–7. Vagenas P, Azbel L, Polonsky M, Kerimi N, Mamyrov M, Dvoryak S, et al. A review of medical and substance use co-morbidities in Central Asian prisons: implications for HIV prevention and treatment. Drug Alcohol Depend. 2013;132(Suppl 1): S25–31. Azbel L, Wickersham JA, Wegman MP, Polonsky M, Suleymanov M, Ismayilov R, et al. Burden of substance use disorders, mental illness, and correlates of infectious diseases among soon-to-be released prisoners in Azerbaijan. Drug Alcohol Depend. 2015;151: 68–75. Azbel L, Polonsky M, Wegman M, Shumanskaya N, Kurmanalieva A, Akylbek A, et al. Intersecting epidemics of HIV, HCV, and syphilis among soon-to-be released prisoners in Kyrgyzstan. Int J Drug Policy. 2016. (in press). Ghanem KG, Hutton HE, Zenilman JM, Zimba R, Erbelding EJ. Audio computer assisted self interview and face to face interview modes in assessing response bias among STD clinic patients. Sex Transm Infect. 2005;81(5): 421–5. Azbel L, Gryshayev E, Wickersham J, Chernova E, Dvoriak S, Polonsky M, et al. Trials and tribulations of conducting bio-behavioral surveys in Prisons: implementation science and lessons from Ukraine. Int J Prison Health. 2016;12. Suresh K, Chandrashekara S. Sample size estimation and power analysis for clinical research studies. J Hum Reprod Sci. 2012;5(1): 7. Azbel L, Wickersham JA, Grishaev Y, Dvoryak S, Altice FL. Burden of infectious diseases, substance use disorders, and mental illness among Ukrainian prisoners transitioning to the community. PLoS One. 2013;8(3): e59643. Brislin RW. Back-translation for cross-cultural research. J Cross Cult Psychol. 1970;1: 185–216. Irwin M, Artin KH, Oxman MN. Screening for depression in the older adult: criterion validity of the 10-item Center for Epidemiological Studies Depression Scale (CES-D). Arch Intern Med. 1999;159(15): 1701–4. Zung WW. A rating instrument for anxiety disorders. Psychosomatics. 1971;12(6): 371–9. Saunders JB, Aasland OG, Babor TF, De la Fuente Jr, Grant M. Development of the alcohol use disorders identification test (AUDIT). WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction. 1993;88: 791–804. McLellan AT, Kushner H, Metzger D, Peters R, Smith I, Grissom G, et al. The fifth edition of the Addiction Severity Index. J Subst Abuse Treat. 1992;9(3): 199–213. Fisher JD, Fisher WA. The information-motivation-behavioral skills model. Emerg Theor Health Promot Pract Res. 2002;2: 40–70. Zimet GD, Powell SS, Farley GK, Werkman S, Berkoff KA. Psychometric characteristics of the multidimensional scale of perceived social support. J Pers Assess. 1990;55(3–4): 610–7. Preacher KJ, Rucker DD, Hayes AF. Addressing moderated mediation hypotheses: theory, methods, and prescriptions. Multivariate Behav Res. 2007;42(1): 185–227. Bollen KA, Stine RA. Bootstrapping goodness-of-fit measures in structural equation models. Sociol Methods Res. 1992;21(2): 205–29. MacKinnon DP, Dwyer JH. Estimating mediated effects in prevention studies. Eval Rev. 1993;17(2): 144–58. Hayes AF. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. New York, NY: Guilford Press; 2013. Bluthenthal R, Lorvick J, Kral A, Erringer E, Kahn J. Collateral damage in the war on drugs: HIV risk behaviors among injection drug users. Int J Drug Policy. 1999;10(1): 25–38. Pollini RA, Brouwer KC, Lozada RM, Ramos R, Cruz MF, Magis-Rodriguez C, et al. Syringe possession arrests are associated with receptive syringe sharing in two Mexico–US border cities. Addiction. 2008;103(1): 101–8. Shannon K, Kaida A, Rachlis B, Lloyd-Smith E, Gray G, Strathdee SA. Reconsidering the impact of conflict on HIV infection among women in the era of antiretroviral treatment scale-up in sub-Saharan Africa: a gender lens. AIDS. 2008;22(14): 1705–7. Gowing L, Farrell MF, Bornemann R, Sullivan LE, Ali R. Oral substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst Rev. 2011;8: CD004145. Aspinall EJ, Nambiar D, Goldberg DJ, Hickman M, Weir A, Van Velzen E, et al. Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. Int J Epidemiol. 2014;43(1): 235–48. Sarang A, Rhodes T, Sheon N, Page K. Policing drug users in Russia: risk, fear, and structural violence. Subst Use Misuse. 2010;45(6): 813–64. Wolfe D. Paradoxes in antiretroviral treatment for injecting drug users: access, adherence and structural barriers in Asia and the former Soviet Union. Int J Drug Policy. 2007;18(4): 246–54. Lucas GM, Chaudhry A, Hsu J, Woodson T, Lau B, Olsen Y, et al. Clinic-based treatment of opioid-dependent HIV-infected patients versus referral to an opioid treatment program: a randomized trial. Ann Intern Med. 2010;152(11): 704–11. Uhlmann S, Milloy MJ, Kerr T, Zhang R, Guillemi S, Marsh D, et al. Methadone maintenance therapy promotes initiation of antiretroviral therapy among injection drug users. Addiction. 2010;105(5): 907–13. Altice FL, Bruce RD, Lucas GM, Lum PJ, Korthuis PT, Flanigan TP, et al. HIV treatment outcomes among HIV-infected, opioid-dependent patients receiving buprenorphine/naloxone treatment within HIV clinical care settings: results from a multisite study. J Acquir Immune Defic Syndr. 2011;56(Suppl 1): S22–32. Palepu A, Tyndall MW, Joy R, Kerr T, Wood E, Press N, et al. Antiretroviral adherence and HIV treatment outcomes among HIV/HCV co-infected injection drug users: the role of methadone maintenance therapy. Drug Alcohol Depend. 2006;84(2): 188–94. Kinlock TW, Gordon MS, Schwartz RP, Fitzgerald TT, O'Grady KE. A randomized clinical trial of methadone maintenance for prisoners: results at 12 months postrelease. J Subst Abuse Treat. 2009;37(3): 277–85. Mlunde LB, Sunguya BF, Mbwambo JK, Ubuguyu OS, Yasuoka J, Jimba M. Association of opioid agonist therapy with the initiation of antiretroviral therapy – a systematic review. Int J Infect Dis. 2016.46: 27–33. Rhodes T. The “risk environment”: a framework for understanding and reducing drug-related harm. Int J Drug Policy. 2002;13(2): 85–94. Rhodas T, Singer M, Bourgois P, Friedman SR, Strathdee SA. The social structural production of HIV risk among injecting drug users. Soc Sci Med. 2005;61(5): 1026–44. Culbert GJ. Violence and the perceived risks of taking antiretroviral therapy in US jails and prisons. Int J Prison Health. 2014;10(1): 1–17. Burris S, Blankenship KM, Donoghoe M, Sherman S, Vernick JS, Case P, et al. Addressing the “risk environment” for injection drug users: the mysterious case of the missing cop. Milbank Q. 2004;82(1): 125–56.