Title: Structural Determinants of HIV Risk Among Women Who Use Drugs in Kazakhstan
Description: Background: Despite substantial global progress against the HIV/AIDS epidemic, the Eastern Europe and Central Asian region has experienced a 43% increase in HIV incidence. The HIV epidemic in Kazakhstan has outpaced that of the region, with the incidence of new infections growing by 73% since 2010. Key populations of people who inject drugs (PWID), female sex workers (FSW) and their sexual partners account for the majority of new infections, where drug policies continue to undermine HIV prevention and control efforts. Kazakhstan has made insufficient progress towards 95-95-95 HIV epidemic control targets, with 78% of people living with HIV (PLWH) knowing their HIV status, of which 57% receive ART, and 48% of those receiving ART achieve viral suppression. Laws, policies and their enforcement can shape social and structural determinants of health, and it is fundamental to understand how punitive legal environments shape the HIV epidemic in Kazakhstan. This dissertation seeks to identify patterns of police violence victimization among FSW who use drugs and examine how police violence is associated with the HIV risk environment.

Given the insufficient progress towards 95-95-95 HIV epidemic control targets, this dissertation also seeks to identify how patterns of injection and sexual HIV transmission risk behaviors vary among men and women who inject drugs and examine how criminal-legal involvement is associated with patterns of HIV transmission risk behaviors. Methods: Data on police violence victimization among FSW who use drugs were drawn from Project Nova, a cluster-randomized control trial that evaluated the efficacy of a combination HIV risk reduction and microfinance intervention. A community-based sample of 255 FSW who use drugs were recruited and enrolled between February 2015 and May 2017 in Almaty, Kazakhstan. Latent class analysis (LCA) was used to characterize women into distinct subgroups (i.e., classes) of police violence victimization. Next, multinomial logistic regression was used to examine how police violence victimization subgroups are associated with the physical, social, economic and policy HIV risk environment.

Data on injection and sexual HIV transmission risk behaviors were drawn from Bridge, an implementation science study that evaluated the effectiveness of HIV service integration into needle/syringe programs on retention in care and viral suppression for PWID living with HIV in Kazakhstan. A random sample of 450 men and 166 women who inject drugs were recruited and enrolled in Almaty, Shymkent, and Temirtau/ Karaganda between February 2017 and June 2019. Similarly, LCA was used to characterize distinct subgroups of HIV transmission risk behaviors among men and women who inject drugs. Multinomial logistic regression was then used to identify associations between criminal-legal involvement and patterns of HIV transmission risk. Results: Three subgroups of police violence victimization among FSW who use drugs emerged. Just over half were characterized as experiencing low violence victimization (“Low Violence;” 51%); over one-third were characterized as experiencing all forms of police violence victimization (Poly-Victimization; 34%), and 15% were characterized as experiencing primarily discrimination and extortion from the police.

Relative to Low Violence, factors associated with Poly-Victimization included being positive for HIV and/or sexually-transmitted infections (STI) (aOR= 1.78 (95% CI: 1.01, 3.14)), prior tuberculosis diagnosis (aOR= 2.73 (1.15, 6.50)), injection drug use (IDU) (aOR= 2.00 (1.12, 3.58)), greater number of unsafe injection behaviors (aOR= 1.21 (1.08, 1.35)), homelessness (aOR= 1.92 (1.06, 3.48)), greater drug use stigma (aOR= 1.22 (1.07, 1.39)) and sex work stigma (aOR= 1.23 (1.06, 1.43)), greater number of sex work clients (aOR= 2.40 (1.33, 4.31)), working for a boss/pimp (aOR= 2.74 (1.16, 6.50)), client violence (aOR= 2.99 (1.65, 5.42)), economic incentives for condomless sex (aOR= 2.77 (1.42, 5.41)), accessing needle/syringe exchange programs (aOR= 3.47 (1.42, 8.50)), recent arrest (aOR= 2.99 (1.36, 6.55)) and detention (aOR= 2.93 (1.62, 5.30)), and negative police perceptions (aOR= 8.28 (4.20, 16.3)). Compared to Low Violence, Discrimination and Extortion was associated with lower odds of experiencing intimate partner violence (aOR= 0.26 (0.12, 0.59)), but no other significant associations with the risk environment upon adjusting for socio-demographic characteristics.

Distinct patterns of HIV transmission risk behaviors emerged among men and women, in which men were characterized as having Low Sexual Risk (41.8%), Injection & Sexual Risk (36.4%), and High Injection Risk (21.8%) behaviors. Class membership in the Injection & Sexual Risk and High Injection Risk class was associated with greater criminal-legal involvement, compared to the Low Sexual Risk class. This is demonstrated by higher odds of multiple detentions ((aORInjection & Sexual Risk = 1.28 (1.10, 1.49); aORHigh Injection Risk = 1.25 (1.06, 1.46)) and drug court participation (aORHigh Injection Risk = 5.29 (1.03, 27.20) in the past six months, committing crimes while under the influence of alcohol or drugs (aORInjection & Sexual Risk = 2.79 (1.53, 5.11); aORHigh Injection Risk = 2.76 (1.34, 5.65), and perceived police discrimination (aORHigh Injection Risk = 1.79 (1.01, 3.19). Women who inject drugs were characterized as having Low Injection & Sexual Risk (60.7%), Sex Work Behaviors (8.4%), High Injection Risk (30.7%) behaviors.

Class membership in the Sex Work Behaviors and High Injection Risk class was associated with greater odds of being detained (aORSex Work Behaviors= 4.59 (1.27, 16.53) and experiencing verbal police harassment (aORSex Work Behaviors= 3.31 (1.20, 9.15); aORHigh Injection Risk = 2.91 (1.32, 6.40), compared to the Low Injection & Sexual Risk class. Conclusion: Results from this dissertation show that police violence against FSW who use drugs is pervasive in Kazakhstan. Patterns of police violence victimization among FSW who use drugs vary, with multiple forms of police violence victimization being associated with greater HIV susceptibility. This dissertation also demonstrates that men and women who inject drugs and are living with HIV have a high prevalence of injection and sexual HIV transmission risk behaviors, despite low viral suppression, and that patterns of HIV transmission risk behaviors vary by gender. Moreover, criminal-legal involvement is associated with injection and sexual HIV transmission risk, particularly among men who inject drugs.

Collectively, these results support drug policy reforms and suggest that decriminalization of drug use and possession may promote enabling environments that support harm reduction, and subsequently reduce HIV transmission through injection and sexual networks of PWID in Kazakhstan.