Differences by sex in associations between injection drug risks and drug crime conviction among people who inject drugs in Almaty, Kazakhstan

Background: The criminalization of drug use leads to high rates of drug crime convictions for engaging in injection drug use behaviors, introducing barriers to HIV prevention and drug treatment for PWID. Females (FWID) face unique vulnerabilities to HIV compared to males (MWID) in Kazakhstan. This study examined sex differences in associations between HIV/HCV infection, HIV knowledge, injection drug risk behaviors, and conviction for a drug crime in a sample of people who inject drugs (PWID) in Almaty, Kazakhstan. Methods: Analyses were performed on baseline data from 510 PWID and stratified by males (MWID) (329) and females (FWID) (181) from Kazakhstan in a couples-focused HIV prevention intervention. Logistic regression analyses using mixed effects (AOR) examined associations between HIV/HCV infection, HIV knowledge, injection drug risk behaviors, drug use severity, drug treatment history and conviction for a drug crime. Results: About three quarters of PWID reported drug crime conviction (73.92%, n = 377). HCV infection was associated with increased odds of drug crime conviction for FWID (AOR = 4.35, CI₉₅ = 1.83–10.31, p <.01) and MWID (AOR = 3.62, CI₉₅ = 1.09–12.07, p <.01). HIV transmission knowledge was associated with increased odds of conviction for MWID (AOR = 1.19, CI₉₅ = 1.00–1.41, p <.05). Injection drug risk knowledge was associated with lower odds of conviction (AOR =.75, CI₉₅ =.59–.94, p <.05) for FWID. Receptive syringe sharing (AOR = 3.48, CI₉₅ = 1.65–7.31, p <.01), splitting drug solutions (AOR = 4.12, CI₉₅ = 1.86–7.31, p <.05), and injecting with more than two partners (AOR = 1.89, CI₉₅ = 1.06–3.34, p <.05) was associated with increased odds of conviction for FWID. Receptive syringe or equipment sharing with intimate partners was associated with conviction for both MWID (AOR = 1.90, CI₉₅ = 1.03–3.92, p <.05) and FWID (AOR = 1.95, CI₉₅ = 1.02–3.70, p <.05). For FWID, injection drug use in public spaces was associated with conviction (AOR_ME = 3.25, CI₉₅ = 1.31–7.39, p <.01). Drug use severity was associated with increased odds of conviction for FWID (AOR = 1.29, CI₉₅ = 1.09–1.53, p <.001) and MWID (AOR = 1.24, CI₉₅ = 1.09–1.41, p <.001). Ever receiving drug treatment was associated with conviction for MWID (AOR = 2.31, CI₉₅ = 1.32–4.12, p <.01). Conclusion: High-risk behaviors, HCV infection and more severe substance use disorders are associated with drug crime conviction for PWID, particularly FWID. Structural interventions are necessary to increase the engagement of PWID with drug crime convictions in HIV prevention and substance abuse treatment.