People who inject drugs and the effects of stigma on HIV treatment

A tale of two cities: Stigma and health outcomes among people with HIV who inject drugs in St. Petersburg, Russia and Kohtla-Jarve, Estonia.

Burke SE, Calabrese SK, Dovidio JF, Levina OS, Uuskula A, Niccolai LM, Abel-Ollo K, Heimer R. Soc Sci Med. 2015 Feb 16;130C:154-161. doi: 10.1016/j.socscimed.2015.02.018. [Epub ahead of print]

Experiences of stigma are often associated with negative mental and physical health outcomes. The present work tested the associations between stigma and health-related outcomes among people with HIV who inject drugs in Kohtla-Jarve, Estonia and St. Petersburg, Russia. These two cities share some of the highest rates of HIV outside of sub-Saharan Africa, largely driven by injection drug use, but Estonia has implemented harm reduction services more comprehensively. People who inject drugs were recruited using respondent-driven sampling; those who indicated being HIV-positive were included in the present sample (n = 381 in St. Petersburg; n = 288 in Kohtla-Jarve). Participants reported their health information and completed measures of internalized HIV stigma, anticipated HIV stigma, internalized drug stigma, and anticipated drug stigma. Participants in both locations indicated similarly high levels of all four forms of stigma. However, stigma variables were more strongly associated with health outcomes in Russia than in Estonia. The St. Petersburg results were consistent with prior work linking stigma and health. Lower barriers to care in Kohtla-Jarve may help explain why social stigma was not closely tied to negative health outcomes there. Implications for interventions and health policy are discussed.

Abstract access [1] 

Editor’s notes: This study provides extremely important evidence on the impact of anticipated and felt stigma in relation to HIV and drug use on health outcomes among people who inject drugs in the context of high prevalence of HIV. People who inject drugs in both Russia and Estonia are highly marginalised. Previous studies indicate prevalence to be as high as 90% in Kohtla-Järve and incidence of five per 100 person-years in St Petersburg. Despite their close geographical proximity the two cities are framed by very different social and structural policies that enable and disable the provision of HIV prevention programmes to people who inject drugs. In Estonia, the provision of needle–syringe programmes and opioid substitution therapy is widespread and supported by the government. In Russia the limited harm reduction programmes are provided by non-governmental organisations with little or no support from government. Ambiguous drug policies often prohibit the use of needle –syringe programmes on the grounds they promote drug use. Opioid substitution therapy (OST) is not prescribed and people who inject drugs are viewed as potential criminals by police. People who inject drugs are frequently put under surveillance through a mandatory registration system by police and drug treatment (narcology) clinics. High levels of both internalised and anticipated stigma in relation to HIV and drug use were found in both sites. In Estonia this was not associated with poorer HIV outcomes including access to HIV care, CD4 count or self-reported HIV symptoms. Conversely in St Petersburg, internalised stigma associated with drug use was associated with lower CD4 count, reduced access to HIV care and increased HIV symptoms. This underscores the effectiveness of low-threshold HIV prevention and treatment services for people who inject drugs in the treatment of HIV, despite the existence of other social and cultural norms that stigmatise HIV and drug use. This study demonstrates the effect of stigma on HIV outcomes. However, further research is needed to understand the mechanisms through which stigma interplays with other social and structural factors, such as migration, poverty and criminalisation, to impact on health outcomes among people who inject drugs.

The study has clear policy implications. They include the need for structural interventions such as increased government support for harm reduction. These are necessary to prevent the reproduction of HIV and drug-use related stigma and its harmful impacts. Shorter-term programmes are required in Russia, including the urgent scale up of harm reduction activities and HIV treatment and care for people who inject drugs as well as the provision of inter-personal support to assist people who inject drugs in facing stigma within health services. 

Europe [7]
Estonia [8], Russian Federation [9]
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