Evolution of Illicit Opioid Use Among People With HIV Infection in St Petersburg, Russia, in the Period 2004–2015

E Blokhina; EM Krupitsky; DM Cheng; AY Walley; O Toussova; T Yaroslavtseva; N Gnatienko; C Bridden; LS Forman; S Bendiks; JH Samet


HIV Medicine. 2019;20(7):450-455. 

In This Article

Abstract and Introduction


Objectives: In the late 1990s, when the current Russian opioid epidemic began, illicit opioids used in Russia consisted almost exclusively of heroin. The type of opioids used has evolved in the early 21st Century. The objective of this study was to describe the evolution of illicit opioid use among people living with HIV (PLWH) reporting recent opioid use in St Petersburg, Russia.

Methods: We examined baseline data from four research studies conducted in the period 2004–2015 that included PLWH who used opioids [Partnership to Reduce the Epidemic Via Engagement in Narcology Treatment (PREVENT; 2004–2005; n = 17), HIV Evolution in Russia–Mitigating Infection Transmission and Alcoholism in a Growing Epidemic (HERMITAGE; 2007–2010; n = 281), Linking Infectious and Narcology Care (LINC; 2013–2014; n = 119) and Russia Alcohol Research Collaboration on HIV/AIDS (Russia ARCH; 2012–2015; n = 121)] and reported recent use of heroin and other opioids.

Results: Although these studies spanned more than a decade, the participants represented similar birth cohorts; the mean age was 24.5 years in 2004 and 33.3 years in 2014. The use of opioid types, however, evolved across cohorts, with the use of any illicit drug other than heroin increasing from 6% [95% confidence interval (CI) 000.2, 29%] in PREVENT (2004–2005) to 30% (95% CI 25, 36%) in HERMITAGE (2007–2010) to 70% (95% CI 61, 78%) in LINC (2013–2014) to 77% (95% CI 68, 84%) in ARCH (2012–2015). Any heroin use consistently decreased over the 10-year period in the cohorts, from 100% (95% CI 80, 100%) in 2004–2005 to 54% (95% CI 44, 63%) in 2012–2015.

Conclusions: Among PLWH who use opioids in St Petersburg, Russia, illicit use of opioids other than heroin appears to be more common than heroin use.


Russia is one of the four countries with the highest burden of illicit drug use as measured by disability-adjusted life years (DALYs), with over 650 DALYs lost per 100 000 population.[1] In the 1990s, there was a rapid increase in the supply of and demand for heroin in Russia as a consequence of social, economic and psychological factors, in conjunction with the increasing importance of Central Asia as a centre of heroin production and trafficking.[2] This confluence of events contributed to the almost exclusive use of heroin at the onset of the opioid epidemic, leading to a rise in the HIV epidemic in Russia, driven by injecting heroin use.[2–4] Since the late 1990s, the HIV and injecting drug use (IDU) epidemics in Russia have grown, with estimates of HIV prevalence among people who inject drugs (PWID) increasing from < 5% prior to 2000[5] to as high as 60% today.[6] Furthermore, the official prevalence of IDU in Russia is probably an underestimate as a consequence of reliance on data based on 'official registration' of PWID.[7]

In a 2010 study of IDU in eight Russian cities, injection of commercial heroin was more common than that of homemade heroin in St Petersburg.[6] Commercial heroin is derived directly from opium, whereas homemade heroin is converted from morphine in local underground laboratories. Data suggest that HIV is more easily transmitted through commercial heroin use than homemade heroin use,[8] implying that the type of heroin is important and may have HIV transmission consequences.

Clinicians have noted substantial changes in the type of illicit opioids used in recent years, but published studies on these changes are limited. In a mixed methods study conducted in 2012 and 2013 among PWID in St Petersburg, 50% of participants (407 of 811) reported any use of illicit methadone in the past 30 days, compared with only 4% of participants (15 of 411) reporting having injected methadone in the past 30 days in a 2010 study.[9] Unlike the situation in most parts of the world, where methadone is used as a treatment for opioid use disorders (OUDs), as of 2018, opioid agonist treatment remains illegal in Russia. Methadone is manufactured in underground laboratories from its chemical precursors. Injection of methadone only, compared with injection of heroin only or a combination of both, is associated with fewer injections and thus reduced HIV-related risk. Furthermore, study participants who injected methadone only were less likely to inject with a previously used syringe.[9]

Given the ongoing HIV and opioid use epidemics in Russia, it is important to understand the changes in patterns of illicit drug use, so that treatment and HIV risk reduction efforts can effectively address these trends. The aim of this study was to describe the evolution of illicit opioid use among people living with HIV (PLWH) who use opioids in St Petersburg, Russia, in four cohorts recruited over a 10-year period.