We then fit a partially adjusted model controlling only for the demographic covariates specified above. Lastly, we fit the final, fully adjusted model controlling for demographic covariates and marital/partner status and respondents’ reports of ART use in the past 6 months, as recorded at the 12 and 24 month follow-up interviews. A posthoc sensitivity analysis was performed excluding observations from participants who used ARTs. All analysis was done using the statistical package SAS 9.3. Most participants reported no form of transactional sex in the past 12 months. The most common transaction was reported by men as having given money, drugs or alcohol in exchange for sex. We did not measure the type of partner involved in this exchange. No women reported giving something for sex and all other forms of transaction were reported by less than 5% of the sample, see Table 1Table 2 shows the proportion of participants who reported on the primary and secondary outcomes of interest at baseline, 12 and 24-month follow-up. High risk sex behaviors were more commonly reported than drug risk behaviors. Although Table 2 only descriptively presents the longitudinal frequencies of each outcome, it is noteworthy that – relative to male participants – a higher estimated proportion of female participants reported engaging in every risk behavior at every time point with the exception of past month alcohol use before sharing equipment, as reported at the 12 month follow-up. In general,cannabis grow tray it appears that there were not substantial changes over time across the various outcomes presented in Table 2. ART use appeared to increase from 12 to 24 months, particularly among men.
All participants were ART-naïve at baseline but 17% and 35% reported having taken ART in the past 6 months at the 12 and 24 month follow-up visits, respectively. Relative to male participants, female participants had significantly higher odds of reporting both primary outcomes, sharing injecting equipment in the past 30 days and condomless sex in the past 90 days in the unadjusted models. After controlling for demographic covariates, partner status and ART use, the association between female gender and sharing injecting equipment was no longer significant. Female gender remained significantly associated with condomless sex in the past 90 days, even after controlling for demographics and additionally, both partner status and ART use , Table 3. The conclusions from posthoc sensitivity analyses excluding observations from participants who used ARTs were consistent with the main analyses for all 5 outcomes. The unadjusted odds of one of the secondary outcomes was higher for female participants than male participants: reporting both drug equipment sharing and condomless sex. After controlling for demographic covariates, female gender remained statistically significant for the outcome, reporting both injection equipment sharing and condomless sex. In the final fully adjusted model, where we controlled for demographics as well as the 3 level partner status covariate and ART use, the association between female gender and reporting both injection equipment sharing and condomless sex was no longer significant. No significant association was found in any of the models between female gender and alcohol use prior to sharing equipment in the past 30 days, or prior to or during sex in the past 90 days, see Table 3.Among a cohort of PLHIV in Russia who have ever injected drugs, we detected a statistically significant association between female gender and condomless sex in the past 90 days, even after controlling for the potentially confounding effects of demographics, partner status, and ART use.
Although we observed notable associations between gender and other outcomes, including sharing drug equipment, alcohol use prior to sharing, and both drug equipment sharing and condomless sex, the results were not statistically significant, possiblydue to limited power given the relatively small number of women in the study. It is also notable that nearly all risk behaviors, other than alcohol use prior to sharing, appeared to be more commonly reported among women compared to men. The increased odds of substance using women having condomless sex, compared to men, has been previously documented in multiple settings , including St. Petersburg, Russia. Prior research from St. Petersburg also found partnership status to be a major factor in PWID’s decision-making process about whether to engage in condomless sex with their partner. In our study, more participants reported being in HIV concordant partnerships which could explain why such a high proportion of respondents engaged in condomless sex. Regardless, female participants had higher odds of reporting condomless sex, irrespective of their partner’s HIV status, posing risk for HIV transmission in this population. Further, the preventive health benefits of HIV-positive persons using a condom or other protective barrier during vaginal or anal sex are indisputable, regardless of their partner’s HIV serostatus. These results are particularly concerning in light of recent research suggesting heterosexual transmission of HIV is increasing in St. Petersburg, and may overtake injection drug use as the primary mode of transmission , and suggest a need for a comprehensive, multi pronged response which should include “treatment as prevention” and pre exposure prophylaxis for HIV-negative partners. Interventions promoting condom usage are also warranted. However, our finding that women were less likely than men to use condoms under all circumstances implies that such approaches must be designed to account for the social, micro, and macro contexts of women’s lives. At the relationship level,vertical grow systems for sale alcohol use prior to sex was common and may have interfered with condom decision making around the time of the sexual event. Connecting women to alcohol harm reduction programming could help to lessen their collective risk for HIV infection and transmission.
Our findings support the value of implementing multi-level interventions and also imply that TasP is a high-yield approach with potential to reduce the risk of transmission with condomless sex, as well as provide a multitude of other health benefits for the HIV-positive individual. Addressing the social and structural factors that contribute to gender differences in condom usage, and providing HIV-negative women with access to PrEP are additional strategies which should also be pursued. As has also been seen in other settings, women in our study were more likely to report drug equipment sharing than men. However, it seems the relationship between female gender and equipment sharing is at least partially explained by demographics, most notably employment and income. Female participants in this study were significantly less likely to be employed than male participants and significantly more likely to earn a monthly income below the sample median of 20,000 Rubles. When there is limited access to clean needles and syringes and/or limited funds to pay for new/unused equipment, women may be more likely to share. These patterns have been observed in other populations, including among PWID in South Africa where more women than men reported always sharing injecting equipment. Low economic status, coupled with limited work opportunities for women, have also been associated with increased sexual risk taking among female substance users, including having multiple sex partners and relying on sex trade/transactional sex to support drug use. Findings from the 2009 National HIV Behavioral Surveillance System, conducted in 20 U.S. cities, suggest more female PWID have sex in exchange for money or drugs. Findings from Russia found that compared to their male counterparts, female injectors who reported high drug use frequency were more likely to also report multiple sex partners. Our findings highlight the need for free access to clean needles/syringes among women who inject drugs, as well as access to opiate agonist therapy to prevent HIV. Our study has limitations. The sample size was relatively modest and participants were predominantly male, which limited study power particularly for outcomes that were less common.
These findings from Russia might not be representative of the relationship between female gender and HIV transmission risk among people who inject drugs or have a history of injection drug use, who are living with HIV in other non Russian settings, or even within Russia but outside of the Russia ARCH study population. Additionally, our research was done with a mixed sample of current and former injection drug users. Another limitation of the current study is that knowledge and perceptions surrounding risk of HIV transmission were not assessed, nor did we specifically explore several key mechanisms known to contribute to sex and drug use behaviors associated with increased risk for HIV transmission. For instance, participants were not asked about their experiences of intimate partner violence, despite that it has been associated with women’s reduced ability to negotiate condom use and talk about HIV prevention with their partner.More research is needed to understand the challenges and preferences of HIV-positive women who inject drugs, which may be contributing to their condom nonuse and harmful drug and alcohol consumption. A better understanding of the factors underlying women’s condom choices, or to what extent they have any choice in the matter, will inform the design of more meaningful and effective prevention strategies. Furthermore, assessing awareness and willingness to use PrEP among HIV-negative women and men who have ever injected drugs or have a known HIV-positive partner is needed to inform future efforts for HIV prevention. We also did not assess participants’ sexual orientation or gender identity, or these characteristics of their sexual partner. Further, we did not assess differences in drug use and sexual behaviors according to whether the partner under consideration was a long-term or casual partner. Nor did we measure partner-specific information on sexual or drug related behaviors of interest. Instead, we only measured behaviors of interest at the individual level. These details should be collected in future research, as understanding partner dynamics contextualizing most at risk situations will help to establish what is needed for prevention efforts.Additionally, different time frames were used for the outcomes which may have differentially impacted participants’ ability to accurately remember their true behaviors. However, the Russia ARCH cohort study team is skilled at interviewing and has extensive experience with this population which likely serves to mitigate this latter bias. The homeless population is aging. People born in the second half of the “baby‐boom” have an elevated risk of homelessness. Homeless adults develop aging‐related conditions, including functional impairment, earlier than individuals in the general population. For this reason, homeless adults aged 50 and older are considered “older” despite their relatively young age. The homeless population has a higher prevalence of mental health and substance use problems than the general population. Individuals experiencing homelessness report barriers to mental health services, due to lack of insurance coverage, high cost of care, and inability to identify sources of care. These barriers can prevent their using services to treat mental health and substance use problems, such as outpatient counseling, prescription medication, and community‐based substance use treatment. Without these, homeless populations may experience more severe behavioral health problems and rely on acute care to address these chronic conditions. Homeless individuals have higher rates of Emergency Department use for mental health and substance use concerns , and are more likely to use psychiatric inpatient or ED services and less likely to use outpatient treatment than those who are housed. Homeless adults with substance use disorders face multiple barriers to engaging in substance use treatment. Competing needs , financial concerns, lack of knowledge about or connection to available services, and lack of insurance are barriers to substance use treatment among homeless adults. Older adults face additional barriers to mental health or substance use treatment due to cognitive and functional impairment, such as difficulty navigating and traveling to healthcare systems. However, there is little known about older adults experiencing homelessness. According to Gelberg and Anderson’s Behavioral Model for Vulnerable Populations, predisposing factors, enabling factors, and need, shape health care utilization. Although prior research has used this model for homeless populations, this work has not included older homeless adults. Little is known about the prevalence of mental health or substance use problems in older homeless adults, the level of unmet need for services, or the factors associated with that need. To understand the factors associated with unmet need for mental health and substance use treatment in older homeless adults, in a population‐based sample of homeless adults age 50 and older, we identified those with a need for mental health and substance use services. Then, we applied the Gelberg and Anderson model to examine predisposing and enabling factors associated with unmet need, which we defined as not receiving mental health and substance use treatment among participants with mental health or substance use problems.