Determinants of willingness to enroll in opioid agonist treatment among opioid dependent people who inject drugs in Ukraine

The impact of emergency guidance to the COVID-19 pandemic on treatment entry, retention and mortality among patients on methadone in Ukraine

BACKGROUND AND AIMS

Ukraine's Ministry of Health released urgent COVID-19 guidelines, allowing for early implementation of take-home dosing (THD) for opioid agonist therapies (OAT) such as methadone. Enrollment in OAT and retention in the program are the most effective HIV prevention strategies for people who inject drugs (PWID). This study aimed to evaluate the impact of Ukraine's COVID-19 emergency guidance on OAT treatment enrollment, retention on treatment and mortality.

DESIGN AND SETTING

Using Ukraine's national OAT registry for 252 governmental clinics across 25 regions, we conducted a 12-month comparative prospective cohort survival analysis. This study compared newly enrolled methadone patients within the initial 6 months following the COVID-19 guidance (COVID) with patients from the preceding year (pre-COVID) in a country with high adult HIV prevalence (1.2%) that is concentrated in PWID.

PARTICIPANTS

In the nation-wide sample of newly enrolled PWID in Ukraine, comprising 2798 individuals, 1423 were in the COVID cohort and 1375 were in the pre-COVID cohort. The majority were male (86.7%), with an average age of 39.3 years.

MEASUREMENTS

Primary outcomes were average monthly enrollment per cohort, treatment retention and mortality, with internal time-dependent predictors, including THD and optimal (> 85 mg) methadone dosing.

RESULTS

Relative to the pre-COVID period, the monthly average patient enrollment was statistically significantly higher during the COVID period (283.7 versus 236.0; P < 0.0001), where patients were more likely to transition to THD and achieve optimal dosing earlier. Significant differences were observed in the proportions of person-months on THD (41 versus 13%, P < 0.0001) and optimal dosing (38 versus 31%, P < 0.0001) between the COVID and pre-COVID cohorts. Predictors of treatment retention, expressed as adjusted hazard ratios (aHR), included early THD [aHR = 1.90, 95% confidence interval (CI) = 1.47-2.45], early optimal dosing (aHR = 1.71, 95% CI = 1.37-2.13) and prior methadone treatment (aHR = 1.39, 95% CI = 1.15-1.68). These factors persisted, respectively, in the pre-COVID (aHR = 2.28, 95% CI = 1.41-3.70; aHR = 1.84, 95% CI = 1.32-2.56; and aHR = 1.36, 95% CI = 1.06-1.74) and COVID (aHR = 1.91, 95% CI = 1.40-2.59; aHR = 1.61, 95% CI = 1.20-2.16; and aHR = 1.49, 95% CI = 1.08-1.94) cohorts. Survival did not differ significantly between the two prospective cohorts.

CONCLUSION

Ukraine's prompt adoption of early take-home dosing for opioid agonist therapies, such as methadone, following the emergency COVID-19 guidance appears to have increased enrollment into methadone and improved treatment retention for people who inject drugs without adverse effects on patient survival.

Impact of the Russian invasion on opioid agonist therapy programs in Ukraine: A qualitative study

BACKGROUND

Opioid Agonist Treatment (OAT) combines opioid agonist medications with counseling and therapy for a whole-patient approach to treating opioid use disorder. The war in Ukraine threatened the continuity of care and well-being of individuals receiving OAT. This study aimed to capture patients' experiences accessing OAT during the war in Ukraine to provide insights that can inform and improve the programs that serve them.

METHODS

In October - November 2022, we conducted semi-structured interviews with 17 OAT patients who are peer advocates in the Ukrainian Patient Network VOLNA. All interviews were conducted virtually via Zoom, recorded, and transcribed. Through thematic analysis, we generated codes from the transcripts, iteratively using both inductive and deductive approaches.

RESULTS

The qualitative interviews revealed four themes: 1) 'medication,' focusing on concerns about availability, dosage, and quality of OAT; 2) 'patient barriers,' discussing access challenges for specific patient groups, such as refugees or patients living under the occupation; 3) 'clinic-level challenges,' involving dosing adequacy, treatment continuity, patient volume, and clinician stigma, and 4) 'regulatory inflexibility,' describing uneven implementation of regulations and increased policing to receive OAT during the war.

CONCLUSION

Our study emphasizes the importance of adapting OAT programs in Ukraine to better serve vulnerable patients affected by the war. The Russian invasion has severely disrupted OAT provision, increasing the risks of opioid withdrawal, overdose, and diversion. By understanding patients' experiences, treatment preferences, and barriers to care, OAT programs can provide continuity of care to those in need.

Preferences and decisional considerations relating to opioid agonist therapy among Ukrainian people who use drugs: A conjoint analysis survey

Scaling up opioid agonist therapies (OAT) is the most effective strategy to control combined HIV and opioid epidemics, especially in Eastern Europe and Central Asia (EECA), where HIV incidence and mortality continue to increase. Patient concerns about OAT, however, have undermined scale-up. The objective of this study is to understand Ukrainian opioid use disorder patient preferences about OAT to guide the development of an evidence-informed decision aid for clinical decision-making. We conducted a conjoint-based choice (CBC) survey. Participants were asked to about their preferences relating to 7 attributes of OAT (cost, dosing frequency, concerns about withdrawal symptoms, adverse side effects, improvements in quality of life, precipitation of withdrawal and legislative requirements to be registered as a drug dependent person) and 20 attribute levels for receiving OAT under differing potential treatment constraints. Data were analyzed using Hierarchical Bayesian models. Using respondent-driven sampling and random sampling, we recruited 2,028 people who inject drugs with opioid use disorder. Relative importance (RIS) and partial-worth utility scores (PWUS) were used to assess preferences for attributes and thresholds within each attribute. Cost and dosing frequency were the most important attributes (RIS = 39.2% and RIS = 25.2%, respectively) to potential patients, followed by concerns about withdrawal symptoms (RIS = 10.8%), adverse side effects (RIS = 9.0%), quality-of-life improvement (RIS = 7.5%), precipitation of euphoria (5.2%) and requirement to be registered as a drug- dependent person (RIS = 3.1%). The monthly cost-threshold for willingness-to-pay was 1,900 UAH ($70 USD). In Ukraine, where both governmental and private OAT clinics have emerged and provide markedly different delivery strategies, preferences are mostly driven by out-of-pocket expenses, despite many patients being willing to pay for OAT. Programmatic demands (flexibility and ease of acquiring medications) remain an important consideration while for a minority, clinical concerns about withdrawal symptoms, adverse side effects and OAT impact on life play a smaller role.

Latent class analysis of perceived stigma among older adults receiving medications for opioid use disorder

RATIONALE

Public stigma surrounds individuals who use medication for their recovery from a substance use disorder. However, we know little about subgroups of individuals with varying levels of perceived stigma and how these levels may be associated with physical and mental health-related quality of life (HRQOL) and social support.

METHODS

We used latent class analysis to define subgroups of people aged 50-72 years of age (N = 104) who were enrolled in eight medication for opioid use disorder (MOUD) programs to explore subgroupings and correlates of group membership.

RESULTS

We found evidence for three distinct classes of individuals and named the classes 1) the high stigma class, 2) the embarrassed class, and 3) the low stigma class. We found that people in the high-stigma class reported more rejection, more abstinence-based support group involvement, and reduced mental HRQOL.

CONCLUSIONS

Results suggest reducing stigma among people on MOUD may help to boost mental HRQOL and improve social support receipt. The results are consistent with iatrogenic effects of AA/NA support groups such that these treatment modalities may increase stigma due to their focus on abstinence-only treatment for substance use disorders.

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.

Introducing methadone maintenance therapy into Ukrainian prisons: a qualitative study of criminal subculture, Russia's full-scale invasion, and contested methadone objects

Background

After pilot testing, methadone was newly being introduced into Ukrainian prisons in 2021 as part of a national scale-up strategy to treat opioid use disorder and prevent transmission of HIV and HCV infections. Opioid agonist therapy (OAT) scale-up in Eastern Europe and Central Asia prisons has been hampered by varying levels of influence of criminal subculture, an extralegal informal governance by a social hierarchy that operates in parallel to formal prison authorities. This study examined the socio-environmental factors influencing the uptake of methadone treatment in Ukrainian prisons, including changes that evolved during Russia's full-scale invasion of Ukraine and the displacement of people deprived of liberty (PDL) from conflict to non-conflict regions.

Methods

In-depth qualitative interviews (N = 37) were conducted from January 2021 to October 2022 in the only two Ukrainian prisons where methadone was being introduced with PDL (N = 18). These two prisons continued to provide methadone after the full-scale invasion. Former PDL (N = 4) were also interviewed and prison staff (N = 15). Interviews were audio-recorded, transcribed, and translated into English. Four authors independently reviewed, coded, and applied a phenomenological framework for data analysis, delineating themes related to criminal subculture, drug use, methadone uptake, and evolving changes during the Russian invasion.

Findings

Criminal subculture perceptions varied, with some seeing it as strongly discouraging drug use among certain groups, while others described it as a residual and weak influence from a more distant past. The influence of the subculture on methadone treatment uptake, however, was less clear. PDL and prison staff struggled to identify and articulate differences between illicit street-bought methadone, used recreationally, and medically prescribed methadone. Thus, the meaning of "methadone" varies in interpretation as it is being introduced, making it potentially conflicting for patients to opt into this evidence-based treatment. As Russia invaded Ukraine in 2022, PDL from conflict zones were transferred to non-conflict regions where methadone was being introduced. The prison environment became more enabling for PDL to start methadone as they were segregated and not subject to the existing criminal subculture's rules and lacked the social ties necessary to procure drugs illegally.

Conclusion

It appears that the criminal subculture is variable and evolving in Ukrainian prisons and appears to be impacted differently by the invasion of Russia. As methadone scale-up in prisons expands, it will be important to distinguish the meaning of methadone perpetuated negatively by the prison subculture versus that in which it is intended as a medical treatment by the formal prison authorities. The current invasion of Ukraine by Russia provides a potential disruption to alter this course.

Aligning public health and public safety: Probation as a touchpoint to identify and link patients with opioid use disorder to opioid agonist treatment

BACKGROUND

People in criminal justice settings (CJS) have high rates of opioid use disorder (OUD) and HIV. Probation is part of the CJS and congregates many individuals with high rates of mental health and substance use disorders relative to the general population; nevertheless, probation remains a major improvement to incarceration. As a steppingstone to full decarceration efforts, community supervision settings like probation can be leveraged as "touchpoints" to identify and link people with OUD (and other co-morbid conditions) to treatment and reduce criminal activity.

METHODOLOGY

To determine the feasibility of a modified screening, brief intervention and referral to treatment (SBIRT) strategy to link probationers to opioid agonist therapies (OAT) in the newly created probation system in Ukraine, we conducted a single-arm SBIRT intervention in eight probation centers in four Ukrainian administrative regions. For those screening positive for OUD, interest in OAT was assessed before and after a brief intervention. Those interested in OAT were referred to community OAT services. Participants with OUD also underwent HIV testing.

PRINCIPAL FINDINGS

Of the 1,298 consecutive individuals screened, 208 (16.0%) met criteria for opioid dependence. Of these, 122 (58.7%) enrolled in brief intervention, of which 54 (44.3%) had HIV and 14 (25.9%) of these were newly diagnosed. After the brief intervention, interest in starting OAT increased significantly from a median of 7.0 to 8.0 (P = <0.001) using a 10-point scale. Thirty (N = 30; 24.6%) of the enrolled participants initiated OAT and 21 of these (70%) were retained in treatment for 6 months.

SIGNIFICANCE

The prevalence of OUD (and HIV) is high among people in probation in Ukraine. SBIRT can identify a large number of people eligible for OAT, many of whom were willing to initiate and remain on OAT. Integrating SBIRT into probation can potentially assist with OAT scale-up and help address HIV prevention efforts.

A mixed methods exploration of injection drug use risk behaviors and place-based norms in Ukraine

INTRODUCTION

Despite global reductions in HIV incidence and significant investment in local harm reduction services, Ukraine continues to experience high HIV and HCV prevalence among people who inject drugs (PWID). Place-based factors and social norms affect drug use-related risk factors, but research has paid little attention to the relationship between drug use practices and place in Ukraine, including how these factors may contribute to or protect against HIV/HCV risk.

METHODS

This project used a sequential mixed methods design. Between March and August 2018, we interviewed 30 PWID in Dnipro, Ukraine. Participants completed a single in-depth interview in which they described where and with whom they lived; how they generated income; and where, when, how, and with whom they purchased and used drugs. Between May 2019 and March 2020, we recruited 150 PWID in Dnipro to complete a survey that was designed based on interview findings and consisted of three components: an activity space inventory, an egocentric social network inventory, and an HIV risk behavior assessment.

RESULTS

Both interview and survey respondents reported consistent use of pharmacies to acquire syringes and nearly universal use of new syringes when injecting. Interview participants reflected that while syringe sharing was previously considered a "common practice," PWID now viewed it as infrequent and unacceptable. However, interview respondents enumerated the contexts in which needle and syringe reuse occurred, including purchasing drugs directly from a dealer and chipping in with other PWID to prepare drugs bought through a stash.

CONCLUSION

Participants described relatively easy access to new needles and syringes through pharmacies and expressed strong social sanctioning against reusing needles or syringes. However, equipment sharing behaviors and norms persisted in certain contexts, creating an opportunity for further harm reduction campaigns that incorporate changing norms in these situations to "close the gap" and further reduce HIV and other infections among PWID.

The effects of childhood trauma and mental disorders on treatment engagement, contact with the criminal justice system, and mortality among people with opioid dependence

BACKGROUND

Childhood trauma and mental disorders increase the risk of opioid dependence. We aimed to examine whether childhood trauma and mental disorders are associated with opioid agonist treatment (OAT) engagement, contact with the criminal justice system, and mortality among people with opioid dependence.

METHODS

This observational study linked survey data from 1482 people receiving OAT in Sydney, Australia (2004-2008) to administrative data on OAT, crime, and mortality through 2017. We used survey data to assess childhood trauma, depression, panic disorder, post-traumatic stress disorder (PTSD), borderline personality disorder, anti-social personality disorder (ASPD), and comorbid substance dependence. We used discrete-time analysis to examine time from opioid dependence onset to OAT entry and mortality. Poisson regressions were used to analyze time receiving OAT and number of charges.

RESULTS

Participants with extensive childhood trauma histories and ASPD were less likely to enter OAT and those with depression were more likely to enter OAT in any given year after opioid dependence onset. Panic disorder, PTSD, and borderline personality disorder were associated with less time in OAT. Extensive histories of childhood trauma, PTSD, ASPD, and comorbid substance dependence increased risk of charges for any offence. There were no significant associations between the exposure variables and mortality.

CONCLUSIONS

Our findings suggest that childhood trauma and mental disorders increase the risk of adverse treatment and social outcomes among people with opioid dependence. Interventions that aim to reduce harm among people with opioid dependence may consider the effect of childhood trauma and mental disorders on OAT engagement and crime.

A qualitative exploration of daily path and daily routine among people in Ukraine who inject drugs to understand associated harms

Background

Patterns of movement, heterogeneity of context, and individual space-time patterns affect health, and individuals’ movement throughout the landscape is shaped by addiction, meeting basic needs, and maintaining relationships. Place and social context enable or constrain behavior and individuals use social networks and daily routines to accomplish individual goals and access resources.

Methods

This article explores drug use as part of daily routines and daily paths among people who inject drugs in Dnipro City, Ukraine. Between March and August 2018, we interviewed 30 people who inject drugs living in Dnipro City, Ukraine. Study participants completed a single interview that lasted between 1 and 2 hours. During the interview, participants described their daily routine and daily path using a printed map of Dnipro as a prompt. Participants were asked to draw important sites; give time estimates of arrival and departure; and annotate on the map the points, paths, and areas most prominent or important to them. Participants also described to what extent their daily routines were planned or spontaneous, how much their daily path varied over time, and how drug use shaped their daily routine.

Results

We identified 3 major types of daily routine: unpredictable, predictable, and somewhat predictable. Participants with unpredictable daily routines had unreliable sources of income, inconsistent drug suppliers and drug use site, and dynamic groups of people with whom they socialized and used drugs. Participants with predictable daily routines had reliable sources of income, a regular drug dealer or stash source, and a stable group of friends or acquaintances with whom they bought and/or used drugs. Participants with somewhat predictable daily routines had some stable aspects of their daily lives, such as a steady source of income or a small group of friends with whom they used drugs, but also experienced circumstances that undermined their ability to have a routinized daily life, such as changing drug use sites or inconsistent income sources.

Conclusions

Greater attention needs to be paid to the daily routines of people who use drugs to develop and tailor interventions that address the place-based and social contexts that contribute to drug-use related risks.

Gaps in hepatitis C virus prevention and care for HIV-hepatitis C virus co-infected people who inject drugs in Canada

BACKGROUND

People who inject drugs (PWID) living with HIV are a priority population for eliminating hepatitis C virus (HCV) as a public health threat. Maximizing access to HCV prevention and treatment strategies are key steps towards elimination. We aimed to evaluate engagement in harm reduction programs and HCV treatment, and to describe injection practices among HIV-HCV co-infected PWID in Canada from 2003 to 2019.

METHODS

We included Canadian Coinfection Cohort study participants who reported injecting drugs between 2003 and 2019 in Quebec, Ontario, Saskatchewan, and British Columbia, Canada. We investigated temporal trends in HCV treatment uptake, efficacy, and effectiveness; injection practices; and engagement in harm reduction programs in three time periods based on HCV treatment availability: 1) interferon/ribavirin (2003-2010); 2) first-generation direct acting antivirals (DAAs) (2011-2013); 3) second-generation DAAs (2014-2019). Harm reduction services assessed included needle and syringe programs (NSP), opioid agonist therapy (OAT), and supervised injection sites (SIS).

RESULTS

Median age of participants (N = 1,077) at cohort entry was 44 years; 69% were males. Province-specific HCV treatment rates increased among HCV RNA-positive PWID, reaching 16 to 31 per 100 person-years in 2014-2019. Treatment efficacy improved from a 50 to 70% range in 2003-2010 to >90% across provinces in 2014-2019. Drug injecting patterns among active PWID varied by province, with an overall decrease in cocaine injection frequency and increasing opioid injections. In the most recent time period (2014-2019), needle/syringe sharing was reported at 8-22% of visits. Gaps remained in engagement in harm reduction programs: NSP use decreased (58-70% of visits), OAT engagement among opioid users was low (8-26% of visits), and participants rarely used SIS (1-15% of visits).

CONCLUSION

HCV treatment uptake and outcomes have improved among HIV-HCV coinfected PWID. Yet, this population remains exposed to drug-related harms, highlighting the need to tie HCV elimination strategies with enhanced harm reduction programs to improve overall health for this population.

Association between opioid agonist therapy use and HIV testing uptake among people who have recently injected drugs: a systematic review and meta-analysis

BACKGROUND AND AIM

Globally, nearly one in five people who inject drugs (PWID) are living with HIV, and the rate of new HIV infections in PWID is increasing in some settings. Early diagnosis is crucial for effective HIV control. We reviewed the evidence on the association between opioid agonist therapy (OAT) and HIV testing uptake among PWID.

METHODS

We conducted a systematic review searching MEDLINE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials and PsycINFO for studies published from January 2000 to March 2019. Reference lists and conference proceedings were hand-searched. Observational and intervention studies were eligible for inclusion. Risk of bias was assessed using the Risk of Bias in Non-Randomised Studies of Interventions (ROBINS-I) tool. Meta-analyses were conducted using random-effects models.

RESULTS

Of 13 373 records identified, 11 studies from Australia, Europe, Malaysia and the United States were included. All studies had at least a serious risk of bias, largely due to confounding and selection bias, making it difficult to draw causal conclusions from the evidence. Ten studies provided data on the association between current OAT use and recent HIV testing. Six showed a positive association, while four provided little evidence of an association: pooled odds ratio (OR) = 1.71, 95% confidence interval (CI) = 1.28-2.27. Looking at having ever been on OAT and having ever been HIV tested, seven studies showed a positive association and three showed either weak or no evidence of an association: pooled OR = 3.82, 95% CI = 2.96-4.95.

CONCLUSIONS

Opioid agonist therapy may increase uptake of HIV testing among people who inject drugs, providing further evidence that opioid agonist therapy improves the HIV treatment care cascade.

The effect of British Columbia's Pharmacare coverage expansion for opioid agonist treatment

Opioid agonist treatment (OAT) is the evidence-based standard of care for people with opioid use disorder. In British Columbia, Canada, only social assistance registrants received full coverage for OAT prior to the introduction of the Pharmacare Plan G coverage expansion on February 1st, 2017. We aimed to determine the effect of the coverage expansion on OAT initiation, re-initiation, and retention. Using linked population-level data, we executed a difference-in-differences analysis to compare outcomes of individuals eligible for the additional coverage and social assistance registrants already receiving the most generous coverage for OAT prior to the policy change, adjusting for individual and prescriber characteristics. We found Plan G coverage expansion significantly increased OAT retention. Specifically, coverage expansion decreased the number of OAT episode discontinuations by 12.8% (95% CI: 8.4%, 17.2%).

Barriers to accessing opioid substitution treatment for opioid use disorder: A systematic review from the client perspective

OBJECTIVES

To update the existing evidence to identify specific barriers to initiation of opioid substitution therapy (OST) for those with opioid use disorder (OUD).

METHODS

The review follows Preferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) guidelines. Six databases were initially searched in November 2019, with the search updated on 11 November 2020, for qualitative or quantitative studies reporting the barriers to initiating OST from the client with OUD perspective. Thematic analysis of the barriers to OST was undertaken to determine barrier themes and subthemes.

RESULTS

There were 37 studies included in the review; 18 were qualitative, 15 were quantitative and four were mixed methods. The barrier themes identified were stigma and fear, regulatory, logistical, attitudinal and social factors. Within these barrier themes 19 barrier subthemes were identified. The most reported OST barrier subthemes were negative treatment perceptions, cost, stigma and lack of flexibility.

CONCLUSION

This review discusses important barriers to OST and examines reported barriers from the client perspective. OST guidelines and programs would benefit by introducing programs that reduce stigma, increase treatment knowledge and health literacy, reduce treatment costs, increase treatment flexibility and allow for easier treatment access.

Depressive symptoms and use of HIV care and medication-assisted treatment among people with HIV who inject drugs

OBJECTIVE

Vietnam, Indonesia, and Ukraine have major burdens of IDU and HIV. We estimated the prevalence of depressive symptoms at baseline among people living with HIV who inject drugs, evaluated associations between depression at baseline and 12-month HIV care outcomes and medication-assisted treatment (MAT), and evaluated the study intervention effect by baseline depression subgroups.

DESIGN

HPTN 074 was a randomized study. The study intervention included psychosocial counseling, systems navigation, and antiretroviral treatment (ART) at any CD4+ cell count.

METHODS

Moderate-to-severe depression was defined as a Patient Health Questionnaire-9 score of 10 or above. ART and MAT were self-reported. Eligibility criteria were: 18-60 years of age, active IDU, and viral load of at least 1000 copies/ml. Adjusted probability differences (aPD) were estimated using inverse-probability weighting.

RESULTS

A total of 502 participants enrolled from April 2015 to June 2016. Median age was 35 years; 85% identified as men. Prevalence of baseline moderate-to-severe depression was 14% in Vietnam, 14% in Indonesia, and 56% in Ukraine. No evident associations were detected between baseline depression and ART, viral suppression, or MAT at 12-month follow-up. The study intervention improved the proportions of people who inject drugs achieving 12-month viral suppression in both the depressed [intervention 44%; standard of care 24%; estimated aPD = 25% (95% confidence interval: 4.0%, 45%)] and nondepressed subgroups [intervention 38%; standard of care 24%; aPD = 13% (95% confidence interval: 2.0%, 25%)].

CONCLUSION

High levels of depressive symptoms were common among people living with HIV who inject drugs in Ukraine but were less common in Vietnam and Indonesia. The study intervention was effective among participants with or without baseline depression symptoms.

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.

Barriers and Facilitators to Substance Use Disorder Treatment in Low-and Middle-Income Countries: A Qualitative Review Synthesis

BACKGROUND AND AIMS

One of the ways to address the treatment gap for substance use disorders is to understand the barriers and facilitators to treatment. This study aimed to synthesize the literature on barriers and facilitators of treatment in Low- and Middle-Income Countries (LMICs).

METHODS

We search Medline electronic database to identify English language peer reviewed empirical studies, both qualitative and quantitative which reported barriers and/or facilitators of treatment of substance use disorders.

RESULTS

Of 1389 titles, we selected 28 studies (14 were qualitative and 14 quantitative studies). The sample sizes of the qualitative studies ranged from 11 to 235. The majority of studies were from community or clinic settings. A wide range of barriers and facilitators were identified from the qualitative studies and were synthesized according to perceived susceptibility/seriousness, self-efficacy, perceived costs, perceived benefits, and cues to action. Most of the quantitative studies were community-based cross sectional-observational by design. Commonly identified barriers in these quantitative studies were perceived lack of problem or lack of need for treatment and low motivation whereas factors such as good family support and availability of effective treatment was found to facilitate substance use disorder treatment.

CONCLUSION

There are a wide range of barriers that hinder the substance use disorder treatment as well as certain factors that facilitate the treatment. Addressing them can help to minimize the treatment gap, which in turn can help in reducing the familial and social burden due to substance use disorders.

The real-world impact of dosing of methadone and buprenorphine in retention on opioid agonist therapies in Ukraine

BACKGROUND AND AIMS

Ukraine's HIV epidemic remains concentrated among opioid-dependent people who inject drugs (PWID) where opioid agonist therapies (OAT) like methadone (MMT) and buprenorphine (BMT) maintenance treatments are the most cost-effective HIV prevention strategies, but remain under-scaled. This study aimed to measure the association between dose and type of OAT prescribed and treatment retention.

DESIGN

Observational longitudinal cohort study.

PARTICIPANTS AND SETTING

Patients (n = 15 290) prescribed OAT throughout Ukraine from 2004 through 2016.

MEASUREMENTS

Data were analyzed using time-event strategies to estimate cumulative treatment retention, defined as time to OAT discontinuation. Cumulative retention proportions at 1, 12 and 36 months were assessed for outcomes. Cox regression with log-rank likelihood assessed independent predictors of treatment discontinuation.

FINDINGS

The proportion prescribed high (MMT: > 85 mg; BMT: ≥ 16 mg), medium (MMT: > 40-85 mg; BMT: > 6-15 mg) and low (MMT: ≤ 40 mg; BMT: ≤ 6 mg) dosages was 25, 43 and 32%, respectively. Retention was significantly higher for BMT than MMT both at 12 (89 versus 75%) and 36 months (80 versus 56%). Although dosing levels for BMT did not influence retention, increasing dosages for MMT were significantly associated with higher retention rates at 1 (90, 96, 99%), 12 (59, 78, 91%) and 36 (34, 59, 79%) months, respectively. Independent predictors associated with 12-month OAT discontinuation were medium [adjusted hazard ratio (aHR) = 2.23; 95% confidence limit (CL) = 1.95-2.54] and low (aHR = 4.96; 95% CL = 4.37-5.63) OAT dosage relative to high dosage, male sex (aHR = 1.27; 95% CL = 1.14-1.41), MMT relative to BMT prescription (aHR = 1.57; 95% CL = 1.32-1.87) and receiving OAT in general (aHR = 1.22; 95% CL = 1.02-1.46) or tuberculosis (aHR = 1.43; 95% CL = 1.10-1.85) hospitals, relative to specialty addiction treatment and AIDS center settings. Lower dosages contributed more to dropout especially at 1 month (aHR 3.12; 95% CL = 2.21-4.41 and aHR 7.71; 95% CL = 5.51-10.79 for medium and low dosages, respectively). Younger age was significantly associated with OAT discontinuation only at 36 months (aHR = 1.08; 95% CI = 1.02-1.15).

CONCLUSIONS

Higher dosages of opioid agonist therapies, especially for methadone maintenance treatment patients, appear to be associated with higher levels of treatment retention in Ukraine.

A systematic review of patients' and providers' perspectives of medications for treatment of opioid use disorder

BACKGROUND

The opioid epidemic is a public health crisis. Medications for opioid use disorder (MOUD) include: 1) buprenorphine, 2) methadone, and 3) extended-release naltrexone (XR-NTX). Research should investigate patients' and providers' perspectives of MOUD since they can influence prescription, retention, and recovery.

METHODS

This systematic review focused on patients' and providers' perceptions of MOUD. The review eligibility criteria included inclusion of the outcome of interest, in English, and involving persons ≥18 years. A PubMed database search yielded 1692 results; we included 152 articles in the final review.

RESULTS

There were 63 articles about buprenorphine, 115 articles about methadone, and 16 about naltrexone. Misinformation and stigma associated with MOUD were common patient themes. Providers reported lack of training and resources as barriers to MOUD.

CONCLUSION

This review suggests that patients have significant misinformation regarding MOUD. Due to the severity of the opioid epidemic, research must consider the effects of patients' and providers' perspectives on treatment for OUD, including the effects on the type of MOUD prescribed, patient retention and adherence, and ultimately the number of patients treated for OUD, which will aid in curbing the opioid epidemic.

The role of access to integrated services at opioid agonist treatment sites in reaching 90-90-90 cascade in people who inject drugs in Ukraine: Country-level data

INTRODUCTION

Opioid agonist treatment (OAT) is an effective means to prevent HIV transmission. Ukraine started integrating HIV services into OAT sites to improve people who inject drugs' (PWID) access to treatment.

METHODS

Data from the national registry of OAT patients (n = 9,983) were analyzed. These data are collected from all 179 OAT sites countrywide. For the cascade, HIV-positive OAT patients (n = 4,084) were stratified into two categories: OAT alone (received OAT at one site and antiretroviral therapy (ART) at different location, n = 1,789) and integrated care (received OAT and ART at one location, n = 2,295) for comparison.

RESULTS

Most HIV-positive OAT patients in Ukraine are male (85.6 %) and the mean age is 40.3 years old. The mean length of injecting before OAT is 17.2 years and the mean length on OAT is 4.2 years. All HIV-positive OAT clients are aware of their HIV status. The proportion of HIV-positive clients receiving ART was higher at integrated care sites compared to OAT alone sites (84.2 vs. 73.1 %, p- = 0.012); distribution of viral suppression among those receiving ART across the strata were 79.4 and 59.2 % for 'integrated care sites' vs. 'OAT only sites' respectively (p < 0.001).

CONCLUSIONS

This analysis clearly demonstrates much better progress towards the 90-90-90 goals among those OAT patients who receive integrated care services (both OAT and ART) at one site at each stage of the HIV care cascade as compared to receiving OAT and ART at different sites. There is an urgent need to further expand the integration of OAT and HIV services in Ukraine.

Perspectives of clients and providers on factors influencing opioid agonist treatment uptake among HIV-positive people who use drugs in Indonesia, Ukraine, and Vietnam: HPTN 074 study

BACKGROUND

Opioid agonist treatment (OAT) is an effective method of addiction treatment and HIV prevention. However, globally, people who inject drugs (PWID) have insufficient OAT uptake. To expand OAT access and uptake, policymakers, program developers and healthcare providers should be aware of barriers to and facilitators of OAT uptake among PWID.

METHODS

As a part of the HPTN 074 study, which assessed the feasibility of an intervention to facilitate HIV treatment and OAT in PWID living with HIV in Indonesia, Ukraine, and Vietnam, we conducted in-depth interviews with 37 HIV-positive PWID and 25 healthcare providers to explore barriers to and facilitators of OAT uptake. All interviews were audio-recorded, transcribed, translated into English, and coded in NVivo for analysis. We developed matrices to identify emergent themes and patterns.

RESULTS

Despite some reported country-specific factors, PWID and healthcare providers at all geographic locations reported similar barriers to OAT initiation, such as complicated procedures to initiate OAT, problematic clinic access, lack of information on OAT, misconceptions about methadone, financial burden, and stigma toward PWID. However, while PWID reported fear of drug interaction (OAT and antiretroviral therapy), providers perceived that PWID prioritized drug use over caring for their health and hence were less motivated to take up ART and OAT. Motivation for a life change and social support were reported to be facilitators.

CONCLUSION

These results highlight a need for support for PWID to initiate and retain in drug treatment. To expand OAT in all three countries, it is necessary to facilitate access and ensure low-threshold, financially affordable OAT programs for PWID, accompanied with supporting interventions. PWID attitudes and beliefs about OAT indicate the need for informational campaigns to counter misinformation and stigma associated with addiction and OAT (especially methadone).

Cost-effectiveness of expanding the capacity of opioid agonist treatment in Ukraine: dynamic modeling analysis

BACKGROUND AND AIMS

Although opioid agonist treatment (OAT) for opioid use disorder (OUD) is cost-effective in settings where the HIV epidemic is concentrated among people who inject drugs, OAT coverage in Ukraine remains far below internationally recommended targets. Scale-up is limited by both OAT availability and demand. This study aimed to evaluate the cost-effectiveness of a range of plausible OAT scale-up strategies in Ukraine incorporating the potential impact of treatment spillover and the real-world demand for addiction treatment.

DESIGN, SETTING AND PARTICIPANTS

Ten-year horizon (2016-25) modeling study of opioid addiction epidemic and treatment that accommodated potential peer effects in opioid use initiation and supply-induced treatment demand in three Ukrainian cities: Kyiv, Mykolaiv and Lviv, comprising a simulated population of people at risk of and with OUD.

MEASUREMENTS

Incremental cost per quality-adjusted life-year gained in the simulated population.

FINDINGS

An estimated 12.2-, 2.4- and 13.4-fold OAT capacity increase over 2016 baseline capacity in Kyiv, Mykolaiv and Lviv, respectively, would be cost-effective at a willingness-to-pay of one per-capita gross domestic product (GDP) per quality-adjusted life-year gained. This result is robust to parametric and structural uncertainty. Even under the most ambitious capacity increase, OAT coverage (i.e. the proportion of people with OUD receiving OAT) over a 10-year modeling horizon would be 20, 11 and 17% in Kyiv, Mykolaiv and Lviv, respectively, owing to limited demand.

CONCLUSIONS

It is estimated that a substantial increase in opioid agonist treatment (OAT) capacity in three Ukrainian cities would be cost-effective for a wide range of willingness-to-pay thresholds. Even a very ambitious capacity increase, however, is unlikely to reach internationally recommended coverage levels. Further increases in coverage may be limited by demand and would require addressing existing structural barriers to OAT access.

Willingness to take buprenorphine/naloxone among people who use opioids in Vancouver, Canada

OBJECTIVES

Opioid agonist therapy is the cornerstone of treatment of opioid use disorder. In Canada, buprenorphine/naloxone has recently been adopted as the first line agonist therapy given its comparable effectiveness to methadone and superior safety profile. This study examines factors associated with willingness to take buprenorphine/naloxone among opioid users.

METHODS

Data were derived from two prospective cohorts of high-risk individuals who use drugs in Vancouver, Canada. Multivariable logistic regression analyses were used to determine factors associated with willingness to use buprenorphine/naloxone among people who use opioids and were not currently accessing this treatment option. Participants who were unwilling to use buprenorphine/naloxone were invited to provide reason(s) and their responses were examined in a sub-analysis.

RESULTS

Between December 2014 and May 2018, 1103 participants were interviewed. Overall, 194 (17.6%) respondents indicated that they would be willing to take buprenorphine/naloxone. Variables independently associated with willingness were previous buprenorphine/naloxone treatment (adjusted odds ratio [AOR] = 2.04), having ever used methadone treatment (AOR = 1.87), and age (AOR = 0.98, per year older) (all p < 0.05). Satisfaction with current agonist therapy (25.4%), not knowing what buprenorphine/naloxone is (25.1%), and wanting more information about buprenorphine/naloxone (15.1%) were the most commonly cited reasons for unwillingness. A low rate of willingness to use buprenorphine/naloxone (15.1%) was also observed among the sub-set of participants not using methadone.

CONCLUSIONS

While an overall low level of willingness to take buprenorphine/naloxone was observed, this appeared to be largely driven by satisfaction with other agonists and a low prevalence of community knowledge about buprenorphine/naloxone.

Opioid Agonist Treatment and Improved Outcomes at Each Stage of the HIV Treatment Cascade in People Who Inject Drugs in Ukraine

BACKGROUND

The HIV treatment cascade is a crucial tool to guide HIV prevention and treatment strategies. The extent to which opioid agonist treatments (OATs) such as methadone and buprenorphine influence this cascade was examined in a nationwide study of people who inject drugs (PWID) in Ukraine.

SETTING

Cross-sectional stratified survey of PWID followed by HIV and hepatitis C virus testing in 5 Ukrainian cities.

METHODS

Opioid-dependent PWID (N = 1613) were sampled from January 2014 to March 2015. Analysis was confined to 520 participants with HIV, with 184 (35.4%) prescribed OAT. Weighted logistic regression models were used to assess independent factors associated with the 5 steps in the HIV treatment cascade.

RESULTS

Compared with PWID not on OAT (N = 336), participants who prescribed OAT (N = 184) were significantly more likely to be diagnosed (91% vs. 71%), linked (81% vs. 52%), and retained (69% vs. 35%) in HIV care, and prescribed (56% vs. 31%) and optimally (>95% of doses) adherent to antiretroviral therapy (41% vs. 22%). Receiving OAT contributed most as an independent factor with every step of the cascade. Other steps in the HIV treatment cascade were influenced by age, depression, and geographical variability.

CONCLUSIONS

OAT remains an essential and effective strategy to not only treat patients with opioid use disorder, but also a crucial strategy to engage PWID in care to meet UNAIDS 90-90-90 targets. Geographical differences suggest local structural impediments. With low OAT coverage prescribed for 2.9% of the estimated 347,000 PWID in Ukraine, OAT expansion requires strategic interventions that target the individual, clinical care settings, policies, and funding.

Treating opioid dependence with extended-release naltrexone (XR-NTX) in Ukraine: Feasibility and three-month outcomes

BACKGROUND

Although opioid agonist treatments (OAT) with methadone or buprenorphine are available to treat opioid use disorders (OUD) in Ukraine, OAT acceptability and coverage remains low. Extended-release naltrexone (XR-NTX) that recently became available as another treatment option provides new opportunities for treating OUDs in this region and we aimed to test its feasibility.

METHODS

Patients with OUD (N=135) and interested in treatment with XR-NTX were initiated on monthly XR-NTX injections and monitored for three months. Correlates of 3-month retention on XR-NTX and drug use at each time-point using self-reports and urine drug testing (UDT) were assessed.

RESULTS

Of the 134 participants initiated XR-NTX, 101 (75%) completed three months, defined as 4 consecutive XR-NTX injections. Independent factors negatively associated with retention in XR-NTX treatment included previous maintenance with OAT (aOR=0.3; 95%CI=0.1-0.9) and extrinsic help-seeking treatment motivation (aOR=0.7; 95%CI=0.5-0.9). Of these 101 participants completing three months of treatment, opioid use markedly reduced using self-report (67%% to 22%; p>0.001) and UDT (77% to 24%; p<0.001) outcomes over time. Alcohol, marijuana and stimulant use, however, remained unchanged. Craving for opioids and symptoms of depression also significantly decreased, while health-related quality of life scores improved over time. No adverse side effects were reported during the period of observation.

CONCLUSION

The first introduction of XR-NTX in Ukraine among persons with OUD resulted in high levels of retention, marked reductions in opioid use and improved quality of life. These descriptive results suggest that XR-NTX treatment is feasible and well-tolerated over a 3-month period in Ukraine.

Outcome evaluation of a "common factors" approach to develop culturally tailored HIV prevention interventions for people who inject drugs

BACKGROUND

Current models of HIV prevention intervention dissemination involve packaging interventions developed in one context and training providers to implement that specific intervention with fidelity. Providers rarely implement these programs with fidelity due to perceived incompatibility, resource constraints, and preference for locally-generated solutions. Moreover, such interventions may not reflect local drug markets and drug use practices that contribute to HIV risk.

PURPOSE

This paper examines whether provider-developed interventions based on common factors of effective, evidence-based behavioral interventions led to reduction in drug-related HIV risk behaviors at four study sites in Ukraine.

METHODS

We trained staff from eight nongovernmental organizations (NGOs) to develop HIV prevention interventions based on a common factors approach. We then selected four NGOs to participate in an outcome evaluation. Each NGO conducted its intervention for at least N = 130 participants, with baseline and 3-month follow-up assessments.

RESULTS

At three sites, we observed reductions in the prevalence of both any risk in drug acquisition and any risk in drug injection. At the fourth site, prevalence of any risk in drug injection decreased substantially, but the prevalence of any risk in drug acquisition essentially stayed unchanged.

CONCLUSIONS

The common factors approach has some evidence of efficacy in implementation, but further research is needed to assess its effectiveness in reducing HIV risk behaviors and transmission. Behavioral interventions to reduce HIV risk developed using the common factors approach could become an important part of the HIV response in low resource settings where capacity building remains a high priority.

Client and Provider Perspectives on Antiretroviral Treatment Uptake and Adherence Among People Who Inject Drugs in Indonesia, Ukraine and Vietnam: HPTN 074

HIV-infected people who inject drugs (PWID) have low uptake of HIV services, increasing the risk of transmission to uninfected injection or sexual partners and the likelihood of AIDS-related deaths. HPTN 074 is a vanguard study assessing the feasibility of an integrated intervention to facilitate treatment as prevention to PWID in Indonesia, Ukraine, and Vietnam. We describe barriers to and facilitators of ART uptake and adherence among PWID. We conducted in-depth interviews with 62 participants, including 25 providers and 37 PWID at baseline across all sites. All interviews were recorded, transcribed, translated into English and coded in NVivo for analysis. Matrices were developed to identify emergent themes and patterns. Overall, differences between provider and PWID perspectives were greater than differences in cross-site perspectives. Providers and PWID recognized clinic access, financial barriers, side effects, and lack of information about HIV testing and ART enrollment as barriers to ART. However, providers tended to emphasize individual level barriers to ART, such as lack of motivation due to drug use, whereas PWID highlighted health systems barriers, such as clinic hours and financial burden, fears, and side effects. Providers did not mention stigma as a barrier though their language reflected stereotypes about drug users. The differences between provider and PWID perspectives suggest a gap in providers' understanding of PWID. This misunderstanding has implications for patient-provider interactions that may affect PWID willingness to access care or adhere to ART. Lessons learned from this study will be important as countries with a significant HIV burden among PWID design and implement programs to engage HIV-infected PWID in care and treatment.

Psychiatric and Substance Use Comorbidity in Treatment-Seeking Injection Opioid Users Referred From Syringe Exchange

OBJECTIVE

The present study evaluated rates of co-occurring current psychiatric and substance use disorders in a sample of opioid-dependent treatment-seeking injection drug users referred from syringe exchange.

METHODS

Participants (N = 208) completed the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV-R to assess current (within the past year) psychiatric and substance use disorders and the two most commonly diagnosed personality disorders (antisocial and borderline personality disorders).

RESULTS

Forty-eight percent of the sample had a current Axis I psychiatric disorder, and 67% had a co-occurring current substance use disorder. Posttraumatic stress disorder (21%), major depression (17%), and bipolar I (12%) were the most prevalent Axis I psychiatric disorders, and cocaine use disorder (53%) was the most commonly co-occurring substance use disorder. Women were more likely to have diagnoses of most anxiety disorders and less likely to have diagnoses of alcohol use disorder or antisocial personality disorder. The presence of a personality disorder was associated with higher rates of cocaine and sedative use disorder.

CONCLUSIONS

Findings suggest the importance of evaluating and treating co-occurring psychiatric and substance use disorders in the treatment of injection drug users with opioid dependence.

Perceptions of Health-Related Community Reentry Challenges among Incarcerated Drug Users in Azerbaijan, Kyrgyzstan, and Ukraine

Facing competing demands with limited resources following release from prison, people who inject drugs (PWID) may neglect health needs, with grave implications including relapse, overdose, and non-continuous care. We examined the relative importance of health-related tasks after release compared to tasks of everyday life among a total sample of 577 drug users incarcerated in Ukraine, Azerbaijan, and Kyrgyzstan. A proxy measure of whether participants identified a task as applicable (easy or hard) versus not applicable was used to determine the importance of each task. Correlates of the importance of health-related reentry tasks were analyzed using logistic regression, with a parsimonious model being derived using Bayesian lasso method. Despite all participants having substance use disorders and high prevalence of comorbidities, participants in all three countries prioritized finding a source of income, reconnecting with family, and staying out of prison over receiving treatment for substance use disorders, general health conditions, and initiating methadone treatment. Participants with poorer general health were more likely to prioritize treatment for substance use disorders. While prior drug injection and opioid agonist treatment (OAT) correlated with any interest in methadone in all countries, only in Ukraine did a small number of participants prioritize getting methadone as the most important post-release task. While community-based OAT is available in all three countries and prison-based OAT only in Kyrgyzstan, Kyrgyz prisoners were less likely to choose help staying off drugs and getting methadone. Overall, prisoners consider methadone treatment inapplicable to their pre-release planning. Future studies that involve patient decision-making and scale-up of OAT within prison settings are needed to better improve individual and public health.

Hepatitis C virus status awareness and test results confirmation among people who inject drugs in Ukraine

BACKGROUND

Among the estimated 340,000 people who inject drugs (PWID) in Ukraine, HCV prevalence is approximately 70%. As HCV treatment availability increases, an assessment of the HCV treatment cascade is needed to guide HCV prevention and treatment strategies.

METHODS

Opioid dependent PWID were interviewed and tested for HIV and HCV in five Ukrainian cities from January 2014 to March 2015. Logistic regression was used to examine the independent correlates of two cascade steps: a) anti-HCV positive status awareness; b) chronic HCV confirmation; and of c) annual HCV testing for PWID.

RESULTS

Among 1613 PWID, 1002 (62.1%) had anti-HCV positive test result, of which 568 (56.7%) were aware of it before the study and 346 (34.5%) reported previous confirmatory testing for chronic HCV. Independent correlates of being aware they had anti-HCV positivity included: current [AOR: 3.08; 95%CI: 2.16-4.40] or prior [AOR: 1.85; 95%CI: 1.27-2.68] opioid agonistic treatment (OAT) experience, relative to no prior OAT, living in Lviv [AOR: 0.50; 95%CI: 0.31-0.81] or Odesa [AOR: 2.73; 95%CI: 1.51-4.93] relative to Kyiv and being aware of having HIV [AOR: 4.10; 95%CI: 2.99-5.62]. Independent correlates of confirming HCV infection among those who were aware of their anti-HCV positive status included: current OAT [AOR: 2.00; 95%CI: 1.24-3.23], relative to prior OAT, the middle income category [AOR: 1.74, 95%CI: 1.15-2.63], relative to the lowest, and receiving ART [AOR: 4.54; 95%CI: 2.85-7.23]. Among 1613 PWID, 918 (56.9%) were either HCV negative or not aware of their HCV positive status, of which 198 (21.6%) reported recent anti-HCV test (during last 12 month). Recent anti-HCV test in this group was associated with current [AOR: 7.17; 95%CI: 4.63-11.13] or prior [AOR: 2.24; 95%CI: 1.32-3.81] OAT experience, relative to no prior OAT.

CONCLUSION

Encouraging PWID to participate in OAT may be an effective strategy to diagnose and link PWID who are HCV positive to care. Among HIV negative participants, regular HCV testing may be ensured by participation in OAT. More studies are needed to assess HCV treatment utilization among PWID in Ukraine and OAT as a possible way to retain them in treatment.

Concurrent drug injection during opioid agonist treatment among people who inject drugs in Ukraine

Ongoing drug use during opioid agonist treatment (OAT) negatively affects treatment and health outcomes, and increases treatment dropout. This study aimed to examine correlates of concurrent illicit drug use among OAT patients in Ukraine. A random sample of 434 patients currently on OAT receiving buprenorphine (BMT) or methadone maintenance treatment (MMT) from five cities in Ukraine were assessed for factors associated with self-reported concurrent illicit drug use during OAT using a multivariable logistic regression. Among 434 OAT patients, 100 (23%) reported concurrent drug injecting in the previous 30 days; 28% of these were injecting ≥20 days. While 100 (100%) of these injected opioids, 24 (24%) injected stimulants; 40 (40%) met criteria for polysubstance use disorder that included opioids, stimulants and alcohol. Independent correlates of concurrent drug injection included: being on MMT vs. BMT (aOR = 2.8, 95%CI = 1.4-5.8), lower OAT dosage (aOR = 1.7, 95%CI = 1.1-2.7), more severe addiction severity (aOR = 2.3, 95%CI = 1.4-3.8), younger age of injection initiation (aOR = 2.3, 95%CI = 1.3-3.9), and presence of alcohol use disorder (aOR = 2.1, 95%CI = 1.3-3.5); participants living with parents were negatively associated with concurrent drug injection. Concurrent drug use was prevalent among OAT patients in Ukraine indicating the urgent needs for tailored interventions and changes in OAT program design and implementation. Results highlight the importance of prescribing an adequate OAT dosage, and discrepancies between MMT and BMT programs in Ukraine addressing needs of OAT patients with specific characteristics such as severe opioid and alcohol dependence.

Retention in medication-assisted treatment programs in Ukraine-Identifying factors contributing to a continuing HIV epidemic

BACKGROUND

Opioid agonist treatments (OAT) are widely-used, evidence-based strategies for treating opioid dependence and reducing HIV transmission. The positive benefits of OAT are strongly correlated with time spent in treatment, making retention a key indicator for program quality. This study assessed patient retention and associated factors in Ukraine, where OAT was first introduced in 2004.

METHODS

Data from clinical records of 2916 patients enrolled in OAT at thirteen sites from 2005 to 2012 were entered into an electronic monitoring system. Survival analysis methods were used to determine the probability of retention and its correlates.

RESULTS

Twelve-month retention was 65.8%, improving from 27.7% in 2005, to 70.9% in 2011. In multivariable analyses, the correlates of retention were receiving medium and high doses of medication (compared to low doses, dropout aHR=0.57 for both medium and high doses), having not been tested for HIV and tuberculosis (compared to not being tested, dropout aHR=4.44 and 3.34, respectively), and among those who were tested-a negative TB test result (compared to receiving a positive test result, dropout aHR=0.67).

CONCLUSION

Retention in Ukrainian OAT programs, especially in recent years, is comparable to other countries. The results confirm the importance of adequate OAT dosing (≥60mg of methadone, ≥8mg of buprenorphine). Higher dosing, however, will require interventions that address negative attitudes toward OAT by patients and providers. Interruption of OAT, in the case developing tuberculosis, should incorporate continuity of OAT for TB patients through integrated care delivery systems.

Patient preferences and extended-release naltrexone: A new opportunity to treat opioid use disorders in Ukraine

BACKGROUND

Scaling up HIV prevention for people who inject drugs (PWID) using opioid agonist therapies (OAT) in Ukraine has been restricted by individual and structural factors. Extended-release naltrexone (XR-NTX), however, provides new opportunities for treating opioid use disorders (OUDs) in this region, where both HIV incidence and mortality continue to increase.

METHODS

Survey results from 1613 randomly selected PWID from 5 regions in Ukraine who were currently, previously or never on OAT were analyzed for their preference of pharmacological therapies for treating OUDs. For those preferring XR-NTX, independent correlates of their willingness to initiate XR-NTX were examined.

RESULTS

Among the 1613 PWID, 449 (27.8%) were interested in initiating XR-NTX. Independent correlates associated with interest in XR-NTX included: being from Mykolaiv (AOR=3.7, 95% CI=2.3-6.1) or Dnipro (AOR=1.8, 95% CI=1.1-2.9); never having been on OAT (AOR=3.4, 95% CI=2.1-5.4); shorter-term injectors (AOR=0.9, 95% CI 0.9-0.98); and inversely for both positive (AOR=0.8, CI=0.8-0.9), and negative attitudes toward OAT (AOR=1.3, CI=1.2-1.4), respectively.

CONCLUSIONS

In the context of Eastern Europe and Central Asia where HIV is concentrated in PWID and where HIV prevention with OAT is under-scaled, new options for treating OUDs are urgently needed.

FINDINGS

here suggest that XR-NTX could become an option for addiction treatment and HIV prevention especially for PWID who have shorter duration of injection and who harbor negative attitudes to OAT. Decision aids that inform patient preferences with accurate information about the various treatment options are likely to guide patients toward better, patient-centered treatments and improve treatment entry and retention.

Willingness to pay for opioid agonist treatment among opioid dependent people who inject drugs in Ukraine

BACKGROUND

In the context of decreasing external and limited Ukrainian governmental funding for opioid agonist treatments (OAT) for opioid dependent people who inject drugs in Ukraine, information on sustainable financial models is needed.

METHODS

Data on 855 opioid dependent people who inject drugs (PWID) were drawn from a cross-sectional nationwide survey of 1613 PWID. They comprised 434 participants who were receiving OAT and 421 who were on OAT in the past or have never been on OAT and were interested in receiving the treatment. Multivariate logistic regression was used to examine factors associated with willingness-to-pay (WTP) for OAT, stratified by OAT experience. Variation in the price which respondents were willing to pay for OAT and its effect on their monthly income among PWID with different OAT experience were assessed as a continuous variable using one-way ANOVA and Kruskal-Wallis test.

RESULTS

Overall, 378 (44%) expressed WTP for OAT. Factors independently associated with WTP differed by OAT experience. Among those using OAT, independent predictors of WTP included: city (Dnipro - aOR=1.9; 95%CI=1.1-4.8 and Lviv - (aOR=2.2; 95%CI=1.1-4.8) compared to those elsewhere in Ukraine), higher income (aOR=1.8; 95%CI=1.2-2.7) and receiving psychosocial counseling (aOR=1.8; 95%CI=1.2-2.7). Among those who had previously been on OAT, positive attitude towards OAT (aOR=1.3; 95%CI=1.1-1.6) and family support of OAT (aOR=2.5; 95%CI=1.1-5.7) were independently associated with WTP. Among PWID who had never been on OAT, being male (aOR=2.2; 95%CI=1.1-4.2), younger age (aOR=1.9; 95%CI=1.2-3.2), higher income (aOR=2.0; 95%CI=1.2-3.4) and previous unsuccessful attempts to enter OAT (aOR=2.3; 95%CI=1.1-4.7) were independently associated with WTP. PWID were willing to commit a large percentage of their monthly income for OAT, which, however, varied significantly based on OAT experience: current OAT: 37% of monthly income, previous OAT: 53%, and never OAT: 60% (p-value=0.0009).

CONCLUSIONS

WTP for OAT was substantial among PWID in Ukraine, supporting the implementation of self-pay or co-payment programs. Such strategies, however, must remain affordable, provide better access to OAT, and consider specific needs of PWID.

Primary healthcare-based integrated care with opioid agonist treatment: First experience from Ukraine

BACKGROUND

Ukraine's HIV epidemic is concentrated among people who inject drugs (PWID), however, coverage with opioid agonist therapies (OATs) available mostly at specialty addiction clinics is extremely low. OAT integrated into primary healthcare clinics (PHCs) provides an opportunity for integrating comprehensive healthcare services and scaling up OAT.

METHODS

A pilot study of PHC-based integrated care for drug users conducted in two Ukrainian cities between 2014 and 2016 included three sub-studies: 1) cross-sectional treatment site preference assessment among current OAT patients (N=755); 2) observational cohort of 107 PWID who continued the standard of care versus transition of stabilized and newly enrolled PWID into PHC-based integrated care; and 3) pre/post analysis of attitudes toward PWID and HIV patients by PHC staff (N=26).

RESULTS

Among 755 OAT patients, 53.5% preferred receiving OAT at PHCs, which was independently correlated with convenience, trust in physician, and treatment with methadone (vs. buprenorphine). In 107 PWID observed over 6 months, retention in treatment was high: 89% in PWID continuing OAT in specialty addiction treatment settings (standard of care) vs 94% in PWID transitioning to PHCs; and 80% among PWID newly initiating OAT in PHCs. Overall, satisfaction with treatment, subjective self-perception of well-being, and trust in physician significantly increased in patients prescribed OAT in PHCs. Among PHC staff, attitudes towards PWID and HIV patients significantly improved over time.

CONCLUSIONS

OAT can be successfully integrated into primary care in low and middle-income countries and improves outcomes in both patients and clinicians while potentially scaling-up OAT for PWID.

Patterns of harm reduction service utilization and HIV incidence among people who inject drugs in Ukraine: A two-part latent profile analysis

BACKGROUND

Program utilization patterns are described within a large network of harm reduction service providers in Ukraine. The relationship between utilization patterns and HIV incidence is determined among people who inject drugs (PWID) controlling for oblast-level HIV incidence and treatment/syringe coverage.

METHODS

Data were extracted from the network's monitoring and evaluation database (January 2011-September 2014, n=327,758 clients). Latent profile analysis was used to determine harm reduction utilization patterns using the number of HIV tests received annually and the number of condoms, syringes, and services (i.e., information and counseling sessions) received monthly over a year. Cox proportional hazards regression determined the relations between HIV seroconversion and utilization class membership.

RESULTS

In the final 4-class model, class 1 (34.0% of clients) received 0.1 HIV tests, 1.3 syringes, 0.6 condom and minimal counseling and information sessions per month; class 2 (33.6%) received 8.6 syringes, 3.2 condoms, and 0.5 HIV tests and counseling and information sessions; class 3 (19.1%) received 1 HIV test, 11.9 syringes, 4.3 condoms, and 0.7 information and counseling sessions; class 4 (13.3%) received 1 HIV test, 26.1 syringes, 10.3 condoms, and 1.8 information and 1.9 counseling sessions. Class 4 clients had significantly decreased risk for HIV seroconversion as compared to those in class 1 after controlling for oblast-level characteristics.

CONCLUSION

Injection drug use continues to be a major mode of HIV transmission in Ukraine, making evaluation of harm reduction efforts in reducing HIV incidence among PWID critical. These analyses suggest that receiving more syringes and condoms decreased risk of HIV. Scaling up HIV testing and harm reduction services is warranted.

Implementation of methadone therapy for opioid use disorder in Russia - a modeled cost-effectiveness analysis

BACKGROUND

Opioid agonist therapy using methadone, an effective treatment of opioid use disorders (OUD) for people who inject drugs (PWID), is recommended by the World Health Organization as essential to curtail the growing HIV epidemic. Yet, despite increasing prevalence of OUD and HIV, methadone therapy has not yet been implemented in Russia. The aim of this modeling study was to estimate the cost-effectiveness of methadone therapy for Russian adults with a diagnosed OUD.

METHODS/DESIGN

We modeled the projected program implementation costs and estimated disability-adjusted life years (DALYs) averted over a 10-year period, associated with the provision of methadone therapy for a hypothetical, unreplenished cohort of Russian adults with an OUD (n = 249,000), in comparison to the current therapies at existing addiction treatment facilities. Our model compared four distinct scenarios of treatment coverage in the cohort ranging from 3.1 to 55%.

RESULTS

Providing methadone therapy to as few as 3.1% of adults with an OUD amounted to an estimated almost 50,000 DALYs averted over 10 years at a cost of just over USD 17 million. Further expanding service coverage to 55% resulted in an estimated almost 900,000 DALYs averted, at a cost of about USD 308 million.

CONCLUSION

Our study indicated that implementing opioid agonist therapy with methadone to treat OUD at existing facilities in Russia is highly cost-effective.

The perfect storm: incarceration and the high-risk environment perpetuating transmission of HIV, hepatitis C virus, and tuberculosis in Eastern Europe and Central Asia

Despite global reductions in HIV incidence and mortality, the 15 UNAIDS-designated countries of Eastern Europe and Central Asia (EECA) that gained independence from the Soviet Union in 1991 constitute the only region where both continue to rise. HIV transmission in EECA is fuelled primarily by injection of opioids, with harsh criminalisation of drug use that has resulted in extraordinarily high levels of incarceration. Consequently, people who inject drugs, including those with HIV, hepatitis C virus, and tuberculosis, are concentrated within prisons. Evidence-based primary and secondary prevention of HIV using opioid agonist therapies such as methadone and buprenorphine is available in prisons in only a handful of EECA countries (methadone or buprenorphine in five countries and needle and syringe programmes in three countries), with none of them meeting recommended coverage levels. Similarly, antiretroviral therapy coverage, especially among people who inject drugs, is markedly under-scaled. Russia completely bans opioid agonist therapies and does not support needle and syringe programmes-with neither available in prisons-despite the country's high incarceration rate and having the largest burden of people with HIV who inject drugs in the region. Mathematical modelling for Ukraine suggests that high levels of incarceration in EECA countries facilitate HIV transmission among people who inject drugs, with 28-55% of all new HIV infections over the next 15 years predicted to be attributable to heightened HIV transmission risk among currently or previously incarcerated people who inject drugs. Scaling up of opioid agonist therapies within prisons and maintaining treatment after release would yield the greatest HIV transmission reduction in people who inject drugs. Additional analyses also suggest that at least 6% of all incident tuberculosis cases, and 75% of incident tuberculosis cases in people who inject drugs are due to incarceration. Interventions that reduce incarceration itself and effectively intervene with prisoners to screen, diagnose, and treat addiction and HIV, hepatitis C virus, and tuberculosis are urgently needed to stem the multiple overlapping epidemics concentrated in prisons.