The mean age at baseline was 33 years and most participants were male; 25% were female and 78% had more than a 9th grade education. More men than women were employed. The monthly median income was 20,000 Rubles , approximately $550 USD at a conversion rate averaged over the time of survey administration , and women appeared more likely than men to have earnings below the research sample’s median income . Approximately half of the participants were not married or in a partnership; 31% were in a concordant relationship with a partner who was living with HIV and 18% were in a discordant relationship with an HIV-negative partner. Women were more likely than men to be in an HIV concordant relationship . Men were more likely than women not to be partnered at all . The mean CD4 cell count in this baseline ART-naïve population was 525 . In terms of drug use, 41% of respondents reported past 30 day heroin or other opioid use. Injection drug use, specifically, was reported by 44% , among whom most injected heroin , followed by heroin and stimulants , stimulants only and neither heroin nor stimulants . Cannabis use in the past 30 days was reported by 17% and 70% reported heavy alcohol use in the past 30 days. Most participants reported no form of transactional sex in the past 12 months. The most common transaction was reported by men as having given money,plant drying rack drugs or alcohol in exchange for sex. We did not measure the type of partner involved in this exchange. No women reported giving something for sex and all other forms of transaction were reported by less than 5% of the sample, see Table 1.
Table 2 shows the proportion of participants who reported on the primary and secondary outcomes of interest at baseline, 12 and 24-month follow-up. High risk sex behaviors were more commonly reported than drug risk behaviors . Although Table 2 only descriptively presents the longitudinal frequencies of each outcome, it is noteworthy that – relative to male participants – a higher estimated proportion of female participants reported engaging in every risk behavior at every time point with the exception of past month alcohol use before sharing equipment, as reported at the 12 month follow-up. In general, it appears that there were not substantial changes over time across the various outcomes presented in Table 2. ART use appeared to increase from 12 to 24 months, particularly among men. All participants were ART-naïve at baseline but 17% and 35% reported having taken ART in the past 6 months at the 12 and 24 month follow-up visits, respectively. Relative to male participants, female participants had significantly higher odds of reporting both primary outcomes, sharing injecting equipment in the past 30 days and condomless sex in the past 90 days in the unadjusted models. After controlling for demographic covariates, partner status and ART use, the association between female gender and sharing injecting equipment was no longer significant. Female gender remained significantly associated with condomless sex in the past 90 days, even after controlling for demographics and additionally, both partner status and ART use , Table 3. The conclusions from posthoc sensitivity analyses excluding observations from participants who used ARTs were consistent with the main analyses for all 5 outcomes . The unadjusted odds of one of the secondary outcomes was higher for female participants than male participants: reporting both drug equipment sharing and condomless sex .
After controlling for demographic covariates, female gender remained statistically significant for the outcome, reporting both injection equipment sharing and condomless sex . In the final fully adjusted model, where we controlled for demographics as well as the 3 level partner status covariate and ART use, the association between female gender and reporting both injection equipment sharing and condomless sex was no longer significant. No significant association was found in any of the models between female gender and alcohol use prior to sharing equipment in the past 30 days, or prior to or during sex in the past 90 days, see Table 3. Among a cohort of PLHIV in Russia who have ever injected drugs, we detected a statistically significant association between female gender and condomless sex in the past 90 days, even after controlling for the potentially confounding effects of demographics, partner status, and ART use. Although we observed notable associations between gender and other outcomes, including sharing drug equipment, alcohol use prior to sharing, and both drug equipment sharing and condomless sex, the results were not statistically significant, possiblydue to limited power given the relatively small number of women in the study. It is also notable that nearly all risk behaviors, other than alcohol use prior to sharing, appeared to be more commonly reported among women compared to men. The increased odds of substance using women having condomless sex, compared to men, has been previously documented in multiple settings , including St. Petersburg, Russia . Prior research from St. Petersburg also found partnership status to be a major factor in PWID’s decision-making process about whether to engage in condomless sex with their partner .
In our study, more participants reported being in HIV concordant partnerships which could explain why such a high proportion of respondents engaged in condomless sex. Regardless, female participants had higher odds of reporting condomless sex, irrespective of their partner’s HIV status, posing risk for HIV transmission in this population. Further, the preventive health benefits of HIV-positive persons using a condom or other protective barrier during vaginal or anal sex are indisputable, regardless of their partner’s HIV serostatus. These results are particularly concerning in light of recent research suggesting heterosexual transmission of HIV is increasing in St. Petersburg, and may overtake injection drug use as the primary mode of transmission , and suggest a need for a comprehensive, multipronged response which should include “treatment as prevention” and preexposure prophylaxis for HIV-negative partners . Interventions promoting condom usage are also warranted. However, our finding that women were less likely than men to use condoms under all circumstances implies that such approaches must be designed to account for the social, micro, and macro contexts of women’s lives. At the relationship level, alcohol use prior to sex was common and may have interfered with condom decision making around the time of the sexual event. Connecting women to alcohol harm reduction programming could help to lessen their collective risk for HIV infection and transmission . Our findings support the value of implementing multi-level interventions and also imply that TasP is a high-yield approach with potential to reduce the risk of transmission with condomless sex,hydroponic rack as well as provide a multitude of other health benefits for the HIV-positive individual. Addressing the social and structural factors that contribute to gender differences in condom usage, and providing HIV-negative women with access to PrEP are additional strategies which should also be pursued. As has also been seen in other settings, women in our study were more likely to report drug equipment sharing than men. However, it seems the relationship between female gender and equipment sharing is at least partially explained by demographics, most notably employment and income. Female participants in this study were significantly less likely to be employed than male participants and significantly more likely to earn a monthly income below the sample median of 20,000 Rubles . When there is limited access to clean needles and syringes and/or limited funds to pay for new/unused equipment, women may be more likely to share . This could be the result of the woman having less money to pay for the drugs/supplies. These patterns have been observed in other populations, including among PWID in South Africa where more women than men reported always sharing injecting equipment . Low economic status, coupled with limited work opportunities for women, have also been associated with increased sexual risk taking among female substance users, including having multiple sex partners and relying on sex trade/transactional sex to support drug use. Findings from the 2009 National HIV Behavioral Surveillance System, conducted in 20 U.S. cities, suggest more female PWID have sex in exchange for money or drugs .
Findings from Russia found that compared to their male counterparts, female injectors who reported high drug use frequency were more likely to also report multiple sex partners . Our findings highlight the need for free access to clean needles/syringes among women who inject drugs, as well as access to opiate agonist therapy to prevent HIV . Our study has limitations. The sample size was relatively modest and participants were predominantly male, which limited study power particularly for outcomes that were less common . These findings from Russia might not be representative of the relationship between female gender and HIV transmission risk among people who inject drugs or have a history of injection drug use, who are living with HIV in other nonRussian settings, or even within Russia but outside of the Russia ARCH study population. Additionally, our research was done with a mixed sample of current and former injection drug users. Another limitation of the current study is that knowledge and perceptions surrounding risk of HIV transmission were not assessed, nor did we specifically explore several key mechanisms known to contribute to sex and drug use behaviors associated with increased risk for HIV transmission. For instance, participants were not asked about their experiences of intimate partner violence, despite that it has been associated with women’s reduced ability to negotiate condom use and talk about HIV prevention with their partner . More research is needed to understand the challenges and preferences of HIV-positive women who inject drugs, which may be contributing to their condom nonuse and harmful drug and alcohol consumption. A better understanding of the factors underlying women’s condom choices, or to what extent they have any choice in the matter, will inform the design of more meaningful and effective prevention strategies. Furthermore, assessing awareness and willingness to use PrEP among HIV-negative women and men who have ever injected drugs or have a known HIV-positive partner is needed to inform future efforts for HIV prevention. We also did not assess participants’ sexual orientation or gender identity, or these characteristics of their sexual partner. Further, we did not assess differences in drug use and sexual behaviors according to whether the partner under consideration was a long-term or casual partner . Nor did we measure partner-specific information on sexual or drug related behaviors of interest . Instead, we only measured behaviors of interest at the individual level. These details should be collected in future research, as understanding partner dynamics contextualizing most at risk situations will help to establish what is needed for prevention efforts. All behavioral measures were self-reported and thus subject to recall and/or social desirability biases. Additionally, different time frames were used for the outcomes which may have differentially impacted participants’ ability to accurately remember their true behaviors. However, the Russia ARCH cohort study team is skilled at interviewing and has extensive experience with this population which likely serves to mitigate this latter bias. Substance use among women living with HIV is a major public health concern that is both an independent and aggravating risk factor for HIV transmission . Although fewer women than men use drugs, women are more likely to experience detrimental health effects from drug use, and may become addicted to substances more quickly . Compared to men, women may have unique reasons for initiating drug use, including the use of substances to lose weight, to cope with anxiety and exhaustion, and to deal with higher rates of chronic pain that has been treated with prescription drugs . In one study 37% of WLHIV had substance-use problems, which was significantly higher than men . Substance use increases the risk of HIV infection while diminishing the ability of PLHIV to adhere to their medications and self-manage their illness . However, few investigations have examined substance use among women living with HIV . Illicit substance use negatively impacts HIV self-management tasks, including HIV medication adherence and initiation and retention in HIV primary care . Recently, data from the Women’s Interagency HIV Study reinforced that women who use illicit substances encounter sub-optimal medication adherence, despite simplification of HIV drug regimens . Social capital is the aggregation of potential resources, linked to a durable network of relationships of mutual acquaintance or recognition.