Drug injection within prison in Kyrgyzstan: elevated HIV risk and implications for scaling up opioid agonist treatments

Abstract

Purpose: Within-prison drug injection (WPDI) is a particularly high HIV risk behavior, yet has not been examined in Central Asia. A unique opportunity in Kyrgyzstan where both methadone maintenance treatment (MMT) and needle/syringe programs (NSP) exist allowed further inquiry into this high risk environment. Methodology: A randomly selected, nationally representative sample of prisoners within six months of release in Kyrgyzstan completed biobehavioral surveys. Inquiry about drug injection focused on three time periods (lifetime, 30 days before incarceration, and during incarceration). We performed bivariate and multivariable generalized linear modeling with quasi-binomial distribution and logit link to determine the independent correlates of current WPDI. Findings: Of 368 prisoners (13% women), 109 (35%) had ever injected drugs, with most (86%) reporting WPDI. Among those reporting WPDI, 34.8% had initiated drug injection within prison. Despite nearly all (95%) drug injectors having initiated MMT previously, current MMT use was low with coverage only reaching 11% of drug injectors. Two factors were independently correlated with WPDI: drug injection in the 30 days before the current incarceration (AOR=12.6; 95%CI=3.3–48.9) and having HCV infection (AOR: 10.1; 95%CI=2.5–41.0). Value: This study is the only examination of WPDI from a nationally representative survey of prisoners where both MMT and NSP are available in prisons and in a region where HIV incidence and mortality are increasing. WPDI levels were extraordinarily high in the presence of low uptake of prison-based MMT. Interventions that effectively scale-up MMT are urgently as well as an investigation of the environmental factors that contribute to the interplay between MMT and WPDI.

The becoming‐methadone‐body: on the onto‐politics of health intervention translations

“…The impetus for the qualitative study upon which we draw here for our case was a large implementation science study designed to inform the delivery of methadone treatment into Kyrgyz prisons. Survey research has indicated moderate to high levels of HIV (10%) and hepatitis C (50%) among prisoners, and significant proportions (35%) of prisoners with a history of injecting drugs (of whom 85% inject drugs while in prison), yet only a minority (11%) of these engaged in methadone treatment (Azbel et al 2018). In response, an implementation science project sought to trial a motivational intervention to encourage methadone treatment uptake, and a parallel qualitative study sought to investigate prisoner engagements with methadone treatment.…”

A qualitative study of diphenhydramine injection in Kyrgyz prisons and implications for harm reduction

“…The parent project was designed to longitudinally and qualitatively assess barriers to MMT uptake during and after incarceration and evaluate the ways in which the prison risk environment influenced perceptions and use of methadone. Findings on HIV risk [ 24 ] suggest that most PWID incarcerated in Kyrgyzstan continue to inject in prison [ 6 ], prisoners are organized into rigid hierarchies that perpetuate inequalities in access to HIV prevention resources [ 23 ], and social factors shape patient engagement with methadone [ 22 ], especially after prison release and during the transition to communities [ 25 ] and among women [ 26 ]. Here, we explore the harmful health effects of Dimedrol injecting in prisons and implications for harm reduction programs.…”

“…Criminalization of drug use in EECA countries has concentrated people with HIV and substance use disorders (SUDs) into jails and prisons. Kyrgyzstan (Kyrgyz Republic) is an EECA country of six million people with high HIV prevalence (11.3%) among prisoners and detainees [ 3 ], most of whom (95%) are male [ 4 ] and one-third of whom are PWID [ 5 , 6 ]. From 2000 to 2018, Kyrgyzstan’s prison population declined by half, from 20,000 to approximately 10,000 detainees; however, seizures of illicit drugs and substance use within prisons increased during that same period.…”

“…In 2001, Kyrgyzstan introduced needle syringe programs (NSP) into prisons, followed by a pilot methadone maintenance program (MMT) in 2008. Despite availability of MMT and NSP in most of Kyrgyzstan’s 28 prisons, which together provide pharmacological treatment with methadone to more than 400 individual patients [ 9 ], utilization of MMT remains suboptimal and many people continue to use and inject drugs within prison [ 6 ]. NSP, which could reduce harmful consequences of drug injection, is not routinely offered to prisoners receiving MMT because they are assumed to be abstinent from heroin.…”

“…NSP, which could reduce harmful consequences of drug injection, is not routinely offered to prisoners receiving MMT because they are assumed to be abstinent from heroin. Major barriers to MMT and NSP include stigma among prisoners and staff [ 10 ], restricted access, and a competing heroin market controlled by the informal prison leadership, as we have described elsewhere [ 6 ].…”