Prisons, Drug Injection and the HIV Risk Environment

艾滋病毒发病率和死亡率在全球范围内下降，但在东欧和中亚(EECA)明显上升，那里的艾滋病毒 疫情仍然不稳定，主要由注射毒品(PWID)的人助长，主要是阿片类药物。对毒品的严厉惩罚 使用已将PWID集中在监狱中。我们最近在吉尔吉斯斯坦(KYR)的发现证实了艾滋病毒使用阿片类药物注射器的高比率 (30.4%)和HIV(10.2%)，85%的PWID是在监狱内注射的。KYR提供了一个独特而及时的机会来 研究和控制艾滋病毒在监狱中的传播为一体，它是世界上仅有的7个国家之一，提供基于监狱的美沙酮 维持治疗(MMT)。新的数学模型表明，监狱内MMT的扩大和释放后的保留是 在由PWID驱动的流行病中，对被监禁的PWID最有效的艾滋病毒预防策略。然而，扩大监狱中的MMT可能会 受个人和环境因素的影响，但监狱的艾滋病毒“风险环境”框架尚未完全形成 对从监狱过渡到风险环境发生变化的社区的PWID患者，构建也不适用于经验性的。 因此，研究KYR监狱MMT交付的动态将为MMT在监狱中的实施和推广提供参考。 这项研究建立在我们对艾滋病毒“危险环境”的研究基础上，首次应用了这一框架，以探索监狱如何 监狱内和释放后的环境放大了艾滋病毒的风险。结构性方法，它超越了个人行为，着眼于 应对环境风险，是降低艾滋病毒风险不可或缺的组成部分。我们最近对乌克兰、摩尔多瓦和印度尼西亚的监狱研究表明， 高风险药物使用处于一个强大的毒品经济和社会等级并存的环境中，并与MMT竞争。在 社区缺乏MMT保留，释放后的高危环境不同于监狱，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较少的“启用/禁用环境”的潜力 在监禁期间和在动荡不安的释放后期间，监狱中的蒙太奇教法被拘留。 这一及时的申请是与MATLINK(R01 DA029910)活动计划一致的，这是在6个国家纵向实施的 一项科学研究，利用激励性访谈，以“个人”为目标，扩大EECA监狱内的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来增加价值，添加了没有收到 激励增强以启动MMT，使用定性数据来补充结构化调查，然后三角测量结果以更好地 了解MATLINK调查数据。建议的混合方法分析非常适合评估“如何”和“为什么”可能的MMT。 在释放前监狱和释放后社区的过渡背景下，患者和工作人员面临MMT和艾滋病毒风险 环境。这些发现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战略提供新的见解， 并优化MMT的扩展和保留，降低WPDI风险。我们的两个相关的具体目标是：1)描述个人- 形成监狱内和释放后与毒品相关的艾滋病毒风险做法和对艾滋病毒+和健康预期的环境相互作用 HIV-PWID；和2)评估监狱内环境风险和其他因素如何影响监狱内MMT的接触 在HIV+和HIV-PWID释放后。我们的研究团队汇集了在定性和定量方面具有专长的国际研究人员。 和混合方法、实施科学、监狱、成瘾治疗(MMT)和艾滋病毒预防，以及KYR合作网站 在欧洲和非洲经济共同体国家和监狱的政治和法律领域取得了明显的成功。 好了！

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. !