title: Pre-incarceration police harassment, drug addiction and HIV risk behaviours among prisoners in Kyrgyzstan and Azerbaijan: results from a nationally representative cross-sectional study.
abstract: The expanding HIV epidemic in Azerbaijan and Kyrgyzstan is concentrated among people who inject drugs (PWID), who comprise a third of prisoners there. Detention of PWID is common but its impact on health has not been previously studied in the region. We aimed to understand the relationship between official and unofficial (police harassment) detention of PWID and HIV risk behaviours.
  
  
  
  In a nationally representative cross-sectional study, soon-to-be released prisoners in Kyrgyzstan (N=368) and Azerbaijan (N=510) completed standardized health assessment surveys. After identifying correlated variables through bivariate testing, we built multi-group path models with pre-incarceration official and unofficial detention as exogenous variables and pre-incarceration composite HIV risk as an endogenous variable, controlling for potential confounders and estimating indirect effects.
  
  
  
  Overall, 463 (51%) prisoners reported at least one detention in the year before incarceration with an average of 1.3 detentions in that period. Unofficial detentions (13%) were less common than official detentions (41%). Optimal model fit was achieved (X (2)=5.83, p=0.44; Goodness of Fit Index (GFI) GFI=0.99; Comparative Fit Index (CFI) CFI=1.00; Root Mean Square Error of Approximation (RMSEA) RMSEA=0.00; PCLOSE=0.98) when unofficial detention had an indirect effect on HIV risk, mediated by drug addiction severity, with more detentions associated with higher addiction severity, which in turn correlated with increased HIV risk. The final model explained 35% of the variance in the outcome. The effect was maintained for both countries, but stronger for Kyrgyzstan. The model also holds for Kyrgyzstan using unique data on within-prison drug injection as the outcome, which was frequent in prisoners there.
  
  
  
  Detention by police is a strong correlate of addiction severity, which mediates its effect on HIV risk behaviour. This pattern suggests that police may target drug users and that such harassment may result in an increase in HIV risk-taking behaviours, primarily because of the continued drug use within prisons. These findings highlight the important negative role that police play in the HIV epidemic response and point to the urgent need for interventions to reduce police harassment, in parallel with interventions to reduce HIV transmission within and outside of prison.
authors.affiliation: Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA; maxim.polonsky@yale.edu.
authors.forename: Maxim
authors.initials: M
authors.lastname: Polonsky
authors.affiliation: London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Lyuba
authors.initials: L
authors.lastname: Azbel
authors.affiliation: Department of Epidemiology, University of Florida Gainesville, FL, USA.|Department of Health Outcomes and Policy, University of Florida, Gainesville, FL, USA.
authors.forename: Martin P
authors.initials: MP
authors.lastname: Wegman
authors.affiliation: Department of Psychiatry, University of California San Francisco School of Medicine, San Francisco, CA, USA.
authors.forename: Jacob M
authors.initials: JM
authors.lastname: Izenberg
authors.affiliation: Department of Medicine, Harvard Medical School, Brigham and Women's Hospital Boston, MA, USA.
authors.forename: Chethan
authors.initials: C
authors.lastname: Bachireddy
authors.affiliation: Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA.|Centre of Excellence on Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Wickersham
authors.affiliation: Ukrainian Institute on Public Health Policy, Kyiv, Ukraine.
authors.forename: Sergii
authors.initials: S
authors.lastname: Dvoriak
authors.affiliation: Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA.|Division of Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, CT, USA.|Centre of Excellence on Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia.
authors.forename: Frederick L
authors.initials: FL
authors.lastname: Altice
mesh_terms: D000328:Adult; D001382:Azerbaijan / Q000453:epidemiology; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control / Q000523:psychology*; D000071277:Harassment, Non-Sexual; D006801:Humans; D007707:Kyrgyzstan / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D016495:Police; D011329:Prisoners / Q000331:legislation & jurisprudence / Q000523:psychology / Q000706:statistics & numerical data*; D011330:Prisons / Q000331:legislation & jurisprudence; D012309:Risk-Taking; D015819:Substance Abuse, Intravenous / Q000150:complications; D019966:Substance-Related Disorders / Q000453:epidemiology / Q000523:psychology*; D000078329:Workforce; D055815:Young Adult
keywords: Azerbaijan; HIV risk behaviours; Kyrgyzstan; addiction severity; drug injection; police harassment; prisoners