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Ponticiello M, Azbel L, Tate MM, Bromberg DJ, Pykalo I, Kiriazova T, Saichuk N, Altice FL. Introducing methadone maintenance therapy into Ukrainian prisons: a qualitative study of criminal subculture, Russia's full-scale invasion, and contested methadone objects. Front Psychiatry 2023; 14:1227216. [PMID: 38098632 PMCID: PMC10720714 DOI: 10.3389/fpsyt.2023.1227216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/17/2023] [Indexed: 12/17/2023] Open
Abstract
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.
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Affiliation(s)
- Matthew Ponticiello
- Yale School of Medicine, Yale University, New Haven, CT, United States
- Department of Epidemiology of Microbial Diseases, Yale University, New Haven, CT, United States
| | - Lyu Azbel
- Department of Social and Behavioral Sciences, Yale University, New Haven, CT, United States
| | - Mary M. Tate
- Department of Epidemiology of Microbial Diseases, Yale University, New Haven, CT, United States
| | - Daniel J. Bromberg
- Department of Social and Behavioral Sciences, Yale University, New Haven, CT, United States
| | - Iryna Pykalo
- European Institute on Public Health Policy, Kyiv, Ukraine
| | | | | | - Frederick L. Altice
- Yale School of Medicine, Yale University, New Haven, CT, United States
- Department of Epidemiology of Microbial Diseases, Yale University, New Haven, CT, United States
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Bromberg DJ, Galvez de Leon SJ, Litz T, Azbel L, Liberman AR, Polonsky M, Dvoriak S, Saichuk N, Taxman F, Altice FL. Aligning public health and public safety: Probation as a touchpoint to identify and link patients with opioid use disorder to opioid agonist treatment. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002349. [PMID: 37910486 PMCID: PMC10619786 DOI: 10.1371/journal.pgph.0002349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 08/10/2023] [Indexed: 11/03/2023]
Abstract
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.
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Affiliation(s)
- Daniel J. Bromberg
- Yale University School of Public Health, New Haven, Connecticut, United States of America
- Yale Center for Interdisciplinary Research on AIDS, Yale University, New Haven, Connecticut, United States of America
| | - Samy J. Galvez de Leon
- Yale Center for Interdisciplinary Research on AIDS, Yale University, New Haven, Connecticut, United States of America
- Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Taylor Litz
- Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Lyu Azbel
- Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Amanda R. Liberman
- Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Maxim Polonsky
- Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Sergii Dvoriak
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | | | - Faye Taxman
- George Mason University Schar School of Policy and Government, Arlington, Virginia, United States of America
| | - Frederick L. Altice
- Yale University School of Public Health, New Haven, Connecticut, United States of America
- Yale Center for Interdisciplinary Research on AIDS, Yale University, New Haven, Connecticut, United States of America
- Yale University School of Medicine, New Haven, Connecticut, United States of America
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Massmann R, Groh T, Jilich D, Bartková D, Bartovská Z, Chmelař J, Chrdle A, Dlouhý P, Cimrman Š, Guimaraes da Silva S, Kapla J, Kubiska M, Snopková S, Svačinka R, Zlámal M, Samsonová O, Sedláček D. HIV-positive Ukrainian refugees in the Czech Republic. AIDS 2023; 37:1811-1818. [PMID: 37352491 PMCID: PMC10481916 DOI: 10.1097/qad.0000000000003633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/12/2023] [Accepted: 06/18/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE Over 480 000 Ukrainian refugees have arrived in the Czech Republic since the Russian invasion of Ukraine in 2022, including over 500 people with HIV. This study describes the demographics, characteristics, and management of Ukrainian refugees with HIV in the Czech Republic. DESIGN Retrospective, observational, noninterventional study. METHODS Ukrainian nationals registering at HIV centers in the Czech Republic with war refugee status were included. Data were collected from medical records between 1 March and 31 July 2022. The study was registered with the Czech State Institute for Drug Control, ID number 2301200000. RESULTS Four hundred and eighty-two patients were included in the study. Most patients were female (69.5%; n = 335/482) with well-controlled HIV. The median [interquartile range] CD4 + cell count was 597 [397] cells/μl of blood, and 79.3% ( n = 361/455) of patients had HIV RNA <40 copies/ml. Coinfections of hepatitis C virus, hepatitis B virus, and/or tuberculosis were reported for 17.4% ( n = 78/449), 9% ( n = 40/446) and 1.3% ( n = 6/446) of patients, respectively. In Ukraine, 85.7% ( n = 384/448) of patients had been receiving an integrase strand transfer inhibitor-based regimen and most (69.7%; n = 310/445) did not switch therapy upon arrival in the Czech Republic. CONCLUSION Migration from Ukraine is changing the characteristics of HIV epidemiology in the Czech Republic. Ukrainian refugees with HIV have been provided with a high standard of medical care in the Czech Republic. Improved coordination between medical services within the Czech Republic and between countries in the European Union is necessary to optimize patient care.
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Affiliation(s)
- Ricardo Massmann
- Department of Infectology and Geographical Medicine, Center for Treatment of HIV/AIDS Patients, Academic L. Derer's University Hospital, Bratislava, Slovakia
- Third Faculty of Medicine, Charles University
| | | | - David Jilich
- Department of Infectious Diseases, Faculty Hospital Bulovka
- First Faculty of Medicine, Charles University, Prague
| | - Daniela Bartková
- Faculty of Medicine, Masaryk University, Brno
- Faculty of Medicine, University of Ostrava
- Department of Infectious Diseases, University Hospital Ostrava, Ostrava
| | - Zofia Bartovská
- Department of Infectious Diseases, First Faculty of Medicine, Charles University and Military University Hospital Prague, Prague
| | - Josef Chmelař
- Department of Infectious Diseases, University Hospital Hradec Králové, Hradec Králové
| | - Aleš Chrdle
- České Budějovice Hospital, České Budějovice
- Faculty of Health and Social Sciences, University of South Bohemia, České Budějovice, Czech Republic
- Royal Liverpool University Hospital, Liverpool, UK
| | | | - Štěpán Cimrman
- First Faculty of Medicine, Charles University, Prague
- Masaryk Hospital, Ústí nad Labem
| | | | - Jaroslav Kapla
- Department of Infectious Diseases, University Hospital Hradec Králové, Hradec Králové
| | - Miroslav Kubiska
- Faculty of Medicine, Charles University
- University Hospital Plzeň, Plzeň
| | - Svatava Snopková
- Department of Infectious Diseases, Faculty Hospital Brno
- Faculty of Medicine Masaryk University Brno, Brno, Czech Republic
| | - Radek Svačinka
- Department of Infectious Diseases, Faculty Hospital Brno
- Faculty of Medicine Masaryk University Brno, Brno, Czech Republic
| | - Milan Zlámal
- Department of Infectious Diseases, First Faculty of Medicine, Charles University and Military University Hospital Prague, Prague
| | | | - Dalibor Sedláček
- Faculty of Medicine, Charles University
- University Hospital Plzeň, Plzeň
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Machavariani E, Bromberg DJ, Dumchev K, Dvoriak S, Zeziulin O, Morozova O, Esserman D, Pykalo I, Saichuk N, Ivasiy R, Haddad MS, Altice FL. Design, implementation and preliminary results of a type-2 hybrid cluster-randomized trial of integrating screening and treatment for major depressive disorder into specialty clinics providing opioid agonist therapies in Ukraine. Contemp Clin Trials 2023; 131:107248. [PMID: 37263492 PMCID: PMC10527419 DOI: 10.1016/j.cct.2023.107248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/22/2023] [Accepted: 05/26/2023] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Ukraine has a high prevalence of co-occurring disorders (COD), defined as having both substance use (SUD) and psychiatric disorders. Major depressive disorder (MDD) is the most prevalent psychiatric disorder among people with SUD. People with COD experience poor health outcomes, and international agencies propose integrated COD care. In Ukraine, treatment for SUD is delivered in specialized substance use clinics, without providing any other medical services for comorbidities, including MDD. Here we present the protocol, along the with the preliminary results of the MEDIUM project, including observations over the first 6 months. METHODS A cluster-randomized type-2 hybrid trial was conducted to integrate MDD treatment into specialty clinics providing opioid agonist therapies (OAT) in Ukraine. Twelve clinics in four regions underwent randomization to control (N = 1) vs experimental arms (N = 2) in each region. Clinicians at experimental sites received tele-education through modified project ECHO using a facilitated screening, evaluation, and treatment algorithm of depression, with or without financial incentives. Service-, patient- and provider-level data were collected for the analysis every 6 months for 24 months. PRELIMINARY RESULTS For service delivery outcomes, 4421 patients enrolled on OAT across all sites were assessed for MDD for screening (76.7%), evaluation with diagnosis (43.5%) and treatment (30.7%) for MDD; 13.8% continued treatment at least for 6 months. For patient-level outcomes, 1345 patients and 54 providers participated in serial surveys every six months. CONCLUSION This study will be the first to explore integrated COD care in Ukraine and generate evidence on effective service integration and delivery strategies for people with COD receiving treatment at substance use clinics with broader implications for Eastern Europe and Central Asia region.
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Affiliation(s)
- Eteri Machavariani
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, United States.
| | - Daniel J Bromberg
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States; Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, CT, United States
| | | | - Sergii Dvoriak
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | | | - Olga Morozova
- Department of Public Health Sciences, University of Chicago, Chicago, IL, United States
| | - Denise Esserman
- Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, CT, United States
| | - Iryna Pykalo
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | | | - Roman Ivasiy
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, United States
| | - Marwan S Haddad
- Center for Key Populations, Community Health Center Inc, Middletown, CT, United States
| | - Frederick L Altice
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, United States; Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States; Division of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States
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Schoenberger SF, Idrisov B, Sereda Y, Kiriazova T, Makarenko O, Bendiks S, Ahuja N, Dutta A, Flanigan T, Gillani FS, Lunze K. Police abuse and care engagement of people with HIV who inject drugs in Ukraine. Glob Public Health 2022; 17:3638-3653. [PMID: 35343870 PMCID: PMC9515241 DOI: 10.1080/17441692.2022.2049341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 02/17/2022] [Indexed: 02/06/2023]
Abstract
Police abuse affects people who inject drugs (PWID), including those with HIV, and negatively impacts care engagement. This cross-sectional study evaluated police abuse among PWID receiving MOUD (medication for opioid use disorder) living with HIV and associations with HIV treatment adherence and receipt of NGO services. We assessed lifetime and past six-month rates of police abuse among a cohort of Ukrainian PWID with HIV receiving MOUD (n = 190) from August to September 2017. Logistic regression models evaluated associations between past six-month police abuse and past 30-day antiretroviral therapy (ART) adherence, and past six-month NGO service receipt. Almost all (90%) participants reported lifetime police abuse: 77% reported physical violence and 75% reported paying the police to avoid arrest. One in four females (25%) reported police-perpetrated sexual violence. Recent police abuse was reported by 16% of males and 2% of females and was not associated with ART adherence (aOR: 1.1; 95% CI:0.3-5.0) or NGO service receipt (aOR: 3.4; 95% CI:0.6-18.3). While lifetime police abuse rates were high, few participants reported recent police abuse, which was not linked to care engagement. These trends should encourage the Ukrainian government for public health-public safety partnerships and legal interventions to eliminate human rights violations against PWID living with HIV.
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Affiliation(s)
- Samantha F Schoenberger
- Clinical Addiction and Research Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Bulat Idrisov
- Institute for Leadership and Health Management, Sechenov First Moscow State Medical University, Moscow, Russia
- Bashkir State Medical University, Ufa, Russia
- Moscow Institute of Physics and Technology, Moscow, Russia
| | | | | | | | - Sally Bendiks
- Clinical Addiction and Research Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | | | - Arunima Dutta
- Section of Internal Medicine, McLaren Flint/Michigan State University, Flint, MI, USA
| | - Timothy Flanigan
- Division of Infectious Disease, Alpert Medical School of Brown University, The Miriam & Rhode Island Hospitals, Brown University, Providence, RI, USA
| | - Fizza S Gillani
- Division of Infectious Disease, Alpert Medical School of Brown University, The Miriam & Rhode Island Hospitals, Brown University, Providence, RI, USA
| | - Karsten Lunze
- Clinical Addiction and Research Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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Tsagkaris C, Matiashova L, Vladychuk V, Moysidis DV, Papadakis M, Trompoukis C. Public health considerations over HIV amidst war and COVID-19 in Ukraine: Harnessing contemporary history to address the syndemic. ETHICS, MEDICINE AND PUBLIC HEALTH 2022; 22:100795. [PMID: 35498441 PMCID: PMC9035367 DOI: 10.1016/j.jemep.2022.100795] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 04/12/2022] [Indexed: 12/02/2022]
Affiliation(s)
- C Tsagkaris
- European Student Think Tank, Public Health and Policy Working Group, 1058 Amsterdam, The Netherlands
| | - L Matiashova
- European Student Think Tank, Public Health and Policy Working Group, 1058 Amsterdam, The Netherlands
- Department of Chronic Diseases Risk Prevention, National Academy of Medical Sciences of Ukraine, Kharkiv, Ukraine
| | - V Vladychuk
- Bogomolets National Medical University, Kyiv, Ukraine
| | - D V Moysidis
- European Student Think Tank, Public Health and Policy Working Group, 1058 Amsterdam, The Netherlands
- Hippokration University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - M Papadakis
- University Witten-Herdecke, Wuppertal, Germany
| | - C Trompoukis
- Department of History of Medicine, University of Ioannina, Ioannina, Greece
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Neduzhko O, Postnov O, Bingham T, Myers JJ, Flanigan T, Kiriazova T. Feasibility and Acceptability of the Modified Antiretroviral Treatment Access Study (MARTAS) Intervention Based on a Pilot Study in Ukraine. J Int Assoc Provid AIDS Care 2020; 18:2325958218823257. [PMID: 30672381 PMCID: PMC6748547 DOI: 10.1177/2325958218823257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
We conducted a pilot of the Modified Antiretroviral Treatment Access Study (MARTAS), a linkage to HIV treatment intervention, prior to implementing a multisite randomized controlled trial (RCT) in Ukraine. The objectives of the pilot were to assess the feasibility and acceptability of the MARTAS intervention among a small sample of adults recently diagnosed with HIV at specialty clinics in the Mykolaiv region of Ukraine in 2015. The adapted intervention consisted of up to 6 individual-level sessions with a linkage coordinator (nurse) over a 90-day period. Overall, 22 persons participated in the pilot. On average, participants received 4.2 sessions and 14 participants linked to HIV care within 3 months of study enrollment. All 18 participants who completed the acceptability survey expressed high satisfaction with their interaction with their linkage coordinator. The results of the pilot demonstrated feasibility and acceptability of the MARTAS intervention in advance of a larger scale RCT in Ukraine.
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Affiliation(s)
| | | | - Trista Bingham
- 2 Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Janet J Myers
- 3 Prevention Research Center, University of California, San Francisco, CA, USA
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Morozova O, Booth RE, Dvoriak S, Dumchev K, Sazonova Y, Saliuk T, Crawford FW. Divergent estimates of HIV incidence among people who inject drugs in Ukraine. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 73:156-162. [PMID: 31405731 DOI: 10.1016/j.drugpo.2019.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 07/05/2019] [Accepted: 07/12/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Divergent estimates of HIV incidence among people who inject drugs (PWID) in Ukraine have been reported in modeling studies, longitudinal cohort studies, and recent infection assays used in cross-sectional surveys. Estimates range from 0.65 to 24.8 infections per 100 person-years with substantial regional variation. In this paper, we study the sources of this discrepancy. METHODS We compared baseline characteristics of study subjects recruited in the cross-sectional integrated bio-behavioral surveillance surveys (IBBS) in 2011 and 2013, with those from the longitudinal network intervention trial (network RCT) conducted between 2010 - 2013, the study that found a remarkably high incidence of HIV among PWID in Ukraine. The analysis was conducted for two cities: Mykolaiv and Odesa. RESULTS Significant differences were found in the characteristics of study subjects recruited in the IBBS surveys and the network RCT, in particular in Odesa, where the mismatch in the estimates of HIV incidence is greatest. In Odesa, recent syringe sharing was about three times as prevalent in the network RCT as in the IBBS; 39% of the network RCT and 16-18% of the IBBS participants indicated stimulants rather than opiates as their drug of choice; 97% of respondents in the network RCT and 45% in the IBBS-2013 reported injecting in a group over half of the time; and the average monthly number of injections in the network RCT was about twice that in the IBBS studies. CONCLUSIONS Differences in study designs and sampling methodologies may be responsible for the substantial differences in HIV incidence estimates among PWID in Ukraine. The potential sources of selection bias differed between the studies and likely resulted in the recruitment of lower risk individuals into the IBBS studies compared to the network RCT. Risk stratification in the population of PWID may have implications for future surveillance and intervention efforts.
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Affiliation(s)
- Olga Morozova
- Department of Biostatistics, Yale School of Public Health, 60 College St., New Haven, CT 06510, USA.
| | - Robert E Booth
- Department of Psychiatry, University of Colorado Denver, 13001 East 17th Place, Aurora, CO 80045, USA.
| | - Sergii Dvoriak
- Academy of Labour, Social Relations and Tourism, 3-A Kiltseva doroha, Kyiv 03187, Ukraine; Ukrainian Institute on Public Health Policy, 5 Mala Zhytomyrska St., Office 61-А, Kyiv 01001, Ukraine.
| | - Kostyantyn Dumchev
- Ukrainian Institute on Public Health Policy, 5 Mala Zhytomyrska St., Office 61-А, Kyiv 01001, Ukraine.
| | - Yana Sazonova
- Alliance for Public Health, 5 Dilova St., building 10-A, Kyiv 03150, Ukraine.
| | - Tetiana Saliuk
- Alliance for Public Health, 5 Dilova St., building 10-A, Kyiv 03150, Ukraine.
| | - Forrest W Crawford
- Department of Biostatistics, Yale School of Public Health, 60 College St., New Haven, CT 06510, USA; Department of Ecology & Evolutionary Biology, Yale University, 165 Prospect St., New Haven, CT 06511, USA; Yale School of Management, Yale University, 165 Whitney Ave, New Haven, CT 06511, USA.
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Abstract
In 2014, Russian authorities in occupied Crimea shut down all medication-assisted treatment (MAT) programs for patients with opioid use disorder. These closures dramatically enacted a new political order. As the sovereign occupiers in Crimea advanced new constellations of citizenship and statehood, so the very concept of "right to health" was re-tooled. Social imaginations of drug use helped single out MAT patients as a population whose "right to health," protected by the state, would be artificially restricted. Here, I argue that such acts of medical disenfranchisement should be understood as contemporary acts of statecraft.
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Affiliation(s)
- Jennifer J Carroll
- Department of Sociology and Anthropology, Elon University , Elon , North Carolina , USA
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Fearnhill E, Gourlay A, Malyuta R, Simmons R, Ferns RB, Grant P, Nastouli E, Karnets I, Murphy G, Medoeva A, Kruglov Y, Yurchenko A, Porter K. A Phylogenetic Analysis of Human Immunodeficiency Virus Type 1 Sequences in Kiev: Findings Among Key Populations. Clin Infect Dis 2019; 65:1127-1135. [PMID: 28575385 DOI: 10.1093/cid/cix499] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 05/24/2017] [Indexed: 12/15/2022] Open
Abstract
Background The human immunodeficiency virus (HIV) epidemic in Ukraine has been driven by a rapid rise among people who inject drugs, but recent studies have shown an increase through sexual transmission. Methods Protease and reverse transcriptase sequences from 876 new HIV diagnoses (April 2013-March 2015) in Kiev were linked to demographic data. We constructed phylogenetic trees for 794 subtype A1 and 64 subtype B sequences and identified factors associated with transmission clustering. Clusters were defined as ≥2 sequences, ≥80% local branch support, and maximum genetic distance of all sequence pairs in the cluster ≤2.5%. Recent infection was determined through the limiting antigen avidity enzyme immunoassay. Sequences were analyzed for transmitted drug resistance mutations. Results Thirty percent of subtype A1 and 66% of subtype B sequences clustered. Large clusters (maximum 11 sequences) contained mixed risk groups. In univariate analysis, clustering was significantly associated with subtype B compared to A1 (odds ratio [OR], 4.38 [95% confidence interval {CI}, 2.56-7.50]); risk group (OR, 5.65 [95% CI, 3.27-9.75]) for men who have sex with men compared to heterosexual males; recent, compared to long-standing, infection (OR, 2.72 [95% CI, 1.64-4.52]); reported sex work contact (OR, 1.93 [95% CI, 1.07-3.47]); and younger age groups compared with age ≥36 years (OR, 1.83 [95% CI, 1.10-3.05] for age ≤25 years). Females were associated with lower odds of clustering than heterosexual males (OR, 0.49 [95% CI, .31-.77]). In multivariate analysis, risk group, subtype, and age group were independently associated with clustering (P < .001, P = .007, and P = .033, respectively). Eighteen sequences (2.1%) indicated evidence of transmitted drug resistance. Conclusions Our findings suggest high levels of transmission and bridging between risk groups.
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Affiliation(s)
| | | | - Ruslan Malyuta
- Perinatal Prevention of AIDS Initiative, Odessa, Ukraine
| | | | | | - Paul Grant
- University College London Hospital NHS Foundation Trust, United Kingdom
| | - Eleni Nastouli
- University College London, United Kingdom.,Perinatal Prevention of AIDS Initiative, Odessa, Ukraine
| | | | - Gary Murphy
- Public Health England, London, United Kingdom; and
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LaMonaca K, Dumchev K, Dvoriak S, Azbel L, Morozova O, Altice FL. HIV, Drug Injection, and Harm Reduction Trends in Eastern Europe and Central Asia: Implications for International and Domestic Policy. Curr Psychiatry Rep 2019; 21:47. [PMID: 31161306 PMCID: PMC6685549 DOI: 10.1007/s11920-019-1038-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW Scaling up evidence-based HIV prevention strategies like opioid agonist therapies (OAT), syringe services programs (SSPs), and antiretroviral therapy (ART) to mitigate the harms of drug injection is crucial within Eastern Europe and Central Asia (EECA), the only region globally where HIV incidence and mortality are increasing. RECENT FINDINGS Though the proportion of new HIV cases directly attributable to drug injection has recently declined, it remains a critical driver of HIV, especially to sexual partners. Concurrently, scale-up of OAT, SSPs, and ART has remained low, contributing to a volatile HIV epidemic among people who inject drugs (PWID). Despite evidence that drug injection contributes to an evolving HIV epidemic in EECA, coverage of evidence-based harm reduction programs remains substantially below needed targets. Due to a combination of punitive drug laws, ideological resistance to OAT among clinicians and policymakers, and inadequate domestic and international funding, limited progress has been observed in increasing the availability of these programs.
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Affiliation(s)
- Katherine LaMonaca
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, 135 College Street Suite 323, New Haven, CT, 06510, USA
| | | | - Sergii Dvoriak
- Academy of Labour, Social Relations and Tourism, Kyiv, Ukraine
| | - Lyuba Azbel
- London School of Hygiene & Tropical Medicine, London, UK
| | - Olga Morozova
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
| | - Frederick L Altice
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, 135 College Street Suite 323, New Haven, CT, 06510, USA.
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13
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Go VF, Hershow RB, Kiriazova T, Sarasvita R, Bui Q, Latkin CA, Rose S, Hamilton E, Lancaster KE, Metzger D, Hoffman IF, Miller WC. Client and Provider Perspectives on Antiretroviral Treatment Uptake and Adherence Among People Who Inject Drugs in Indonesia, Ukraine and Vietnam: HPTN 074. AIDS Behav 2019; 23:1084-1093. [PMID: 30306437 DOI: 10.1007/s10461-018-2307-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Vivian F Go
- Department of Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA.
| | - Rebecca B Hershow
- Department of Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
| | - Tetiana Kiriazova
- Ukrainian Institute on Public Health Policy, Malopidvalna Street, 4, Kiev, 02000, Ukraine
| | - Riza Sarasvita
- National Narcotics Board, Jalan Letnan Jendral M.T. Haryono No.11, RT.1/RW.6, Cawang, Kramatjati, RT.1/RW.6, Cawang, Kramatjati, Kota Jakarta Timur, Daerah Khusus Ibukota, Jakarta, 13630, Indonesia
- Cipto Mangunkusumo Hospital, University of Indonesia, Jalan Pangeran Diponegoro No.71, Salemba, Senen, Jakarta Pusat, Daerah Khusus Ibukota, Jakarta, 10430, Indonesia
| | - Quynh Bui
- UNC Project Vietnam, Yen Hoa Health Clinic, Lot E2, Duong Dinh Nghe Street, Cau Giay District, Hanoi, Vietnam
| | - Carl A Latkin
- Department of Health, Behavior, and Society, Johns Hopkins University, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Scott Rose
- Science Facilitation Department, FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA
| | - Erica Hamilton
- Science Facilitation Department, FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA
| | - Kathryn E Lancaster
- Division of Epidemiology, College of Public Health, The Ohio State University, 300-D Cunz Hall, 1841 Neil Avenue, Columbus, OH, 43210, USA
| | - David Metzger
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 4th Floor - Suite 4000, Philadelphia, PA, 19104-3309, USA
| | - Irving F Hoffman
- Division of Infectious Diseases, School of Medicine, The University of North Carolina at Chapel Hill, 130 Mason Farm Rd, Chapel Hill, NC, 27599, USA
| | - William C Miller
- Division of Epidemiology, College of Public Health, The Ohio State University, 300-D Cunz Hall, 1841 Neil Avenue, Columbus, OH, 43210, USA
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14
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Lancaster KE, Miller WC, Kiriazova T, Sarasvita R, Bui Q, Ha TV, Dumchev K, Susami H, Hamilton EL, Rose S, Hershow RB, Go VF, Metzger D, Hoffman IF, Latkin CA. Designing an Individually Tailored Multilevel Intervention to Increase Engagement in HIV and Substance Use Treatment Among People Who Inject Drugs With HIV: HPTN 074. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2019; 31:95-110. [PMID: 30917014 PMCID: PMC6594165 DOI: 10.1521/aeap.2019.31.2.95] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
People who inject drugs (PWID) face barriers to engagement in antiretro-viral treatment (ART) and medication-assisted treatment (MAT). We detail the design, rapid preparation and adaptation, and systematic implementation of a flexible, individually tailored intervention for PWID in multiple settings: Indonesia, Ukraine, and Vietnam. HPTN 074 integrated systems navigation and counseling to facilitate entry and adherence to ART and MAT. Site-level guidance on the intervention involved in-depth interviews (IDIs) among PWID and their supporters and site-specific document review. IDIs emphasized ART misinformation and importance of social support for adherence. The document review revealed differences in health care system barriers, requiring an intervention that was flexible and tailored enough to address key outcomes. Implementation included regular debriefs for iterative adaptations based on participants' needs, including booster counseling sessions and subsidizing pre-ART testing. HPTN 074 provides a unique framework implementing a flexible and scalable intervention to improve ART and MAT outcomes among PWID across multiple settings.
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Affiliation(s)
| | - William C Miller
- College of Public Health, The Ohio State University, Columbus, Ohio
| | | | | | | | - Tran Viet Ha
- UNC Project Vietnam, Hanoi, Vietnam
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina
| | | | - Hepa Susami
- Abhipraya Foundation and Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | | | - Scott Rose
- Science Facilitation Department, Durham, North Carolina
| | - Rebecca B Hershow
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina
| | - Vivian F Go
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina
| | - David Metzger
- Perelman School of Medicine, University of Pennsylvania and the Treatment Research Institute, Philadelphia, Pennsylvania
| | - Irving F Hoffman
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | - Carl A Latkin
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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15
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Zelenev A, Shea P, Mazhnaya A, Meteliuk A, Pykalo I, Marcus R, Fomenko T, Prokhorova T, Altice FL. Estimating HIV and HCV prevalence among people who inject drugs in 5 Ukrainian cities using stratification-based respondent driven and random sampling. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 67:91-101. [PMID: 30503695 DOI: 10.1016/j.drugpo.2018.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 08/14/2018] [Accepted: 09/06/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Ukraine, a country of 45.5 million people, has one of the most volatile HIV and HCV epidemics in the world. In this paper, we estimate the prevalence of HIV and HCV among PWID in five Ukrainian cities. METHODS A cross-sectional study was conducted in 2014-2015, based on stratified hybrid sampling with random and respondent driven sampling in five cities: Kyiv, Odesa, Mykolaiv, Dnipro and Lviv. Using data on HIV and HCV antibody testing from 1613 respondents, we evaluate selection bias in the sampling methods by analyzing spatial and network patterns of sampling processes. We develop and apply inverse probability weights in order to estimate the HIV and HCV prevalence in each city, as well as in the overall sample. FINDINGS The aggregate HIV prevalence for the five cities is 35.1% (95% CI: 29.5%-38.5%) but this varied considerably by city: in Kyiv the HIV prevalence is 26.6% (95% CI: 20.3.8%-33.4%), in Odesa - 38.2% (95% CI: 29.8% and 47.1%), in Mykolaiv - 42.0% (95% CI: 34.3%-49.2%), in Dnipro - 58.8% (95% CI: 52.2%-65.8%), and in Lviv 24.6% (95% CI: 18.8%-30.8%). The aggregate HCV prevalence estimate for the five cities is 58.6% (95% CI: 54.9%-61.7%). The highest HCV prevalence is estimated in Kyiv - 84.8% (95% CI: 78.5%-90.1%). HCV prevalence in Odesa is the lowest and estimated to be 36.5% (95% CI: 29.5%-45.1%), in Mykolaiv - 49.1% (95% CI: 41.5%-57.0%), in Dnipro - 56.1% (95% CI: 50.3%-63.4%) and in Lviv 38.5% (95% CI: 31.8%-45.0%). CONCLUSIONS Monitoring behavioral and health outcomes of PWID on a regular basis is necessary for determining prevention and treatment priorities for HIV and HCV infections in Ukraine and elsewhere. The heterogeneity of the local epidemics provides insights into the best prevention and treatment strategies to be deployed in low-resource settings.
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Affiliation(s)
- Alexei Zelenev
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, 06510, USA.
| | - Portia Shea
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, 06510, USA
| | - Alyona Mazhnaya
- ICF Alliance for Public Health in Ukraine, 5 Dilova str. Building 10A, Kyiv 03150, Ukraine; Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, 624 N Broadway, Baltimore, MD 21205, USA
| | - Anna Meteliuk
- ICF Alliance for Public Health in Ukraine, 5 Dilova str. Building 10A, Kyiv 03150, Ukraine
| | - Iryna Pykalo
- Ukrainian Institute on Public Health Policy, Mala Zhytomyrska St, 5, Kyiv, 01001, Ukraine
| | - Ruthanne Marcus
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, 06510, USA
| | - Tatiana Fomenko
- ICF Alliance for Public Health in Ukraine, 5 Dilova str. Building 10A, Kyiv 03150, Ukraine
| | - Tatiana Prokhorova
- ICF Alliance for Public Health in Ukraine, 5 Dilova str. Building 10A, Kyiv 03150, Ukraine
| | - Frederick L Altice
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, 06510, USA; Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, 06510, USA
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16
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Zou X, Xu Y, Chen W, Xia Y, Liu Y, Gong C, Ling L. Strategies to control HIV and HCV in methadone maintenance treatment in Guangdong Province, China: a system dynamic modeling study. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2018; 13:1. [PMID: 29321039 PMCID: PMC5763976 DOI: 10.1186/s13011-017-0140-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 12/27/2017] [Indexed: 12/31/2022]
Abstract
Background Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections among methadone maintenance treatment (MMT) participants remain high. Optimized HIV and HCV prevention strategies for MMT clinics in resource-limited regions are urgently needed. This study aims to develop an MMT system dynamic model (SDM) to compare and optimize HIV and HCV control strategies in the MMT system. Methods We developed an MMT-SDM structure based on literature reviews. Model parameters were estimated from a cohort study, cross-sectional surveys and literature reviews. We further calibrated model outputs to historical data of HIV and HCV prevalence among MMT participants in 13 MMT clinics of Guangdong Province. Lastly, we simulated the impact of integrated interventions on HIV and HCV incidence among MMT participants using the MMT-SDM. Results The MMT-SDM comprises MMT clinics, MMT participants, detoxification centers, and HIV and HCV transmission, testing and treatment systems. We determined that condom promotion was the most effective way to reduce HIV infection (2013-2020: 2.86% to 1.76%) in MMT setting, followed by needle exchange program (2013-2020: 2.86% to 2.56%), psychological counseling (2013-2020: 2.86% to 2.71%) and contingency management (2013-2020: 2.86% to 2.72%). Health education had marginal impact on reducing HIV incidence among MMT participants (2013-2020:2.86% to 2.84%) from 2013 to 2020. By contrast, psychological counseling (2013-2020: 7.54% to 2.42%) and contingency management (2013-2020: 7.54% to 2.96%) had been shown to be the most effective interventions to reduce HCV incidence among MMT participants, followed by needle exchange program (2013-2020: 7.54% to 5.76%), health education (2013-2020: 7.54% to 6.35%), and condom promotion program (2013-2020: 7.54% to 6.40%). Notably, HCV treatment reduced HCV incidence by 0.32% (2013-2020: 7.54% to 7.22%). Conclusions In conclusion, we generated a valuable system dynamic model to analyze the Chinese MMT system and to guide the decision-making process to further improve this system. This study underscores the importance of promoting condom use in MMT clinics and integrating psychosocial interventions to reduce HIV and HCV infections in MMT clinics in China. Electronic supplementary material The online version of this article (10.1186/s13011-017-0140-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xia Zou
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, People's Republic of China.,Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Yong Xu
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, People's Republic of China.,Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Wen Chen
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, People's Republic of China.,Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Yinghua Xia
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, People's Republic of China.,Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Yin Liu
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, People's Republic of China.,Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Cheng Gong
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, People's Republic of China.,Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Li Ling
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, People's Republic of China. .,Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, People's Republic of China.
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17
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Hoff E, Marcus R, Bojko MJ, Makarenko I, Mazhnaya A, Altice FL, Meyer JP. The effects of opioid-agonist treatments on HIV risk and social stability: A mixed methods study of women with opioid use disorder in Ukraine. J Subst Abuse Treat 2017; 83:36-44. [PMID: 29129194 PMCID: PMC5726590 DOI: 10.1016/j.jsat.2017.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 10/07/2017] [Accepted: 10/10/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Emily Hoff
- Yale School of Medicine, New Haven, CT, United States
| | - Ruthanne Marcus
- Yale School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, United States
| | - Martha J Bojko
- Yale School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, United States
| | - Iuliia Makarenko
- Yale School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, United States; ICP Alliance for Public Health, Kyiv, Ukraine
| | - Alyona Mazhnaya
- ICP Alliance for Public Health, Kyiv, Ukraine; Johns Hopkins School of Public Health, Department of Health, Behavior and Society, Baltimore, MD, USA
| | - Frederick L Altice
- Yale School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, United States; Yale School of Public Health, Epidemiology of Microbial Diseases, New Haven, CT, United States; University of Malaya, Kuala Lumpur, Malaysia
| | - Jaimie P Meyer
- Yale School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, United States.
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18
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Rozanova J, Marcus R, Taxman FS, Bojko MJ, Madden L, Farnum SO, Mazhnaya A, Dvoriak S, Altice FL. Why People Who Inject Drugs Voluntarily Transition Off Methadone in Ukraine. QUALITATIVE HEALTH RESEARCH 2017; 27:2057-2070. [PMID: 28942704 DOI: 10.1177/1049732317732307] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Methadone maintenance therapy (MMT) treats opioid use disorder among people who inject drugs (PWID). To understand why PWID may voluntarily discontinue MMT, we analyzed data from 25 focus groups conducted in five Ukrainian cities from February to April 2013 with 199 participants who were currently, previously, or never on MMT. Using constant comparison method, we uncovered three themes explaining why PWID transition off MMT: (a) purposeful resistance to rigid social control associated with how MMT is delivered and to power asymmetries in provider-patient relationships, (b) self-management of a PWID's "wounded identity" that is common in socially stigmatized and physically sick persons-MMT serves as a reminder of their illness, and (c) the quest for a "normal life" uninterrupted by daily MMT site visits, harassment, and time inefficiencies, resources, and social capital. Focusing on holistic principles of recovery would improve addiction treatment and HIV prevention in Ukraine and globally.
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Affiliation(s)
| | | | - Faye S Taxman
- 2 George Mason University, Washington, District of Columbia, USA
| | | | - Lynn Madden
- 1 Yale University, New Haven, Connecticut, USA
- 4 APT Foundation, New Haven, Connecticut, USA
| | | | | | - Sergii Dvoriak
- 6 Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | - Frederick L Altice
- 1 Yale University, New Haven, Connecticut, USA
- 4 APT Foundation, New Haven, Connecticut, USA
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Adolescents with HIV and transition to adult care in the Caribbean, Central America and South America, Eastern Europe and Asia and Pacific regions. J Int AIDS Soc 2017; 20:21475. [PMID: 28530040 PMCID: PMC5577698 DOI: 10.7448/ias.20.4.21475] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION The HIV epidemics in the Caribbean, Central America and South America (CCASA), Eastern Europe (EE) and Asia and Pacific (AP) regions are diverse epidemics affecting different key populations in predominantly middle-income countries. This narrative review describes the populations of HIV-positive youth approaching adolescence and adulthood in CCASA, EE and AP, what is known of their outcomes in paediatric and adult care to date, ongoing research efforts and future research priorities. METHODS We searched PubMed and abstracts from recent conferences and workshops using keywords including HIV, transition and adolescents, to identify published data on transition outcomes in CCASA, EE and AP. We also searched within our regional clinical/research networks for work conducted in this area and presented at local or national meetings. To give insight into future research priorities, we describe published data on characteristics and health status of young people as they approach age of transition, as a key determinant of health in early adulthood, and information available on current transition processes. RESULTS AND DISCUSSION The perinatally HIV-infected populations in these three regions face a range of challenges including parental death and loss of family support; HIV-related stigma and socio-economic disparities; exposure to maternal injecting drug use; and late disclosure of HIV status. Behaviourally HIV-infected youth often belong to marginalized sub-groups, with particular challenges accessing services and care. Differences between and within countries in characteristics of HIV-positive youth and models of care need to be considered in comparisons of outcomes in young adulthood. The very little data published to date on transition outcomes across these three regions highlight some emerging issues around adherence, virological failure and loss to follow-up, alongside examples of programmes which have successfully supported adolescents to remain engaged with services and virologically suppressed. CONCLUSIONS Limited data available indicate uneven outcomes in paediatric services and some shared challenges for adolescent transition including retention in care and adherence. The impact of issues specific to low prevalence, concentrated epidemic settings are poorly understood to date. Outcome data are urgently needed to guide management strategies and advocate for service provision in these regions.
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20
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Marcus R, Makarenko I, Mazhnaya A, Zelenev A, Polonsky M, Madden L, Filippovych S, Dvoriak S, Springer SA, Altice FL. Patient preferences and extended-release naltrexone: A new opportunity to treat opioid use disorders in Ukraine. Drug Alcohol Depend 2017; 179:213-219. [PMID: 28806638 PMCID: PMC5599372 DOI: 10.1016/j.drugalcdep.2017.07.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 07/12/2017] [Accepted: 07/15/2017] [Indexed: 01/13/2023]
Abstract
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.
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Affiliation(s)
- Ruthanne Marcus
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA.
| | | | | | - Alexei Zelenev
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | - Maxim Polonsky
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | | | | | - Sergii Dvoriak
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | - Sandra A Springer
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | - Frederick L Altice
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA; Yale School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven CT, USA; Centre of Excellence on Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
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21
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Willingness to pay for opioid agonist treatment among opioid dependent people who inject drugs in Ukraine. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017. [PMID: 28628853 DOI: 10.1016/j.drugpo.2017.05.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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.
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Guise A, Albers ER, Strathdee SA. 'PrEP is not ready for our community, and our community is not ready for PrEP': pre-exposure prophylaxis for HIV for people who inject drugs and limits to the HIV prevention response. Addiction 2017; 112:572-578. [PMID: 27273843 PMCID: PMC5145792 DOI: 10.1111/add.13437] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 02/16/2016] [Accepted: 04/19/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Pre-exposure prophylaxis for HIV, or 'PrEP', is the use of antiretroviral medicines by people who are HIV-negative to protect themselves against acquiring HIV. PrEP has shown efficacy for preventing HIV acquisition. Despite the potential, many concerns have been voiced by people who inject drugs (PWID) and their organizations. There is a need to engage with these views and ensure their integration in to policy and strategy. This paper presents PWID views on PrEP to foster the uptake of these opinions into scientific and policy debate around PrEP METHODS: Critical analysis of a report of a community consultation led by the International Network of People who Use Drugs (INPUD). RESULTS The INPUD report highlights enthusiasm from PWID for PrEP, but also three main concerns: the feasibility and ethics of PrEP, its potential use as a substitute for other harm reduction strategies and how a focus on PrEP heralds a re-medicalization of HIV. Each concern relates to evidenced gaps in essential services or opposition to harm reduction and PWID human rights. CONCLUSIONS People who use drugs have fundamental concerns about the potential impacts of pre-exposure prophylaxis for HIV which reflect a 'fault line' in HIV prevention: a predominance of biomedical approaches over community perspectives. Greater community engagement in HIV prevention strategy is needed, or we risk continuing to ignore the need for action on the underlying structural drivers and social context of the HIV epidemic.
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Affiliation(s)
- Andy Guise
- Department of Medicine, University of California San Diego, 9500 Gilman Drive , La Jolla , 92093-0507, USA
| | - Eliot Ross Albers
- International Network of People who Use Drugs, Unit 2C05, South Bank Technopark, 90 London Road, London, SE1 6LN, United Kingdom
| | - Steffanie A. Strathdee
- Department of Medicine, University of California San Diego, 9500 Gilman Drive , La Jolla , 92093-0507, USA
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Ompad DC, Wang J, Dumchev K, Barska J, Samko M, Zeziulin O, Saliuk T, Varetska O, DeHovitz J. Patterns of harm reduction service utilization and HIV incidence among people who inject drugs in Ukraine: A two-part latent profile analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 43:7-15. [PMID: 28160736 DOI: 10.1016/j.drugpo.2016.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 11/11/2016] [Accepted: 12/16/2016] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Danielle C Ompad
- New York University College of Global Public Health, New York, NY, USA; Center for Drug Use and HIV Research, New York University, New York, NY, USA; Center for Health, Identity, Behavior, and Prevention Studies, New York University, New York, NY, USA.
| | - Jiayu Wang
- Center for Health, Identity, Behavior, and Prevention Studies, New York University, New York, NY, USA
| | | | - Julia Barska
- National University of Kyiv-Mohyla Academy, Kiev, Ukraine
| | - Maria Samko
- Alliance for Public Health (Formerly ICF International HIV/AIDS Alliance in Ukraine), Kiev, Ukraine
| | | | - Tetiana Saliuk
- Alliance for Public Health (Formerly ICF International HIV/AIDS Alliance in Ukraine), Kiev, Ukraine
| | - Olga Varetska
- Alliance for Public Health (Formerly ICF International HIV/AIDS Alliance in Ukraine), Kiev, Ukraine
| | - Jack DeHovitz
- SUNY Downstate Medical Center, Department of Medicine, Brooklyn, NY, USA
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Polonsky M, Rozanova J, Azbel L, Bachireddy C, Izenberg J, Kiriazova T, Dvoryak S, Altice FL. Attitudes Toward Addiction, Methadone Treatment, and Recovery Among HIV-Infected Ukrainian Prisoners Who Inject Drugs: Incarceration Effects and Exploration of Mediators. AIDS Behav 2016; 20:2950-2960. [PMID: 27011378 PMCID: PMC5035551 DOI: 10.1007/s10461-016-1375-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In this study, we use data from a survey conducted in Ukraine among 196 HIV-infected people who inject drugs, to explore attitudes toward drug addiction and methadone maintenance therapy (MMT), and intentions to change drug use during incarceration and after release from prison. Two groups were recruited: Group 1 (n = 99) was currently incarcerated and Group 2 (n = 97) had been recently released from prison. This paper's key finding is that MMT treatment and addiction recovery were predominantly viewed as mutually exclusive processes. Group comparisons showed that participants in Group 1 (pre-release) exhibited higher optimism about changing their drug use, were less likely to endorse methadone, and reported higher intention to recover from their addiction. Group 2 participants (post-release), however, reported higher rates of HIV stigma. Structural equation modeling revealed that in both groups, optimism about recovery and awareness of addiction mediated the effect of drug addiction severity on intentions to recover from their addiction.
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Affiliation(s)
- Maxim Polonsky
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | - Julia Rozanova
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | - Lyuba Azbel
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Jacob Izenberg
- University of California San Francisco School of Medicine, Department of Psychiatry, San Francisco, CA, USA
| | | | - Sergii Dvoryak
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | - Frederick L. Altice
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
- Yale School of Public health, Department of Epidemiology of Microbial Diseases, New Haven, CT, USA
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Determinants of willingness to enroll in opioid agonist treatment among opioid dependent people who inject drugs in Ukraine. Drug Alcohol Depend 2016; 165:213-20. [PMID: 27370527 PMCID: PMC5094181 DOI: 10.1016/j.drugalcdep.2016.06.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 06/10/2016] [Accepted: 06/11/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Coverage with opioid agonist treatments (OAT) that include methadone and buprenorphine is low (N=8400, 2.7%) for the 310,000 people who inject drugs (PWID) in Ukraine. In the context of widespread negative attitudes toward OAT in the region, patient-level interventions targeting the barriers and willingness to initiate OAT are urgently needed. METHODS A sample of 1179 PWID with opioid use disorder not currently on OAT from five regions in Ukraine was assessed using multivariable logistic regression for independent factors related to willingness to initiate OAT, stratified by their past OAT experience. RESULTS Overall, 421 (36%) PWID were willing to initiate OAT. Significant adjusted odds ratios (aOR) for covariates associated with the willingness to initiate OAT common for both groups included: higher injection frequency (previously on OAT: aOR=2.7; never on OAT: aOR=1.8), social and family support (previously on OAT: aOR=2.0; never on OAT: aOR=2.0), and positive attitude towards OAT (previously on OAT: aOR=1.3; never on OAT: aOR=1.4). Among participants previously on OAT, significant correlates also included: HIV-negative status (aOR=2.6) and depression (aOR=2.7). Among participants never on OAT, however, living in Kyiv (aOR=4.8) or Lviv (aOR=2.7), previous imprisonment (aOR=1.5), registration at a Narcology service (aOR=1.5) and recent overdose (aOR=2.6) were significantly correlated with willingness to initiate OAT. CONCLUSIONS These findings emphasize the need for developing interventions aimed to eliminate existing negative preconceptions regarding OAT among PWID with opioid use disorder in Ukraine, which should be tailored to meet the needs of specific characteristics of PWID in geographically distinct setting based upon injection frequency, prior incarceration, and psychiatric and HIV status.
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McLarty L, Becker M, Pavlova D, Isak S, Emmanuel F, Balakireva O, Bondar T, Sazonova Y, Sakovych O, Blanchard J. Characterizing HIV risk and vulnerability among commercial sex workers in Zaporizhzhya, Ukraine. ACTA ACUST UNITED AC 2016. [DOI: 10.15407/socium2016.01.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Podlekareva DN, Efsen AMW, Schultze A, Post FA, Skrahina AM, Panteleev A, Furrer H, Miller RF, Losso MH, Toibaro J, Miro JM, Vassilenko A, Girardi E, Bruyand M, Obel N, Lundgren JD, Mocroft A, Kirk O. Tuberculosis-related mortality in people living with HIV in Europe and Latin America: an international cohort study. Lancet HIV 2016; 3:e120-e131. [PMID: 26939735 DOI: 10.1016/s2352-3018(15)00252-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 12/11/2015] [Accepted: 12/14/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Management of tuberculosis in patients with HIV in eastern Europe is complicated by the high prevalence of multidrug-resistant tuberculosis, low rates of drug susceptibility testing, and poor access to antiretroviral therapy (ART). We report 1 year mortality estimates from a multiregional (eastern Europe, western Europe, and Latin America) prospective cohort study: the TB:HIV study. METHODS Consecutive HIV-positive patients aged 16 years or older with a diagnosis of tuberculosis between Jan 1, 2011, and Dec 31, 2013, were enrolled from 62 HIV and tuberculosis clinics in 19 countries in eastern Europe, western Europe, and Latin America. The primary endpoint was death within 12 months after starting tuberculosis treatment; all deaths were classified according to whether or not they were tuberculosis related. Follow-up was either until death, the final visit, or 12 months after baseline, whichever occurred first. Risk factors for all-cause and tuberculosis-related deaths were assessed using Kaplan-Meier estimates and Cox models. FINDINGS Of 1406 patients (834 in eastern Europe, 317 in western Europe, and 255 in Latin America), 264 (19%) died within 12 months. 188 (71%) of these deaths were tuberculosis related. The probability of all-cause death was 29% (95% CI 26-32) in eastern Europe, 4% (3-7) in western Europe, and 11% (8-16) in Latin America (p<0·0001) and the corresponding probabilities of tuberculosis-related death were 23% (20-26), 1% (0-3), and 4% (2-8), respectively (p<0·0001). Patients receiving care outside eastern Europe had a 77% decreased risk of death: adjusted hazard ratio (aHR) 0·23 (95% CI 0·16-0·31). In eastern Europe, compared with patients who started a regimen with at least three active antituberculosis drugs, those who started fewer than three active antituberculosis drugs were at a higher risk of tuberculosis-related death (aHR 3·17; 95% CI 1·83-5·49) as were those who did not have baseline drug-susceptibility tests (2·24; 1·31-3·83). Other prognostic factors for increased tuberculosis-related mortality were disseminated tuberculosis and a low CD4 cell count. 18% of patients were receiving ART at tuberculosis diagnosis in eastern Europe compared with 44% in western Europe and 39% in Latin America (p<0·0001); 12 months later the proportions were 67% in eastern Europe, 92% in western Europe, and 85% in Latin America (p<0·0001). INTERPRETATION Patients with HIV and tuberculosis in eastern Europe have a risk of death nearly four-times higher than that in patients from western Europe and Latin America. This increased mortality rate is associated with modifiable risk factors such as lack of drug susceptibility testing and suboptimal initial antituberculosis treatment in settings with a high prevalence of drug resistance. Urgent action is needed to improve tuberculosis care for patients living with HIV in eastern Europe. FUNDING EU Seventh Framework Programme.
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Affiliation(s)
- Daria N Podlekareva
- CHIP, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Anne Marie W Efsen
- CHIP, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anna Schultze
- Department of Infection and Population Health, University College London Medical School, London, UK
| | - Frank A Post
- Department of Sexual Health, King's College Hospital, London, UK
| | - Alena M Skrahina
- Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | | | - Hansjakob Furrer
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Robert F Miller
- Centre for Sexual Health and HIV Research, University College London, London, UK
| | - Marcelo H Losso
- Department of Immunocompromised, Hospital J M Ramos Mejia, Buenos Aires, Argentina
| | - Javier Toibaro
- Department of Immunocompromised, Hospital J M Ramos Mejia, Buenos Aires, Argentina
| | - Jose M Miro
- Infectious Diseases Service, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Anna Vassilenko
- Belarusian State Medical University, Minsk, Belarus; Department of Infectious Diseases, City Clinical Hospital of infectious Diseases, Minsk, Belarus
| | - Enrico Girardi
- Department of Infectious Diseases INMI "L. Spallanzani", Ospedale L Spallanzani, Rome, Italy
| | - Mathias Bruyand
- INSERM, ISPED, Centre Inserm U897-Epidemiologie-Biostatistique, Bordeaux, France
| | - Niels Obel
- Department of Infectious Diseases, Finsencentret, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens D Lundgren
- CHIP, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Amanda Mocroft
- Department of Infection and Population Health, University College London Medical School, London, UK
| | - Ole Kirk
- CHIP, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Polonsky M, Azbel L, Wickersham JA, Taxman FS, Grishaev E, Dvoryak S, Altice FL. Challenges to implementing opioid substitution therapy in Ukrainian prisons: Personnel attitudes toward addiction, treatment, and people with HIV/AIDS. Drug Alcohol Depend 2015; 148:47-55. [PMID: 25620732 PMCID: PMC4330127 DOI: 10.1016/j.drugalcdep.2014.12.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 12/07/2014] [Accepted: 12/07/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Ukraine is experiencing one of the most volatile HIV epidemics globally, fueled primarily by people who inject drugs (PWIDs), and a parallel incarceration epidemic. Opioid substitution therapy (OST) is internationally recognized as one of the most effective forms of treatment for opioid dependence and is among the most effective HIV prevention strategies available, yet efforts to adopt it in Ukraine's Criminal Justice System (CJS) have been thwarted. METHODS To understand the reluctance of the Ukrainian CJS to adopt OST despite the overwhelming evidence pointing to its health benefits and improved criminal justice outcomes, we conducted the first survey of Ukrainian prison administrative, medical and custodial staff (N=243) attitudes towards addiction in general, OST, and people living with HIV/AIDS (PLWHA) in representative regions of Ukraine. RESULTS Results revealed that Ukrainian CJS workers' attitudes toward OST, PLWHA, and drug addiction were universally negative, but differed substantially along geographic and occupational lines. Whereas geographic and cultural proximity to the European Union drove positive attitudes in the west, in the southern region we observed an identifiability effect, as workers who worked directly with prisoners held the most positive attitudes. We also found that knowledge mediated the effect of drug intolerance on OST attitudes. CONCLUSION In Ukraine, adoption of OST is more influenced by myths, biases and ideological prejudices than by existing scientific evidence. By elucidating existing attitudes among CJS personnel, this study will help to direct subsequent interventions to address the barriers to implementing evidence-based HIV prevention treatments.
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Affiliation(s)
- Maxim Polonsky
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA; Ukrainian Institute on Public Health Policy, Kiev, Ukraine.
| | - Lyuba Azbel
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA; Ukrainian Institute on Public Health Policy, Kiev, Ukraine
| | - Jeffrey A Wickersham
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | | | | | - Sergey Dvoryak
- Ukrainian Institute on Public Health Policy, Kiev, Ukraine
| | - Frederick L Altice
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA; Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, USA
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Filippovych S. Impact of armed conflicts and warfare on opioid substitution treatment in Ukraine: responding to emergency needs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2014; 26:3-5. [PMID: 25483411 DOI: 10.1016/j.drugpo.2014.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 11/06/2014] [Accepted: 11/11/2014] [Indexed: 12/22/2022]
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