Supporting the Health of HIV-Positive People Who Inject Drugs During COVID-19 and Beyond: Lessons for the United States from St. Petersburg, Russia

People who use drugs have faced unique challenges during the COVID-19 pandemic. As the pandemic began, experts voiced particular concern for the welfare of people who inject drugs and are living with HIV (PWID with HIV), anticipating they would experience more severe COVID-19,^1,2 reduced access to essential health care services, and increased social isolation.^2–4

In the United States, an estimated 13% of the total population of adults 18 years or older reported initiating or increasing substance use since the start of the pandemic,⁵ and the annual incidence of fatal overdose increased more than 30% between 2019 and 2020, when an estimated 93 000 people died of this cause.⁶ These troubling statistics emerged even as regulations for the provision of medications for opioid use disorder (MOUD) were relaxed in a concerted effort to improve access to this life-saving form of care during pandemic restrictions.⁷ Though certain success stories have emerged from these policy changes,⁸ evidence also suggests that barriers to treatment may have persisted—or emerged anew—during the pandemic.⁹ Currently, we lack a comprehensive understanding of the drivers of and interactions between these many challenges faced by PWID with HIV during the pandemic. A careful consideration of how PWID with HIV living in other high-income nations have fared during the pandemic could offer much-needed insight for making sense of these seemingly contradictory substance use–related outcomes and policy changes in the United States.

The Russian Federation (Russia) faces a growing HIV epidemic historically concentrated among PWID.¹⁰ Independent organizations estimate that as many as 2 million Russians are living with HIV,¹¹ of whom only 63% know their HIV status and as little as 41% are virally suppressed.¹² PWID in Russia experience poor access to essential harm reduction services,¹³ no access at all to MOUD (both methadone and buprenorphine are classified as illegal substances in Russia),¹⁴ and poor linkage to HIV care overall.¹⁵ Furthermore, more than 7000 people died of drug overdoses in Russia in 2020, a 60% increase since 2019.¹⁶

Our recent research has explored the pandemic-related impacts on PWID with HIV in Russia as a comparison case with the US experience. From April to July 2021, we conducted interviews with 13 residents of St. Petersburg, Russia (purposively sampled; age range, 28–56 years; 46% female; 54% unemployed; all consented participants recruited from a randomized controlled trial¹⁷ with ClinicalTrials.gov identifier: NCT03695393). All reported current- or past-year illicit methadone use (none reported using cathinones, or “salts,” which is increasingly popular in younger populations), all were living with HIV, and all were identified through participation in local harm reduction programs. We also interviewed 11 health care and harm reduction professionals (age range, 36–54 years; 55% female; purposive sample identified via professional networks) who provide services for PWID with HIV in St. Petersburg, a high-incidence, high-prevalence hot spot of the HIV epidemic in Russia. All participants provided verbal consent and received an incentive of 2500 rubles (∼34 USD at the time of the study).

Findings from these interviews suggest that PWID with HIV in St. Petersburg may be uniquely vulnerable to negative pandemic impacts; however, they may also have experienced relief from—or exacerbations of—structural harms that have long been drivers of negative health outcomes among this population. Specifically, the following pandemic impacts may have affected this population: (1) impacts on the drug market, (2) the easing of some barriers to health care, and (3) the worsening stigma and other barriers to care. We elaborate on these trends below and offer our thoughts on how insights from this study may be useful for US health care providers and policymakers seeking to mitigate negative pandemic effects and improve overall health and well-being for PWID with HIV in the United States.

IMPACTS ON THE DRUG MARKET

In the early stages of the pandemic, experts hypothesized that patterns of substance use and overdose would be affected by (1) mobility restrictions faced by those participating in drug markets, including difficulty crossing borders and moving through cities; (2) temporary reduction in and subsequent renormalization of global trade and supply chains; and (3) changes in the kind and severity of law enforcement activity at the local level.¹⁸ Our data suggest that these impacts were observable but limited in effect.

Drug markets in cities across Eastern Europe are transitioning to dark Web sales and delivery via “dead drops.”¹⁹ In St. Petersburg, making purchases from Web site stores and then arranging anonymous “drops” of their purchased goods has become the predominant method for obtaining opioids, stimulants, and other drugs. In the first weeks of the pandemic, when St. Petersburg residents were under strict lockdown, PWID with whom we spoke reported that accessing dead drops became riskier. With few people on the streets during the early days of lockdown, at the very start of pandemic restrictions, many more police than usual patrolled the streets to enforce the quarantine. In this short period, some reported reducing the frequency of their drug use. Others reported pooling money with friends and purchasing larger quantities to reduce the frequency of excursions to dead drop locations. Within a few weeks, however, local residents increasingly left their homes, and this aspect of drug procurement renormalized.

Importantly, the PWID with whom we spoke in St. Petersburg reported no significant changes in drug availability—or in their own drug use behaviors. Most reported lower drug quality and higher drug prices, but this was generally described as a long-term market trend, not a result of the pandemic. None reported needing alternative strategies for obtaining drugs because of market disruption.

EASING OF STRUCTURAL HARMS AND REDUCED BARRIERS TO CARE

Notably, PWID with HIV in St. Petersburg experienced many positive effects of the pandemic. The most noteworthy of these was the reprieve from regular police harassment. Some experts predicted that overpolicing of PWID would increase—or have worse impacts—during the pandemic.¹⁸ Many interview participants, however, described the opposite effect. During the first few weeks of strict lockdown, more police were out on the street to enforce the quarantine order. Yet, participants universally described this as a short-lived phenomenon; some estimated that the lockdown, for all practical purposes, lasted less than one month, at which time visible police presence across St. Petersburg decreased significantly.

Before the pandemic, PWID with HIV described police officers in Russia extorting them for bribes, making false accusations, and planting false evidence to ensure an arrest.^20,21 Many described such police stops and interactions as frequent occurrences before the pandemic. All explicitly stated they had experienced no police interaction related to substance use, and many reported no police contact at all, since the pandemic began. Some participants suggested that concerns about SARS-CoV-2 transmission reduced police officers’ enthusiasm for interacting with anyone on the street.

Interview participants also reported that pandemic-related changes in the delivery of HIV care effectively transformed Russia’s high-barrier HIV care system into more accessible care for those who sought treatment. This was due, in large part, to the implementation of prescription refill services by phone. In-person visits for prescription refills were no longer necessary for patients already receiving antiretroviral therapy (ART). In addition, the process of initiating ART was streamlined, and home delivery of ART became available on demand, removing the burden of long commutes to St. Petersburg’s centrally located AIDS center, where many PWID with HIV receive treatment. Ending such hours-long commutes to the AIDS center was a distinctly positive outcome of the pandemic for some patients.

WORSENING IMPACTS OF STIGMA AND OTHER BARRIERS TO CARE

Participants also reported several negative impacts of the COVID-19 pandemic on PWID with HIV in St. Petersburg, including reduced access to addiction treatment and barriers to meaningful COVID-19 prevention measures because of stigma against PWID. For instance, according to providers of outpatient treatment of substance use disorders, as much as 80% of persons receiving addiction treatment had been sentenced by the courts to 3 months of mandated treatment at their facility. The remaining 20%, they reported, received outpatient treatment voluntarily. Because of the extensive face-to-face interactions required for psychotherapy, the outpatient addiction treatment facility was officially shut down during the pandemic. This left all patients in a bind: those voluntarily seeking treatment were left without (but wanting) care, whereas court-ordered patients could not make progress toward the completion of their sentences.

As has been seen elsewhere,²² PWID with HIV experienced similarly poor access to COVID-19 prevention measures, often for reasons related to HIV and drug use stigma in outpatient care settings. Most PWID with HIV with whom we spoke were not interested in and did not voluntarily seek out COVID-19 testing. Some, however, were forced to pursue testing to access inpatient detoxification services. Although most hospital facilities can perform COVID-19 tests on-site, the addiction treatment facility was not approved to do so. Addiction treatment providers were therefore forced to refer patients seeking inpatient detoxification to COVID-19 testing centers elsewhere. That referral consisted of a written document indicating the patient’s association with the addiction treatment facility, essentially outing them to other health care providers as PWID. Nearly all patients who entered the detoxification program ended up paying out of pocket for a COVID-19 test at a private clinic rather than having to disclose their substance use at the primary care facility.

PWID with HIV anticipated similar barriers to the COVID-19 vaccine. Several shared the perception that most residents of St. Petersburg believe that a person with HIV must be someone who uses drugs, which would deprioritize this group for vaccine access. Many other PWID with HIV believed that the vaccine was contraindicated by their HIV status, meaning they could not safely receive it. Thus, despite Russia’s status as the first country worldwide to make a COVID-19 vaccine publicly available, most PWID with HIV did not even consider receiving one; they were so confident that they would be denied access to the vaccine for one reason or another that they all considered the question moot.

SUPPORTING DRUG USER HEALTH BEYOND THE PANDEMIC

PWID globally are at heightened risk of negative health impacts during the COVID-19 pandemic.^1–4 Efforts have been made to mitigate these harms in the United States, including the loosening of regulations regarding access to MOUD,⁷ but these changes have not prevented record numbers of overdose deaths during the pandemic.⁶ What pieces of the puzzle are US policymakers missing? Our qualitative research conducted in Russia’s second largest urban center underscores several key features of COVID-19’s impact on PWID with HIV, and PWID in general, that are not well captured in current narratives of disproportionate harm.

First, changes in both practice and policy during the pandemic produced several noteworthy improvements in the treatment access and overall quality of life enjoyed by PWID with HIV in St. Petersburg. Punitive criminal policies and aggressive policing of PWID have long hampered efforts to reduce the harms associated with substance use in Russia; in particular, extrajudicial arrests of PWID are both common and associated with nonfatal overdose and riskier substance use behaviors.²³ Yet, interviewees universally reported reduced contact or no contact with police during the pandemic. Furthermore, low-barrier options for accessing essential HIV care replaced historical systems of care with high barriers to entry, increasing treatment access and, at least anecdotally, enabling treatment initiation. Briefly, many systems that had hindered the health and well-being of PWID with HIV were themselves hindered from normal operations by the pandemic.

Second, many of the challenges faced by PWID with HIV in St. Petersburg predate the pandemic. Pervasive stigma against PWID and people living with HIV within the health care system reduced access to COVID-19 testing. Personal experiences of extreme prejudice from health care providers and wider society limited access to COVID-19 vaccines de facto because PWID with HIV have been taught through negative experiences that they will not be granted these public services. The Russian state’s refusal to implement evidence-based treatments for opioid use disorder (specifically methadone and buprenorphine) resulted in Russia’s limited array of treatment options for substance use disorders becoming practically nonexistent under lockdown. That these challenges were exacerbated during the pandemic does not change the fact that action could have been (but was not) taken to mitigate them before.

Finally, our interviews indicate that the illicit drug market in St. Petersburg remained relatively stable even as pandemic restrictions disrupted manufacturing processes and supply chains around the world. This resilience may have reduced the risk of drug-related harms by protecting PWID’s access to a predictable and familiar drug supply. At the same time, overdose rates in Russia have been rising,¹⁶ and causal mechanisms remain poorly understood. Any fluctuations observed in the US drug market during the pandemic may or may not be attributable to the broader trade impacts of COVID-19 and may or may not be impacting overdose directly. Rather than assuming cause and effect, US policymakers and researchers should dig deeper to identify and mitigate the structural forces (such as drug policy, drug criminalization, treatment access, and systemic racism) that shape the US drug market and the harms it confers.²⁴

Much US research on how COVID-19 has impacted people who use drugs has centered on population-level surveillance, such as rates of fatal and nonfatal overdose, emergency medical services or emergency department use, and treatment initiation and retention.²⁵ Such research is vitally important; yet, the picture it paints is incomplete. If, as seen in St. Petersburg, pandemic disruptions also disrupt structural harms or barriers to care, research is needed to identify and document the ways in which quality of life and general well-being improved for people who use drugs in the United States during the pandemic. We must capitalize on beneficial disruptions to systems that harm and oppress, working to sustain such structural changes as society renormalizes to a postpandemic world.

Furthermore, the pandemic has had direct and devastating psychosocial impacts on the individual level, with as many as 40% of US adults struggling with mental wellness in June 2020.⁵ Yet, the case of St. Petersburg demonstrates the need for equal attention to the drivers of pandemic-related challenges stemming from origins that predate the pandemic. A recent systematic review of scientific literature on the impacts of the COVID-19 pandemic on people who use drugs in the United States identified evidence of reduced access to MOUD in jails and prisons, reductions in MOUD initiation by as much as 30%, difficulty accessing necessary services despite receiving buprenorphine via telehealth, and modest increases in the receipt of take-home privileges at methadone clinics (benefiting only ∼25% of clinic patients),²⁵ all despite enormously relaxed federal regulations that reduced barriers to MOUD.⁷ These disappointing outcomes suggest that more than MOUD regulation limits access to evidence-based care. People who use drugs in the United States have long faced criminalization, overincarceration, epistemic injustice, racism, stigma, and outright prejudice in their daily lives,²⁴ and these challenges create durable inequities that no telehealth system or naloxone access program can address.

Pandemic preparedness requires more than institutional readiness for emergency response; it requires us to meaningfully acknowledge and address the systems of structural harms that have been producing health inequities for people who use drugs and other marginalized groups all along.