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Injection Drug Use, Commercial Sex Work, and the HIV/STI Epidemic in the Russian Federation

2003; Lippincott Williams & Wilkins; Volume: 30; Issue: 1 Linguagem: Inglês

10.1097/00007435-200301000-00010

1537-4521

Catherine M Lowndes, Michel Alary, Lucy Platt,

HIV/AIDS Research and Interventions

THE RUSSIAN FEDERATION is currently experiencing one of the fastest-growing injection drug use–associated HIV epidemics in the world. Since 1995, a series of rapidly occurring, explosive outbreaks of HIV infection have occurred among vulnerable populations of injection drug users (IDUs) in over 30 cities of the Federation, including Kaliningrad, Krasnodar, Nizniyi-Novgorod, Rostov, Tula, Tver, and more recently the Moscow region, where a massive new outbreak occurred in 1999, with almost 7000 newly reported cases. 1–3 Official figures put the total number of notified cases of HIV infection in Russia at 173,068 by the end of 2001, 3,4 but it is estimated that the true number of people living with HIV infection/AIDS in Russia is approximately 700,000. 5 Analysis of HIV case reports indicates that more than 70% of registered HIV cases in Russia are associated with injection drug use. 3,6 In many cities, including in Rostov-Don, 7 Volgograd, 8 and Togliatti, 9 this figure is higher than 90%. Available data also indicate that HIV prevalence among IDUs has risen very rapidly to extremely high levels in a number of Russian cities. 2 Recorded HIV prevalence rates are 56% among a sample of community-recruited IDUs in Togliatti, Samara Oblast, 9 and 33% among needle-exchange attenders in Rostov-Don. 10 The Togliatti survey showed that 41% of IDUs who reported a negative antibody test result in 2000 and 2001 were HIV-positive by the time of the survey in September 2001, suggesting very high rates of HIV incidence in this population. 9 The central role of drug injection in the recent spread of HIV in Russia is related to a number of interacting behavioral, environmental, and structural factors. 11,12 Concurrent with the enormous sociopolitical and economic changes that have occurred in Russia since the beginning of the 1990s is a dramatic increase in rates of injection drug use, especially among young people. 1,2 Studies indicate high levels of injecting risk behavior among IDUs in Russia and very low coverage of IDU populations by harm-reduction initiatives, including needle/syringe exchange programs. 1,2 As discussed by Aral et al, 13 the recent economic, political, and social transitions in the Russian Federation have also been associated with an exponential increase in the number of women working as sex workers. 14–16 In Moscow, the economic center of the Federation, it is estimated that there are between 30,000 and 150,000 female sex workers. 17 As detailed by Aral et al, 13 many different types of prostitution exist in Moscow, with women working in a variety of locations, including railway stations, truck stops, streets, brothels, massage parlors, saunas, and hotels. Furthermore, there is a high degree of overlap between injection drug use and commercial sex work in Russia. Estimates of the proportion of female sex workers who inject drugs vary between 25% and 80%. 6,12,15,18 Highest frequencies of injection drug use are seen among the most vulnerable street sex workers, in contrast with women who work from apartments, saunas, and hotels, where frequencies of injection drug use tend to be lower. 16,19 Injection drug use itself may be a factor contributing to the increase in the number of sex workers in Russia. Commercial sex appears to be very frequently practiced by female IDUs in Russia as a means to obtain drugs and/or money to buy drugs. Studies among female IDUs in different Russian cities have shown that between 15% and 50% are involved in sex work. 6,20 As would be expected, given the very high HIV prevalence rates among IDUs in Russia, the limited data available indicate that HIV prevalence among female IDU sex workers is also very high, ranging from 17% in St Petersburg to 61% in Togliatti and 65% in Kaliningrad. 2,6,20 In Moscow, a small study of sex workers attending outreach programs showed an HIV prevalence of 15%. 6 Drug injecting and the sharing of previously used injecting equipment are probably the major current risk factors for HIV infection among sex workers. However, this situation could change rapidly, particularly in the context of a high background prevalence of STIs—notably, syphilis—in the general population 21 and specifically among sex workers; a syphilis prevalence as high as 34% among sex workers in Moscow has been reported. 6,21 Among female IDUs themselves, data from Togliatti suggest that sex work is associated with a much higher frequency of STIs. 20 Furthermore, numbers of reported new HIV infections acquired through heterosexual contact are now increasing in Eastern Europe as a whole and particularly in locations where the HIV epidemic among IDUs is maturing, such as the Ukraine and certain cities in Russia. In Odessa (Ukraine) and Kaliningrad, for example, the proportion of new cases of HIV infection associated with heterosexual transmission increased from approximately 10% in 1996 to approximately 35% in 2000, with a corresponding decrease in the proportion of new cases attributed to injection drug use, from approximately 90% to 65%. 6 In addition to the vulnerability of sex workers to STI and HIV infection, the potential for heterosexual transmission of HIV from sex workers to their male clients is high. Factors contributing to this risk include a high prevalence and incidence of HIV among IDU sex workers; high STI prevalence; high numbers of clients for penetrative sex reported by sex workers; and suboptimal condom use rates, particularly among the most vulnerable street sex workers. 13,20,22 Male clients of female sex workers may then transmit HIV to their other, non-IDU, female sex partners, thus acting as a bridge for sexual transmission of HIV between IDUs and non-IDUs in the general population. The size of this population of male clients and their sexual behavior will be crucial factors affecting the rate and extent of HIV spread within the general population. 23 In a random-digit-dialing telephone survey in St. Petersburg, 7% of men aged 15 to 55 years reported having had sex with sex workers, 24 and half of these said they had done so more than once. The potential for seeding HIV infections in the noninjecting population would be additionally increased if male clients of female IDU sex workers also have sex with non-IDU sex workers. 23 Given this situation, there is an urgent need both for research into the determinants of epidemic heterosexual HIV spread in the Russian context and for the implementation of interventions targeted toward sex workers. In order to assess the likely extent of the heterosexual HIV epidemic in Russia, it is important to obtain detailed behavioral data (including qualitative and quantitative data on sexual networking) and STI/HIV prevalence data for both sex workers and their sex partners, in order to (1) assess and appreciate the severity of the HIV/STI epidemiologic situation in this population; (2) understand the role of commercial sex work in the dynamics of the HIV/STI epidemic in Russia; (3) design appropriate interventions; and (4) monitor the situation over time, including potential indications of the impact of preventive interventions. Despite the lack of currently available data addressing these issues, it is apparent that sex workers are highly vulnerable to HIV/STI through both injection drug use and commercial sex and that there is a high potential in Russia for both continued rapid spread of HIV among IDUs and significant first-wave heterosexual transmission of HIV from IDUs. 23 Furthermore, it is apparent that female sex workers and their male clients could play a major role in dissemination of the epidemic into the noninjecting general population. Effective interventions that provide appropriate STI treatment and care services and aim to reduce both injecting and sexual risk behavior among sex workers, with high coverage of target populations, are urgently required. A number of effective small-scale interventions, involving outreach programs, provision of health promotion information and condoms, and referral of sex workers to subsidized STI services, are currently being implemented in Moscow. Notable among these is a collaboration between the nongovernmental organization AIDS Infoshare and the State Dermatovenereology Service in Moscow, which provides accessible STI care and HIV prevention services to the most vulnerable sex workers. 16 At present, however, coverage of the at-risk population by such interventions is very low, and massive scaling up of interventions, with appropriate financial and legal support, is required in order to reach higher proportions of the target population and have a significant effect on rates of HIV and STI transmission. Structural changes are also necessary to reduce the vulnerability and stigmatization of sex workers and to enable them to work safely. As highlighted by Aral et al, 13 one important aspect of the vulnerability of many sex workers in Moscow is their relationship with the police. In Russia, soliciting for money in exchange for sex is not a criminal offense but an administrative one. 6 In Moscow, women are arrested under administrative codes for "petty hooliganism" or for not possessing the correct documents. 15,16 This system is open to abuse by the police, who use the ambiguity of the legislation to enrich themselves financially through bribes or by taking sexual services. 6 Close links also exist between the police and statutory health services, including enforced testing of arrested sex workers for STIs and HIV and the risk of hospitalization for STI treatment. Particularly in the case of migrant sex workers in Moscow, who without official registration papers cannot access free health care services, such a situation has led to a negative perception of clinical services by sex workers. As Aral et al 13 describe, this perception is further exacerbated by negative attitudes of health care workers toward sex workers. Such a situation discourages contact with state structures and can act as a deterrent to sex workers seeking both help and HIV/STI testing, 15,18 and it will tend to drive both injection drug use and sex work underground. Advocacy among policy-makers to encourage more favorable legislation concerning sex work and drug use is necessary. Action at multiple levels is required to reduce stigmatization and marginalization of sex workers by society as well as their victimization and exploitation by police, to reverse the negative attitudes of sex workers about state structures (including health services), and to facilitate the implementation of pragmatic public health interventions by both the state and nongovernmental organizations.