Trends in Injection Risk Behaviors among People Who Inject Drugs and the Impact of Harm Reduction Programs in Ukraine, 2007-2013

Integrated biobehavioral surveillance among people who inject drugs in Ukraine, 2007-2020

BACKGROUND

Repeated integrated biobehavioral surveys (IBBS) have been implemented among people who inject drugs (PWID) in Ukraine to monitor the trends in key epidemiologic and programmatic indicators.

METHODS

The study analyzed seven PWID IBBS rounds from 2007 to 2020 in seven Ukrainian cities. Participants were recruited using respondent-driven sampling, tested for HIV and anti-HCV antibodies, and completed a structured questionnaire. Composite weights (based on individual sampling probability and population size) were applied to generate point estimates and confidence intervals for HIV and HCV prevalence, injection risk behaviors, prevention service coverage, and HIV treatment cascade. Multi-level regression assessed temporal trends in these indicators in 2007-2020.

RESULTS

The samples consisted of 1587 participants in 2007, 1905 in 2008/9, 3066 in 2011, 2846 in 2013, 2699 in 2015, 2798 in 2017, and 3651 in the 2020 rounds. HIV prevalence decreased from 27% to 19% overall, and among PWID younger than 25 from 10.5% to 5.5%. Anti-HCV prevalence increased from 50% to 73% overall but decreased from 58% to 27% in the younger subgroup. Past-30-days injection risk behaviors consistently decreased, reaching a minimum of 38% for any risk in 2020. HIV treatment cascade indicators and coverage with opioid agonist treatment substantially improved in the last three rounds. Harm reduction services coverage fluctuated, declining from 52% to 33% in the last three rounds.

CONCLUSIONS

This analysis demonstrates the potential of repeated IBBS for monitoring the HIV epidemic and program coverage. We confirmed a sustained decline in overall HIV and HCV transmission, likely driven by reduced risky injection practices among PWID. The impact of harm reduction services requires further study. HIV status awareness and treatment coverage among PWID markedly increased, reaching the national average, possibly indicating the success of case-finding and linkage-to-care interventions. The upcoming IBBS round in Ukraine will also assess the impact of the war on service provision, risk behavior, and HIV transmission among PWID.

Qualitative exploration of the early experiences of opioid use disorder patients from private clinics after Russia's invasion of Ukraine in five major cities in Ukraine

Introduction

Following the full-scale invasion of Ukraine by the Russian Federation on 24 February 2022, over 6,000 patients were at risk of potential disruptions in treatment with medications for opioid use disorder (MOUD) in Ukraine. Before 2022, privatized MOUD clinics had emerged, partly driven by restrictive governmental policies and practices in state-funded facilities. Nevertheless, scant information exists regarding their operation and the patient's experiences, especially during crises. This study seeks to elucidate the initial lived experiences of patients utilizing private MOUD clinics, integrating these insights with an analysis of the responding health system during war.

Methods

The findings are derived from 20 qualitative semi-structured interviews conducted between March and June 2022, engaging participants from five major Ukrainian cities: Kharkiv, Kyiv, Odesa, Poltava, and Zaporizhzhya. Employing a rapid analysis procedure, we examined the data through descriptive and analytical summaries aligned with the domains of the data collection instrument.

Results

Emergent themes encompassed stress and uncertainty following the invasion's onset, challenges accessing MOUD, and consequent perceptions concerning state-funded versus private clinics. The study identified disruptions in the operation of private MOUD clinics across most cities examined. Issues pertaining to MOUD medication availability were linked to dosage reductions at state-funded clinics or pharmacy medication shortages or closures. Despite varied experiences at different MOUD clinics and cities, most participants continued their treatment.

Discussion

This qualitative exploration provides a perspective on lived experiences with MOUD treatment at private clinics amidst the initial months of the invasion, illuminating how the early days' stress, access challenges, varied responses from private MOUD clinics, and precarious conditions informed or altered preferences regarding MOUD treatment options. Moreover, these findings corroborate previously documented efforts by myriad stakeholders to mitigate war-related disruptions to MOUD delivery. These insights contribute to the international understanding of health system navigation and resilience during major crises, offering valuable lessons for preparedness development.

Early disruptions to syringe services programs during the Russian invasion of Ukraine

Introduction

The widespread HIV epidemic in Ukraine is concentrated among people who inject drugs (PWID), making access to sterile injection paraphernalia (SIP) like sterile needles and syringes a critical method of HIV/AIDS prevention; however, the Russian invasion has threatened to disrupt the operations of syringe services programs (SSPs), creating a risk of HIV outbreaks among PWID.

Methods

We conducted 10 semi-structured interviews with outreach workers from SSPs. Interviews were purposively sampled to cover three prototypic regions of Ukraine: temporarily Russian-controlled, frontline, and destination. Qualitative results from interviews were then compared against a standardized, nationwide harm reduction database.

Results

We found that the Russian invasion triggered both supply and demand challenges for SSPs. Demand increased for all regions due to client transitions from pharmacies that closed to SSPs, increases in illicit drug use, greater client openness to NGO support, and displacement of clients to destination regions. Supply decreased for all areas (except for remote destination regions) due to battle-related barriers like curfews, roadblocks, and Internet disruptions; diminished deliveries of SIP and funding; and staff displacement. Time series plots of the number of unique clients accessing harm reduction services showed that an initial decrease in service provision occurred at the start of the war but that most regions recovered within several months except for Russian-controlled regions, which continued to provide services to fewer clients relative to previous years.

Conclusion

To ensure continued scale-up of SIP and other HIV prevention services, the SyrEx database should be leveraged to serve as a streamlined harm reduction locator that can inform workers and clients of open site locations and other pertinent information.

Injection Drug Use and Sexual Risk Behaviors Among People who Inject Drugs in Ukraine: A Random-Intercept Latent Transition Analysis

HIV transmission in Ukraine is driven in part by unsafe injection drug use and sexual risk behaviors among people who inject drugs. We performed a random-intercept latent transition analysis on responses to 9 binary injection drug use and sexual behavior items from 1195 people who inject drugs with negative HIV status enrolled in a clustered randomized clinical trial of a social network intervention in Odessa, Donetsk, and Nikolayev, Ukraine. We identified 5 baseline classes: "Social injection/equipment-sharing" (11.7%), "Social injection" (25.9%), "High-risk collective preparation/splitting" (17.0%), "Collective preparation/splitting" (11.3%), and "Dealer-facilitated injection" (34.1%). After 12 months, intervention participants were more likely to transition to the "Collective preparation/splitting" class, which featured the fewest risk behaviors. Transitioning from the "Collective preparation/splitting" to the "Social injection/equipment-sharing" class was associated with HIV acquisition for control participants. Research to illuminate the stability of these patterns and how they may benefit from uniquely tailored programming to reduce unsafe behaviors is needed.

HIV Prevalence and Related Behaviors Among People Who Inject Drugs in Iran from 2010 to 2020

Injection drug use has been the leading route of HIV transmission in Iran. We assessed HIV prevalence, risk behaviors, and uptake of prevention services among people who inject drugs (PWID) in Iran between 2010 and 2020. We also examined the individual and environmental determinants of HIV among PWID. PWID were recruited in major cities across the country in three national bio--behavioral surveillance surveys in 2010, 2014, and 2020. Participants were tested for HIV and interviewed using a behavioral questionnaire. Between 2010 and 2020, the prevalence of HIV (15.1% to 3.5%), receptive needle sharing (25.2% to 3.9%) and unprotected sex (79.4% to 65.2%) decreased. Moreover, uptake of free needle/syringe increased (57.4% to 87.9%), while uptake of free condoms remained relatively stable across the surveys (34.3% to 32.6%). Multivariable analysis for the 2020 survey showed that a history of homelessness, incarceration, and a longer injection career significantly increased the odds of HIV seropositivity. During the past decade, HIV prevalence and drug- and sexual-related risk behaviors decreased among Iranian PWID. However, individual and structural determinants continue to drive HIV among this population. HIV prevention, diagnosis, and treatment among marginalized PWID with a history of homelessness or incarceration and those who inject drugs for a longer period, should be further prioritized in HIV care planning and resource allocation in Iran.

Access to HIV-prevention in female sex workers in Ukraine between 2009 and 2017: Coverage, barriers and facilitators

The provision of comprehensive prevention services is vital for reducing the high burden of HIV amongst Ukrainian female sex workers (FSWs). To identify barriers and facilitators that influence access to HIV prevention amongst this population between 2009 and 2017, we developed a literature-informed conceptual framework and conducted a document analysis to identify the components of the Ukrainian prevention package (PP). Using the Integrated Bio Behavioural Surveillance Surveys, we then conducted descriptive analyses to explore PP coverage from 2009 to 2017 and the influence of factors, identified by our conceptual framework. After increasing over four years, a drop in PP coverage was observed from 2013 onwards. Being a client of a non-governmental organisation, street and highway solicitation, non-condom use, and knowledge of HIV may influence access to HIV prevention in the Ukrainian context. Future interventions should consider barriers and facilitators to HIV prevention and the multiple structural levels on which they operate.

Past 12-month nonfatal overdose among people who inject drugs in Ukraine: City-level estimates and risk factors from a cross-sectional study

BACKGROUND

Nonfatal overdose contributes to high morbidity and is among the strongest proxies for the occurrence of overdose fatality - the leading cause of death among those who use opioids. In Ukraine, a majority of people who inject drugs (PWID) use opioids, but little is known about the relationship between drug market characteristics, nonfatal overdose (NFOD) prevalence, and risk factors for NFOD.

METHODS

We used cross-sectional respondent-driven sampling (RDS) data to explore the variability of recent (past 12 months) NFOD among PWID across Ukrainian cities and associations with individual factors. The population-averaged -cross-sectional associations were estimated and compared using generalized linear models for the binary outcome (NFOD vs. not) with robust variance estimates.

RESULTS

Recent self-reported NFOD varied between 1% and 14 % across Ukrainian cities. In adjusted analyses, overdose was associated with fewer years of injecting drugs; a higher number of types of drugs used in the past 12 months; using desomorphine, methadone, tramadol, heroin, amphetamine-type drugs or cocaine within past 12 months; using alcohol daily or weekly; recent drug treatment; and history of incarceration. Buying drugs or their ingredients through "stashes" (i.e., drugs secretly hidden in various places) and the perception of drug price increase were associated with higher odds of reporting NFOD.

CONCLUSION

The identified risk factors underscore the importance of evidence-based prevention efforts, such as scaling-up opioid agonist therapy, providing naloxone in the community and upon prison release, targeting those most likely to witness overdose and sharing overdose prevention strategies with them, and continuous monitoring of trends and contributing factors.

Young people in HIV care in Ukraine: a national survey on characteristics and service provision

Background: Ukraine's perinatally HIV-infected (PHIV) young people are ageing into adolescence/young adulthood and, alongside those with horizontally-acquired HIV infections, require transitional and other support services. We aimed to map this population and policies/service provision at specialist HIV centres, to inform future service development. Methods: A national survey was conducted of 28 HIV/AIDS centres on number, characteristics (age group, HIV acquisition mode) and care setting (paediatric/adult) of 10-24 year olds in HIV care in each of 24 regions in January 2016. Information was collected on policies/service provision at each centre. Results: Of 13,286 young people aged 10-24 years registered for HIV care nationally in Ukraine in January 2016, 1,675 were aged 10-18 years. Three-quarters of ≤19 year olds were PHIV, while 72% of 20-24-year-olds had sexually-acquired infection. Five regions accounted for two-thirds of 10-18 year olds in paediatric and 85% of 19-24 year olds in adult services. In 2015, 97 young people transitioned from paediatric to adult services nationally, typically at 18 years although with flexibility in timing at 17/28 centres. At 27/28 centres, horizontally HIV-infected young people aged <18 years began their HIV care in paediatric services sometimes (5) or always (22). Transition support most commonly consisted of a joint appointment with paediatrician and adult doctor, and support from a psychologist/social worker (both at 24/28 centres). Only 5/28 centres offered routine HIV care during the evening or weekend, and availability of integrated sexual/reproductive health and harm reduction services was uneven. Of 16/28 centres selectively following-up patients who did not attend for care, 15 targeted patients in paediatric services. Conclusions: Heterogeneity in the population and in service availability at the main regional/municipal HIV/AIDS centres has implications for potential structural barriers to HIV care, and development of services for this group.

Young people in HIV care in Ukraine: a national survey on characteristics and service provision

Background: Ukraine's perinatally HIV-infected (PHIV) young people are ageing into adolescence/young adulthood and, alongside those with behaviourally-acquired infections (BHIV), require transitional and other support services. We aimed to map this population and policies/service provision at specialist HIV centres, to inform future service development. Methods: A national survey was conducted of 28 HIV/AIDS centres on number, characteristics (age group, HIV acquisition mode) and care setting (paediatric/adult) of 10-24 year olds in HIV care in each of 24 regions in January 2016. Information was collected on policies/service provision at each centre. Results: Of 13,286 young people aged 10-24 years registered for HIV care nationally in Ukraine in January 2016, 1,675 were aged 10-18 years. Three-quarters of ≤19 year olds were PHIV, while 72% of 20-24-year-olds had sexually-acquired infection. Five regions accounted for two-thirds of 10-18 year olds in paediatric and 85% of 19-24 year olds in adult services. In 2015, 97 young people transitioned from paediatric to adult services nationally, typically at 18 years although with flexibility in timing at 17/28 centres. At 27/28 centres, BHIV young people aged <18 years began their HIV care in paediatric services sometimes (5) or always (22). Transition support most commonly consisted of a joint appointment with paediatrician and adult doctor, and support from a psychologist/social worker (both at 24/28 centres). Only 5/28 centres offered routine HIV care during the evening or weekend, and availability of integrated sexual/reproductive health and harm reduction services was uneven. Of 16/28 centres selectively following-up patients who did not attend for care, 15 targeted patients in paediatric services. Conclusions: Heterogeneity in the population and in service availability at the main regional/municipal HIV/AIDS centres has implications for potential structural barriers to HIV care, and development of services for this group.

Overdose mortality rates in Croatia and factors associated with self-reported drug overdose among persons who inject drugs in three Croatian cities

BACKGROUND

Drug overdose is the major cause of morbidity and mortality among persons who inject drugs (PWID). We assessed factors associated with the non-fatal drug overdose among PWID in three Croatian cities and national trends of overdose-related mortality (OM), and rates of uptake of opioid agonist drug treatment (OAT).

METHODS

We used a respondent-driven sampling method to recruit 830 PWID in Zagreb, Split and Rijeka in 2014/2015. Participants completed behavioural questionnaires that included questions about overdose history, and we used Poisson regression to assess factors associated with self-reported overdose. We used joinpoint regression to calculate national trends of OM from 2001 to 2015 and rates of uptake of drug treatment from 2005 to 2015.

RESULTS

Lifetime prevalence of self-reported drug overdose in our RDS sample was 45.2%, while 4.1% of PWID reported overdose in the past 12 months; PWID who injected more than one type of drug in the past 12 months (adjusted prevalence ratio [aPR] = 4.56, 95% confidence intervals [CI] = 1.35-15.38) compared to injecting only heroin, and those enrolled in OAT (aPR = 1.94, 95% CI = 1.01-3.74) were more likely to report overdose in the past 12 months. We observed an increase in annual percent change (APC) of the national OM rates from 2001 to 2007 (APC = 22.5%, 95% CI = 16.3-29.0) and a decline from 2007 to 2015 (APC = -8.0%, 95% CI = -5.3- -10.5). The national rates of drug treatment enrollment increased from 2005 to 2010 (APC = 12.0%, 95% CI = 10.3-13.8), mostly due to increase in provision of buprenorphine from 2005 to 2008 (APC = 130.4%, 95% CI = 102.1-162.7).

CONCLUSION

Injecting more than one type of drugs and enrollment in OAT while still injecting drugs was positively associated with non-fatal overdose in our sample. To further reduce OM in Croatia we suggest improvements in coverage and delivery of OAT and establishment of provision of naloxone for PWID.

Association between injection in public places and HIV/HCV risk behavior among people who use drugs in Ukraine

BACKGROUND

In Eastern Europe and Central Asia new HIV infections occur at a high rate among people who inject drugs (PWID). Injection risk behavior may be associated with injecting in public places. However, there is a lack of studies exploring this association in Ukraine, which has an HIV prevalence 21-42% among PWID.

METHODS

Data came from a baseline survey of PWID recruited to participate in a behavioral HIV prevention intervention. The association between HIV/HCV injection risk behavior and place of injection (private vs. public) was assessed using multivariable Poisson regression with robust variance estimate.

RESULTS

Most of the sample was male (73%), > 30 years (56%), and reported opioids as their drug of choice (55%). One in six participants (15.8%, n = 57) reported using a syringe after somebody, and 70% (n = 253) reported injecting in public places within last 30-days. In the adjusted model, injection risk behavior was associated with injecting in public places (PrR: 4.24, 95% CI: 1.76-10.20), unstable housing situation (PrR: 2.46, 95% CI:1.26-4.83), higher than secondary education (PrR:1.82, 95%CI:1.04-3.16), injecting with a sex partner day (PrR:2.13, 95% CI:1.28-3.56), and injecting with a stranger (PrR: 1.47, 95% CI: 0.93-2.31).

CONCLUSIONS

Injecting in a public place is associated with increased prevalence of risky behavior. Therefore, understanding and addressing place-based context should be part of the national strategy to fight HIV and HCV in Ukraine. National programs would benefit from expanding models to include contextual and structural determinants of health.

Trends in HIV prevalence among people injecting drugs, men having sex with men, and female sex workers in Ukraine

Once recognized as the most severe in Europe, the HIV epidemic in Ukraine is concentrated among people who inject drugs, men who have sex with men, and female sex workers. Integrated biobehavioral surveys, as a part of the second generation surveillance, are used to monitor HIV infection trends in key populations since 2002. The present paper is focused on the analysis of HIV prevalence trends in four nationally representative rounds of integrated biobehavioral surveys from 2008/9, 2011, 2013, and 2015 in people who inject drugs, men who have sex with men, and female sex workers. Between 2008/9 and 2015, the HIV prevalence has decreased significantly in people who inject drugs (24.2 to 22.0%) and female sex workers (13.6 to 6.3%), while the change in men who have sex with men was not significant (8.5 to 7.8%). There was a significant increase in people who inject drugs and men who have sex with men between 2013 and 2015. In subgroups younger than 25 years, prevalence increased more than twofold in men who have sex with men (1.9 to 4.3%), with no changes in people who inject drugs and female sex workers. The observed decline in prevalence, especially in young subgroups, may result from the effect of extensive prevention efforts on drug injection-related transmission. Recent increase in young men who have sex with men may be a sign of a new wave of the epidemic in this group.