Date of Award

January 2014

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Frederick L. Altice

Subject Area(s)

Epidemiology, Medicine

Abstract

Ukraine is a large European country facing a major Human Immunodeficiency Virus (HIV) epidemic historically driven by drug-injection, with adult prevalence exceeding 1.0%. We hypothesize the criminalization of drug use and people who inject drugs (PWIDs) in Ukraine is having a major impact on HIV risk-behavior and access to treatment for substance dependence and HIV in both community and criminal justice settings. We aim to empirically investigate two matters closely related to this concern: 1) the prevalence and correlates of illicit drug injection and injection equipment sharing within the prison, and 2) the extent of unofficial police detention of HIV-infected individuals after release from prison and its impact on treatment and prevention activities.

Ninety-seven HIV-infected adults released from prison between one and twelve months were recruited in two major Ukrainian cities--Kyiv and Odessa--and interviewed in Russian as part of a cross-sectional, quantitative survey. Surveys inquired about within-prison drug injection and equipment sharing, post-release detention and related adverse events, drug use, service access, and demographics.

Of 95 valid respondents, 54 (56.8%) reported within-prison drug injection, among which 40 (74.1%) shared injecting equipment with a mean of 4.43 (range 0- 30) other injectors per needle/syringe. Independent correlates of within-prison drug injection were recruitment in Kyiv (AOR 7.46, p=0.003), male gender (AOR 22.07,

p=0.006), and active pre-incarceration opioid use (AOR 8.66, p=0.005). Of 94 individuals providing valid responses regarding detention, 55 (58.5%) reported police detention without charge since release from prison (mean calculated rate=9.4 per person-year). Independent correlates of detention included post-release antiretroviral therapy use (AOR 4.98, p=0.021), high-risk injection practices (AOR 5.03, p=0.011), male gender (AOR 10.88, p=0.010), and fewer lifetime months of imprisonment (AOR 0.99, p=0.031).

Both within-prison drug injection and injection equipment sharing are alarmingly widespread and strongly related to opioid use prior to incarceration, pointing to an increased risk of HIV transmission and poor outcomes post-release. In the community, recent inmates face a high burden of police detention and related abuses, with the potential to further stigmatize and these individuals and prevent them from accessing critical services. These findings support the conclusion that there are major risks in Ukraine associated with criminalization of drug use; a shift in focus to public-health approaches emphasizing treatment provision and police-public health partnerships is urgently needed.

Comments

This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.

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