Prisons, Drug Injection and the HIV Risk Environment

艾滋病毒的发病率和死亡率在全球范围内有所下降，但在东欧和中亚（EECA）却明显上升， 流行病仍然不稳定，主要由注射毒品（PWID）的人助长，主要是阿片类药物。对毒品的严厉处罚 在监狱中集中使用PWID。我们最近在吉尔吉斯斯坦（KYR）的调查结果证实了阿片类药物注射者的艾滋病毒高感染率 (30.4艾滋病毒感染者（10.2%）和艾滋病毒感染者（10.2%），85%的艾滋病感染者在监狱内注射过。KYR提供了一个独特而及时的机会， 研究和控制艾滋病毒在监狱中的传播，它是世界上仅有的7个提供监狱美沙酮的国家之一 维持治疗（MMT）。新的数学模型表明，监狱内MMT的规模扩大与释放后的保留是 最有效的艾滋病毒预防战略，监禁PWID在PWID驱动的流行病。然而，在监狱中扩大MMT的规模， 监狱的艾滋病毒"风险环境"框架尚未得到充分考虑， 构建或经验性地应用于从监狱过渡到风险环境变化的社区的PWID。 因此，研究KYR监狱MMT交付的动态将为监狱MMT的实施和扩展提供信息。 本研究建立在我们对艾滋病“风险环境”的研究基础上，首次应用这一框架，探讨监狱如何 监狱环境放大了监狱内和释放后的艾滋病毒风险。结构性方法，它超越个人行为， 解决环境风险，是减少艾滋病毒风险的组成部分。我们最近在乌克兰、摩尔多瓦和印度尼西亚的监狱研究表明， 高风险药物使用所处环境是一个强大的毒品经济和社会等级制度并存的环境，并与MMT竞争。在 社区中没有MMT保留，释放后的高风险环境不同于监狱，但也导致健康状况不佳 结果。为了解决这一转变，我们建议纵向探索研究稀少的"有利/不利环境"的潜力 在监禁期间和动荡的释放后时期，监狱为基础的MMT。 这一及时应用计划与MATLINK（R01 DA029910）活动同时进行，MATLINK活动是一项6国纵向实施活动 一项科学研究，利用动机访谈，通过针对"个人"，在EECA监狱内扩大MMT。建议的R21 研究通过生成MATLINK参与者和监狱工作人员的定性数据增加了价值， 动机增强启动MMT，使用定性数据来补充结构化调查，然后三角调查结果，以更好地 了解MATLINK测量数据。所提出的混合方法分析非常适合于评估“如何”和“为什么”将成为MMT 在释放前监狱和释放后社区的过渡背景下，患者和工作人员接触MMT和艾滋病毒风险 环境.研究结果将为如何优化监狱中的生物行为和/或结构性艾滋病毒预防策略提供新的见解， 优化MMT规模扩大和保留，并降低WPDI风险。我们的两个相关的具体目标是：1）描述个人- 环境相互作用影响监狱内和释放后与毒品有关的艾滋病毒风险做法和对艾滋病毒+的健康期望， 评估监狱内环境风险和其他因素如何影响监狱内和监狱内的MMT参与 以及释放后的HIV+和HIV-PWID。我们的研究团队汇集了国际研究人员，他们具有定性和定量分析方面的专业知识。 和混合方法，实施科学，监狱，成瘾治疗（MMT），艾滋病毒预防，以及KYR合作网站 在政治和法律的背景下，在欧亚经济共同体国家和监狱开展工作，取得了显著的成功。 !

HIV incidence and mortality decreased globally yet increased markedly in Eastern Europe and Central Asia (EECA) where the HIV epidemic remains volatile and fueled primarily by people who inject drugs (PWIDs), primarily of opioids. Harsh penalties for drug use have concentrated PWID in prisons. Our recent findings in Kyrgyzstan (KYR) confirm HIV high rates of opioid injectors (30.4%) and HIV (10.2%), with 85% of PWID having injected within prison. KYR presents a unique and timely opportunity to research and control HIV transmission in prisons as one it is one of only 7 countries worldwide to offer prison-based methadone maintenance therapy (MMT). New mathematical modeling suggests within-prison MMT scale-up with post-release retention is the most effective HIV prevention strategy for incarcerated PWID in PWID-driven epidemics. Scaling-up MMT in prison, however, may be influenced by individual and environmental factors, but the HIV “risk environment” framework for prisons has yet to be fully constructed nor applied empirically to PWID who transition from prisons to communities where the risk environment changes. Thus, researching the dynamics of prison-based MMT delivery in KYR will inform the implementation and expansion of MMT in prisons. 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 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 propose to longitudinally explore the sparsely researched `enabling/disabling environment' potential of prison-based MMT during incarceration and during the tumultuous post-release period. This timely application is planned coincident with MATLINK (R01 DA029910) activities, a 6-country longitudinal implementation science study that uses motivational interviewing to expand MMT within EECA prisons by targeting the “individual”. The proposed R21 research adds value by generating qualitative data with MATLINK participants and prison staff, adding study participants who do not receive motivational enhancement to start MMT, uses qualitative data to supplement structured surveys and then triangulates findings to better understand MATLINK survey data. The proposed mixed methods analysis is ideally suited to assess “how” and “why” would-be MMT patients and personnel engage with MMT and HIV risk in the transitional context of both the pre-release prison and post-release community environments. Findings will provide new insights into how to optimize biobehavioral and/or structural HIV prevention strategies in prisons, and optimize MMT scale-up and retention and reduce WPDI risks. Our two related specific aims are to: 1) describe the individual- environment interactions that shape within-prison and post-release drug-related HIV risk practices and health expectations for HIV+ and HIV- PWID; and 2) evaluate the how within-prison environment risk and other factors influence engagement with MMT both within prison and after release for HIV+ and HIV- PWID. Our research team brings together international researchers with expertise in qualitative and mixed-methods, implementation science, prisons, addiction treatment (MMT), and HIV prevention, and KYR collaborating sites with demonstrated successes working in the political and legal context in EECA countries and prisons. !