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1.  Short Communication: HIV Prevalence and Risk Behavior Among Injection Drug Users and Their Sex Partners in Two Russian Cities 
The HIV epidemic in Russia remains concentrated mostly among injection drug users (IDUs). Little is known about the extent to which sexual partnerships are the bridge between IDUs and the general population and create the potential for generalizing the epidemic. IDUs in two Russian cities, Novosibirsk and Ivanovo (N=593), were recruited via respondent-driven sampling. A modified one-step snowball strategy was used to recruit IDU's sex partners who do not themselves use drugs (PIDU, N=82). Sexual behaviors of all participants were assessed using an interviewer-administered questionnaire. All participants provided blood specimens for HIV and hepatitis C virus (HCV) testing. HIV and HCV prevalence among IDUs was 34.0% and 44.4% in Ivanovo and 3.8% and 54.3% in Novosibirsk. HIV prevalence among PIDUs was 6.8% in Ivanovo and 8.7% in Novosibirsk. In both cities large proportions of IDUs reported sexual partnerships with non-IDUs—49.7% in Ivanovo vs. 62.7% in Novosibirsk (p≤0.001) and fewer than one in four IDUs reported constant condom use in such partnerships. This pilot study shows that two IDU populations with a significantly different HIV prevalence both form sexual partnerships with non-IDUs and practice unsafe sexual behavior within such types of partnerships. However, the proportion of PIDUs who form partnerships with other non-IDUs that therefore could lead to a generalization of the epidemic is very different between the two cities and this difference needs to be considered when estimating the spread of HIV into the general population. Unsafe sexual behavior and HIV testing should be specific targets for prevention activities for IDUs and their sex partners in Russia.
PMCID: PMC3607905  PMID: 23186172
2.  The Feasibility of HIV Vaccine Efficacy Trials among Russian Injection Drug Users 
Vaccine  2007;25(41):7014-7016.
IDU exposure remains a primary driver of the Russian HIV epidemic, and recent incidence data provide little evidence that this epidemic is slowing. While there are multiple important challenges that need to be further explored before starting vaccine trials, most importantly access to evidence-based drug treatment services for trial participants, the current context of high HIV incidence and low genetic diversity of HIV strains, suggests the need for intensified prevention strategies and supports the feasibility of mounting efficacy trials of HIV vaccines among IDUs in the Russian Federation.
PMCID: PMC3747029  PMID: 17707960
HIV; Injection Drug use; St. Petersburg; Molecular Epidemiology; Vaccines
3.  Individual-level, network-level and city-level factors associated with HIV prevalence among people who inject drugs in eight Russian cities: a cross-sectional study 
BMJ Open  2013;3(6):e002645.
To ascertain HIV prevalence among people who inject drug (injection drug users (IDUs)) in the Russian Federation and identify explanations for the disparity in different cities.
Cross-sectional survey with serological testing for HIV and hepatitis C virus prevalent infections.
8 Russian cities—Irkutsk, Omsk, Chelyabinsk, Yekaterinburg, Naberezhnye Chelny, Voronezh, Orel and St Petersburg.
In 2007–2009 active IDUs were recruited by respondent-driven sampling with a target sample size of 300 or more in each city.
Main outcome measures
Participants were administered a questionnaire covering sociodemographics, injection risk and protective behaviours, sexual behaviours, HIV knowledge, experiences with drug treatment and harm reduction programmes and social networks. Participants were tested for HIV and hepatitis C by enzyme immunoassay. Data were analysed to identify individual-level, network-level and city-level characteristics significantly associated with HIV prevalence. Factors significant at p≤0.1 were entered into a hierarchical regression model to control for multicollinearity.
A total of 2596 active IDUs were recruited, interviewed and tested for HIV and hepatitis C virus infection. HIV prevalence ranged from 3% (in Voronezh) to 64% (in Yekaterinburg). Although individual-level and network-level variables explain some of the difference in prevalence across the eight cities, the over-riding variable that seems to account for most of the variance is the emergence of commercial, as opposed to homemade, heroin as the predominant form of opioid injected.
The expansion of commercial heroin markets to many Russian cities may have served as a trigger for an expanding HIV epidemic among IDUs in that country.
PMCID: PMC3686233  PMID: 23794559
Public Health
4.  Access to syringes for HIV prevention for injection drug users in St. Petersburg, Russia: syringe purchase test study 
BMC Public Health  2013;13:183.
The HIV epidemic in Russia is concentrated among injection drug users (IDUs). This is especially true for St. Petersburg where high HIV incidence persists among the city’s estimated 80,000 IDUs. Although sterile syringes are legally available, access for IDUs may be hampered. To explore the feasibility of using pharmacies to expand syringe access and provide other prevention services to IDUs, we investigated the current access to sterile syringes at the pharmacies and the correlation between pharmacy density and HIV prevalence in St. Petersburg.
965 pharmacies citywide were mapped, classified by ownership type, and the association between pharmacy density and HIV prevalence at the district level was tested. We selected two districts among the 18 districts – one central and one peripheral – that represented two major types of city districts and contacted all operating pharmacies by phone to inquire if they stocked syringes and obtained details about their stock. Qualitative interviews with 26 IDUs provided data regarding syringe access in pharmacies and were used to formulate hypotheses for the pharmacy syringe purchase test wherein research staff attempted to purchase syringes in all pharmacies in the two districts.
No correlation was found between the density of pharmacies and HIV prevalence at the district level. Of 108 operating pharmacies, 38 (35%) did not sell syringes of the types used by IDUs; of these, half stocked but refused to sell syringes to research staff, and the other half did not stock syringes at all. Overall 70 (65%) of the pharmacies did sell syringes; of these, 49 pharmacies sold single syringes without any restrictions and 21 offered packages of ten.
Trainings for pharmacists need to be conducted to reduce negative attitudes towards IDUs and increase pharmacists’ willingness to sell syringes. At a structural level, access to safe injection supplies for IDUs could be increased by including syringes in the federal list of mandatory medical products sold by pharmacies.
PMCID: PMC3616994  PMID: 23452390
Injection drug use; HIV prevention; Syringe access; Pharmacy
5.  Age at First Alcoholic Drink as Predictor of Current HIV Sexual Risk Behaviors Among a Sample of Injection Drug Users (IDUs) and Non-IDUs who are Sexual Partners of IDUs, in St. Petersburg, Russia 
AIDS and Behavior  2012;16(6):1597-1604.
This study investigates whether age at first alcoholic drink is associated with sexual risk behaviors among injection drug users (IDUs) and non-IDUs who are sexual partners of IDUs in St. Petersburg, Russia. A path analysis was used to test a model of age at first drink, age at sexual debut, age at first drug use, current substance use patterns and current sexual risk behaviors among 558 participants. Results revealed that age at first drink had an effect on multiple sex partners through age at sexual debut and injection drug use, but no effect on unprotected sex. Age at first drug use was not related to sexual risk behaviors. Investigation of age of drinking onset may provide useful information for programs to reduce sexual risk behaviors and injection drug use. Different paths leading to unprotected sex and multiple sexual partners call for different approaches to reduce sexual risk behaviors among this population.
PMCID: PMC3320686  PMID: 21800183
Age at first alcoholic drink; HIV sexual risks; IDU; Russia; Age at first drug use; Sexual debut
6.  Epidemiologic trends and geographic patterns of fatal opioid intoxications in Connecticut, USA: 1997 – 2007 
Drug and alcohol dependence  2010;115(3):221-228.
The leading cause of injury death among adults in Connecticut (CT), USA is drug poisonings. We analyzed the epidemiology and geographic distribution of opioid-involved accidental drug-involved intoxication deaths (“overdoses”) in CT over an 11-year period.
We reviewed data from 1997 to 2007 on all adult accidental/undetermined drug intoxication deaths in CT that were referred to the Office of the Chief Medical Examiner (OCME). Regression analyses were conducted to uncover risk factors for fatal opioid-involved intoxications and to compare heroin- to prescription opioid- and methadone-involved deaths. Death locations were mapped to visualize differences in the geographic patterns of overdose by opioid type.
Of the 2900 qualifying deaths, 2231 (77%) involved opioids. Trends over time revealed increases in total opioid-related deaths although heroin-related deaths remained constant. Methadone, oxycodone and fentanyl, the most frequently cited prescription opioids, exhibited significant increases in opioid deaths. Prescription opioid-only deaths were more likely to involve other medications (e.g., benzodiazepines) and to have occurred among residents of a suburban or small town location, compared to heroin-involved or methadone-involved deaths. Heroin-only deaths tended to occur among non-Whites, were more likely to involve alcohol or cocaine and to occur in public locations and large cities.
The epidemiology of fatal opioid overdose in CT exhibits distinct longitudinal, risk factor, and geographic differences by opioid type. Each of these trends has implications for public health and prevention efforts.
PMCID: PMC3095753  PMID: 21131140
overdose; opioid; mortality; prescription opioid; heroin
7.  Sub-populations of illicit drug users reached by targeted street outreach and respondent driven sampling strategies: Implications for research and public health practice 
Annals of epidemiology  2011;21(4):280-289.
To determine whether illicit drug users recruited through Respondent-Driven Sampling (RDS) and targeted street outreach (TSO) differ by comparing two samples recruited concurrently with respect to sample selection and potential recruitment biases.
217 heroin, crack, and cocaine users aged 18-40 were recruited through TSO in New York City (2006-2009). 46 RDS seeds were recruited similarly and concurrently yielding a maximum of 14 recruitment waves and 357 peer recruits. Baseline questionnaires ascertained sociodemographic, drug use, and drug network characteristics. Descriptive statistics and log-binomial regression were used to compare RDS and TSO samples.
RDS recruits were more likely to be male (prevalence ratio [PR]:1.28), Hispanic (PR:1.45), black (PR:1.58), older (PR:1.02), homeless (PR:1.19), and crack users (PR:1.37). RDS recruited fewer injectors (PR:0.35) and heroin users (PR:0.74). Among injectors, RDS recruits injected less frequently (PR:0.77) and were less likely to use Needle Exchange Programs (PR:0.35).
These data suggest that RDS and TSO strategies reach different sub-groups of drug users. Understanding the differing capabilities of each recruitment strategy will enable researchers and public health practitioners to select an appropriate recruitment tool for future research and public health practice.
PMCID: PMC3062521  PMID: 21376275
Respondent Driven Sampling; Targeted Street Outreach; HIV; illicit drug users; sampling bias
8.  The roles of law, client race and program visibility in shaping police interference with the operation of US syringe exchange programs 
Addiction (Abingdon, England)  2010;106(2):357-365.
To determine the comparative levels of and associations between policing interference and characteristics of US syringe exchange programs (SEPs).
A national survey of US SEPs.
A total of 111 program managers (representing 59% of all US SEPs).
Program manager self-report.
With overall interference profiles ranging from systematic to totally interference-free, 43% of respondents reported at least monthly client harassment, 31% at least monthly unauthorized confiscation of clients’ syringes, 12% at least monthly client arrest en route to or from SEP and 26% uninvited police appearances at program sites at least every 6 months. In multivariate modeling, legal status of SEP, jurisdiction’s syringe regulation environment and affiliation with health department were not associated with frequency of police interference. Programs serving pre-dominantly injection drug users (IDUs) of color were 3.56 times more likely to report frequent client arrest en route to or from SEP and 3.92 times more likely to report unauthorized syringe confiscation. Those serving more than three sites were 3.96 times more likely to report client harassment, while stationary operation was protective against uninvited police appearances. The majority (56%) reported not documenting adverse police events; those who did were 2.92 times more likely to report unauthorized syringe confiscation from clients.
Findings highlight limitations of the impact of legal reforms on aligning police activities with SEP operations. Systematic adverse event surveillance and evidence-based structural interventions are needed to maximize the benefits of public health prevention targeting IDUs and other criminalized populations. SEPs that report no adverse events may represent programs already working in harmony with law enforcement agencies, a priority highlighted in US Centers for Disease Control’s new SEP guidelines. The significance of mechanisms translating criminal justice disparities into health disparities is discussed.
PMCID: PMC3088513  PMID: 21054615
Criminal justice system; HIV; injection drug use; policy interventions; racial disparities; structural barriers; structural interventions; syringe access; syringe exchange programs
9.  Survival of Hepatitis C Virus in Syringes: Implication for Transmission among Injection Drug Users 
The Journal of infectious diseases  2010;202(7):984-990.
We hypothesized that the high prevalence of HCV among injection drug users (IDUs) might be due to prolonged virus survival in contaminated syringes.
We developed a microculture assay to examine the viability of HCV. Syringes were loaded with blood spiked with HCV reporter virus (Jc1/GLuc2A) to simulate two scenarios of residual volumes; low (2 μl) void volume for 1-ml insulin syringes, and high (32 μl) void volume for 1-ml tuberculin syringes. Syringes were stored at 4°C, 22°C, and 37°C for up to 63 days before testing for HCV infectivity using luciferase activity.
The virus decay rate was biphasic (t½ α = 0.4h and t½β = 28h). Insulin syringes failed to yield viable HCV beyond day one at all storage temperatures except for 4o in which 5% of syringes yielded viable virus on day 7. Tuberculin syringes yielded viable virus from 96%, 71%, and 52% of syringes following storage at 4o, 22° and 37o for 7 days, respectively, and yielded viable virus up to day 63.
The high prevalence of HCV among IDUs may be partly due to the resilience of the virus and the syringe type. Our findings may be used to guide prevention strategies.
PMCID: PMC2932767  PMID: 20726768
Hepatitis C virus; injection drug users; syringes; survival; transmission; luciferase activity
10.  Clostridium difficile Infection in Outpatients, Maryland and Connecticut, USA, 2002–2007 
Emerging Infectious Diseases  2011;17(10):1946-1949.
Clostridium difficile, the most commonly recognized diarrheagenic pathogen among hospitalized persons, can cause outpatient diarrhea. Of 1,091 outpatients with diarrhea, we found 43 (3.9%) who were positive for C. difficile toxin. Only 7 had no recognized risk factors, and 3 had neither risk factors nor co-infection with another enteric pathogen.
PMCID: PMC3310666  PMID: 22000379
Clostridium difficile; diarrhea; outpatient; enteric; pathogen; bacteria; Maryland; Connecticut; United States; dispatch
11.  Prevalence and predictors of transitions to and away from syringe exchange use over time in 3 US cities with varied syringe dispensing policies 
Drug and alcohol dependence  2010;111(1-2):74-81.
Syringe exchange programs (SEPs) can reduce HIV risk among injecting drug users (IDUs) but their use may depend heavily on contextual factors such as local syringe policies. The frequency and predictors of transitioning over time to and from direct, indirect, and non-use of SEPs are unknown. We sought, over one year, to: (1) quantify and characterize transition probabilities of SEP attendance typologies; (2) identify factors associated with (a) change in typology, and (b) becoming and maintaining direct SEP use; and (3) quantify and characterize transition probabilities of SEP attendance before and after changes in policy designed to increase access. Using data collected from 583 IDUs participating in a three-city cohort study of SEPs, we conducted a latent transition analysis and multinomial regressions. Three typologies were detected: Direct SEP users, Indirect SEP users and Isolated IDUs. Transitions to direct SEP use were most prevalent. Factors associated with becoming or maintaining direct SEP use were female sex, Latino ethnicity, fewer injections per syringe, homelessness, recruitment city, injecting speedballs (cocaine and heroin), and police contact involving drug paraphernalia possession. Similar factors influenced transitions in the syringe policy change analysis. Policy change cities experienced an increase in Indirect SEP users (43% to 51%) with little increased direct use (29% to 31%). We found that, over time, IDUs tended to become Direct SEP users. Policies improving syringe availability influenced SEP use by increasing secondary syringe exchange. Interactions with police around drug paraphernalia may encourage SEP use for some IDUs and may provide opportunities for other health interventions.
PMCID: PMC3087197  PMID: 20537814
syringe exchange; injecting drug use; HIV/AIDS; longitudinal study; latent transition analysis
12.  Distinguishing signs of opioid overdose and indication for naloxone: an evaluation of six overdose training and naloxone distribution programs in the United States 
Addiction (Abingdon, England)  2008;103(6):979-989.
This study assessed overdose and naloxone administration knowledge among current or former opioid abusers trained and untrained in overdose–response in the United States.
Design and participants
Ten individuals, divided equally between those trained or not trained in overdose recognition and response, were recruited from each of six sites (n = 62).
US-based overdose training and naloxone distribution programs in Baltimore, San Francisco, Chicago, New York and New Mexico.
Participants completed a brief questionnaire on overdose knowledge that included the task of rating 16 putative overdose scenarios for: (i) whether an overdose was occurring and (ii) if naloxone was indicated. Bivariate and multivariable analyses compared results for those trained to untrained. Responses were also compared to those of 11 medical experts using weighted and unweighted kappa statistics.
Respondents were primarily male (72.6%); 45.8% had experienced an overdose and 72% had ever witnessed an overdose. Trained participants recognized more opioid overdose scenarios accurately (t60 = 3.76, P < 0.001) and instances where naloxone was indicated (t59 = 2.2, P < 0.05) than did untrained participants. Receipt of training and higher perceived competency in recognizing signs of an opioid overdose were associated independently with higher overdose recognition scores. Trained respondents were as skilled as medical experts in recognizing opioid overdose situations (weighted kappa = 0.85) and when naloxone was indicated (kappa = 1.0).
Results suggest that naloxone training programs in the United States improve participants’ ability to recognize and respond to opioid overdoses in the community. Drug users with overdose training and confidence in their abilities to respond may effectively prevent overdose mortality.
PMCID: PMC3163671  PMID: 18422830
Cocaine; harm reduction; injection drug use; naloxone distribution; opioids; overdose
13.  Patterns of drug use and abuse among aging adults with and without HIV: A latent class analysis of a US Veteran cohort* 
Drug and alcohol dependence  2010;110(3):208-220.
This study characterized the extent and patterns self-reported drug use among aging adults with and without HIV, assessed differences in patterns by HIV status, and examined pattern correlates. Data derived from 6351 HIV infected and uninfected adults enrolled in an eight-site matched cohort, the Veterans Aging Cohort Study (VACS). Using clinical variables from electronic medical records and sociodemographics, drug use consequences, and frequency of drug use from baseline surveys, we performed latent class analyses (LCA) stratified by HIV status and adjusted for clinical and socio-demographic covariates. Participants were, on average, age 50 (range 22–86), primarily male (95%) and African-American (64%). Five distinct patterns emerged: non-users, past primarily marijuana users, past multidrug users, current high consequence multidrug users, and current low consequence primarily marijuana users. HIV status strongly influenced class membership. Non -users were most p revalent among HIV uninfected (36.4%) and current high consequence multidrug users (25.5%) were most prevalent among HIV infected. While problems of obesity marked those not currently u sing drugs, current users experienced higher prevalences of medical or mental health disorders. Multimorbidity was highest among past and current multidrug users. HIV-infected participants were more likely than HIV-uninfected participants to be current low consequence primarily marijuana users. In this sample, active drug use and abuse were common. HIV infected and uninfected Veterans differed on extent and patterns of drug use and on important characteristics within identified classes. Findings have the potential to inform screening and intervention efforts in aging drug users with and without HIV.
PMCID: PMC3087206  PMID: 20395074
aging; Veterans; HIV; substance-related disorders; latent class analysis; illicit drugs; cohort studies
14.  Drug Network Characteristics and HIV Risk Among Injection Drug Users in Russia: The roles of Trust, Size, and Stability 
AIDS and behavior  2011;15(5):1003-1010.
We investigated the influence of drug network characteristics including trust, size, and stability on HIV risk behaviors and HIV testing among injection drug users (IDUs) in St. Petersburg, Russia. Overall, male and female IDUs who reported having high levels of trust in their drug networks were significantly more likely to share syringes than those with lower levels of trust (OR [95% CI]) 2.87 [1.06, 7.81] and 4.89 [1.05, 21.94], respectively). Male and female IDUs in larger drug networks were more likely to share syringes than those in smaller networks (4.21 [1.54, 11.51] and 4.80 [1.20, 19.94], respectively). Characteristics that were significantly associated with not having been HIV tested included drug network instability among men and larger network size among women. High trust, large size, and instability were positively and significantly associated with syringe sharing and not having been HIV tested. Effectiveness of interventions in Russia to reduce the risk of HIV infection may be enhanced if network characteristics are addressed.
PMCID: PMC3112286  PMID: 20872063
Drug networks; HIV; Russia; IDU
15.  High HIV Prevalence, Suboptimal HIV Testing, and Low Knowledge of HIV-Positive Serostatus Among Injection Drug Users in St. Petersburg, Russia 
AIDS and behavior  2010;14(4):932-941.
The purpose of this analysis was to estimate human immunodeficiency virus (HIV) prevalence and testing patterns among injection drug users (IDUs) in St. Petersburg, Russia. HIV prevalence among 387 IDUs in the sample was 50%. Correlates of HIV-positive serostatus included unemployment, recent unsafe injections, and history/current sexually transmitted infection. Seventy-six percent had been HIV tested, but only 22% of those who did not report HIV-positive serostatus had been tested in the past 12 months and received their test result. Correlates of this measure included recent doctor visit and having been in prison or jail among men. Among the 193 HIV-infected participants, 36% were aware of their HIV-positive serostatus. HIV prevalence is high and continuing to increase in this population. Adequate coverage of HIV testing has not been achieved, resulting in poor knowledge of positive serostatus. Efforts are needed to better understand motivating and deterring factors for HIV testing in this setting.
PMCID: PMC3116648  PMID: 18843531
Russia; Injection drug users; HIV prevalence; HIV testing; HIV serostatus; Knowledge
16.  Statistical design for a small serial dilution series 
Statistics in medicine  2010;29(3):411-420.
We describe statistical plans for a serial dilution series designed to detect and estimate the number of viral particles in a solution. The design addresses a problem when a very limited number of aliquots are available for proliferation. A gamma prior distribution on the number of viral particles allows us to describe the marginal probability distribution of all experimental outcomes. We examine a design that minimizes the expected reciprocal information and compare this with the maximum entropy design. We argue that the maximum entropy design is more useful from the point of view of the laboratory technician. The problem and design are motivated by our study of the viability of human immunodeficiency virus in syringes and other equipment that might mediate blood-borne viral transmission.
PMCID: PMC3113538  PMID: 19943329
experimental design; entropy; binomial distribution; HIV infection; syringe exchange; harm reduction
Drug and alcohol dependence  2010;109(1-3):79-83.
The conjoined epidemics of HIV and injection drug abuse have progressed rapidly in many parts of the Russian Federation, including the City of St. Petersburg, which now has more cases of HIV than any other region in the country. Official estimates of the number of injection drug users (IDUs), which rely on official registration of IDUs, greatly underestimate their number. We have combined official statistics that register HIV cases and attribute risk to causes including injection drug use with data from a study that collected data from IDUs about their HIV serostatus and their history of HIV testing to estimate the number of IDUs in the city. We conclude that there are 83,118 ± 5,799 total IDUs. Since many IDUs have not been tested and even some who have been officially tested do not know their serostatus, a first step in countering the growing HIV epidemic among IDUs in St. Petersburg must be expanded access to HIV testing, prevention, and treatment that is targeted to IDUs.
PMCID: PMC2875272  PMID: 20060238
Injection drug use; HIV; Russia; population estimation
18.  Comparing sexual risks and patterns of alcohol and drug use between injection drug users (IDUs) and non-IDUs who report sexual partnerships with IDUs in St. Petersburg, Russia 
BMC Public Health  2010;10:676.
To date, the great majority of Russian HIV infections have been diagnosed among IDUs and concerns about the potential for a sexual transmission of HIV beyond the IDU population have increased. This study investigated differences in the prevalence of sexual risk behaviors between IDUs and non-IDUs in St. Petersburg, Russia and assessed associations between substance use patterns and sexual risks within and between those two groups.
Cross-sectional survey data and biological test results from 331 IDUs and 65 non-IDUs who have IDU sex partners were analyzed. Multivariate regression was employed to calculate measures of associations.
IDUs were less likely than non-IDUs to report multiple sexual partners and unprotected sex with casual partners. The quantity, frequency and intensity of alcohol use did not differ between IDUs and non-IDUs, but non-IDUs were more likely to engage in alcohol use categorized as risky per the alcohol use disorders identification test (AUDIT-C). Risky sexual practices were independently associated with monthly methamphetamine injection among IDUs and with risky alcohol use among non-IDUs. Having sex when high on alcohol or drugs was associated with unprotected sex only among IDUs.
Greater prevalence of sexual risk among non-IDUs who have IDU sex partners compared to IDUs suggests the potential for sexual transmission of HIV from the high-prevalence IDU population into the general population. HIV prevention programs among IDUs in St. Petersburg owe special attention to risky alcohol use among non-IDUs who have IDU sex partners and the propensity of IDUs to have sex when high on alcohol or drugs and forgo condoms.
PMCID: PMC2988741  PMID: 21054855
19.  Hepatitis C Virus Infection among Drug Injectors in St. Petersburg, Russia: Social and Molecular Epidemiology of an Endemic Infection 
Addiction (Abingdon, England)  2009;104(11):1881-1890.
To understand the epidemiology and transmission patterns of hepatitis C virus (HCV), the predominant blood borne-pathogen infecting drug injectors (IDUs), in a part of the former Soviet Union.
Cross-sectional respondent driven sample of IDUs.
St. Petersburg, RF
387 IDUs were recruited in late 2005 and throughout 2006.
Participants were surveyed to collect demographic, medical, and both general and dyad specific drug injection and sexual behaviors. A blood sample was collected to detect antibodies to hepatitis C and to amplify viral RNA for molecular analysis. The molecular data, including genotypes, were analyzed spatially and linkage patterns were compared to the social linkages obtained by respondent driven sampling (RDS) for chains of respondents and among the injection dyads.
HCV infection was all but ubiquitous: 94.6% of IDUs were HCV-seropositive. Among the 208 viral sequences amplified, genotype 3a predominated (n=119, 56.9%) followed by 1b (n=61, 29.2%), and 1a (n=25, 11.9%). There was no significant clustering of genotypes spatially. Neither genotypes nor closely related sequences were clustered within RDS chains. Analysis of HCV sequences from dyads failed to find associations of genotype or sequence homology within pairs.
Genotyping reveals that there have been at least five unique introductions of HCV genotypes into the IDU community in St. Petersburg. Analysis of prevalent infections does not appear to correlate with the social networks of IDUs, suggesting that simple approaches to link these networks to prevalent infections, rather than incident transmission, will not prove meaningful. On a more positive note, the majority of IDUs are infected with 3a genotype that is associated with sustained virologic response to antiviral therapy.
PMCID: PMC2763027  PMID: 19712125
HCV; genotyping; Injection drug users; Respondent Driven Sampling; Russia
20.  The Relative Role of Perceived Partner Risks in Promoting Condom Use in a Three-City Sample of High-Risk, Low-Income Women 
AIDS and Behavior  2010;15(7):1347-1358.
We examined the effect of women’s perceptions of sexual partner risks on condom use. Women from three US cities (n = 1,967) were recruited to provide data on HIV risks. In univariate models, increased odds of condom use were associated with perceiving that partners had concurrent partners and being unaware of partners': (a) HIV status, (b) bisexuality, (c) concurrency; and/or (d) injection drug use. In multivariate models, neither being unaware of the four partner risk factors nor perceiving a partner as being high risk was associated with condom use. Contextual factors associated with decreased odds of condom use were having sex with a main partner, homelessness in the past year, alcohol use during sex, and crack use in the past 30 days. Awareness of a partner’s risks may not be sufficient for increasing condom use. Contextual factors, sex with a main partner in particular, decrease condom use despite awareness of partner risk factors.
PMCID: PMC3180610  PMID: 20976538
Perceptions of partner HIV risk behaviors; Condom use; HIV transmission to women; Crack; Alcohol
22.  Estimates of HIV incidence among drug users in St. Petersburg, Russia: continued growth of a rapidly expanding epidemic 
Background: Russia has one of the world’s fastest growing HIV epidemics and it has been largely concentrated among injection drug users (IDU). St Petersburg, Russia’s second largest city, is one of the country’s regions that has been most affected by the HIV epidemic. To monitor the current epidemic situation, we sought to estimate recent HIV incidence among IDU in St Petersburg. Methods: In a cross-sectional study of 691 IDU recruited during 2005–08, HIV incidence was estimated by two methods: a retrospective cohort analysis and BED capture enzyme immunoassay (EIA) results. Socio-demographic and behavioural correlates of incident infections and spatial patterns were examined. Results: In the retrospective cohort analysis, the incidence rate was estimated to be 14.1/100 person-years [95% confidence interval (CI) 10.7–17.6]. Using results of BED EIA and two correction formulas for known misclassification, incidence estimates were 23.9 (95% CI 17.8–30.1) and 25.5 (95% CI 18.9–32.0) per 100 person-years. Independent correlates of being recently infected included current unemployment (P = 0.004) and not having injected drugs in the past 30 days (P = 0.03). HIV incident cases were detected in all but one district in the city, with focal areas of transmission observed to be expanding. Conclusions: High HIV incidence among IDU in St Petersburg attests to continued growth of the epidemic. The need for expansion of HIV prevention interventions targeted to vulnerable populations throughout the city is urgent. These results also suggest that the BED EIA may over-estimate incidence even after correction for low specificity.
PMCID: PMC3180633  PMID: 20798184
human immunodeficiency virus; HIV; incidence; injection drug users; Russia
23.  High prevalence of blood-borne virus infections and high-risk behaviour among injecting drug users in Tallinn, Estonia 
The HIV epidemic in Estonia is rapidly expanding, and injection drug users (IDUs) are the major risk group contributing to the expansion. A convenience sample of 159 IDUs visiting syringe-exchange programmes (SEPs) was selected to quantify the association of HIV-risk behaviours and blood-borne infections. A high prevalence of HIV, hepatitis B core antibody (HBVcore), hepatitis B surface antigen (HbsAg) and hepatitis C virus antibodies (56, 85.1, 21.3, and 96.2%, respectively) was associated with high-risk injections, unsafe sexual behaviour and alcohol abuse. These findings emphasize the importance of evidence-based secondary prevention among the HIV-infected, especially given the uncertain sustainability of antiretroviral and substance abuse treatments.
PMCID: PMC2925660  PMID: 17326862
injection drug use; HIV; HBV; HCV; high-risk behaviour; Estonia
24.  HIV Disclosure, Condom Use, and Awareness of HIV Infection Among HIV-Positive, Heterosexual Drug Injectors in St. Petersburg, Russian Federation 
AIDS and Behavior  2010;15(1):45-57.
We examined the prevalence of HIV disclosure to sexual partners by HIV-positive drug injectors (IDUs) in St. Petersburg, Russia and compared the magnitude and direction of associations of condom use with awareness of one’s HIV infection and disclosure to partners. Among 157 HIV-infected participants, awareness of infection at time of last intercourse was associated with condom use with partners perceived to be HIV-negative (aOR 6.68, 95% CI 1.60–27.88). Among the 70 participants aware of their infection prior to enrolment, disclosure to potentially uninfected sexual partners was independently and negatively associated with condom use (aOR 0.13, 95% CI 0.02–0.66). Disclosure was independently associated with having injected ≥9 years (aOR 6.04, 95% CI 1.53–23.77) and partnership with another IDU (aOR 3.61, 95% CI 1.44–9.06) or HIV-seropositive (aOR 45.12, 95% CI 2.79–730.46). Scaling up HIV testing services and interventions that increase the likelihood of individuals receiving their test results is recommended.
PMCID: PMC3023022  PMID: 20700645
HIV disclosure; HIV testing; Condom use; Injection drug use; Russia
25.  Surveillance of HIV, Hepatitis B Virus, and Hepatitis C Virus in an Estonian Injection Drug–Using Population: Sensitivity and Specificity of Testing Syringes for Public Health Surveillance 
The Journal of infectious diseases  2005;193(3):455-457.
Surveillance of bloodborne infections among injection drug users (IDUs) can be accomplished by determining the presence of pathogen markers in used syringes. Parallel testing of returned syringes and venous blood from IDUs was conducted to detect antibodies to human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). Syringe surveillance for HIV yielded a sensitivity and specificity of 92% and 89%, respectively, and provided a reasonable estimate of the prevalence of HIV among participants. Because sensitivity for HBV (34%) and HCV (55%) was low, syringe testing may be useful for surveillance of hepatitis over time but not for estimation of prevalence.
PMCID: PMC2917983  PMID: 16388495

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