High levels of mental distress, unprotected sex, needle sharing, unmet prevention needs found among HIV-infected patients in St Petersburg

Risky sex and drug use are common among HIV-positive people in Russia, investigators report in AIDS and Behavior. Discrimination was a common experience, and there was a high prevalence of depression and anxiety.

“Policies and public health programs for PLH [people living with HIV] need to focus on comprehensive strategies to address continuing transmission risk behaviors as well as improve…psychological well-being [and] social circumstances,” comment the study’s authors.

Russia has one of the fastest growing HIV epidemics in the world, and it is estimated that as many as 940,000 people in the country (1.1% of the population) are HIV-positive.

However, little is known about the transmission risk behaviours, mental health characteristics, and levels of adherence to antiretroviral therapy among Russia’s HIV-positive patients.

St Petersburg is an epicentre of the epidemic in Russia, and in 2008-09 investigators from the city conducted a cross sectional study that included 492 HIV-positive adults.

These patients completed questionnaires enquiring about their demographics, disclosure of HIV, experience of perceived discrimination, sexual and drug use behaviour, use of HIV therapy and adherence, and mental health.

The patients had a mean age of 30, and 53% reported they were in employment. The overwhelming majority (86%) reported that they were exclusively heterosexual, and the patients had been living with diagnosed HIV infection for a mean of 58 months.

There were high rates of disclosure to family members (80%), close friends (76%), or other people with HIV (68%).

However, reported discrimination was common. A fifth of patients reported that they had been tested for HIV without their consent. Moreover, a quarter of patients reported that they had been refused medical care, including 9% who said that they had been refused general health care because of their HIV status. In addition, 12% of respondents said that they had been forced by the police or their physician to sign a written statement declaring their HIV-positive status, “a procedure used to create evidence that may form the basis for criminal charges against those suspected of putting others at risk”.

Many reported that they had experienced discrimination in the workplace. Approximately 11% had been refused a job because they were HIV-positive, 7% said they had been dismissed from employment because of their status, and 6% stated that they had been forced by family members to leave their homes due to their infection.

Mental health distress was common. Clinical depression was present in 39% of individuals and 37% had anxiety levels comparable to those found in psychiatric inpatients.

“Levels of depression, anxiety, and poor social support in this sample…were high and prevalent. Reports of discrimination were also common and show that AIDS-related stigma remains high in Russia,” comment the authors.

Unprotected sex with a partner of the opposite sex who was HIV-negative or of an unknown status was reported by 58% of individuals. Higher rates of sexual risk behaviour (71%) were present in men who have sex with men. Overall, approximately one-third of all acts of anal or vaginal sex were unprotected.

Greater experience of perceived HIV-related discrimination was associated with poorer condom use (p = 0.012).

A history of injecting drug use was reported by 346 people, and  52% of these individuals said they had injected in the past three months. Needle sharing was reported by 47% of these patients.

Sharing needles was associated with not having a primary partner, lower levels of education, and experiencing discrimination (all p < 0.05).

“These findings demonstrate the need to implement programs designed to encourage…risk reduction for infected persons seen in HIV clinical, social support, or other care service programs,” write the investigators.

Antiretroviral therapy had been offered to 54% of the patients. Two-thirds of these individuals were taking treatment, 18% were waiting to start, and 16% had declined. The median duration of therapy was a little under 20 months.

Not being offered HIV therapy was associated with shorter duration of HIV infection (p < 0.01), and depression (p < 0.01). Poor mental health was also associated with a refusal to start taking antiretroviral therapy (p < 0.01).

Reported adherence was high: 90% of patients had an adherence level of at least 90%.“However, we relied on self-reports of adherence for only a 2-day period, and self-report data can reflect an underreporting of socially undesirable responses,” caution the investigators. Heroin use in the past three months was associated with poorer adherence (p < 0.01).

Concerned by their findings, the authors conclude: “It is imperative that PLH in Russia should receive improved and tailored services to reduce HIV transmission risk behaviors and improve life quality.”