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1.  Factors mediating HIV risk among female sex workers in Europe: a systematic review and ecological analysis 
BMJ Open  2013;3(7):e002836.
Objectives
We reviewed the epidemiology of HIV and selected sexually transmitted infections (STIs) among female sex workers (FSWs) in WHO-defined Europe. There were three objectives: (1) to assess the prevalence of HIV and STIs (chlamydia, syphilis and gonorrhoea); (2) to describe structural and individual-level risk factors associated with prevalence and (3) to examine the relationship between structural-level factors and national estimates of HIV prevalence among FSWs.
Design
A systematic search of published and unpublished literature measuring HIV/STIs and risk factors among FSWs, identified through electronic databases published since 2005. ‘Best’ estimates of HIV prevalence were calculated from the systematic review to provide national level estimates of HIV. Associations between HIV prevalence and selected structural-level indicators were assessed using linear regression models.
Studies reviewed
Of the 1993 papers identified in the search, 73 peer-reviewed and grey literature documents were identified as meeting our criteria of which 63 papers provided unique estimates of HIV and STI prevalence and nine reported multivariate risk factors for HIV/STI among FSWs.
Results
HIV in Europe remains low among FSWs who do not inject drugs (<1%), but STIs are high, particularly syphilis in the East and gonorrhoea. FSWs experience high levels of violence and structural risk factors associated with HIV, including lack of access to services and working on the street. Linear regression models showed HIV among FSWs to link with injecting drug use and imprisonment.
Conclusions
Findings show that HIV prevention interventions should be nested inside strategies that address the social welfare of sex workers, highlighting in turn the need to target the social determinants of health and inequality, including regarding access to services, experience of violence and migration. Future epidemiological and intervention studies of HIV among vulnerable populations need to better systematically delineate how microenvironmental and macroenvironmental factors combine to increase or reduce HIV/STI risk.
doi:10.1136/bmjopen-2013-002836
PMCID: PMC3731729  PMID: 23883879
2.  HIV among people who inject drugs in Central and Eastern Europe and Central Asia: a systematic review with implications for policy 
BMJ Open  2012;2(5):e001465.
Background and objectives
HIV among people who inject drugs (PWID) is a major public health concern in Eastern and Central Europe and Central Asia. HIV transmission in this group is growing and over 27 000 HIV cases were diagnosed among PWID in 2010 alone. The objective of this systematic review was to examine risk factors associated with HIV prevalence among PWID in Central and Eastern Europe and Central Asia and to describe the response to HIV in this population and the policy environments in which they live.
Design
A systematic review of peer-reviewed and grey literature addressing HIV prevalence and risk factors for HIV prevalence among PWID and a synthesis of key resources describing the response to HIV in this population. We used a comprehensive search strategy across multiple electronic databases to collect original research papers addressing HIV prevalence and risk factors among PWID since 2005. We summarised the extent of key harm reduction interventions, and using a simple index of ‘enabling’ environment described the policy environments in which they are implemented.
Studies reviewed
Of the 5644 research papers identified from electronic databases and 40 documents collected from our grey literature search, 70 documents provided unique estimates of HIV and 14 provided multivariate risk factors for HIV among PWID.
Results
HIV prevalence varies widely, with generally low or medium (<5%) prevalence in Central Europe and high (>10%) prevalence in Eastern Europe. We found evidence for a number of structural factors associated with HIV including gender, socio-economic position and contact with law enforcement agencies.
Conclusions
The HIV epidemic among PWID in the region is varied, with the greatest burden generally in Eastern Europe. Data suggest that the current response to HIV among PWID is insufficient, and hindered by multiple environmental barriers including restricted access to services and unsupportive policy or social environments.
doi:10.1136/bmjopen-2012-001465
PMCID: PMC3488708  PMID: 23087014
3.  High-prevalence and high-estimated incidence of HIV infection among new injecting drug users in Estonia: need for large scale prevention programs 
Objective
To examine HIV risk behavior and HIV infection among new injectors in Tallinn, Estonia.
Design and methods
Data from two cross-sectional surveys of injecting drug users (IDUs) recruited from a syringe exchange program (N = 162, Study 1) or using respondent driven sampling (N = 350, Study 2). Behavioral surveys were administered; serum samples were collected for HIV testing. Subjects were categorized into new injectors (injecting ≤ 3 years) and long-term injectors (injecting > 3 years).
Results
Twenty-eight of 161 (17%, Study 1) and 73/350 (21%, Study 2) of the study subjects were new injectors. HIV infection was substantial among the newer injectors: HIV prevalence was 50% (Study 1) and 34% (Study 2), and estimated HIV incidence 31/100 PY and 21/100 PY, respectively. In Study 2, new injectors were more likely to be female and ethnic Estonian and less likely to be injecting daily compared with long-term injectors. No significant difference was found among two groups on sharing injecting equipment or reported number of sexual partners.
Conclusions
A continuing HIV epidemic among new injectors is of critical public health concern. Interventions to prevent initiation into injecting drug use and scaling up HIV prevention programs for IDUs in Estonia are of utmost importance.
doi:10.1093/pubmed/fdn014
PMCID: PMC2925676  PMID: 18308743
Estonia; HIV; IDU; injection drug use; new injecting drug users
4.  Improving survey methods in sero-epidemiological studies of injecting drug users: a case example of two cross sectional surveys in Serbia and Montenegro 
Background
Little is known about the prevalence of HIV or HCV in injecting drug users (IDUs) in Serbia and Montenegro. We measured prevalence of antibodies to HIV (anti-HIV) and hepatitis C virus (anti-HCV), and risk factors for anti-HCV, in community-recruited IDUs in Belgrade and Podgorica, and determined the performance of a parallel rapid HIV testing algorithm.
Methods
Respondent driven sampling and audio-computer assisted survey interviewing (ACASI) methods were employed. Dried blood spots were collected for unlinked anonymous antibody testing. Belgrade IDUs were offered voluntary confidential rapid HIV testing using a parallel testing algorithm, the performance of which was compared with standard laboratory tests. Predictors of anti-HCV positivity and the diagnostic accuracy of the rapid HIV test algorithm were calculated.
Results
Overall population prevalence of anti-HIV and anti-HCV in IDUs were 3% and 63% respectively in Belgrade (n = 433) and 0% and 22% in Podgorica (n = 328). Around a quarter of IDUs in each city had injected with used needles and syringes in the last four weeks. In both cities anti-HCV positivity was associated with increasing number of years injecting (eg Belgrade adjusted odds ratio (AOR) 5.6 (95% CI 3.2–9.7) and Podgorica AOR 2.5 (1.3–5.1) for ≥ 10 years v 0–4 years), daily injecting (Belgrade AOR 1.6 (1.0–2.7), Podgorica AOR 2.1 (1.3–5.1)), and having ever shared used needles/syringes (Belgrade AOR 2.3 (1.0–5.4), Podgorica AOR 1.9 (1.4–2.6)). Half (47%) of Belgrade participants accepted rapid HIV testing, and there was complete concordance between rapid test results and subsequent confirmatory laboratory tests (sensitivity 100% (95%CI 59%–100%), specificity 100% (95%CI 98%–100%)).
Conclusion
The combination of community recruitment, ACASI, rapid testing and a linked diagnostic accuracy study provide enhanced methods for conducting blood borne virus sero-prevalence studies in IDUs. The relatively high uptake of rapid testing suggests that introducing this method in community settings could increase the number of people tested in high risk populations. The high prevalence of HCV and relatively high prevalence of injecting risk behaviour indicate that further HIV transmission is likely in IDUs in both cities. Urgent scale up of HIV prevention interventions is needed.
doi:10.1186/1471-2334-9-14
PMCID: PMC2647543  PMID: 19203380
5.  Police violence and sexual risk among female and transvestite sex workers in Serbia: qualitative study 
Objective To explore female and transvestite sex workers’ perceptions of risk in the sex work environment in Serbia.
Design Qualitative interview study.
Setting Street based locations for sex work in Belgrade and Pancevo, Serbia.
Participants 31 female and transvestite sex workers.
Results Violence, including police violence, was reported as a primary concern in relation to risk. Violence was linked to unprotected sex and the reduced capacity for avoiding sexual risk. Participants reported that coerced sex was routinely provided to the police in exchange for freedom from detainment, arrest, or fine, and was enforced by the perceived threat of violence, sometimes realised. Accounts contained multiple instances of physical and sexual assault, presented as abuses of police authority, and described policing as a form of moral punishment. This was largely through non-physical means but was also enforced through physical violence, especially towards transvestite and Roma sex workers, whose experience of police violence was reported as relentless and brutal and connected with broader social forces of discrimination in this setting, especially towards Roma.
Conclusion Preventing violence towards sex workers, which can link with vulnerability to sexually transmitted infections, is a priority in Serbia. This requires monitoring perpetrators of violence, providing legal support to sex workers, and creating safer environments for sex work.
doi:10.1136/bmj.a811
PMCID: PMC2492575  PMID: 18667468
6.  Street Policing, Injecting Drug Use and Harm Reduction in a Russian City: A Qualitative Study of Police Perspectives 
We undertook a qualitative exploration of police perspectives on injecting drug use and needle and syringe access among injecting drug users (IDUs) in a Russian city which has witnessed explosive spread of HIV associated with drug injecting. Twenty-seven in-depth qualitative interviews were conducted in May 2002 with police officers of varying rank who reported having regular contact with IDUs. All interviews were tape-recorded, transcribed, translated and coded thematically. Accounts upheld an approach to policing which emphasised high street-based visibility and close surveillance of IDUs. IDUs were depicted as ‘potential criminals’ warranting a ‘pre-emptive’ approach to the prevention of drug-related crime. Street policing was described as a means of maintaining close surveillance leading to the official registration of persons suspected or proven to be users of illicit drugs. Such registration enabled further ongoing surveillance, including through stop and search procedures. While aware of drug users' reluctance to carry injecting equipment linked to their fears of detention or arrest, accounts suggested that the confiscation of previously used injecting equipment can constitute evidence in relation to drugs possession charges and that discovery of clean injecting equipment may be sufficient to raise suspicion and/or further investigation, including through stop and search or questioning. Our findings suggest an uneasy relationship between street policing and needle and syringe access, whereby policing strategies can undermine an HIV prevention ethos promoting needle and syringe accessibility among IDUs. We conclude that facilitating partnerships between policing agencies and HIV prevention initiatives are a critical feature of creating environments conducive for risk reduction.
doi:10.1007/s11524-006-9085-y
PMCID: PMC2438598  PMID: 16855880
Harm reduction; HIV/AIDS; Injecting drug use; Policing; Russia; Syringe exchange
7.  Exploring Barriers to ‘Respondent Driven Sampling’ in Sex Worker and Drug-Injecting Sex Worker Populations in Eastern Europe 
Respondent driven sampling (RDS) has been used in several counties to sample injecting drug users, sex workers (SWs) and men who have sex with men and as a means of collecting behavioural and biological health data. We report on the use of RDS in three separate studies conducted among SWs between 2004 and 2005 in the Russian Federation, Serbia, and Montenegro. Findings suggest that there are limitations associated with the use of RDS in SW populations in these regions. Findings highlight three main factors that merit further investigation as a means of assessing the feasibility and appropriateness of RDS in this high risk population: the network characteristics of SWs; the appropriate level of participant incentives; and lack of service contact. The highly controlled and hidden nature of SW organizations and weak SW social networks in the region can combine to undermine assumptions underpinning the feasibility of RDS approaches and potentially severely limit recruitment. We discuss the implications of these findings for recruitment and the use of monetary and non-monetary incentives in future RDS studies of SW populations in Eastern Europe.
doi:10.1007/s11524-006-9098-6
PMCID: PMC1705510  PMID: 17109206
Respondent driven sampling; Hidden populations; Russia; Serbia; Montenegro; Sex workers
8.  Methods to Recruit Hard-to-Reach Groups: Comparing Two Chain Referral Sampling Methods of Recruiting Injecting Drug Users Across Nine Studies in Russia and Estonia 
Evidence suggests rapid diffusion of injecting drug use and associated outbreaks of HIV among injecting drug users (IDUs) in the Russian Federation and Eastern Europe. There remains a need for research among non-treatment and community-recruited samples of IDUs to better estimate the dynamics of HIV transmission and to improve treatment and health services access. We compare two sampling methodologies “respondent-driven sampling” (RDS) and chain referral sampling using “indigenous field workers” (IFS) to investigate the relative effectiveness of RDS to reach more marginal and hard-to-reach groups and perhaps to include those with the riskiest behaviour around HIV transmission. We evaluate the relative efficiency of RDS to recruit a lower cost sample in comparison to IFS. We also provide a theoretical comparison of the two approaches. We draw upon nine community-recruited surveys of IDUs undertaken in the Russian Federation and Estonia between 2001 and 2005 that used either IFS or RDS. Sampling effects on the demographic composition and injecting risk behaviours of the samples generated are compared using multivariate analysis. Our findings suggest that RDS does not appear to recruit more marginalised sections of the IDU community nor those engaging in riskier injecting behaviours in comparison with IFS. RDS appears to have practical advantages over IFS in the implementation of fieldwork in terms of greater recruitment efficiency and safety of field workers, but at a greater cost. Further research is needed to assess how the practicalities of implementing RDS in the field compromises the requirements mandated by the theoretical guidelines of RDS for adjusting the sample estimates to obtain estimates of the wider IDU population.
doi:10.1007/s11524-006-9101-2
PMCID: PMC1705540  PMID: 17096189
Estonia; HIV; Indigenous field workers; Injecting drug users; Respondent-driven sampling; Russia.
9.  Methods to Recruit Hard-to-Reach Groups: Comparing Two Chain Referral Sampling Methods of Recruiting Injecting Drug Users Across Nine Studies in Russia and Estonia 
Evidence suggests rapid diffusion of injecting drug use and associated outbreaks of HIV among injecting drug users (IDUs) in the Russian Federation and Eastern Europe. There remains a need for research among non-treatment and community-recruited samples of IDUs to better estimate the dynamics of HIV transmission and to improve treatment and health services access. We compare two sampling methodologies “respondent-driven sampling” (RDS) and chain referral sampling using “indigenous field workers” (IFS) to investigate the relative effectiveness of RDS to reach more marginal and hard-to-reach groups and perhaps to include those with the riskiest behaviour around HIV transmission. We evaluate the relative efficiency of RDS to recruit a lower cost sample in comparison to IFS. We also provide a theoretical comparison of the two approaches. We draw upon nine community-recruited surveys of IDUs undertaken in the Russian Federation and Estonia between 2001 and 2005 that used either IFS or RDS. Sampling effects on the demographic composition and injecting risk behaviours of the samples generated are compared using multivariate analysis. Our findings suggest that RDS does not appear to recruit more marginalised sections of the IDU community nor those engaging in riskier injecting behaviours in comparison with IFS. RDS appears to have practical advantages over IFS in the implementation of fieldwork in terms of greater recruitment efficiency and safety of field workers, but at a greater cost. Further research is needed to assess how the practicalities of implementing RDS in the field compromises the requirements mandated by the theoretical guidelines of RDS for adjusting the sample estimates to obtain estimates of the wider IDU population.
doi:10.1007/s11524-006-9101-2
PMCID: PMC1705540  PMID: 17096189
Estonia; HIV; Indigenous field workers; Injecting drug users; Respondent-driven sampling; Russia.
10.  Exploring Barriers to ‘Respondent Driven Sampling’ in Sex Worker and Drug-Injecting Sex Worker Populations in Eastern Europe 
Respondent driven sampling (RDS) has been used in several counties to sample injecting drug users, sex workers (SWs) and men who have sex with men and as a means of collecting behavioural and biological health data. We report on the use of RDS in three separate studies conducted among SWs between 2004 and 2005 in the Russian Federation, Serbia, and Montenegro. Findings suggest that there are limitations associated with the use of RDS in SW populations in these regions. Findings highlight three main factors that merit further investigation as a means of assessing the feasibility and appropriateness of RDS in this high risk population: the network characteristics of SWs; the appropriate level of participant incentives; and lack of service contact. The highly controlled and hidden nature of SW organizations and weak SW social networks in the region can combine to undermine assumptions underpinning the feasibility of RDS approaches and potentially severely limit recruitment. We discuss the implications of these findings for recruitment and the use of monetary and non-monetary incentives in future RDS studies of SW populations in Eastern Europe.
doi:10.1007/s11524-006-9098-6
PMCID: PMC1705510  PMID: 17109206
Respondent driven sampling; Hidden populations; Russia; Serbia; Montenegro; Sex workers

Results 1-10 (10)