BARRIERS TO SUCCESSFUL ENGAGEMENT IN CARE AMONG MEN WHO HAVE SEX WITH MEN IN MOSCOW, RUSSIA
Wirtz, Andrea Lacey
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Background: Globally, men who have sex with men (MSM) face a high and disproportionate burden of HIV infection. The framework of the HIV care continuum provides both an individual and population-based approach to addressing the HIV epidemic including the HIV epidemics among MSM. This continuum includes early identification of HIV infection, successful linkage and engagement in HIV care, appropriate treatment and successful virologic suppression. Increasing access to and improving methods for HIV testing provides the dual benefit of identifying infections early on, as well as improving surveillance, which is necessary to inform programming related to HIV prevention and care. Engagement in regular HIV care also provides an opportunity for monitoring and identification of comorbidities, with the aim of improving overall health and longevity. In the Russian Federation, there is limited data on the HIV epidemic among MSM and engagement in care for those living with HIV infection. Moreover, increasing stigma of the population may challenge access to testing and care for MSM. This study aimed to assess key points along the HIV care continuum for MSM living in Moscow, Russia. Methods: A total of 1,541 MSM were recruited by respondent-driven sampling (N=1,376) and internet-based sampling (N=165), as part of a larger epidemiologic study of HIV among MSM in Moscow, Russia. Among a sample of 1,376 MSM recruited via RDS between October 2010 and April 2013, we compared estimates produced by crude analysis and three available estimators, RDS-I, RDS-II (Volz-Heckathorn), and Gile’s RDS-SS. Analysis investigated the influence of the numbers of waves of recruitment, homophily and network size on the HIV prevalence estimates generated as well as the ability to conduct subgroup analysis. Among this same sample of men, we further estimated the proportions living with HIV, linked to care, currently taking ART, and who report virologic suppression. Multivariable regression analyses were further conducted to identify correlates of being unaware of one’s HIV infection. Finally, a subsample of HIV infected and uninfected MSM were selected from the pool of RDS and IBS participants for anal HPV genotype testing to identify circulating genotypes and correlates of infection. Results: We identified a high burden of HIV infection, with a 12% RDS-weighted population prevalence (16% crude), relative to the general adult population prevalence of 1%. Comparison of RDS estimation and inference methods found great similarity in estimates and levels of variability among the three estimators that are currently in use. The coefficient of variation (Cv) for estimates pertaining to HIV prevalence illustrate this case, with low variability among the sample proportion (Cv-SP = 0.043), compared to higher variability among the other RDS estimators (Cv-RDS-I= 0.074; Cv-RDS-II= 0.093; Cv-RDS-SS= 0.092) across recruitment depths. At low recruitment depth, more variation is seen among the estimators and particularly among the RDS-I estimator; however, after sufficient recruitment depths and equilibrium has been reached, there is little difference in inference of HIV prevalence or other characteristics by these estimators. Among the 16% of participants (n=184) who were identified with HIV infection only 23.4% were aware of their HIV infection, 8.7% were currently on ART, and 4.4% reported an undetectable viral load. Further multivariable analysis of this large proportion who were unaware of their infection (76.6%) found that bisexual identity (ref: homosexual; AOR: 3.69; 95%CI: 1.19-11.43), having >5 sexual partners in the last 6 months (ref: <1; AOR 4.23; 95%CI: 1.17-15.28), and being required to have an HIV test by an employer (ref: no; AOR: 15.43; 95%CI: 1.62-147.01) were positively associated with being unaware of one’s HIV infection. HIV infection was also highly correlated with anal HPV infection. Though almost 40% of the total subsample of HIV infected and uninfected men had some form of HPV infection, infection with oncogenic genotypes HPV 16 and18 was more prevalent among HIV infected than uninfected men (41.4% vs. 23.1%; p=0.03). In the final multivariable model, HIV infection was independently associated with HPV 16/18 (AOR:5.08; 95%CI:1.49-17.34), along with migration to/within Russia and having increased numbers of male sexual partners in the last 12 months. Discussion: By any means of inference, there is a high burden of HIV infection among the population; yet, there is a steep gradient along the HIV care continuum for Moscow-based MSM. Awareness of one’s HIV diagnosis is low, reducing opportunities for engagement in care and treatment. Efforts that focus on improving access to acceptable HIV testing strategies, encourage engagement in care for those who are living with HIV, and provide support and care for other co-infections are needed to improve HIV care among this population at risk for HIV infection.