Intersecting epidemics of HIV, HCV, and syphilis among soon-to-be released prisoners in Kyrgyzstan: Implications for prevention and treatment

Abstract

Background Central Asia is plagued by increasing HIV incidence, low antiretroviral therapy (ART) coverage and increasing AIDS mortality, driven primarily by people who inject drugs (PWID). Reliable data about HIV, other infectious diseases, and substance use disorders in prisoners in this region is lacking and could provide important insights into how to improve HIV prevention and treatment efforts in the region. Methods A randomly sampled, nationwide biobehavioral health survey was conducted in 8 prisons in Kyrgyzstan among all soon-to-be-released prisoners; women were oversampled. Consented participants underwent computer-assisted, standardized behavioral health assessment surveys and testing for HIV, HCV, HBV, and syphilis. Prevalence and means were computed, and generalized linear modeling was conducted, with all analyses using weights to account for disproportionate sampling by strata. Results Among 381 prisoners who underwent consent procedures, 368 (96.6%) were enrolled in the study. Women were significantly older than men (40.6 vs. 36.5; p=0.004). Weighted prevalence (%), with confidence interval (CI), for each infection was high: HCV (49.7%; CI: 44.8-54.6%), syphilis (19.2%; CI: 15.1-23.5%), HIV (10.3%; CI: 6.9-13.8%), and HBV (6.2%; CI: 3.6-8.9%). Among the 31 people with HIV, 46.5% were aware of being HIV-infected. Men, compared to women, were significantly more likely to have injected drugs (38.3% vs.16.0%; p=0.001). Pre-incarceration and within-prison drug injection, primarily of opioids, was 35.4% and 30.8%, respectively. Independent correlates of HIV infection included lifetime drug injection (adjusted odds ratio [AOR]=38.75; p=0.001), mean number of years injecting (AOR=0.93; p=0.018), mean number of days experiencing drug problems (AOR=1.09; p=0.025), increasing duration of imprisonment (AOR=1.08; p=0.02 for each year) and having syphilis (AOR=3.51; p=0.003), while being female (AOR=3.06; p=0.004) and being a recidivist offender (AOR=2.67; p=0.008) were independently correlated with syphilis infection. Conclusion Drug injection, syphilis co-infection, and exposure to increased risk during incarceration are likely to be important contributors to HIV transmission among prisoners in Kyrgyzstan. Compared to the community, HIV is concentrated 34-fold higher in prisoners. A high proportion of undiagnosed syphilis and HIV infections presents a significant gap in the HIV care continuum. Findings highlight the critical importance of evidence-based responses within prison, including enhanced testing for HIV and sexually transmitted infections, to stem the evolving HIV epidemic in the region.

The perfect storm: incarceration and the high-risk environment perpetuating transmission of HIV, hepatitis C virus, and tuberculosis in Eastern Europe and Central Asia

“…Although no reliable data exist for Turkmenistan and Belarus, HIV prevalence in prisons exceeds 10% in four countries—Latvia (20.4%), Ukraine (19.4%), Estonia (14.1%), and Kyrgyzstan (10.3%)—and remains markedly higher than in the community in Uzbekistan (4.7%), Lithuania (3.4%), Kazakhstan (3.9%), Azerbaijan (3.7%), Armenia (2.4%), Tajikistan (2.4%), Moldova (2.6%), and Georgia (0.9%). In nationally representative prison surveillance studies, HIV prevalence is 22 times, 19 times, and 34 times higher in prisons than in surrounding communities in Ukraine, 23,24 Azerbaijan, 59 and Kyrgyzstan, 60 respectively. Factors contributing to this increased concentration include harsh policies, laws, and policing targeted at people who inject drugs, and high levels of within-prison drug injection.…”

“…Only half of people living with HIV in Ukrainian and Kyrgyz prisons are diagnosed before leaving prison. 23,24,60 In Ukraine, fewer than 12% of people living with HIV were aware of having HIV, with another 40% being diagnosed during incarceration, leaving almost half still not aware of their status. 24 In Azerbaijan, however, HIV diagnosis approaches 75% of cases.…”

“…24 In Azerbaijan, however, HIV diagnosis approaches 75% of cases. 59 Although both Azerbaijan and Kyrgyzstan provide high coverage of antiretroviral therapy for people living with HIV who are diagnosed within prison, 59,60 fewer than 4% of people living with HIV in Ukrainian prisons receive it. 23,24 No EECA country has data for antiretroviral therapy coverage after release, but even data from high-income countries suggest that the transition period from prison is one of heightened vulnerability, when antiretroviral therapy coverage falls precipitously and HIV risk is high, 73 especially for women.…”

“…76 Representative prison biosurveillance studies show hepatitis C prevalence to be substantially higher in Ukraine (60.2%), 23 Kyrgyzstan (49.7%), 60 and Azerbaijan (38.2%), 59 even though self-reported lifetime prevalence of injection drug use was substantially lower. These data suggest that drug injection is often under-reported in surveys.…”

A qualitative assessment of an abstinence-oriented therapeutic community for prisoners with substance use disorders in Kyrgyzstan

“…Kyrgyzstan is experiencing a rapidly expanding HIV epidemic concentrated among people who inject drugs (PWID), primarily with heroin. Both HIV prevalence and within-prison drug injection remain high [3]. Without utilization of evidence-based HIV prevention interventions, these individuals often engage in high risk-taking behaviors that are likely to result in transmission of blood-borne infections to others in prison and community settings.…”