Fellowship Site: Kyrgyzstan through collaboration with the Ukranian Institute on Public Health Policy
U.S. Institution: Yale University
Project Title: Prisons, Drug Injection, and HIV Risk Environment
HIV incidence and mortality decreased globally yet increased markedly in Eastern Europe and Central Asia (EECA) where the HIV epidemic remains volatile and fueled by injection drug use, primarily of opioids. Harsh penalties for drug use have concentrated people who inject drugs (PWID) in prisons. Recent findings in among prisoners in Kyrgyzstan confirm high rates of opioid injectors (30.4%) and HIV(10.2%), with 85% of PWID having injected within prison. Kyrgyzstan presents a unique and timely opportunity to research and control HIV transmission in prisons as it is one of only 7 countries worldwide to offer prison-based methadone maintenance therapy (MMT). This study builds on our research on HIV “risk environments” by applying this framework, for the first time, to explore how the prison environment amplifies HIV risk within prison and post-release. Structural approaches, which look beyond individual behaviors to address environmental risk, are integral to reducing HIV risk. Our recent prison research in Ukraine, Moldova ,and Indonesia suggests high-risk drug use in prisons is situated in an environment where a robust drug economy and social hierarchy co-exists and competes with MMT. In the absence of MMT retention in the community, the high-risk environment post-release differs from prison but also contributes to poor health outcomes. To address this transition, we will longitudinally explore the sparsely researched ‘enabling/disabling environment’ potential of prison-based MMT during incarceration as well as during the tumultuous post-release period. The proposed mixed methods analysis is ideally suited to assess “how” and “why” would-be prisoners with opioid use disorders and prison personnel engage with MMT and HIV risk in the transitional context of both the pre-release prison and post-release community environments. The first phase will be a secondary analysis of are presentative bio behavioral survey of soon-to-be released prisoners in Kyrgyzstan to determine the correlates of within-prison drug injection and access to MMT. Secondly, I will generate qualitative data with opioid dependent prisoners and prison staff to describe the individual-environment interactions that shape within-prison and post-release drug-related HIV risk practices and health expectations. Findings will provide new insights into how to optimize bio behavioral and/or structural HIV prevention strategies in prisons, and optimize MMT scale-up and retention and reduce within-prison drug injection risks.