Burden of substance use disorders, mental illness, and correlates of infectious diseases among soon-to-be released prisoners in Azerbaijan
Introduction
The Southern Caucuses, countries of the former Soviet Union (FSU) that includes Azerbaijan, Armenia, and Georgia, have low HIV prevalence (<0.3%), with HIV concentrated among most-at-risk groups (Joint United Nations Programme on HIV/AIDS (UNAIDS), 2014). Whereas HIV incidence is decreasing globally, the prevalence has increased 35-fold since 2000 in the Southern Caucuses (574–19,100 estimated cases in the region; (UNAIDS, 2012, Kvitsinadze et al., 2010). In Azerbaijan, adult HIV prevalence is 0.2%, primarily concentrated among people who inject drugs (PWIDs; Kvitsinadze et al., 2010). HIV prevalence among PWIDs ranges from 19% to 24% (Cook and Kanaef, 2008). Recent data, however, suggest emerging new cases among commercial sex workers (CSWs), heterosexual men and women, and migratory populations, indicating bridges to the general population through sexual contact (Ministry of Health of the Republic of Azerbaijan, 2014). Many of the vestiges of FSU infrastructure and drug-related policies persist in Azerbaijan, leaving it vulnerable to a volatile HIV epidemic in the absence of adequately scaled HIV prevention.
Prisons have long been sentinel sites for identifying emerging HIV epidemics because the individual and structural factors associated with HIV transmission (e.g., PWIDs, sexually transmitted infections (STIs), mental illness, homelessness, proscriptive drug policies) are concentrated among individuals who cycle through the criminal justice system (CJS; Altice et al., 2005, Altice et al., 1998, Flanigan et al., 2010, Springer and Altice, 2005). In Azerbaijan, 72% of people living with HIV/AIDS (PLWHA) have a history of imprisonment (United Nations Office on Drugs and Crime, 2010). Azerbaijan's CJS, however, has not been harnessed to implement evidence-based interventions (EBIs) like opioid substitution therapy (OST) for treating substance use disorders (SUDs). OST prevents HIV transmission for at-risk individuals (Gowing et al., 2008) and improves HIV treatment outcomes for PLWHA (Altice et al., 2010b, Dutta et al., 2013, Kerr et al., 2004). OST, however, is highly restricted in the general population and unavailable in prisons (Vagenas et al., 2013), although the scale up has been under consideration for more than five years (United Nations Office on Drugs and Crime, 2010). We therefore conducted an extensive, nationally representative bio-behavioral survey of soon-to-be-released prisoners in Azerbaijan in order to identify their burden of disease, with a specific focus on inter-related factors that might foreshadow an emerging epidemic in a low HIV prevalence FSU country.
Section snippets
Methods
A nationally representative, bio-behavioral survey assessing health status, addiction and infectious diseases (HIV, hepatitis C, hepatitis B, and syphilis) was conducted in 13 prisons in Azerbaijan from February to May 2014.
Sociodemographic characteristics
The final sample (N = 510) represents 59% of all Azerbaijan's soon-to-be-released prisoners in the selected facilities and 49% of all soon-to-be-released prisoners. As planned per our sampling strategy, high and medium security prisons each represent about 40% and mixed security prisons represent 10% of the 862 soon-to-be-released prisoners in the selected facilities. Similarly, women were over-sampled and account for about 10% of the sample (N = 58). About a third (N = 171) of the total sample were
Discussion
This prison-based biosurveillance study is the first in Azerbaijan—a country with a low HIV prevalence concentrated among PWIDs. The prevalence of infectious diseases, HIV risk behaviors, and SUDs in our sample is high. For example, HIV prevalence is 18.5-fold greater among prisoners than found in the community (3.7% vs 0.2%). Our results are consistent with a concentrated HIV epidemic among PWIDs in Azerbaijani prisoners, similar to those in other FSU countries. At the same time, these data
Role of funding source
This research received funding from the National Institute on Drug Abuse for research (R01 DA029910, Altice, PI and R01 DA033679), career development (K24 DA017072 for Altice and K01 DA038529 for Wickersham). This work was also supported in part by the Doris Duke Charitable Foundation through a grant supporting the Doris Duke International Clinical Research Fellows Program at Yale University School of Medicine. Wegman is a Doris Duke International Clinical Research Fellow.
Contributors
FLA and JAW conceived and designed the study along with SD and LA, analyzed the data with LA and revised the manuscript in association with SD, MP, and MW. LA was responsible for performing the experiments along with JAW and wrote the manuscript together with MW and MP.
Conflict of interest
No conflict declared.
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