By Andrea L. Wirtz

162 Pages·2015·2.48 MB·English

by  Andrea Wirtz

BARRIERS TO SUCCESSFUL ENGAGEMENT IN CARE AMONG MEN WHO HAVE
SEX WITH MEN IN MOSCOW, RUSSIA

By
Andrea L. Wirtz

A dissertation submitted to Johns Hopkins University in conformity with
the requirements for the degree of Doctor of Philosophy

Baltimore, Maryland
May 2015

© 2015 Andrea L. Wirtz
All Rights Reserved
Abstract:
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

  ii
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- = 0.043), compared to higher variability among the other RDS
SP
estimators (Cv = 0.074; Cv = 0.093; Cv = 0.092) across recruitment depths. At low
-RDS-I -RDS-II -RDS-SS
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

  iii
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.

  iv
Thesis Committee

Shruti Mehta, PhD, MPH
Professor
Department of Epidemiology
Johns Hopkins School of Public Health

Alison G. Abraham, PhD, MHS, MS
Associate Scientist
Department of Epidemiology
Johns Hopkins School of Public Health

Gypsyamber D’Souza, PhD
Associate Professor
Department of Epidemiology
Johns Hopkins School of Public Health

Thesis Readers & Final Examination Committee

Shruti Mehta, PhD, MPH
Professor
Department of Epidemiology
Johns Hopkins School of Public Health

Carl Latkin, PhD
Chair of Examination Committee
Professor
Department of Health, Behavior and Society
Johns Hopkins School of Public Health

Gypsyamber D’Souza, PhD
Associate Professor
Department of Epidemiology
Johns Hopkins School of Public Health

Gregory Lucas, MD, PhD
Associate Professor
Department of Medicine, Division of Infectious diseases
Johns Hopkins School of Medicine

Alternate Committee Members

Alison G. Abraham, PhD, MHS, MS
Associate Scientist
Department of Epidemiology
Johns Hopkins School of Public Health

Andrea Ruff, MD
Associate Professor
Department of International Health
Johns Hopkins School of Public Health

  v
Acknowledgements:
There are many people to whom I owe sincere gratitude for their support in this doctorate, as well
as for the development of my career in Epidemiology. Dr. Shruti Mehta kindly took on the job of
serving as my advisor over the last three years and has provided more support than I could have
ever requested. I learned an incredible amount about epidemiologic methods from her both in and
outside of coursework. She challenged me to explore more about the methods underlying
respondent-driven sampling and provided thoughtful support during the difficult, sometimes
stagnant, parts of my dissertation writing. On top of it all, she has impressed me as an incredibly
successful researcher and I’ve done my best to learn from her strategies and examples over the
last few years. Drs. Alison Abraham and Gypsyamber D’Souza also served on my thesis
committee. Before this, they taught me a great deal during my courses in the epidemiology
program and much more through their attentive feedback on my dissertation. I have a deep
appreciation for this group’s knowledge of epidemiologic methods and statistics and hope that
this dissertation does justice in demonstrating the outcome of their instruction. I thank Drs.
Gregory Lucas, Carl Latkin, Gypsyamber D’Souza and Shruti Mehta for serving as my
examining committee. Their thoughtful questions were challenging, but made for an enjoyable
discussion. Within the Department of Epidemiology, there are many other faculty and staff who
made the completion of my PhD successful and enjoyable. I’ve had the pleasure of learning from
some of the leading researchers in the field and am grateful for the knowledge they’ve shared and
appreciate their availability to discuss lingering questions and content at deeper levels. I
especially thank Dr. Susan Sherman who has been a great mentor and role model since my
Masters degree in 2005 and throughout the PhD program. She is a model of a researcher whose
compassion drives her research and who endeavors to give back to the communities she studies. I
owe a sincere thanks to Fran Burman and Matthew Miller for their endless support provided to
me and the other students in the Department.

  vi
I cannot complete these Acknowledgments without recognizing the team that made this research
possible. Though I started the PhD program in 2012, my training unofficially began in 2008,
when I began working with Dr. Chris Beyrer in the Center for Public Health and Human Rights.
When I joined him, Chris and the rest of the team were in the midst of the grant submission for
the Russia study and from then on I had the opportunity to join them and develop skill sets in
grant writing, study implementation, analysis and write-up. Within and outside of this study,
Chris has taught me a great deal about HIV research, as well as the importance of using
epidemiologic research for the advancement of human rights and to positively impact the
marginalized populations that we study– a motivation that I hope to carry with me throughout my
career. I am deeply grateful to him for his endless support and for giving me the opportunity to
work on numerous other research studies with him and other affiliated faculty in the Center for
Public Health and Human Rights. These projects have taught me a great deal about research and
have provided opportunities to build many valuable relationships and research studies. Drs. Carla
Zelaya, Carl Latkin, and Noya Galai also formed the core research team for this study in Russia. I
owe great thanks to Carla for teaching me the details of survey development, quality data
collection and analysis, and for making this work and travel even more enjoyable. I am grateful to
Carl for teaching me about the social and behavioral aspects of this study and its measurement. I
owe him many thanks for always providing incredibly thoughtful (and amazingly fast) feedback
on papers and any questions I have. Our partners at AIDS Infoshare in Russia, Alena Peryshkina,
Vladimir Mogilnyi, and Petr Dhyzigun and others are amazingly dedicated to improving the
situation of HIV in the country and are working hard to provide services for key populations in
Russia in the midst of a challenging time. It is because of their work and passion that this study
was possible.

  vii
Finally, I owe my deepest gratitude to my family for their endless support. Sharon and Art Wirtz,
Elaine and Andy Darling, and Stanley Liu have been my cheerleaders and my motivation for
many years. I appreciate the hard work that my parents put into veterinary school and the
dedication they had to the veterinary hospital they ran for so many years. Despite all of their
work, they were always there for my sister and I and continue so today. Elaine, my twin sister,
has been by my side since birth. I’ve continued to enjoy and appreciate her thoughtful listening
and encouragement during these last three years. That we both work in Public Health gives us
one more interest in common - I enjoy being able to have discussions about our work and am very
proud of her for her efforts in advancing public health in West Virginia. I was lucky enough to
meet my fiancé Stan just before I began the PhD program and before he began his Cardiology
fellowship. He’s made these last few years much easier: cheering me up at the end of a difficult
day, making me laugh so hard I cry, and enjoying shared moments of relaxation in between our
work. He’s given me great advice and encouraged me every step of the way. I dedicate this
dissertation to them.
I acknowledge and thank the NIMH for funding this research study and the Charlotte Silverman
fund for providing additional support for the PhD program.

  viii
Table of Contents: Page
CHAPTER 1: INTRODUCTION AND REVIEW OF LITERATURE 1
Specific Aims 11
References 14
CHAPTER 2: ESTIMATING THE UNKNOWN: USE OF DIFFERENT RDS
ESTIMATORS TO DETERMINE HIV PREVALENCE AND POPULATION
CHARACTERISTICS AMONG MEN WHO HAVE SEX WITH MEN IN
MOSCOW, RUSSIA 19
Abstract 20
Introduction 22
Methods 26
Results 31
Discussion 35
References 56
CHAPTER 3: THE HIV CARE CONTINUUM AMONG MEN WHO HAVE SEX
WITH MEN IN MOSCOW, RUSSIA 59
Abstract 60
Introduction 61
Methods 63
Results 67
Discussion 70
References 83
CHAPTER 4: ANAL HUMAN PAPILLOMAVIRUS AND HIV: AN
EXPLORATORY STUDY AMONG MEN WHO HAVE SEX WITH MEN IN
MOSCOW, RUSSIA 88
Abstract 89
Introduction 90
Methods 92
Results 97
Discussion 100
References 112
CHAPTER 5: CONCLUSIONS 117
Summary of Results 118
Strengths and Limitations 122
Public Health Importance 124

  ix
Conclusions 125
References 126
Chapter 6: Curriculum Vitae 129

  x