Engagement in HIV care and its correlates among people who inject drugs in St Petersburg, Russian Federation and Kohtla-Järve, Estonia

Abstract

Background and aims: HIV infection and mortality in Eastern Europe are driven by unsafe injection drug use. We sought to compare engagement in care from HIV testing through receipt of antiretroviral treatment among HIV-positive people who inject drugs (PWID) in St Petersburg, Russian Federation (RF) and Kohtla-Järve, Estonia and identify factors associated significantly with failure to progress at each stage of the HIV treatment cascade.

Design: Cross-sectional biobehavioral surveys of PWID with an analysis stratified by location-two Russian-speaking regions with similar HIV epidemic histories and current prevalence.

Setting: Field-based surveys conducted in St Petersburg, RF and Kohtla-Järve, Estonia.

Participants: We recruited 452 HIV-positive PWID in St Petersburg (November 2012 to June 2013) and 370 HIV-positive PWID in Kohtla-Järve (June-August 2012) using respondent-driven sampling.

Measurements: Participants were tested for antibodies to HIV, and administered a questionnaire focusing on participants' medical care histories. Engagement in care was categorized as a cascade of five transitional steps through six stages, ranging from HIV testing to current receipt of antiretroviral medications.

Findings: Progress along the cascade was greater in Kohtla Järve (32.7% were receiving antiretroviral medications) than in St Petersburg (9.7%). In both locations, we found the steps with high failure rates were the transitions from being aware of one's HIV diagnosis to being in regular care and initiation of highly active antiretroviral therapy (HAART). Factors associated significantly with transition failure in both locations and across steps included high alcohol consumption, variables associated with drug choice and injection frequency and lack of basic medical insurance.

Conclusion: The two steps in treatment cascade for HIV-positive PWID in St Petersburg, RF and Kohtla-Järve, Estonia requiring greatest improvement are retention in regular care and initiation of HAART. Both individual behavioral and structural factors are associated with failure to transition along the cascade.

Keywords: Antiretroviral therapy; Eastern Europe; HIV; HIV testing; people who inject drugs; treatment cascade.

Figure 1. Treatment Cascade for (A) St. Petersburg, RF and (B) Kohtla-Järve, Estonia

Progress along the cascade is plotted as the percentage of people remaining at each stage and the number of individuals at each of the six steps in the cascade appears at the top of each bar. The numbers between the bars indicate the decrease in the percentage of people at the prior stage who had not yet made the transition to the next step.