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HIV Risks, Testing, and Treatment 

in the Former Soviet Union: 

Challenges and Future Directions in 

Research and Methodology 

 

 

Victoria M. Saadat 

 
Department of Health Research and 
Policy, Stanford University of Medicine, 
Stanford, CA 

 

 

 

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DOI 10.5195/cajgh.2015.225   |   http://cajgh.pitt.edu 

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Abstract 

Background. The dissolution of the USSR resulted in independence for constituent republics but left them battling an unstable 

economic environment and healthcare. Increases in injection drug use, prostitution, and migration were all widespread responses 

to this transition and have contributed to the emergence of an HIV epidemic in the countries of former Soviet Union. Researchers 

have begun to identify the risks of HIV infection as well as the barriers to HIV testing and treatment in the former Soviet Union. 

Significant methodological challenges have arisen and need to be addressed. The objective of this review is to determine common 

threads in HIV research in the former Soviet Union and provide useful recommendations for future research studies.  

Methods. In this systematic review of the literature, Pubmed was searched for English-language studies using the key search terms 

“HIV”, “AIDS”, “human immunodeficiency virus”, “acquired immune deficiency syndrome”, “Central Asia”, “Kazakhstan”, 

“Kyrgyzstan”, “Uzbekistan”, “Tajikistan”, “Turkmenistan”, “Russia”, “Ukraine”, “Armenia”, “Azerbaijan”, and “Georgia”. 

Studies were evaluated against eligibility criteria for inclusion.  

Results. Thirty-nine studies were identified across the two main topic areas of HIV risk and barriers to testing and treatment, 

themes subsequently referred to as “risk” and “barriers”. Study design was predominantly cross-sectional. The most frequently 

used sampling methods were peer-to-peer and non-probabilistic sampling. The most frequently reported risks were condom misuse, 

risky intercourse, and unsafe practices among injection drug users.  Common barriers to testing included that testing was 

inconvenient, and that results would not remain confidential.  Frequent barriers to treatment were based on a distrust in the treatment 

system.   

Conclusion. The findings of this review reveal methodological limitations that span the existing studies. Small sample size, cross-

sectional design, and non-probabilistic sampling methods were frequently reported limitations. Future work is needed to examine 

barriers to testing and treatment as well as longitudinal studies on HIV risk over time in most-at-risk populations.  

Keywords: HIV, HIV treatment, HIV testing, barriers, sex workers, literature review, Central Asia, Russia

HIV Risks, Testing, and Treatment in 

the Former Soviet Union:  
Challenges and Future Directions in 
Research and Methodology 
 

Victoria M. Saadat 

 
Department of Health Research and Policy, 
Stanford University of Medicine, Stanford, 
CA 

Research 

Historical overview 

The Former Soviet Union (FSU)—a group of 

countries and republics spread out across a vast area 

spanning Europe and Asia—is harboring one of the 

fastest growing epidemics of Human Immunodeficiency 

Virus/Acquired Immune Deficiency Syndrome 

(HIV/AIDS) in the world.1 Little attention, however, was 

paid to the epidemic during its early years. The 

epidemic’s growth was masked by low infection rates 

throughout the region and the pressure felt by each newly 

formed nation to establish new and independent political 

and economic infrastructures before addressing public 

health issues. What remains today is a low-profile, yet 

alarming, spread of HIV that necessitates a strategic 

response. Large parts of the FSU, especially Central 

Asia, have been experiencing one of the fastest-growing 

epidemics of HIV in the world.2 Some areas have 

recorded infection rates doubling every year since 2000, 

when steady record keeping began.3 Another study 

demonstrated a 13% increase in new HIV infections in 

Central Asia and Eastern Europe between 2006 to 2012.4  

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Research into the causes of the epidemic and the barriers 

to its alleviation is the crux of an effective strategy.   

When the Soviet Union collapsed in 1991, the 

constituent republics (Russian Federation, Ukraine, 

Uzbekistan, Kazakhstan, Belarus, Azerbaijan, Georgia, 

Armenia, Tajikistan, Moldova, Kyrgyzstan, Lithuania, 

Turkmenistan, Latvia, and Estonia) were left to transition 

to independence with limited resources and guidance. 

During the transition period, economic collapse and 

political turmoil catalyzed many societal changes.5 

Economic transition severely weakened public health 

infrastructure due to loss of funding from state subsidies, 

widespread unemployment, and an increase in private 

practice—where fee-for-service and hidden payments 

became the norm.6 After the healthcare infrastructure 

became stagnated and devoid of necessary funding, 

physicians and researchers began to notice a rise in HIV 

prevalence. The spread of HIV also coincided with a 

decline in life expectancy, higher levels of alcohol and 

injection drug use (IDU), and increased rates of co-

infection with tuberculosis (TB), hepatitis C virus 

(HCV), and syphilis among other sexually transmitted 

infections (STI).7,8  

Driving forces behind the epidemic 

Efficacy of HIV testing and access to treatment 

have been evaluated at both the individual and societal 

levels in many regions of the world, but studies of how 

vulnerable populations—especially IDU—access these 

services in the FSU have been limited.9 In recent years, 

approaches to HIV/AIDS worldwide have broadened to 

focus not only on individual risk-taking behavior, but 

also on the environmental and societal factors that 

influence risky behavior and use of health services.10,11  

Most-at-risk populations—IDU, migrant workers, and 

commercial sex workers (CSW)—are particularly 

vulnerable without access to HIV testing, treatment, and 

prevention resources. They also are among the FSU’s 

least studied groups.10 Initiating public health research 

around highly stigmatized populations, however, has 

proven to be especially challenging in the FSU.12 In the 

most extreme case, this stigma has resulted in little to no 

research on HIV in Turkmenistan, where it is unlawful to 

diagnose or report a patient with HIV.13,14 This review 

makes little reference to the HIV situation in 

Turkmenistan, where there is limited national data.   

Furthermore, the body of literature on HIV in 

the FSU is just beginning to take shape. However, the 

eventual goal of building a substantive body of literature 

around the causes of and barriers to reduction of HIV is 

to identify why at-risk populations are more vulnerable 

to HIV, as well as the barriers underlying suboptimal 

access to testing and treatment.15 Knowing these barriers, 

programs can be redirected and new initiatives prepared. 

Furthermore, in order to conduct more effective research, 

challenges and limitations of past studies must be 

discussed. The primary aim of this review is to 

systematically evaluate the literature and provide a 

concise review of research and methodological 

challenges to-date on the HIV epidemic in the FSU. A 

second goal of this analysis is to provide guiding factors 

for the planning and implementation of future studies for 

the design of more effective testing and treatment 

programs in the region.  

 

Methods 

Search methods 

Search terms used on PubMed included “HIV”, 

“AIDS”, “human immunodeficiency virus”, “acquired 

immune deficiency syndrome”, “Central Asia”, 

“Kazakhstan”, “Kyrgyzstan” “Uzbekistan”, “Tajikistan”, 

“Turkmenistan”, “Russia”, “Ukraine”, “Armenia”, 

“Azerbaijan”, and “Georgia” (Countries were chosen on 

the basis of availability of research literature). 

Bibliographies of relevant articles and reviews were 

scanned for further studies.  

To be eligible, studies had to be published in 

English, contain primary data, and identify HIV risk 

factors and/or barriers to HIV testing or treatment as 

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primary outcomes. These overarching themes are 

subsequently referred to as “risk” and “barriers”.  Studies 

highlighting risks and barriers were chosen for review 

because HIV prevention and treatment efforts cannot be 

realized unless the underlying risks are understood.16  

The flow of study selection is illustrated in Figure 1. The 

search engine PubMed was used in the collection of 

studies for this review. Studies deemed irrelevant were 

either only tangentially related to HIV in the former 

Soviet Union or contained the key words but were not 

answering a research question that contributed to the 

aims of the review.   

 

Figure 1. Flow chart depicting the review process of 

selecting studies for inclusion and analysis of 

manuscripts examining risks of HIV infection, barriers to 

HIV treatment and challenges in HIV prevention  

 

Data extraction 

Table 1 shows the main features of each study; 

Tables 2a, 2b, and 2c summarize the most frequently 

reported risks, barriers to testing, and barriers to 

treatment, respectively.  

 

Table 1. Summary of studies examining risks of HIV 

infection, barriers to HIV treatment and challenges in 

HIV prevention.  Pertinent characteristics include 

location, study aim, design, population, sampling 

method(s), and sample size 

 

Results 

Study location 

The literature collected was sorted into 

geographical categories by country. The number of 

studies from each are as follows: Armenia (n=3)17-19; 

Azerbaijan (n=2)20,21; Georgia (n=2)22,23; Kazakhstan 

(n=6)24-29; Kyrgyzstan (n=3)30-32; Russia (n=13)33-45; 

Tajikistan (n=5)46-50; Ukraine (n=3)32,51,52; and 

Uzbekistan (n=2)53,54. Studies were most heavily 

represented in Russia (33% of studies), Kazakhstan 

(15%), and Tajikistan (13%).   

Study design 

The majority of studies employed a cross-

sectional design (n=36). Of these studies, 10 also 

obtained biological samples to determine HIV status of 

participants. The only longitudinal study was from 

Georgia where investigators and implemented both HIV 

testing and biobehavioral surveys at two different time 

points, three years apart from each other.23 However, the 

study reported that the sample size was insufficient to 

power a comparison between the two time points. 

Therefore, small sample size among a marginalized 

population was a key limiting factor.   

Study population 

IDU were the target population in 17 studies 

(44%) and were conducted in each country except 

Turkmenistan. Other major populations were migrant 

workers (n=8), female and CSW (n=7).   

Sampling methods 

The most common sampling methods were 

purposive sampling (n=19), convenience sampling (n=6), 

and respondent-driven sampling (includes snowball 

sampling) (n=5).  

Study limitations 

The most frequently reported methodological 

challenges were cross-sectional study design (n=12), 

inability to obtain a representative sample (n=11), use of 

self-report (n=11), sub-optimal participant recruiting 

procedures (n=8), and/or a small sample size (n=6).  

Further methodological limitations included: data were 

found not to be generalizable outside of the country in 

which the research was conducted (n=5), specifically 

having used purposive or snowball sampling to recruit 

participants (n=5), low participation rates (including not 

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having obtained data on specific groups that declined to 

participate) (n=4), translation issues and cultural 

misunderstanding of qualitative data (n=4), and likely 

underreporting of risky, illegal, and/or stigmatized 

behaviors in surveys and interviews (n=4).   

Risk factors for HIV infection 

The most frequently reported categories of risks 

were condom misuse (n=9), risky intercourse (n=9), 

unsafe injection practices among IDU (n=8), and spread 

of infection through people who inject drugs (n=8) (Table 

2). Additional groups of risk factors included migration 

challenges (n=6), low HIV/AIDS knowledge (n=4), and 

a history of STI (n=4).  

 

Table 2. Risk factors for infection with HIV as 

determined by the reviewed studies with detailed aspects 

as well as the supporting studies  

 

Barriers to HIV testing 

The most prominent barriers to testing for HIV 

status included the perception that it was shameful to test 

for HIV (n=2), that testing was inconvenient (n=2), and 

that test results would not be held confidential (n=2) 

(Table 3).   

 

Table 3. Barriers to HIV testing as determined by the 

reviewed studies detailed aspects of each category and 

supporting studies  

 

Barriers to HIV treatment 

The most frequently reported barriers to 

obtaining treatment for HIV were based on a distrust in 

the treatment system and experience with the lack of 

efficiency in the structure of the treatment system (Table 

4). Specifically, the barriers included a fear of disclosure 

of treatment status (n=6), an inefficient and ineffective 

treatment structure (n=6), difficulty in registering for 

and/or being accepted into a treatment facility (n=5), and 

difficulty in accessing treatment facilities (n=5).  

 

Table 4. Barriers to HIV treatment as determined by the 

reviewed studies with detailed aspects of each and a list 

of the supporting studies for each category   

 

Discussion 

This is, to our knowledge, the first systematic 

review of the current body of research spanning the 

stages of HIV infection in the FSU, from risk/infection 

through testing and treatment. The results reveal several 

important areas in which the current state of research and 

knowledge is incomplete due to methodological 

limitations of many studies. As shown in Tables 3 and 4, 

barriers to testing and treatment remain strong among at-

risk populations (IDU, CSW, and migrant workers) but 

remain inadequately researched when compared to the 

number of studies examining risk factors for HIV 

infection. Among the reasons for this include sample 

recruitment challenges, and other methodological 

challenges, which are further discussed below.   

Most-at-risk populations 

CSW, men who have sex with men (MSM), 

IDU, and migrant workers have been found to be key 

players in the spread of HIV.1,4,7 However, they are the 

most stigmatized and marginalized groups and have very 

little access to HIV treatment.55 Further, economic, 

social, and institutional factors in the region can be linked 

to the spread of HIV among these groups.   

Migrant workers 

Migration between Russia, the Caucuses, and 

Central Asia has been observed as a driver of the 

epidemic.1,11,56 Many Tajik and Kyrgyz migrants travel 

through Kazakhstan and into Russia to find work. As 

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might be expected, extensive travel often puts them at 

risk.56 Often, financially compromised and separated 

from family, migrants have been shown to engage in 

behaviors that increase the risk of HIV transmission.57 

Their financial and legal status in the host country make 

it extremely difficult to access medical care should HIV 

be suspected or treatment needed.9   

Injection drug users 

Throughout the FSU, the IDU population has 

been growing and is associated with harmful drug use 

and co-infections of TB and HCV.4 The example of 

Central Asia demonstrates both behavioral, economic, 

and geographical factors, among others, at play in the 

concentration of HIV among IDU.58-60 The trafficking of 

opium out of Afghanistan results in large amounts of the 

drug being transported through Kazakhstan, fueling rapid 

growth of the nation’s population of IDU. Additionally, 

Kazakhstan and other Central Asian nations’ location at 

the centers of labor migration routes compound the effect 

of drug trafficking: when migratory patterns considerably 

overlapped with drug trafficking routes, the number of 

cases among IDU increased five-fold in the 13 years 

following Kazakhstan’s independence.61  

Commercial sex workers 

This group consists of both men and women 

who engage in sex work for compensation and suffer 

tremendously from the stigma that accompanies their 

work. Among this group, female sex workers are more 

stigmatized than their male counterparts.  Those who also 

inject drugs experience a form of double jeopardy.62    

Methodological challenges 

One, studies have been conducted in many, but 

not all, of the countries of the FSU. Research in the field 

of HIV/AIDS is particularly limited in Ukraine and 

Georgia, along with being severely limited in 

Turkmenistan. While the number of studies from Russia 

and Kazakhstan, for instance, are relatively numerous, 

they cannot necessarily be generalized to other FSU 

countries. This could be explained by the simultaneous 

similar-and-different nature of the countries: on one 

hand, they shared some common elements of their 

political, social, and economic history for most of the 20th 

century. On the other hand, each country has its own 

history and ethno-cultural fabric, which is likely to 

uniquely affect the mentality and psychology of its 

people. Therefore, studying the risks and barriers within 

every FSU country is necessary in order to help each one 

best prepare and implement an approach to ameliorate the 

HIV/AIDS epidemic.   

Two, many of the studies used a cross-sectional 

design in collecting their data. It is difficult to make 

statements of causation from such designs. More 

longitudinal designs are needed to study the range of 

factors for any given at-risk group. For example, migrant 

workers may need to be studied throughout the migration 

process to evaluate the stage of the migration experience 

that introduces the most vulnerability to exhibit HIV risk 

behaviors. 

Three, many of the studies employed non-

probabilistic sampling. It is difficult to know the 

probability with which the target population has been 

represented in the sample when using a non-probabilistic 

method of sampling. Such methods that have been 

employed in this review’s studies include convenience 

sampling, purposive sampling, and snowball sampling.  

The studies required participation by individuals who 

exhibit illicit, illegal, or stigmatized behaviors and are, 

therefore, socially marginalized. Convenience sampling, 

purposive sampling, and snowball sampling were used to 

gain access to such populations. Although migrant 

workers, IDU and CSW are understandably difficult to 

access and representatively sample, studies could be 

designed in a more rigorous way that takes into account 

these limitations of working with hard-to-sample 

populations that are hidden and lack most formal forms 

of rosters or lists of documentation, from which 

probabilistic samples could be obtained. In a separate 

search of the literature about HIV risk behavior studies in 

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other parts of the world, including Thailand and 

Australia, it was interesting to find that many of the 

studies did not demonstrate a need for purposive or 

respondent-driven sampling techniques, for instance.  

Instead, the researchers often approached CSW, in many 

cases, in testing or treatment facilities.63,64 This may 

likely indicate a difference in the difficulties inherent in 

recruiting marginalized populations in the FSU, when 

compared to the same task in other parts of the world.65 

Four, many of the studies reported that it was 

likely that subjects may have underreported stigmatized, 

illegal, or risky behaviors in self-report questionnaires 

and interviews. Although not verified, it was an 

observation made by researchers who were likely aware 

of the stigmatized nature of most-at-risk populations. For 

this reason, it was thought to be likely, given that study 

participants may have distrusted the researchers and 

feared that the interview results deemed confidential 

would be released to the police.66 Furthermore, data 

obtained from self-report can be subject to the “social-

desirability bias,” by which a participant may answer 

questions in a certain manner in order to portray 

themselves as lawful and socially acceptable. While this 

insight is helpful in interpreting the data, it sill reveals 

that the data acquired are not thoroughly accounting for 

the range and prevalence of behaviors that put subjects at 

risk for HIV infection or pose barriers to testing and 

treatment.   

Limitations  

There are several limitations of the review that 

must be noted. First, while most of the studies were 

generally accessible in English, several studies were 

available only in Russian (n=8) or full-text was 

inaccessible. Without the ability to identify and retrieve 

all relevant studies, the review’s scope may diminish 

from the ideal. Second, the study of HIV is a relatively 

new area of epidemiologic and public health focus in the 

FSU, and thus the number of relevant studies is limited, 

resulting in 39 eligible studies for review. Third, the 

methodological limitations that were extracted from the 

study manuscripts and tabulated above were based on 

what the authors had listed in their own evaluation of 

study limitations and/or from what was available in the 

methodological descriptions of the studies. For instance, 

purposive sampling—as a methodological limitation in a 

study—was determined from the methodological 

descriptions and/or from the discussion of limitations 

provided by the study’s authors. This means that certain 

methodological limitations deemed infrequent in this 

review—especially “distrust of researchers” (3% of 

studies reviewed)—should not be viewed as certainly 

infrequent. Many of the studies may have suffered from 

participant distrust, which may have either gone 

unnoticed and had an effect on data or sampling 

outcomes or have been noticed but not reported in the 

manuscript. Participant distrust of the researchers can 

have an effect on many parts of a study that involve most-

at-risk populations: participation rate, sample size, and 

underreporting can all be affected, but it is important to 

note in FSU-based studies when distrust occurs in order 

to help determine ways to improve the relationship 

between most-at-risk populations and researchers.  

 

Conclusion 

HIV research in the former Soviet Union 

Today, the epidemic grows as risky behavior 

continues, and prevention and treatment programs face 

difficulties gaining a foothold in the still-transitioning 

atmosphere of the FSU. However, the findings of this 

review reveal a few particular ways in which the current 

state of knowledge is incomplete as a result of 

methodological limitations of many of the existing 

studies. For instance, while 20 studies reported risk 

factors for HIV infection, only seven of the 39 studies 

reported barriers to HIV testing, and 9 studies reported 

barriers to treatment. These numbers illustrate where the 

bulk of the research has been conducted in the HIV 

infection pathway (risks factors and infection, testing, 

and treatment) in the FSU. One reason for this finding 

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may be that there are many more individuals at risk for 

or infected with HIV than there are individuals who have 

sought testing and/or treatment. Given that small sample 

size has been a limitation and concern among many of 

the reviewed studies, it may be a reason for the relative 

scarcity of studies on barriers to testing and treatment 

when compared to studies on the risk factors for HIV 

infection.   

Recommendations for future studies 

Going forward, energy and resources would be 

best spent on research to study the barriers to getting 

tested and treated for HIV. Of the studies included, the 

number of which that looked barriers to testing and 

treatment was minimal compared to what was aimed at 

studying the risks of HIV infection. Future research 

would include a combination of studies that address the 

described methodological challenges and one or more 

attempts at meta-analysis of the data from thematically 

aligned studies. Efforts to apply the results from the 

above-mentioned research would assist in improving 

existing HIV programs and advising the development of 

new ones in the FSU.67,68 

 

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Table 1: Summary of studies examining risks of HIV infection, barriers to HIV treatment and challenges in HIV prevention.  
Pertinent characteristics include location, study aim, design, population, sampling method(s), and sample size 

Reference Location Aims Outcome Methods Population Sampling Method Sample 

Markosyan et al. 

(2007) 

Armenia Describe HIV 

risk/preventive behaviors 

and correlates among 

Armenian FSW 

Questionnaire, focus 

groups, interviews 

Armenian FSW Convenience sample  98 

Lang et al. 

(2013) 

Armenia Identify the association of 

gender-based violence with 

sexual risk among FSW 

Survey Armenian FSW Convenience and snowball 

sampling 

120 

Johnston et al., 

(2014) 

Armenia Present risk behavior 

associations for HIV and 

HCV infection among 

PWID 

Interview and 

testing for HIV and 

HCV 

PWID injecting drugs 

within the past three 

months 

RDS 270 

Nassibov et al., 

(2005) 

Azerbaijan Examine the prevalence and 

context of injection drug use 

and HIV-risk behaviors and 

trends in HIV transmission 

Survey and focus 

groups 

IDU and key 

informants (medical 

staff, police, and 

legal experts) 

Not described 400 

Botros et al., 

(2009) 

Azerbaijan Assess HIV prevalence and 

associated risk behaviors 

among truck drivers 

Questionnaire and 

sero-surveillance 

blood testing 

Truck drivers 

traveling through 

Azerbaijan 

Convenience sampling 3,763 

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Central Asian Journal of Global Health 

Volume 4, No. 2 (2015)  |  ISSN 2166-7403 (online)  |  DOI 10.5195/cajgh.2015.225  |  http://cajgh.pitt.edu 

  

 

Otiashvili et al. 

(2013) 

Georgia Investigate the factors that 

may facilitate or hinder 

substance-using women’s 

help-seeking behavior or 

access to treatment services 

Secondary analysis 

of in-depth 

interviews 

Substance-using 

women and providers 

of health-related 

services 

Word-of-mouth  89 

Tsereteli et al. 

(2013) 

Georgia Investigate HIV testing 

practice among FSW and 

MSM and to identify 

determinants of never 

testing behavior among 

MSM 

Bio-behavioral 

surveys 

FSW and MSM in 

Tbilisi, Georgia 

FSWs were recruited through 

time-location sampling; 

Recruitment of MSM was 

carried out through RDS 

278 

Viale, BN (2010) Kazakhstan Assess perceived barriers to 

seeking and accessing 

voluntary testing 

Survey IDU in Kazakhstan RDS 1,071 

El-Bassel et al. 

(2014) 

Kazakhstan Compare FWID and females 

who do not inject drugs, 

examining associations 

between history of IDU and 

HIV and HCV risk 

behaviors 

Reanalysis of data 

from prior RCT with 

self-reported 

responses and bio-

logical assays 

Female partners of 

MWID: Both FWID 

and non-injecting 

female partners 

Trained research assistants 

recruited potential study 

participants from neighborhoods 

where IDU gather as well as 

HIV clinics and needle exchange 

programs (for more detail see El-

Bassel et al.,2013) 

364 

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SAADAT 

 

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of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 4, No. 2 (2015)  |  ISSN 2166-7403 (online)  |  DOI 10.5195/cajgh.2015.225  |  http://cajgh.pitt.edu 

 

 

El-Bassel et al. 

(2011) 

Kazakhstan Examine associations 

between mobility patterns 

and HIV risks among male 

and female migrant market 

vendors 

Structured interview Male and female 

migrant market 

vendors in Almaty 

Randomized sampling using GIS 

(mapping of stalls at 

Barakholka) 

422 

El-Bassel et al. 

(2013) 

Kazakhstan Examine associations 

between HIV serostatus, 

socio-demographic factors, 

and sexual and drug risk 

behaviors 

Self-report data and 

biological assays for 

HIV serostatus 

IDU and their 

heterosexual intimate 

partners 

Word-of-mouth and targeted 

outreach in known neighborhood 

locations where IDU gather 

 

728 

Berry et al. 

(2012) 

Kazakhstan Measure HIV risk factors 

and HIV prevalence among 

MSM 

Questionnaire and 

HIV test 

MSM in Almaty  RDS  400 

Boltaev et al. 

(2012) 

Kazakhstan Evaluate the quality and 

effectiveness of the MAT 

pilot in Kazakhstan and 

review implementation 

In-depth qualitative 

interview 

MAT patients in 

Kazakhstan 

Not specified 93 

Deryabina, A. 

(2011) 

Kyrgyzstan Understand the current 

status of HIV services for 

most-at-risk populations 

(MARP), access to, and 

quality of services provided 

Semi-structured 

interviews and focus 

groups 

IDU, CSW, former 

prisoners, and leaders 

of various HIV/AIDS 

groups in Chui Oblast 

and Bishkek City 

MARP representatives who 

participated in FGDs or 

individual interviews were 

recruited through NGO 

representatives (outreach 

243 

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workers) and thus only included 

clients of HIV-related services 

Messner et al. 

(2013) 

Kyrgyzstan Identify gender-based 

constraints to accessing 

HIV/AIDS programs and 

services 

Interviews Individuals from 

various governmental 

organizations 

A list of key informants was 

developed in collaboration with 

USAID/Kyrgyzstan and 

additional interviewees were 

identified during the in-country 

data collection 

60 

Spicer et al. 

(2011) 

Kyrgyzstan Explore access barriers to 

HIV/AIDS services 

experienced by a key risk 

group of IDU 

Semi-structured 

interviews 

IDU and stakeholders 

in Ukraine and 

Kyrgyzstan 

Purposive sampling 228 

Tkatchenko-

Schmidt, et al. 

(2008) 

Russia Examine attitudes of 

Russian policy-makers and 

HIV stakeholders towards 

HR scale up 

Semi-structured 

interviews 

HIV-focused 

governmental 

organizations and 

NGOs in Volgograd 

Purposive and chain sampling 58 

Bobrova et al. 

(2006) 

Russia Assess factors that impact 

IDU access to treatment  

Qualitative 

interviews 

IDU Purposive sampling 86 

Sarang et al. 

(2008) 

Russia Investigate IDU access to 

needles and syringes 

Qualitative 

interviews 

IDU in Moscow, 

Volgograd, Barnaul 

Targeted and snowball sampling 209 

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King et al. 

(2013) 

Russia Determine facilitators of and 

barriers to accessing HIV 

services 

In-depth qualitative 

interviews 

FSW in St. 

Petersburg 

Purposive sampling  29 

King et al. 

(2013) 

Russia Better understand how 

stigma and discrimination 

influence HIV service 

utilization 

Questionnaire FSW Purposive sampling 139 

Vasquez et al. 

(2013) 

Russia Define characteristics and 

barriers to HIV care 

Questionnaire People receiving HIV 

treatment in St. 

Petersburg 

Convenience sampling 152 

Sarang et al. 

(2013) 

Russia Explore barriers to 

accessing ART among 

PWID 

In-depth qualitative 

interviews 

PWID in  

Yekaterinburg 

Purposive sampling 42 

Zabrocki et al. 

(2013) 

Russia Understand socio-structural 

barriers, protective factors, 

and HIV sexual risk 

Interviews Unmarried female 

migrants in Moscow 

Purposive sampling 30 

Niccolai et al. 

(2010) 

Russia Estimate HIV prevalence 

and testing patterns among 

IDUs 

HIV and STI 

testing; Survey 

IDU in St. Petersburg RDS 387 

Kruse et al. 

(2009) 

Russia Examine behaviors 

associated with HIV risk 

Questionnaire and 

HIV testing 

IDU Purposive sampling 900 

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among IDUs 

Amirkhanian et 

al. (2011) 

Russia Explore health service 

access of persons living with 

HIV 

Questionnaire Individuals with 

HIV/AIDS from 5 St. 

Petersburg health 

care and social 

service agencies 

Convenience sampling 470 

Amirkhanian et 

al. (2011) 

Russia Determine how well migrant 

workers understand HIV 

risk factors and behaviors 

that increase HIV risk 

Questionnaire and 

survey 

Male labor migrants 

in St. Petersburg 

Convenience sampling 499 

Weine et al. 

(2008) 

Russia Characterize HIV/AIDS 

risk; Identify contextual 

factors that could impede or 

facilitate a preventive 

intervention 

 

Ethnographic 

interview and 

survey 

Tajik male migrant 

workers in Moscow 

Purposive sampling at work sites 30 

Stachowiak et al. 

(2006) 

Tajikistan Examine differences by 

ethnicity of HIV prevalence 

and correlates among IDU 

Questionnaire and 

HIV testing 

Active adult IDUs Purposive sampling 489 

Beyrer et al. Tajikistan Determine HIV, HCV, and Survey; HIV, HCV, Active adult IDUs Purposive sampling 491 

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(2009) syphilis prevalence and 

correlates 

and syphilis testing 

Weine et al. 

(2012) 

Tajikistan Determine the role of 

trauma and PTSD symptoms 

in the context of migration-

associated HIV risk 

behaviors 

Survey Tajik married male 

labor migrants in 

Moscow 

Probabilities proportionate to 

size (PPS) methods; simple 

random sampling (SRS) 

400 

Golobof et al. 

(2011) 

Tajikistan Understand labor migrants' 

wives' knowledge, attitudes, 

and behaviors regarding 

HIV/AIDS risk and 

protection 

Minimally 

structured 

interviews and field 

observations 

Tajik wives in 

Dushanbe married to 

male migrant workers 

in Moscow 

Purposive sampling 30 

Jing et al. (2012) Tajikistan Investigate powerlessness in 

HIV risk among internal and 

external male labor migrant 

workers from Tajikistan 

Minimally 

structured 

interviews and field 

observations 

Migrants working in 

Regar; Migrants 

working in Moscow 

Purposive sampling 60 

Mimiaga et al. 

(2010) 

Ukraine Examine barriers and 

facilitators to HAART 

adherence 

Semi-structured 

focus groups 

HIV-infected IDU 

seeking treatment at 

the City AIDS 

Center, Kiev 

Purposive/convenience 

sampling: Participants recruited 

from those attending treatment 

the AIDS Center 

16 

Booth et al. Ukraine Learn how experiences with 

the legal system (police and 

Semi-structured IDU; police and Not specified 19 

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(2013) courts) correlate with HIV 

among IDU 

interviews members of the court 

Spicer et al. 

(2011) 

Ukraine Explore multiple access 

barriers to HIV/AIDS 

services experienced by a 

key risk group of IDU 

Semi-structured 

interviews 

IDU (current and 

former) and national 

and sub-national 

stakeholders in 

Ukraine and 

Kyrgyzstan 

Purposive sampling: Client 

interviewees were recruited with 

the agreement of HIV/AIDS 

service providers who 

introduced potential 

interviewees to the researchers 

391 

Todd et al. 

(2007) 

Uzbekistan Examine condom use and 

HIV testing use among FSW 

Questionnaire, 

interview, and HIV 

testing 

FSW in Tashkent Purposive sampling by outreach 

workers affiliated with Istiqbolli 

Avlod, a NGO in Tashkent 

448 

Sanchez et al. 

(2006) 

Uzbekistan Determine HIV prevalence 

and potential associations 

with sociodemographic and 

behavioral factors among 

IDU 

Survey and HIV 

biosurveillance  

IDU in Tashkent Purposive sampling by the 

Center for AIDS Prevention and 

Control and in IDU gathering 

locations 

 

701 

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SAADAT 

 

 

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of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

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Table 2. Risk factors for infection with HIV as determined by the reviewed studies with 

detailed aspects as well as the supporting studies 

Risk Factor Reported Details Supporting Studies 

Condom use Irregular, inconsistent, and incorrect use of condoms Beyrer et al. (2009), Botros et al. 

(2009), Lang et al. (2013), 

Amirkhanian et al. (2011), Sanchez 

et al. (2006), Markosyan et al. 

(2007), Vasquez et al. (2013), 

Zabrocki et al. (2013), Jing et al. 

(2012) 

Risky intercourse Sex with IDU clients, MSM status, unprotected sex, unprotected 

sex with CSW, earlier age of initiation of sex work, 

transactional sex, multiple female partners in last 3 months, 

having unprotected anal intercourse with male partners, 

unprotected receptive anal sex 

Markosyan et al. (2007), 

Amirkhanian et al. (2011), Lang et 

al. (2013), Weine et al. (2008), 

Lang et al. (2013), Berry et al. 

(2012), Amirkhanian et al. (2011), 

Berry et al. (2012), Berry et al. 

(2012) 

Unsafe injection 

practices 

Daily injecting, injecting alone, starting injecting at a younger 

age of initiation of illegal drug use, longer history of drug 

abuse, rushed injections due to fear of the police, IDU status, 

being female IDU 

Stachowiak et al. (2006), Beyrer et 

al. (2009), Vasquez et al. (2013), 

Booth et al. (2013), Vasquez et al. 

(2013), Amirkhanian et al. (2011), 

El-Bassel et al. (2014), El-Bassel et 

al. (2011) 

Migration 

challenges 

Being Tajik or Uzbek nationality, frequent travel outside of 

current place of residence, harsh living and working conditions, 

lack of legal protection from the government, poor social 

support 

Beyrer et al. (2009), El-Bassel et 

al. (2013), El-Bassel et al. (2013), 

Weine et al. (2008), El-Bassel et al. 

(2013), Amirkhanian et al. (2003) 

Threats from 

police 

Police planting drugs, IDU paying police to avoid arrest, prior 

confiscation of pre-filled syringes, history of incarceration 

Booth et al. (2013), Booth et al. 

(2013), Booth et al. (2013), Booth 

et al. (2013), El-Bassel et al. 

(2014) 

Low HIV/AIDS 

knowledge 

Incomplete or vague knowledge of HIV transmission Jing et al. (2012), Markosyan et al. 

(2007), Zabrocki et al. (2013), 

Amirkhanian et al. (2011) 

History of STI Current STI symptoms, history of STI, prior history of hepatitis Berry et al. (2012), Botros et al. 

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Central Asian Journal of Global Health 

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(2009), Sanchez et al. (2006), Lang 

et al. (2013) 

Concurrent 

alcohol and drug 

use 

Drinking alcohol, non-injection drug use  Jing et al. (2012), Markosyan et al. 

(2007), Berry et al. (2012) 

Pressure not to 

use condom 

Fear of sexual partners’ reaction to condom use Lang et al. (2013), Golobof et al. 

(2011) 

History of drug 

abuse treatment 

History of undergoing drug abuse treatment multiple times Stachowiak et al. (2006), Beyrer et 

al. (2009) 

  

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SAADAT 

 

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of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

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Table 3. Barriers to HIV testing as determined by the reviewed studies detailed aspects of 

each category and supporting studies 

Barrier to Testing Reported Details Supporting Studies 

Shame Thoughts that testing is shameful, HIV stigma Golobof et al. (2011), King 

et al. (2013) 

Convenience of testing Low access and hard to find testing locations, 

inconvenient clinic hours 

Tsereteli et al. (2013), 

Viale, BN (2010) 

Confidentiality of testing  Fear of being disclosed as an IDU, fear that testing 

results would not remain confidential 

Nassibov et al. (2005), 

Tkatchenko-Schmidt, et al. 

(2008) 

Fear of result Fear of a positive test result Viale, BN (2010) 

Priorities Perception that more immediate problems take priority Viale, BN (2010) 

Self-perception of HIV risk Considering self at low or no risk for HIV Tsereteli et al. (2013) 

Lack of experience in sex work Engaging in sex work less than 2 years, younger than 

21, initiated sex work at the age of 18 or younger 

Todd et al. (2007) 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

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Table 4. Barriers to HIV treatment as determined by the reviewed studies with detailed 

aspects of each and a list of the supporting studies for each category 

Barriers to treatment Reported details Supporting studies 

Fear of disclosure Lack of anonymity/confidentiality of treatment, fear of 

registration as IDU, fear of police around treatment 

centers, criminalization of drug use at treatment centers, 

harassment and discrimination by police 

King et al. (2013), Bobrova et 

al. (2006), Otiashvili et al. 

(2013), Sarang et al. (2008), 

Spicer et al. (2011), Mimiaga et 

al. (2010) 

Inefficient and ineffective 

treatment structure  

Shortages of commodities and human resources, low 

knowledge and skills of service providers, insufficient 

drug policies, limited opportunities for staff development, 

complexity of drug treatment regimen, services and 

entitlements 

Spicer et al. (2011), Otiashvili 

et al. (2013), Otiashvili et al. 

(2013), Boltaev et al. (2012), 

Mimiaga et al. (2010), Spicer et 

al. (2011) 

Difficult to register for or be 

accepted into treatment 

Bureaucracy, tough registration system, organizational 

barriers, lack of legal status while being a migrant worker 

Sarang et al. (2008), King et al. 

(2013), Spicer et al. (2011), 

Zabrocki et al. (2013), King et 

al. (2013) 

Difficult to access treatment 

facilities 

Scarce infrastructure of narcological facilities, inadequate 

access and coverage, insufficient supply management, 

geographic proximity and access, lack of availability of 

comprehensive treatment programs, restrictive methadone 

dispensing policies 

Boltaev et al. (2012), Boltaev 

et al. (2012), Boltaev et al. 

(2012), Otiashvili et al. (2013), 

Boltaev et al. (2012) 

Unable to afford treatment Financial constraints (especially for migrant workers) Zabrocki et al. (2013), Bobrova 

et al. (2006), Otiashvili et al. 

(2013), King et al. (2013) 

Stigma Stigmatization of HIV/AIDS and drug use, discrimination 

among government service providers 

Spicer et al. (2011), Mimiaga et 

al. (2010), Spicer et al. (2011), 

Bobrova et al. (2006) 

Distrust in treatment Lack of belief in treatment effectiveness, perceived low 

efficacy, feeling that harm reduction programs are forced 

on them from outside 

Tkatchenko-Schmidt, et al. 

(2008), Bobrova et al. (2006), 

Tkatchenko-Schmidt, et al. 

(2008) 

Drug use policies in treatment  Opioid dependence, fear of treatment being withheld b/c 

drug use 

Mimiaga et al. (2010), Sarang 

et al. (2008) 

Limited knowledge Limited knowledge of HIV/AIDS risk factors Spicer et al. (2011) 

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SAADAT 

 

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Central Asian Journal of Global Health 

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Mental Health Problems Co-morbid mental health problems Mimiaga et al. (2010) 

 

  

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CENTRAL ASIAN JOURNAL OF GLOBAL HEALTH 

 

 

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Central Asian Journal of Global Health 

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Figure 1. Flow chart depicting the review process of selecting studies for inclusion and 

analysis of manuscripts examining risks of HIV infection, barriers to HIV treatment and 

challenges in HIV prevention  

 

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