Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2014 Nov 1.
Published in final edited form as: Drug Alcohol Depend. 2013 Jun 12;133(1):154–160. doi: 10.1016/j.drugalcdep.2013.05.018

High Rates of Police Detention Among Recently Released HIV-infected Prisoners in Ukraine: Implications for Health Outcomes

Jacob M Izenberg 1, Chethan Bachireddy 1, Michael Soule 2, Tetiana Kiryazova 3, Sergey Dvoryak 4, Frederick L Altice 1,5
PMCID: PMC3786010  NIHMSID: NIHMS494314  PMID: 23769160

Abstract

Background

Ukraine’s HIV epidemic, primarily affecting people who inject drugs (PWID), is expanding and transitioning despite free opioid substitution therapy (OST) and antiretroviral therapy (ART), two effective ways to reduce HIV transmission. Police detention not resulting in imprisonment, defined as police harassment, of PWID is common, but its prevalence and impact on health is not known.

Method

HIV-infected individuals (N=97) released from prison within one year were recruited and surveyed in two HIV-endemic Ukrainian cities about post-release police detention experiences. Data on the frequency of police detention, related adverse events, and impact on OST and ART continuity were collected, and correlates of detention were examined using logistic regression.

Results

Detention responses were available for 94 (96.9%) participants, of which 55 (58.5%) reported police detentions (mean=9.4 per person-year). For those detained while prescribed OST (N=28) and ART (N=27), medication interruption was common (67.9% and 70.4%, respectively); 23 of 27 participants prescribed OST (85.2%) were detained en route to/from OST treatment. Significant independent correlates of detention without charges included post-release ART prescription (AOR 4.98, p=0.021), current high-risk injection practices (AOR 5.03, p=0.011), male gender (AOR 10.88, p=0.010), and lower lifetime months of imprisonment (AOR 0.99, p=0.031).

Conclusions

HIV-infected individuals recently released from prison in Ukraine experience frequent police detentions, resulting in withdrawal symptoms, confiscation of syringes, and interruptions of essential medications, including ART and OST. Structural changes are urgently needed to reduce police detentions in order to control HIV transmission and improve both individual and public health.

Keywords: HIV, police detention, police harassment, antiretroviral therapy, opioid substitution therapy, injection drug use, Ukraine, Eastern Europe

1. Introduction

During the first decade of the twenty-first century, Eastern Europe and Central Asia collectively experienced a 24% increase in HIV incidence despite a 19% decline globally (Spicer et al., 2011; UNAIDS, 2010). Of these countries, Ukraine is the most severely affected, with adult prevalence exceeding 1% (Bobrovskyy et al., 2012). Despite growing transmission through heterosexual intercourse (Burruano and Kruglov, 2009), PWID account for 70% of Ukraine’s cumulative HIV incidence (UNAIDS, 2010), reflecting a regional epidemic among people who inject drugs (PWID) (Mathers et al., 2008). In Ukraine, this syndemic of HIV and drug injection is reflected in the fact that of approximately 290,000 PWID, primarily using opioids, (Kruglov, 2008; Nieburg and Carty, 2012), HIV prevalence ranges from 21.3%–41.8% (Balakiryeva et al., 2012; Mathers et al., 2008). As a consequence mathematical modeling of the HIV epidemic among both PWID and non-PWID has identified expansion of opioid substitution therapy (OST), one of few evidence-based interventions effective at reducing HIV transmission among opioid injectors (Gowing et al., 2008), as the most cost-effective (and in combination with ART, the most efficacious) approach to reducing overall HIV incidence and prevalence (Alistar et al., 2011).

Ukrainian law mandates free ART (Judice et al., 2011) and OST (Bruce et al., 2007; Mathers et al., 2010), yet access remains very limited due to numerous prevention and treatment barriers (Altice et al., 2010; Bruce et al., 2007; Izenberg and Altice, 2010; Judice et al., 2011; Wood et al., 2008). Among these, police detention and harassment is not empirically described, yet likely plays a significant role in both facilitating high-risk injection behavior among PWID and undermining ART and OST uptake and expansion (Bruce and Schleifer, 2008; Mimiaga et al., 2010; Strathdee et al., 2010; Wolfe et al., 2010).

Ukrainian law allows police to detain individuals for 72 hours without a criminal charge (Wolfe and Cohen, 2010). Unsanctioned detentions, beatings, forced-confessions, and other forms of police abuse have also been reported (Schleifer, 2009), making police detention without charge but one form of police harassment. PWID, particularly those with HIV, are often targeted when visiting services venues, including syringe-exchange sites, pharmacies (which legally sell clean syringes in Ukraine) (Spicer et al., 2011), and OST and HIV clinics (Judice et al., 2011; Mimiaga et al., 2010). Additional documented abuses include the confiscation of HIV medications (Mimiaga et al., 2010), intimidation of OST providers (Cohen, 2010), and forced confessions (Schleifer, 2009). By promoting “rushed” or “hidden” injection and discouraging use of treatment facilities, these policing practices contribute profoundly to what Rhodes and colleagues call the “HIV risk-environment”, so much so that by their estimates, elimination of police beatings alone in three Ukrainian cities would avert between 2–19% of future HIV infections in those locales (Strathdee et al., 2010).

Although qualitative data confirm that detention of PWID and HIV-infected individuals is a major problem in Ukraine and a likely contributor to the country’s unrelenting HIV epidemic, the practice has not to our knowledge been quantitatively evaluated anywhere in the region among any group, including HIV-infected individuals. Thus, our aim was to characterize the prevalence and impact on health of police detention on a group of HIV-infected individuals recently released from prison in Ukraine.

2. METHODS

2.1 Patient Population and Study Design

From November 2010 through January 2011, trained staff in Odessa and Kyiv, two HIV-endemic Ukrainian cities, recruited a sample of 88 men and 11 women according the following criteria: 1) age >18 years; 2) HIV-infected by self-report; and 3) released from prison between 1–12 months. Potential participants were not told about inclusion criteria during recruitment, but that only that their post-release experiences were being assessed. A convenience approach was used to recruit an adequate sample of this hidden, highly marginalized target population. In Odessa, a prisoner outreach organization conducted a snowball sample with 7 initial seed respondents. In Kyiv, a different organization recruited respondents at a post-release services center where former prisoners periodically access services. Only verbal consent was obtained as no identifying information was gathered, with a copy of the consent form given to each consenting respondent. No eligible recruit refused further participation, consistent with previous experiences in Ukraine (Booth et al., 2009). The 60-minute surveys were then conducted in a private room with no prison staff or government representatives present. After completion, participants were paid UAH 50 ($8.25 USD) for time and travel. Ethical oversight was provided by Institutional Review Boards at the Ukrainian Institute on Public Health Policy and Yale University School of Medicine.

2.2 Study Measures

Surveys were created in English, translated into Russian, and back-translated into English using previously described methods (Bullinger et al., 1998), verified by bilingual staff, and piloted to verify quality and respondent understanding.

Unofficial detention, defined here as detention not accompanied by a “charge” (e.g., theft, drug possession, etc.), was the primary outcome of interest. Respondents were asked to report the number of unofficial detentions they had experienced since prison-release, and those reporting one or more were categorized as “detained”. The total number of detentions experienced by each respondent since prison-release was counted and, because respondents had been out for varying periods of time, a rate of detentions per person-year was calculated for each respondent. To streamline the survey process, further characterization of detentions was limited to the 5 most recent episodes per individual. For these episodes only, respondents were asked if any of the following related adverse events had occurred: confiscation of needles, experience of withdrawal symptoms, or interruption of either OST or ART for greater than 24 hours. Detained respondents were asked if they had experienced a coerced confession, defined as having their access to medications (OST or ART) or the threat of withdrawal used to extract a confession. Finally, all respondents were asked if they had been stopped, detained or harassed while en route to or from an OST venue at any time since release.

Demographic measures included age and gender. Income was stratified as above or below poverty (monthly 888 UAH, approximately $110 USD, in 2010). Relationship status was defined as stable partner (spouse or “girlfriend/boyfriend”) or no stable partner. Housing was stratified into “stable” versus “unstable” according to established definitions (Chen et al., 2011), with stable housing defined as an apartment rented by or belonging to the respondent, relative, or stable partner or residency in a long-term treatment facility. Residency in a brothel or shelter or self-reported homelessness was considered unstable. Criminal justice measures included length of last incarceration, lifetime prison sentences, total number of months in prison, lifetime detentions not resulting in a prison sentence, and age of first incarceration.

Two standardized scales validated in Russian were used to screen for substance use disorders—the Alcohol Use Disorders Identification Test (AUDIT; Nilssen et al., 2005) and the 10-item Drug Abuse Severity Test (DAST-10; Uusküla et al., 2012). DSM-IV criteria were used to measure opioid dependence. We used validated AUDIT cut-offs for men (≥8) and women (≥4) for hazardous drinking (Allen et al., 2001; Neumann et al., 2004; Peng et al., 2012), and ≥20 for dependence (Babor et al., 2001). A cut-off of ≥ 3 was used on the DAST-10 to define moderate to high drug abuse severity (Skinner, 1982).

Current drug use was defined as use on at least one day in the last thirty days, and measured using an inventory of typical drugs of abuse, expanded to include those common in Ukraine, including homemade compounds. For simplicity, these were categorized as stimulants, illegal opioids, alcohol, and poly-substance. Heroin, morphine, opium, and homemade “poppy straw” were classified as illegal opioids. Stimulants included amphetamines, ecstasy, cocaine, and homemade stimulants. Poly-substance was defined as use of substances in at least two substance groups in a single day, with the exception of OST. Respondents reported total injection days and typical number of injections on a given day, with current injection defined as at least one injection day in the prior month and current high-risk injection defined as injecting with a shared needle or syringe or with liquid drugs drawn from a shared container in the last thirty days. Respondents were also asked the age at which they first injected.

To evaluate healthcare use post-release, respondents were asked about receiving OST, HIV care (defined as a visit with a doctor or nurse to get HIV care other than an HIV test), and ART since release from prison.

2.3 Data Analysis

Data analysis was conducted using SPSS version 20 (SPSS Inc, Chicago, Il, USA). Respondents were placed into one of two categories for the primary outcome: “detention” and “no detention.” Descriptive data on the prevalence of detention and related adverse events were tallied from the descriptions given for each detention. Bivariate correlations of detention were determined using appropriate tests (chi square for binary responses, independent t-tests for normally distributed continuous variables and Mann-U Whitney tests for all other continuous variables). Characteristics with p<0.20 on bivariate analysis were selected for an initial model, which was further fitted using backward stepwise regression based on small-sample corrected AIC. After the initial stepwise regression, time since prison-release was forced into the final model to control the potential effect of time since release on the primary outcome. Because of our interest in understanding the relationship between detention and HIV transmission, active high-risk injection was also retained in the model through forced entry while active injection was eliminated because of colinearity. During the backwards-stepwise elimination approach, recruitment location and age were dropped from the final model (neither demonstrated a significant effect on the outcome, improvement in AIC, or significant interaction effects with other parameters when reintroduced).

3. RESULTS

3.1 Baseline Characteristics

Table 1 describes characteristics of the sample stratified by detention status. Of 97 respondents recruited (50 from Odessa, 47 from Kyiv), 94 provided valid information on their detention experiences and were included in the analysis. Respondents were primarily men (88.4%) in their mid-thirties (mean = 35.7 years) who were stably housed (75.3%). Compared to those not detained, those detained were significantly more likely to be male (96.4% vs 76.9%, p = 0.004) and recruited in Kyiv (61.8% vs. 28.2%, p < 0.001).

Table 1.

Comparison of Detained and Not Detained Participant Characteristics (N=94)

Characteristic Valid
N		 Total
n (%)		 Not Detained
n (%)		 Detained
n (%)		 p-
value
Recruited in Kyiv 94 45 (47.9) 11 (28.2) 34 (61.8) 0.001
Mean days since release (SD) 92 171.4 (69.2) 166.3 (70.8) 175.1 (63.4) 0.550
Mean duration of last prison term –
months (SD)		 92 49.6 (27.1) 48.26 (27.9) 50.7 (26.7) 0.540
Mean age (SD) 94 35.7 (8.1) 37.6 (8.07) 34.3 (7.86) 0.053
Male gender 94 83 (88.3) 30 (76.9) 53 (96.4) 0.004
In a stable relationship 90 58 (64.4) 25 (67.6) 33 (62.3) 0.605
Secondary education or higher complete 94 60 (63.8) 27 (69.2) 33 (60.0) 0.359
Stable Housing 93 78 (83.9) 36 (92.3) 42 (77.8) 0.060
Income above poverty 93 30 (31.9) 8 (20.5) 22 (40.0) 0.046
Mean lifetime detentions not resulting in
sentencing to prison (SD)		 89 11.0 (11.7) 9.6 (13.08) 12.1 (10.6) 0.024
Mean lifetime prison sentences (SD) 94 2.9 (2.0) 3.05 (2.1) 2.87 (1.9) 0.984
Mean lifetime months in prison (SD) 90 91.3 (78.6) 116.8 (93.2) 73.8 (61.5) 0.035
Mean age of first incarceration (SD) 94 21.1 (6.3) 22.36 (6.9) 20.3 (5.7) 0.134
Screened positive for prior hazardous
drinking		 86 53 (61.6) 27 (73.0) 26 (53.0) 0.060
Screened positive for prior alcohol
dependence		 86 16 (18.6) 8 (21.6) 8 (16.3) 0.532
High drug abuse severity 94 77 (81.9) 29 (74.4) 48 (87.3) 0.109
Screened positive for opioid dependence 94 79 (84.0) 30 (75.9) 49 (89.1) 0.112
Current illegal opioid use 92 48 (49.5) 17 (45.9) 31 (58.3) 0.240
Current stimulant use 80 16 (20.0) 5 (14.3) 11 (24.4) 0.260
Current alcohol use 86 61 (70.9) 27 (71.1) 34 (70.8) 0.982
Current poly-substance use 81 49 49.4) 15 (40.5) 25 (56.8) 0.144
Ever injected drugs 94 91 (96.8) 36 (92.3) 55 (100.0) 0.068
Current drug injection 92 53 (57.6) 16 (42.1) 37 (68.4) 0.012
  Mean total injections last 30 days 53 13.5 (8.9) 11.3 (9.8) 14.4 (8.4) --
  Mean injections per injection day 51 1.8 (2.1) 1.6 (0.9) 2.4 (0.4) --
Any current high-risk injection 92 34 (37.0) 6 (15.8) 28 (51.9) <0.001
Current injection with used syringe 91 13 (14.3) 1 (2.6) 12 (22.6) 0.007
Current common liquid drug injection 92 32 (24.8) 6 (15.8) 26 (48.1) 0.002
Current unprotected sexual intercourse 92 22 (23.9) 9 (23.1) 13 (24.5) 0.872
  Mean episodes in past 30 days 22 1.8 (1.6) 1.3 (.7) 2.2 (1.9) --
Moderate to severe symptoms of depression 94 53 (56.4) 22 (56.4) 31 (56.4) 0.996
Mean Berger Scale global stigma score (SD) 91 110.3 (13.2) 110.0 (17.1) 110.5 (9.8) 0.721
Received HIV care post-release 85 61 (71.8) 25 (67.6) 36 (75.0) 0.450
Received ART post-release 89 26 (29.2) 6 (15.8) 20 (39.2) 0.016
Received OST post-release 88 28 (31.8) 6 (15.8) 22 (44.0) 0.005
Open in a new tab

Legend: SD=standard deviation; ART=antiretroviral therapy; OST=opioid substitution therapy

The mean duration of last prison term was 49.6 months, and the mean time since release was 171.4 days. Neither differed significantly by detention status (p=0.548 and p=0.673, respectively). The lifetime rates of incarceration and detentions not resulting in imprisonment were high, averaging 2.9 and 11.0, respectively.

The majority of respondents met pre-incarceration screening criteria for high drug abuse severity (81.9%), opioid dependence (84.0%) and hazardous drinking (61.6%); 18.6% met criteria for alcohol dependence. About half reported current illegal opioid use and one in five reported current stimulant use.

3.2 HIV transmission risk behaviors

A majority of respondents was currently injecting drugs (57.6%), with a mean of 1.8 injections per injection day. Overall, 37.0% met criteria for “high risk” injection, with 24.8% having drawn from a common liquid container and 14.3% sharing a syringe; 11.7% reported both. Those reporting detentions were significantly more likely to report “high risk” injections (51.9%, vs. 15.8%, p < 0.001).

3.3 Access to Post-Release Healthcare Services

Access to post-release healthcare services is presented in Table 1. Two thirds of all respondents (67.6%) reported receiving HIV care since release; however; less than a third received medications, including ART (29.2%) or OST (31.8%) and only 15.1% received both. Compared to those not detained, those detained were significantly more likely to have received both ART (39.2% vs. 15.8%, p = 0.016) and OST (44.0% vs. 15.8%, p = 0.005).

3.4 Correlates of Police Detention

Table 2 provides an overview of key detention events with 58.5% reporting at least one unofficial police detention post-release (range 1–30). Among those detained, the calculated mean annual detention rate was 9.4 per person-year.

Table 2.

Experiences Associated with Police Detention (N=94)

Detentions and Related Events Valid N n (%)
Detained (without charges) by Police After Release from Prison 94 55 (58.5)
Mean Number of Post-Release Detentions (among those detained) 55 4.3
Mean Annual Detention Rate Ratio (among those detained) 55 9.4
Needles or syringes confiscated during a detention (among those carrying
needles or syringes at time of detention)		 23 18 (78.3)
Experienced withdrawal during a detention (among those using drugs at time of detention) 49 34 (69.4)
ART interrupted during detention (among those detained while on therapy) 27 19 (70.4)
OST interrupted during detention (among those detained while on therapy) 28 19 (67.9)
Had restricted access to ART or OST used as a means to extract a confession
during a detention (among those on ART or OST)		 54 31 (57.4)
Detained en route to or from an OST site since release from prison (among those on OST since release) 27 23 (85.2)
Open in a new tab

Legend: ART=antiretroviral therapy; OST=opioid substitution therapy

Of 55 reporting detentions, 7 respondents experienced >5 episodes. As described in our methods, we report on only the 150 detentions for which we collected detailed data on detention experiences. Among those detained while on OST (N = 28), the majority (67.9%; 43 instances) reported at least one interruption lasting >24 hours. Among those detained while on ART (N = 27), over two-thirds (70.4%; 42 instances) experienced an interruption >24 hours. Likewise, over two-thirds (69.4%; 83 episodes) of those detained while using drugs (N = 49) reported experiencing withdrawal symptoms. Over three-quarters (78.3%; 34 total episodes) of those detained while carrying needles or syringes (N = 23) reported having them confiscated at least once. Among all those detained, 57.4% experienced police efforts to extract a confession through threats of withdrawal or withholding of medication. The vast majority (85.2%) of those prescribed OST reported arrest or harassment en route to or from an OST site.

The final logistic regression model for correlates of detention is depicted in Table 3. Significant independent correlates for detention included being prescribed ART post-release (AOR 4.98, p = 0.021), male gender (AOR 10.88 p = 0.010), high-risk injection practices (AOR 5.03, p = 0.011), and cumulative lifetime months in prison (AOR 0.99, p = 0.031). Time since release from prison did not significantly correlate with detention (p = 0.202)

Table 3.

Bivariate and multivariate correlates associated with police detention (N=94)

Parameter Bivariate Regression Multivariate Regression
UOR 95% CI p-value AOR 95% CI p-
value
Number of days since prison release 1.00 1.00 – 1.01 0.548 1.01 1.00 – 1.01 0.202
Male gender 7.95 1.61 – 39.23 0.011 10.88 1.78 – 66.57 0.010
Cumulative lifetime months in prison 0.99 0.99 – 0.99 0.015 0.99 0.99 – 0.99 0.031
Current high-risk injection (needle sharing or common container use past 30 days) 5.74 2.07 – 15.97 0.001 5.03 1.46 – 17.38 0.011
Prescribed antiretroviral therapy post-release 3.44 1.22 – 9.71 0.020 4.98 1.28 – 19.40 0.021
Corrected AIC = 94.37
Open in a new tab

Legend: UOR=unadjusted odds ratio; AOR=adjusted odds ratio; CI=confidence interval; AIC=Akaike Information Criterion

4. DISCUSSION

4.1 Police Detention and Its Impact on HIV Prevention and Treatment

Although the recently incarcerated, HIV-infected individuals represented in our data are particularly high-risk, this study is nonetheless the first, to our knowledge, to systemically quantify the prevalence of unofficial police detentions and related disruptions in ART and OST prescription among HIV-infected individuals in Ukraine. Importantly, over half of participants reported at least one detention since release from prison, which is consistent with prior findings of widespread detention and harassment of vulnerable groups associated with HIV risk, particularly PWID (Jürgens et al., 2010; 2011; Schleifer, 2009; Spicer et al., 2011). Moreover, the mean rate of detention among this group exceeded 9 episodes per person-year, suggesting the practice is not only prevalent but also recurrent, ultimately leading to disruptions in essential healthcare.

The finding that nearly three quarters of respondents detained while prescribed ART had experienced at least one interruption longer than 24 hours is consistent with prior findings of routine medication interruption during incarceration (Wolfe et al., 2010) and of associations between detention or other police interdiction efforts and ART non-adherence and discontinuation, or non-persistence (Bae et al., 2011), in Ukraine (Mimiaga et al., 2010) and elsewhere (Clements-Nolle et al., 2008; Kerr et al., 2005; Small et al., 2009). Considering that even short ART interruptions are linked with the development of drug resistance (Oyugi et al., 2007)1 and poor virologic outcomes (Liu et al., 2006; Malta et al., 2010), this finding is extremely troubling, particularly given the frequency of detention observed in our study.

Among those detained while on OST, over two-thirds experienced an interruption exceeding 24 hours. While disturbing, this finding is not surprising; though approved for use in Ukrainian pre-trial detention settings in 2012 (but still not provided), OST was not available in any prison or detention setting at the time of this study, meaning any detention >24h would presumably have involved missing OST doses. The significant HIV-related benefits that OST confers on this high-risk population are threatened by such interruptions. Retention in community-based OST programs is associated with improved HIV outcomes (Altice et al., 2011; Roux et al., 2009), moderated risk behavior and, perhaps most importantly, reduced HIV incidence (Bruce, 2009; Metzger et al., 2010). Similar results are documented in criminal justice settings (Hedrich et al., 2012; Jürgens et al., 2009) and after release to the community (Springer et al., 2012). Disruption of daily OST is associated with decreased long-term treatment retention, relapse to drug injection, higher rates of HCV seroconversion, and increased likelihood of incarceration (Hedrich et al., 2012). Moreover, prolonged OST lapses may result in reduced tolerance to opioids and resultant subsequent overdose, which contributes to a high incidence of post-release death among individuals who use opioids (Binswanger and Wortzel, 2009) when OST is not provided (Kinlock et al., 2009).

Our analysis, while limited by a small sample size, indicated that receiving ART post-release was an independent correlate of detention. There are limited data to help interpret this potentially critical finding (or the similar bivariate association observed between access to OST and detention). We surmise, however, that at least some of those detained may have been detained en route to or from an ART or OST site, evidenced by the large number of OST recipients reporting police harassment while accessing services. Moreover, qualitative studies have implicated police targeting individuals prescribed ART and OST while accessing treatment (Mimiaga et al., 2010; Schleifer, 2009). The need to physically access services and the requirement that individuals receiving either service “register” with authorities both dramatically increase the visibility of PWID who may otherwise remain hidden from authorities (Izenberg and Altice, 2010). Additionally, provider stigmatization of PWID, who constitute the majority of HIV-infected individuals, means PWID cannot necessarily expect their treatment providers to protect them (Cooper et al., 2005; Wolfe et al., 2010). While our data allow us only to speculate on causal mechanisms, there is reason to believe that accessing ART and OST may in effect be a risk factor for targeted detention, which in turn raises a substantial barrier for those most in need of these services. Further research into this association is warranted.

Another strong correlation identified by our model was that of high-risk injection practices and unofficial detentions. Without drawing any definitive conclusions, at least two possible mechanisms linking detention and high-risk injection are plausible. The first is that profound withdrawal from opioids during detention leads to desperation and disregard for safe injecting practices. This mechanism is suggested by prior research demonstrating increased high-risk injection behavior following prison terms (Wood et al., 2005). The second is that fear of future detention (and confiscation of syringes) among having experienced detentions may encourage use of high-risk venues like shooting galleries where contaminated injection equipment and drugs are readily available and easily dispensable without risk of re-arrest. Both mechanisms have been observed in prior research (Bastos and Strathdee, 2000; Rhodes et al., 2003; 2005; Schleifer, 2009; Spicer et al., 2011; Strathdee et al., 2010; Werb et al., 2008). Irrespective of the forces at play, this is clearly a high-risk group that merits access to risk reduction services such as OST and/or adequate amounts of sterile injection equipment.

Though we found that male gender was highly correlated with being detained, this finding should be interpreted with caution due to the small number of women surveyed. Despite this, detained and imprisoned populations are disproportionately male (Hudson et al., 2011), including those with HIV (Stein et al., 2012), and it is possible that men are more frequently targeted by Ukrainian police. The finding that fewer cumulative lifetime months in prison were associated with detention could be that explained by the fact that PWID with more prison experience are more “street-wise,” having larger social networks and easier access to drugs thus less visibility to police. This explanation is admittedly speculative, however, and further research will be required to understand this better.

4.2 Limitations

This study has several important limitations. First, data were obtained by self-report leading to possible underreporting of sensitive measures including detention; however, observed rates of detention were high, suggesting this to be unlikely. Furthermore, limited police cooperation makes it difficult to imagine a better immediately available approach. Second, respondents had been out of prison for varying lengths of time, raising the possibility that the outcome was confounded by risk timeframe. We controlled for this bias by establishing no bivariate relationship between time since prison-release and detention and retaining this in our final model. Third, all data were derived from structured interviews, limiting the detail with which we were able to characterize individual detentions; thus we cannot describe the durations of and reasons for detentions and for medication interruptions we can only determine that they exceeded 24 hours. This study, nonetheless, is one of the first to quantitatively characterize detention and key related adverse events in a population that can profoundly and negatively be impacted by detentions. Finally, due to resource limitations and a hidden target population, we recruited a convenience sample from two major Ukrainian cities in lieu of a random representative sample. While this limits generalizability, our findings provide a substantial first look at this complex problem, and our sample size of 97 HIV-infected, recently released prisoners represents a substantial portion of this population and will be useful in guiding further research.

4.3 Directions for future research

Given the limitations described above, future research efforts might focus on a more detailed understanding of the mechanisms by which medication interruptions and other adverse events occur, better characterization of the most frequently targeted populations, and gathering of additional data such as detention length, much of which could be accomplished through a longitudinal design. Perhaps more important, however, is the building of better partnerships between police and public health authorities. Recent programs of this sort in Southeast Asia show promise for better these groups in combating HIV (Beyrer, 2012; Chheng et al., 2012; Jardine et al., 2012; Sharma and Chatterjee, 2012). While the potential success of similar efforts in Ukraine remains unknown, these approaches are promising and should be piloted for study and eventual large-scale implementation in the region.

4.4 Conclusions

The first decade of this century saw a substantial increase in HIV incidence in Eastern Europe and Central Asia even while the rest of the world saw declines (UNAIDS, 2010). As opposed to many regions where reductions in HIV occurred, the epidemic in this region has been largely driven by PWID. Among this group, HIV prevention has been undermined by a harsh, punitive political and social climate that features frequent and long-term imprisonment, limited harm-reduction services, extreme stigmatization, and widespread police abuse toward PWID (Atun and Olynik, 2008; Barcal et al., 2005; Cohen, 2010; UNAIDS, 2010; Wolfe et al., 2010; Wolfe and Cohen, 2010). While our data are derived from a subset of recently imprisoned HIV-infected individuals in Ukraine, there is little reason to think the situation is much different for other HIV-infected individuals, particularly PWID. These data advance earlier investigations by providing quantitative documentation of frequent, systematic police detention of HIV-infected PWID in which ART and OST are routinely interrupted, injecting equipment is frequently confiscated, and withdrawal is commonplace. All of these events contribute significantly to the ‘HIV risk-environment’, inhibiting access and adherence to free ART and OST and thus undermining these services’ promised benefits while potentially contributing to drug resistance, encouraging risky behavior, and further marginalizing an extremely vulnerable population. If Ukraine and its regional neighbors are to successfully control a rapidly growing HIV epidemic, the agendas of law enforcement and public health must be better coordinated, widespread police detention and intimidation of high-risk individuals should not be tolerated, and both ART and OST, where indicated, must be guaranteed to those detained for any reason and for any duration.

Acknowledgements

We would like to acknowledge the assistance of Tiara Winn, Maua Herme, and Artem Kopelev at the Yale University AIDS Program for data management, guidance from Dr. Jeffrey Wickersham of the Yale University School of Medicine and Dr. Russel Barbour of the Yale Center for Interdisciplinary Research on AIDS on data analysis, and the organizational and translation assistance of the staff of the Ukrainian Institute for Public Health Policy.

Author Disclosures

Role of Funding Source

Funding for this project was provided in part by the International Renaissance Foundation, Kyiv, Ukraine as well grants from from the National Institute on Drug Abuse for research (R01 DA033679 and R01 DA029910) and for career development (K24 DA017072) and the Yale University School of Medicine’s Office of Student Research and Yale University Global Health Initiative. No funding source had any role in study design, collection or analysis of data, writing or review of the manuscript, or decision to submit this paper for publication.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Contributors

JI participated in study design, survey preparation, and data analysis and wrote the manuscript

CB, MS participated in study design, data analysis, and critical editing of the manuscript

SD, TK participated in study design, survey preparation, study logistics, data collection, and critical editing of the manuscript

FLA participated in study design, survey preparation, study logistics, and critical editing of the manuscript

Conflicts of Interest

All authors declare that they have no conflicts of interest

REFERENCES

  1. Alistar SS, Owens DK, Brandeau ML. Effectiveness and cost effectiveness of expanding harm reduction and antiretroviral therapy in a mixed HIV epidemic: a modeling analysis for Ukraine. PLoS Med. 2011;8:e1000423. doi: 10.1371/journal.pmed.1000423. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Allen JP, Reinert DF, Volk RJ. The alcohol use disorders identification test: an aid to recognition of alcohol problems in primary care patients. Prev. Med. 2001;33:428–433. doi: 10.1006/pmed.2001.0910. [DOI] [PubMed] [Google Scholar]
  3. Altice FL, Bruce RD, Lucas GM, Lum PJ, Korthuis PT, Flanigan TP, Cunningham CO, Sullivan LE, Vergara-Rodriguez P, Fiellin DA, Cajina A, Botsko M, Nandi V, Gourevitch MN, Finkelstein R BHIVES Collaborative. HIV treatment outcomes among HIV-infected, opioid-dependent patients receiving buprenorphine/naloxone treatment within HIV clinical care settings: results from a multisite study. J. Acquir. Immune Defic. Syndr. 2011;56(Suppl. 1):S22–S32. doi: 10.1097/QAI.0b013e318209751e. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Altice FL, Kamarulzaman A, Soriano VV, Schechter M, Friedland GH. Treatment of medical, psychiatric, and substance-use comorbidities in people infected with HIV who use drugs. Lancet. 2010;376:367–387. doi: 10.1016/S0140-6736(10)60829-X. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Atun R, Olynik I. Resistance to implementing policy change: the case of Ukraine. Bull. World. Health Organ. 2008;86:147–154. doi: 10.2471/BLT.06.034991. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. The Alcohol Use Disorders Identification Test (No. WHO/MSD/MSB/01.6a) World Health Organization. 2001 [Google Scholar]
  7. Bae JW, Guyer W, Grimm K, Altice FL. Medication persistence in the treatment of HIV infection: a review of the literature and implications for future clinical care and research. AIDS. 2011;25:279–290. doi: 10.1097/QAD.0b013e328340feb0. [DOI] [PubMed] [Google Scholar]
  8. Balakiryeva OM, Bondar TV, Sereda YV, Sazonova YO. Analytical Report. Kyev, Ukraine: International HIV/AIDS Alliance in Ukraine; 2012. [Google Scholar]
  9. Barcal K, Barcal K, Schumacher JE, Schumacher JE, Dumchev K, Dumchev K, Moroz LV, Moroz LV. A situational picture of HIV/AIDS and injection drug use in Vinnitsya, Ukraine. Harm Reduct. J. 2005;2:16. doi: 10.1186/1477-7517-2-16. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Bastos FI, Strathdee SA. Evaluating effectiveness of syringe exchange programmes: current issues and future prospects. Soc. Sci. Med. 2000;51:1771–1782. doi: 10.1016/s0277-9536(00)00109-x. [DOI] [PubMed] [Google Scholar]
  11. Beyrer C. Afterword: Police, policing, and HIV: new partnerships and paradigms. Harm Reduct. J. 2012;9:32. doi: 10.1186/1477-7517-9-32. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Binswanger IA, Wortzel HS. Treatment for individuals with HIV/AIDS following release from prison. JAMA. 2009;302:147. doi: 10.1001/jama.2009.919. author reply 148–author reply 148. [DOI] [PubMed] [Google Scholar]
  13. Bobrovskyy O, Bochkova L, Eschenko O, Hayovych Y, Kobyschcha Y, Kruhlov Y, Kuzin I, Martsynovksa V, Nechosina O, Nikolko M, Nizova N, Pygolenko I, Saliuk T, Sharapka K, Shcherbinska A, Shvab I, Shyder Y, Sosidko T, Varetska O, Zelenska M, Zelinskiy Y, Zhyinas O. Ukraine Harmonized AIDS Respose Progress Report. Kyiv, Ukraine: International HIV/AIDS Alliance in Ukraine; 2012. [Google Scholar]
  14. Booth RE, Lehman WEK, Dvoryak S, Brewster JT, Sinitsyna L. Interventions with injection drug users in Ukraine. Addiction (Abingdon, England) 2009;104:1864–1873. doi: 10.1111/j.1360-0443.2009.02660.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Bruce RD. Methadone as HIV prevention: high volume methadone sites to decrease HIV incidence rates in resource limited settings. Int. J. Drug Policy. 2009;21:122–124. doi: 10.1016/j.drugpo.2009.10.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Bruce RD, Dvoryak S, Sylla L, Altice FL. HIV treatment access and scale-up for delivery of opiate substitution therapy with buprenorphine for IDUs in Ukraine-programme description and policy implications. Int. J. Drug Policy. 2007;18:326–328. doi: 10.1016/j.drugpo.2006.12.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Bruce RD, Schleifer RA. Ethical and human rights imperatives to ensure medication-assisted treatment for opioid dependence in prisons and pre-trial detention. Int. J. Drug Policy. 2008;19:17–23. doi: 10.1016/j.drugpo.2007.11.019. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Bullinger M, Alonso J, Apolone G, Leplège A, Sullivan M, Wood-Dauphinee S, Gandek B, Wagner A, Aaronson N, Bech P, Fukuhara S, Kaasa S, Ware JE. Translating health status questionnaires and evaluating their quality: the IQOLA Project approach. International Quality of Life Assessment. J. Clin. Epidemiol. 1998;51:913–923. doi: 10.1016/s0895-4356(98)00082-1. [DOI] [PubMed] [Google Scholar]
  19. Burruano L, Kruglov Y. HIV/AIDS epidemic in Eastern Europe: recent developments in the Russian Federation and Ukraine among women. Gend. Med. 2009;6:277–289. doi: 10.1016/j.genm.2009.04.009. [DOI] [PubMed] [Google Scholar]
  20. Chen NE, Meyer JP, Avery AK, Draine J, Flanigan TP, Lincoln T, Spaulding AC, Springer SA, Altice FL. Adherence to HIV treatment and care among previously homeless jail detainees. AIDS Behav. 2011 doi: 10.1007/s10461-011-0080-2. epub ahead of print. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Chheng K, Leang S, Thomson N, Moore T, Crofts N. Harm reduction in Cambodia: a disconnect between policy and practice. Harm Reduct. J. 2012;9:30. doi: 10.1186/1477-7517-9-30. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Clements-Nolle K, Marx R, Pendo M, Loughran E, Estes M, Katz M. Highly active antiretroviral therapy use and HIV transmission risk behaviors among individuals who are HIV infected and were recently released from jail. Am. J. Public Health. 2008;98:661–666. doi: 10.2105/AJPH.2007.112656. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Cohen Jon. Law enforcement and drug treatment: a culture clash. Science. 2010;329:169. doi: 10.1126/science.329.5988.169. [DOI] [PubMed] [Google Scholar]
  24. Cooper H, Moore L, Gruskin S, Krieger N. The impact of a police drug crackdown on drug injectors' ability to practice harm reduction: a qualitative study. Soc. Sci. Med. 2005;61:673–684. doi: 10.1016/j.socscimed.2004.12.030. [DOI] [PubMed] [Google Scholar]
  25. Gowing L, Farrell M, Bornemann R, Sullivan L, Ali R. Substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst. Rev. 2008:CD004145. doi: 10.1002/14651858.CD004145.pub3. [DOI] [PubMed] [Google Scholar]
  26. Hedrich D, Alves P, Farrell M, Stöver H, Møller L, Mayet S. The effectiveness of opioid maintenance treatment in prison settings: a systematic review. Addiction (Abingdon, England) 2012;107:501–517. doi: 10.1111/j.1360-0443.2011.03676.x. [DOI] [PubMed] [Google Scholar]
  27. Hudson AL, Nyamathi A, Bhattacharya D, Marlow E, Shoptaw S, Marfisee M, Leake B. Impact of prison status on HIV-related risk behaviors. AIDS Behav. 2011;15:340–346. doi: 10.1007/s10461-009-9570-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Izenberg JM, Altice FL. Next steps for Ukraine abolition of HIV registries, implementation of routine human immunodeficiency virus testing and expansion of services. Addiction (Abingdon, England) 2010;105:569–570. doi: 10.1111/j.1360-0443.2009.02881.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Jardine MM, Van Anh VA Thi Nguyen, Khuat THT. Case study: methadone maintenance treatment in Hanoi, Vietnam. Harm Reduct. J. 2012;9:26–26. doi: 10.1186/1477-7517-9-26. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Judice N, Zaglada O, Mbuya-Brown R. HIV Policy Assessment: Ukraine. Futures Group, Health Policy Project, USAID; 2011. [Google Scholar]
  31. Jürgens R, Ball A, Verster A. Interventions to reduce HIV transmission related to injecting drug use in prison. Lancet Infect. Dis. 2009;9:57–66. doi: 10.1016/S1473-3099(08)70305-0. [DOI] [PubMed] [Google Scholar]
  32. Jürgens R, Csete J, Amon JJ, Baral S, Beyrer C. People who use drugs, HIV, and human rights. Lancet. 2010;376:475–485. doi: 10.1016/S0140-6736(10)60830-6. [DOI] [PubMed] [Google Scholar]
  33. Jürgens R, Nowak M, Day M. HIV and incarceration: prisons and detention. J. Int. AIDS Soc. 2011;14:26. doi: 10.1186/1758-2652-14-26. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Kerr T, Marshall A, Walsh J, Palepu A, Tyndall M, Montaner J, Hogg R, Wood E. Determinants of HAART discontinuation among injection drug users. AIDS Care. 2005;17:539–549. doi: 10.1080/09540120412331319778. [DOI] [PubMed] [Google Scholar]
  35. Kinlock TW, Gordon MS, Schwartz RP, Fitzgerald TT, O’Grady KE. A randomized clinical trial of methadone maintenance for prisoners: results at 12 months postrelease. J. Subst. Abuse Treat. 2009;37:277–285. doi: 10.1016/j.jsat.2009.03.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Kruglov The most severe HIV epidemic in Europe: Ukraine's national HIV prevalence estimates for 2007. Sex. Transm. Infect. 2008;84(Suppl. 1):i37–i41. doi: 10.1136/sti.2008.031195. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Liu H, Miller LG, Hays RD, Golin CE, Wu T, Wenger NS, Kaplan AH. Repeated measures longitudinal analyses of HIV virologic response as a function of percent adherence, dose timing, genotypic sensitivity, and other factors. J. Acquir.Immune Defic. Syndr. 2006;41:315–322. doi: 10.1097/01.qai.0000197071.77482.6e. [DOI] [PubMed] [Google Scholar]
  38. Malta M, Magnanini MMF, Strathdee SA, Bastos FI. Adherence to antiretroviral therapy among HIV-infected drug users: a meta-analysis. AIDS Behav. 2010;14:731–747. doi: 10.1007/s10461-008-9489-7. [DOI] [PubMed] [Google Scholar]
  39. Mathers BM, Degenhardt L, Ali H, Wiessing L, Hickman M, Mattick RP, Myers B, Ambekar A, Strathdee SA. Reference Group to the UN on HIV and Injecting Drug Use, 2010. HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage. Lancet. 2009;375:1014–1028. doi: 10.1016/S0140-6736(10)60232-2. [DOI] [PubMed] [Google Scholar]
  40. Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, Wodak A, Panda S, Tyndall M, Toufik A, Mattick RP. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet. 2008;372:1733–1745. doi: 10.1016/S0140-6736(08)61311-2. [DOI] [PubMed] [Google Scholar]
  41. Metzger DS, Woody GE, O'brien CP. Drug treatment as HIV prevention: a research update. J. Acquir. Immune Defic. Syndr. 2010;55(Suppl. 1):S32–S36. doi: 10.1097/QAI.0b013e3181f9c10b. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Mimiaga MJ, Safren SA, Dvoryak S, Reisner SL, Needle R, Woody G. “We fear the police, and the police fear us”: structural and individual barriers and facilitators to HIV medication adherence among injection drug users in Kiev, Ukraine. AIDS Care. 2010;22:1305–1313. doi: 10.1080/09540121003758515. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Neumann T, Neuner B, Gentilello LM, Weiss-Gerlach E, Mentz H, Rettig JS, Schröder T, Wauer H, Müller C, Schütz M, Mann K, Siebert G, Dettling M, Müller JM, Kox WJ, Spies CD. Gender differences in the performance of a computerized version of the alcohol use disorders identification test in subcritically injured patients who are admitted to the emergency department. Alcohol. Clin. Exp. Res. 2004;28:1693–1701. doi: 10.1097/01.alc.0000145696.58084.08. [DOI] [PubMed] [Google Scholar]
  44. Nieburg P, Carty L. Injection Drug Use in Ukraine. C.S.I.S. 2012 Mar; [Google Scholar]
  45. Nilssen O, Averina M, Brenn T, Brox J, Kalinin A, Archipovski V. Alcohol consumption and its relation to risk factors for cardiovascular disease in the northwest of Russia: the Arkhangelsk study. Intl. J. Epidemiol. 2005;34:781–788. doi: 10.1093/ije/dyi078. [DOI] [PubMed] [Google Scholar]
  46. Oyugi JH, Byakika-Tusiime J, Ragland K, Laeyendecker O, Mugerwa R, Kityo C, Mugyenyi P, Quinn TC, Bangsberg DR. Treatment interruptions predict resistance in HIV-positive individuals purchasing fixed-dose combination antiretroviral therapy in Kampala, Uganda. AIDS. 2007;21:965–971. doi: 10.1097/QAD.0b013e32802e6bfa. [DOI] [PubMed] [Google Scholar]
  47. Peng C-Z, Wilsnack RW, Kristjanson AF, Benson P, Wilsnack SC. Gender differences in the factor structure of the Alcohol Use Disorders Identification Test in multinational general population surveys. Drug Alcohol Depend. 2012;124:50–56. doi: 10.1016/j.drugalcdep.2011.12.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Rhodes T, Mikhailova L, Sarang A, Lowndes CM, Rylkov A, Khutorskoy M, Renton A. Situational factors influencing drug injecting, risk reduction and syringe exchange in Togliatti City, Russian Federation: a qualitative study of micro risk environment. Soc. Sci. Med. 2003;57:39–54. doi: 10.1016/s0277-9536(02)00521-x. [DOI] [PubMed] [Google Scholar]
  49. Rhodes T, Singer M, Bourgois P, Friedman SR, Strathdee SA. The social structural production of HIV risk among injecting drug users. Soc. Sci. Med. 2005;61:1026–1044. doi: 10.1016/j.socscimed.2004.12.024. [DOI] [PubMed] [Google Scholar]
  50. Roux P, Carrieri MP, Cohen J, Ravaux I, Poizot-Martin I, Dellamonica P, Spire B. Retention in opioid substitution treatment: a major predictor of long-term virological success for HIV-infected injection drug users receiving antiretroviral treatment. Clin. Infect. Dis. 2009;49:1433–1440. doi: 10.1086/630209. [DOI] [PubMed] [Google Scholar]
  51. Schleifer R. Rhetoric and Risk-Human Rights Abuses Impeding Ukraine’s Fight against HIV/AIDS. New York: Human Rights Watch; 2009. [Google Scholar]
  52. Sharma M, Chatterjee A. Partnering with law enforcement to deliver good public health: the experience of the HIV/AIDS Asia regional program. Harm Reduct. J. 2012;9:24. doi: 10.1186/1477-7517-9-24. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Skinner HA. The drug abuse screening test. Addict. Behav. 1982;7:363–371. doi: 10.1016/0306-4603(82)90005-3. [DOI] [PubMed] [Google Scholar]
  54. Small W, Wood E, Betteridge G, Montaner J, Kerr T. The impact of incarceration upon adherence to HIV treatment among HIV-positive injection drug users: a qualitative study. AIDS Care. 2009;21:708–714. doi: 10.1080/09540120802511869. [DOI] [PubMed] [Google Scholar]
  55. Spicer N, Bogdan D, Brugha R, Harmer A, Murzalieva G, Semigina T. ‘It’s risky to walk in the city with syringes': understanding access to HIV/AIDS services for injecting drug users in the former Soviet Union countries of Ukraine and Kyrgyzstan. Global Health. 2011;7:22. doi: 10.1186/1744-8603-7-22. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Springer SA, Qiu J, Saber-Tehrani AS, Altice FL. Retention on buprenorphine is associated with high levels of maximal viral suppression among HIV-infected opioid dependent released prisoners. PLoS ONE. 2012;7:e38335. doi: 10.1371/journal.pone.0038335. [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Stein MS, Spaulding AC, Cunningham M, Messina LC, Kim BI, Chung K-W, Draine J, Jordan AO, Harrison A, Avery AK, Flanigan TP. HIV-positive and in jail: race, risk factors, and prior access to care. AIDS Behav. 2012 doi: 10.1007/s10461-012-0340-9. epub ahead of print. [DOI] [PubMed] [Google Scholar]
  58. Strathdee SA, Hallett TB, Bobrova N, Rhodes T, Booth R, Abdool R, Hankins CA. HIV and risk environment for injecting drug users: the past, present, and future. Lancet. 2010;376:268–284. doi: 10.1016/S0140-6736(10)60743-X. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. UNAIDS. Global Report. New York: Joint United Nations Program on HIV/AIDS; 2010. [Google Scholar]
  60. Uusküla A, Laisaar K-T, Raag M, Smidt J, Semjonova S, Kogan J, Amico KR, Sharma A, Dehovitz J. Antiretroviral therapy (ART) adherence and correlates to nonadherence among people on ART in Estonia. AIDS Care. 2012;24:1470–1479. doi: 10.1080/09540121.2012.672724. [DOI] [PubMed] [Google Scholar]
  61. Werb D, Wood E, Small W, Strathdee S, Li K, Montaner J, Kerr T. Effects of police confiscation of illicit drugs and syringes among injection drug users in Vancouver. Int. J. Drug Policy. 2008;19:332–338. doi: 10.1016/j.drugpo.2007.08.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  62. Wolfe D, Carrieri MP, Shepard D. Treatment and care for injecting drug users with HIV infection: a review of barriers and ways forward. Lancet. 2010;376:355–366. doi: 10.1016/S0140-6736(10)60832-X. [DOI] [PubMed] [Google Scholar]
  63. Wolfe D, Cohen Jonathan. Human rights and HIV prevention, treatment, and care for people who inject drugs: key principles and research needs. J. Acquir. Immune Defic. Syndr. 2010;55(Suppl. 1):S56–S62. doi: 10.1097/QAI.0b013e3181f9c0de. [DOI] [PubMed] [Google Scholar]
  64. Wood E, Kerr T, Tyndall MW, Montaner JSG. A review of barriers and facilitators of HIV treatment among injection drug users. AIDS. 2008;22:1247–1256. doi: 10.1097/QAD.0b013e3282fbd1ed. [DOI] [PubMed] [Google Scholar]
  65. Wood E, Li K, Small W, Montaner JS, Schechter MT, Kerr T. Recent incarceration independently associated with syringe sharing by injection drug users. Public Health Rep. 2005;120:150–156. doi: 10.1177/003335490512000208. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES