Speaking the truth: an analysis of gender differences in serostatus disclosure practices among HIV-infected patients in St Petersburg,Russia

Abstract

The Russian HIV epidemic is primarily fuelled by injection drug use, but heterosexual spread may be playing an increasing role in transmission. Government-funded AIDS clinics provide most HIV treatment in Russia, and represent an important contact point between the medical community and infected population. Little is known about the population actively seeking HIV treatment. To describe demographics, perceived mode of acquisition and serostatus disclosure practices of HIV-infected individuals seeking treatment in St Petersburg, Russia, we conducted a cross-sectional study of 204 HIV-infected patients presenting to the St Petersburg City AIDS Center between May and June 2007. Mean age of respondents was 28 years old, 51% were women and two-thirds (67%) reported a history of injection drug use. Men were more likely to report injection (62% versus 45%) while women were more likely to identify sexual transmission (45% versus 32%) as their perceived infection route. Predictors of serostatus disclosure were female gender, married status and higher education. Women represent half of all patients seeking HIV treatment in St Petersburg, and are more likely than men to have disclosed their HIV-positive serostatus to sexual partners. While this population may not represent the burden of HIV disease in Russia, it is an important target group for secondary prevention.

Keywords

HIV serostatus disclosure sexual behaviour gender injection drug use Russia

INTRODUCTION

The Russian Federation has experienced an explosion of HIV infection over the last decade, and now ranks among the countries with the highest HIV incidence in the world.^1–3 To date, HIV in Russia has remained concentrated primarily among the injecting drug user (IDU) population; studies indicate that between 70% and 80% of total HIV cases can be attributed to IDUs.^4–7 However, emerging evidence suggests that heterosexual transmission is becoming an important route of infection.^8,9 While men have comprised the majority of HIV infections, the proportion of newly diagnosed cases among commercial sex workers and pregnant women presenting for routine prenatal care is increasing (Vladinova G. HIV infections in Russia. Unpublished presentation, 2007).^4,10

Currently all HIV care – with the exception of that bought at market costs, and therefore beyond the reach of most Russians – is provided through government-funded AIDS centres. As a result of the recent rise in HIV detection rates, these AIDS centres have experienced a rapid increase in patient volume. It is likely that many Russians living with HIV/AIDS, particularly IDUs, do not seek medical treatment due to perceived discrimination and psychosocial stressors.¹¹ Those individuals who do actively seek HIV care represent an important bridge between the general HIV-infected population and the medical community, and therefore serve as a key target population for secondary HIV prevention strategies. To date, few studies have been published on this important group. One recent study evaluating demographics and sexual behaviour of non-IDU patients referred to St Petersburg's AIDS Center found that approximately two-thirds were women, and over half (52%) had had at least one sexual partner whom they knew to be either an IDU or HIV-infected.¹²

As Russia's public health officials look towards new HIV prevention strategies, physician-initiated partner notification programmes, which were highly effective for other sexually transmitted infections (STIs) in the past under Soviet rule, will likely be among the proposed tactics.¹³ To date, little is known about contemporary Russian attitudes towards such programmes.

The primary aim of the current study is to characterize the demographics, sexual behaviours and perceived mode of HIV acquisition among patients actively seeking care at St Petersburg's City AIDS Center in 2007. The secondary aims are to evaluate how these factors influence patients’ decisions to disclose their positive serostatus to sexual partners, and to assess patients’ attitudes towards a potential physician-initiated partner notification programme as a means of secondary prevention. Our goal is to provide evidence that might effectively guide future HIV prevention strategies.

METHODS

St Petersburg's City AIDS Center, a government-funded clinic, provides comprehensive outpatient and inpatient HIV care to all of the city's HIV-infected residents. In 2008, this clinic provided care to approximately 10,400 of the more than 40,000 people known to be living with HIV/AIDS (PLWHA) in the city. This consecutive case series using a cross-sectional survey of 204 HIV-infected patients presenting to the St Petersburg City AIDS Center was conducted in May and June 2007. The study was approved by the Institutional Review Board that serves The Biomedical Center and St Petersburg State University.

The investigator was present throughout the clinic's full working hours, approximately three days a week, during which time all HIV-infected patients presenting for care were approached in the waiting room of the AIDS centre and invited to complete a five-page, 25-question, self-administered, investigator-generated survey, in Russian. Questions related to demographics, personal sexual and injecting drug use behaviours, serostatus disclosure to both IDU partners and sexual partners, and feelings toward physician-initiated partner notification policies. Participants were asked two questions about their route of HIV transmission. The first was designed to obtain information about transmission risks, whether they had engaged in injecting drug use or unsafe heterosexual intercourse and, for men, if they were men who had sex with men (MSM). The second was designed to determine how the respondent thought s/he had become infected. The survey did not ascertain information about the serostatus of participants’ sexual partners. A patient's decision to refuse participation was recorded; refusal did not affect his or her treatment.

DATA ANALYSIS

Descriptive statistics were generated for demographic characteristics for men and women. To assess associations between HIV serostatus disclosure to sexual partners and specific demographic and risk factor characteristics, we performed multivariate statistical analyses. Likelihood ratio estimates were used to compare the full model with subsequent models subtracting one variable at a time. Independent variables included in the final regression model were gender, age, education, antiretroviral therapy (ART) status, injecting drug use, number of sexual partners and condom use.

RESULTS

Table 1 describes demographics and HIV-related risk factors of study participants, stratified by gender. Two hundred and forty patients were invited to participate in the study; 20 (8%) declined participation. Sixteen participants were excluded due to incomplete surveys, leaving a total of 204 completed questionnaires for analysis. Mean participant age was 28 years and 105 (51%) respondents were women. Approximately two-thirds of participants (67%) reported a history of being an IDU, with heroin being the drug most commonly injected. Men were more likely than women to report ever having injected drugs, with 76% of men and 58% of women reporting a positive lifetime history of being an IDU (P = 0.03). In contrast, injecting drug use was less often identified as the most likely route of transmission; only 102 participants (50%) reported this as the most likely route. Men were more likely to identify injection (60% versus 37%) and women were more likely to report sexual transmission (43% versus 32%) as their most likely route of transmission (P = 0.02) (Figure 1). Forty-two (42%) men and 38 (36%) women were taking ART at the time of survey completion (Table 1).

Figure 1

Perceived mode of HIV transmission

Table 1

Demographics and risk behaviours of study participants

	Men (%)	Women (%)	P value
n	99 (48.5)	105 (51.5)
Average age (years)	30	27.8	0.05
Education			0.1
Incomplete secondary education	15 (15.3)	9 (8.6)
Completed secondary education	68 (68.6)	68 (64.8)
Higher degree (college or university)	15 (15.3)	28 (26.7)
Did not answer	1 (1)
Marital status
Married	27 (27.2)	54 (51.5)	0.001
Single	60 (61.2)	37 (35.2)
Divorced/widowed	11 (11.1)	13.3 (9.5)
Did not answer	1 (1.0)
Ever injected drugs
Yes	75 (76.0)	61 (58.0)	0.03
No	23 (23.0)	43 (41.0)
Unknown	1 (1.0)	1 (1.0)
Perceived route of transmission
Injection	61 (62.0)	41 (39.0)	0.02
Sexual	32 (32.0)	45 (43.0)
Blood transfusion	1 (1.0)	0
Unknown	5 (5.0)	19 (18.0)
On antiretroviral therapy
Yes	42 (42.0)	38 (36.0)	0.43
No	57 (58.0)	66 (63.0)
Unknown		1 (1.0)
Number of sexual partners in past 6 months
0	27 (27.3)	11 (10.5)	0.003
1	56 (56.6)	83 (79.1)
2–5	13 (13.1)	7 (6.7)
>5	3 (3.0)	4 (3.8)
Condom use
Always	58 (59.2)	50 (47.6)	0.14
Sometimes	30 (30.6)	47 (44.8)
Never	6 (6.1)	6 (5.7)
Unknown	5 (5.1)	2 (1.9)
HIV-positive serostatus disclosure
Disclosed to at least one sexual partner	38 (36.9)	65 (63.1)	0.002
Disclosed to at least one injection partner	23 (51.1)	22 (48.9)	0.58
Disclosed to no-one	10 (10.1)	6 (5.7)	0.32

Seventy-two (73%) men and 94 (90%) women reported at least one sexual partner in the previous six months (males range 0–8, females range 0–10); 57% of men and 79% of women reported one sexual partner during this time. Importantly, only 38 (36.9%) men and 65 (63.1%) women reported disclosing their HIV-positive serostatus to at least one sexual partner (P = 0.002). The mean number of sexual partners reported in the past six months did not significantly differ by gender (1.1 for men and 1.3 for women). A majority (52%) of men and 41% of women reported unsafe sex (defined as inconsistent or never using a condom) (Table 1).

Eighteen (18%) men reported having sex with a male partner in the previous six months with none reporting concurrent sex with a women during this time. Of these, 15 disclosed their serostatus to at least one partner. Among MSM, approximately one-third (31%) reported not always using a condom during the past six months, and seven (39%) reported ever having injected drugs. When asked about their perceived route of transmission, 11 (61%) reported sexual contact, whereas five (28%) reported injection. Two respondents among this group did not know their most likely route of transmission. No women reported female sexual partners over the six months prior to survey administration.

Fifty-nine (59%) men and 53 (51%) women responded favourably when asked if physicians should discuss risk of HIV exposure with sexual partners of HIV-infected patients.

There were no statistically significant correlations observed between serostatus disclosure and age, IDU status, self-reported route of transmission, ART status or number of sexual partners in the six months prior to the survey. Results from the final multivariate analysis are shown in Table 2. Female gender, education and marital status were positively correlated with serostatus disclosure. Condom use was negatively associated with disclosure. Participants who reported they would disclose their positive serostatus to a future sexual partner were more likely to have already told a previous partner than those who indicated that they would not disclose to a future sexual partner.

Table 2

Predictors of serostatus disclosure to sexual partner

Variable	Adjusted OR	95% CI
Female gender	2.03	1.01–4.09
Age*	0.99	0.96–1.04
Education^†	1.68	1.28–2.21
Married	2.74	1.31–5.71
Had a sexual partner in 6 months prior to survey	1.98	0.91–4.32
Willing to disclose serostatus to new sexual partner	3.38	1.48–7.67
Condom use^†,‡	0.5	0.29–0.85
Belief that doctors should inform sexual partners of patients of HIV exposure	0.42	0.2–0.85
Willingness to come for treatment if doctors ask for sexual partner contact information	0.49	0.2–0.85

*Continuous variable

^†Categorical variable

^‡Condom use: always, sometimes, never

DISCUSSION

Demographics

The primary aims of this study were to characterize the demographics as well as the sexual and injecting drug use behaviours of HIV-infected patients seeking care in St Petersburg's sole HIV treatment centre. Secondary aims were to identify predictors of serostatus disclosure practices among this population, and to explore this group's attitudes regarding physician-initiated partner notification policies. The results of this study suggest that the population actively seeking HIV treatment differs from Russia's HIV-infected population typically described in the literature.^7,14,15 Specifically, half of our study population were women. For a significant percentage of these women (43%), sexual transmission, as opposed to injecting drug use, was the self-identified route of infection. Over half (52%) of women were married; the vast majority (87%) had completed secondary education. Despite evidence suggesting an increasing feminization of the HIV epidemic in Russia,^8,9,16 it is understood that the current majority of HIV-infected Russians are male IDUs.^4,5,7 These findings suggest that the population seeking HIV care at the City AIDS Center, St Petersburg's only HIV treatment centre, is inconsistent with the burden of disease in Russia, and supports the hypothesis that many IDUs avoid medical care due to the negative public attitudes toward IDUs and the persistent social stigma associated with HIV.^12,17 It is not surprising that women and MSM, two groups that are less likely to include IDUs, may be over-represented in this sample because active drug users in Russia are excluded from receiving ART. This important finding highlights the need to institute broad-reaching policies aimed at decreasing IDU-associated discrimination, and improving the interpersonal management of potential patient populations. Furthermore, because this population serves as the medical community's only formal access to Russians living with HIV, it is of importance to understand the demographics and sexual behaviours of this group. Specifically, efforts to promote condom use, discourage needle sharing and encourage strict ART adherence may be directly targeted to this population, as such measures are difficult to promote to a population who avoids medical treatment.

Condom use

Over half (59%) of men and 48% of women in our study reported consistent condom use. Our data agree with the findings of Amirkhanian et al. ¹¹ and Grau et al.,¹⁵ who found a 50% self-reported condom use among HIV-infected people, and is higher than that reported by Benotsch,¹⁸ who found a 21% self-reported condom use among patients presenting at an STI clinic in St Petersburg. Multivariate analysis revealed that persistent condom use was negatively associated with serostatus disclosure, consistent with other studies.^15,19 Grau et al. ¹⁵ reported a negative correlation between condom use and intercourse with a primary sexual partner, and a positive correlation between condom use and perceived seronegativity of the sexual partner. In our study, those reporting always wearing a condom were half as likely to have disclosed to their sexual partner. This does not necessarily mean that unsafe sex was occurring following disclosure, since one limitation of our survey is that we did not assess whether partnerships were seroconcordant or serodiscordant. This lack of association may reflect the nature of the sexual relationships, as people are more likely to disclose positive serostatus if they are in a stable relationship, precisely the type of relationships that witness a decrease or cessation of condom use.

Serostatus disclosure

The predictors of serostatus disclosure in our study were female gender, married status and higher education. Women were twice as likely as men to have revealed their HIV-positive status. This finding differs from Grau et al.,¹⁵ who found no association between gender and serostatus disclosure to sexual partners among St Petersburg's IDUs. One possible explanation for this difference is that, as opposed to Grau's study population, women in our study tended to be married, and were more likely than men to have perceived their own route of transmission as sexual.

Physician-initiated partner notification

Overall, participants responded favourably to the idea of physician participation in the notification of their sexual partners regarding HIV exposure. Belief that a doctor should inform their patient's sexual partners of their exposure to HIV was associated with serostatus non-disclosure (Table 2). Furthermore, those who indicated they would be willing to come for treatment if their physician requested the names of their sexual partners were less likely to have disclosed their positive serostatus to their sexual partner (Table 2). The practice of physician-initiated partner notification remains highly controversial in the USA. However, this was a common and effective practice in the Soviet Union.^13,20 Given Russia's unique historical precedent for this practice, and its need for effective measures to curb the HIV spread, this may be a reasonable intervention to explore as future prevention policies evolve.

Although our study population is not representative of the majority of Russians living with HIV/AIDS, this population represents a crucial group to access for targeted HIV secondary prevention efforts, specifically measures to increase condom use, encourage serostatus disclosure to sexual partners and lower viral load to reduce the likelihood of transmission. The results also provide potentially useful demographic and behavioural information about a subset of St Petersburg's HIV-infected population that is accessing local, municipality-supported medical services.

LIMITATIONS

This was a self-administered survey completed in the waiting room of a busy clinic. Participant privacy was limited, which may have influenced responses regarding sensitive information. Due to the structure of our survey, we were unable to assess serostatus of sexual partners, which restricted our ability to obtain information on potential sexual transmission of HIV. Demographic data were not available for subjects who declined participation, and thus we are unable to comment on possible selection bias. Our patient population, as described above, is not representative of the majority of people living with HIV/AIDS in Russia. Thus, it is not possible to generalize our findings beyond the subpopulation of HIV-infected individuals who are actively seeking treatment.

CONCLUSIONS

Russia's HIV epidemic may be transitioning from one fuelled by IDU to one of increasing heterosexual transmission. Women now make up half of all HIV-infected patients seeking medical care in St Petersburg and represent an important target population for secondary prevention. Women are more likely than men to disclose their HIV-positive status to sexual partners and consistent condom use is infrequent in this population. The population actively seeking treatment at the St Petersburg AIDS Center is over-represented by women and MSM, and not representative of the generalized HIV-infected population. This phenomenon highlights the importance of initiating efforts to decrease IDU-related stigma and increase patient acceptance of care at this institution. Attitudes toward physician-initiated partner notification appear positive and warrant further research into the feasibility and efficacy of such programmes in the Russian Federation.

Footnotes

ACKNOWLEDGEMENT

This project was funded by the Fogarty International Center (FIC) of the National Institutes of Health.

References

World Health Organization. Epidemiological Country Profile on HIV and AIDS. Geneva: WHO, 2010

UNAIDS. AIDS Epidemic Update: November 2009. Geneva: WHO, 2009

Cohen

. Late for the epidemic: HIV/AIDS in Eastern Europe. Science 2010;329:160–4

Kelly

, Amirkhanian

. The newest epidemic: a review of HIV/AIDS in Central and Eastern Europe. Int J STD AIDS 2003;14:361–71

Rhodes

, Lowndes

, Judd

, Explosive spread and high prevalence of HIV infection among injecting drug users in Togliatti City, Russia. AIDS 2002;16:F25–31

Centers for Disease Control and Prevention. Rapid Increase in HIV Rates Orel Oblast, Russian Federation, 1999–2001. MMWR Morb Mortal Weekly Rep 2003;52:657–60

Kozlov

, Shaboltas

, Toussova

, HIV incidence and factors associated with HIV acquisition among injection drug users in St Petersburg, Russia. AIDS 2006;20:901–6

Khaldeeva

, Hillis

, Vinogradova

, HIV-1 seroprevalence rates in women and relinquishment of infants to the state in St Petersburg, Russia, 2002. Lancet 2003;362:1981–2

Burchell

, Calzavara

, Orekhovsky

, Ladnaya

. Characterization of an emerging heterosexual HIV epidemic in Russia. Sex Transm Dis 2008;35:807–13

10.

Aral

, St Lawrence

, Dyatlov

, Kozlov

. Commercial sex work, drug use, and sexually transmitted infections in St. Petersburg, Russia. Soc Sci Med 2005;60:2181–90

11.

Amirkhanian

, Kelly

, Kuznetsova

, People with HIV in HAART-Era Russia: transmission risk behavior prevalence, antiretroviral medication-taking, and psychosocial distress. AIDS Behav 2011;15:767–77

12.

Toussova

, Shcherbakova

, Volkova

Potential bridges of heterosexual HIV transmission from drug users to the general population in St. Petersburg, Russia: is it easy to be a young female?

J Urban Health 2009;86(Suppl. 1):121–30

13.

Borisenko

. STD surveillance in the Russian Federation. Int J STD AIDS 1998;9(Suppl. 1):15

14.

Shaboltas

, Toussova

, Hoffman

, HIV prevalence, sociodemographic, and behavioral correlates and recruitment methods among injection drug users in St. Petersburg, Russia. J Acquir Immune Defic Syndr 2006;41:657–63

15.

Grau

, White

, Niccolai

, HIV disclosure, condom use, and awareness of HIV infection among HIV-positive, heterosexual drug injectors in St. Petersburg, Russian Federation. AIDS Behav 2011;15:45–57

16.

Niccolai

, Shcherbakova

, Toussova

, The potential for bridging of HIV transmission in the Russian Federation: sex risk behaviors and HIV prevalence among drug users (DUs) and their non-DU sex partners. J Urban Health 2009;86(Suppl. 1):131–43

17.

Rechel

. HIV/AIDS in the countries of the former Soviet Union: societal and attitudinal challenges. Cent Eur J Public Health 2010;18:110–5

18.

Benotsch

, Pinkerton

, Dyatlov

, HIV risk behavior in male and female Russian sexually transmitted disease clinic patients. Int J Behav Med 2006;13:26–33

19.

Parsons

, Missildine

, Van Ora

, HIV serostatus disclosure to sexual partners among HIV-positive injection drug users. AIDS Patient Care STDS 2004;18:457–69

20.

Borisenko

, Tichonova

, Renton

. Syphilis and other sexually transmitted infections in the Russian Federation. Int J STD AIDS 1999;10:665–8