title: Engagement in HIV care and its correlates among people who inject drugs in St Petersburg, Russian Federation and Kohtla-Järve, Estonia.
abstract: OBJECTIVE
  HIV infection and mortality in Eastern Europe are driven by unsafe injection drug use. We sought to compare engagement in care from HIV testing through receipt of antiretroviral treatment among HIV-positive people who inject drugs (PWID) in St Petersburg, Russian Federation (RF) and Kohtla-Järve, Estonia and identify factors associated significantly with failure to progress at each stage of the HIV treatment cascade.
  
  
  METHODS
  Cross-sectional biobehavioral surveys of PWID with an analysis stratified by location-two Russian-speaking regions with similar HIV epidemic histories and current prevalence.
  
  
  METHODS
  Field-based surveys conducted in St Petersburg, RF and Kohtla-Järve, Estonia.
  
  
  METHODS
  We recruited 452 HIV-positive PWID in St Petersburg (November 2012 to June 2013) and 370 HIV-positive PWID in Kohtla-Järve (June-August 2012) using respondent-driven sampling.
  
  
  METHODS
  Participants were tested for antibodies to HIV, and administered a questionnaire focusing on participants' medical care histories. Engagement in care was categorized as a cascade of five transitional steps through six stages, ranging from HIV testing to current receipt of antiretroviral medications.
  
  
  RESULTS
  Progress along the cascade was greater in Kohtla Järve (32.7% were receiving antiretroviral medications) than in St Petersburg (9.7%). In both locations, we found the steps with high failure rates were the transitions from being aware of one's HIV diagnosis to being in regular care and initiation of highly active antiretroviral therapy (HAART). Factors associated significantly with transition failure in both locations and across steps included high alcohol consumption, variables associated with drug choice and injection frequency and lack of basic medical insurance.
  
  
  CONCLUSIONS
  The two steps in treatment cascade for HIV-positive PWID in St Petersburg, RF and Kohtla-Järve, Estonia requiring greatest improvement are retention in regular care and initiation of HAART. Both individual behavioral and structural factors are associated with failure to transition along the cascade.
authors.affiliation: Department of the Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA.|Center for Interdisciplinary Research at Yale University, New Haven, CT, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Heimer
authors.affiliation: NGO-Stellit, St Petersburg, Russian Federation.
authors.forename: Nina
authors.initials: N
authors.lastname: Usacheva
authors.affiliation: Department of the Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA.|Center for Interdisciplinary Research at Yale University, New Haven, CT, USA.
authors.forename: Russell
authors.initials: R
authors.lastname: Barbour
authors.affiliation: Department of the Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA.|Center for Interdisciplinary Research at Yale University, New Haven, CT, USA.
authors.forename: Linda M
authors.initials: LM
authors.lastname: Niccolai
authors.affiliation: Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
authors.forename: Anneli
authors.initials: A
authors.lastname: Uusküla
authors.affiliation: NGO-Stellit, St Petersburg, Russian Federation.
authors.forename: Olga S
authors.initials: OS
authors.lastname: Levina
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D015897:Comorbidity; D003430:Cross-Sectional Studies; D004957:Estonia / Q000453:epidemiology; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology*; D006801:Humans; D008297:Male; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D015995:Prevalence; D012426:Russia / Q000453:epidemiology; D015819:Substance Abuse, Intravenous / Q000453:epidemiology*
chemical_list: D019380:Anti-HIV Agents
keywords: Antiretroviral therapy; Eastern Europe; HIV; HIV testing; people who inject drugs; treatment cascade