Impact of armed conflicts and warfare on opioid substitution treatment in Ukraine: responding to emergency needs

Effects of a social network intervention on HIV seroconversion among people who inject drugs in Ukraine: moderation by network gender composition

BACKGROUND

Women who inject drugs in Ukraine are disproportionately burdened by HIV. To help address the needs of this population, a greater understanding of how interventions may uniquely benefit women who inject drugs is needed.

METHODS

Data come from a randomized controlled trial of a social network intervention targeting people who inject drugs in Ukraine (N = 1195). Indexes, plus two of their injection network members, received HIV testing and counseling (control arm) or HIV testing and counseling plus a social network intervention (intervention arm), in which indexes were trained to influence network members' risk behaviors. We used Cox regressions with interaction terms to assess differences in time to HIV seroconversion between arms by network gender composition and gender of the index. For significant interaction terms, we calculated simple effects, generated survival functions using Kaplan-Meier methods, and compared survival curves using log-rank tests.

RESULTS

At 12 months, there were 45 seroconversions among women (40.0 [28.3, 51.7] per 100 person years) and 111 among men (28.4 [23.1, 33.6] per 100 person years) in the control arm; there were 27 seroconversions among women (17.1 [10.7, 23.6] per 100 person years) and 77 among men (18.7 [14.5, 22.9] per 100 person years) in the intervention arm. Network gender composition (but not gender of the index) moderated the intervention effect on HIV incidence (p < 0.05). Specifically, the intervention appeared to be even more protective against HIV acquisition as female gender composition increased. In the intervention arm, the HIV seroconversion hazard rate was 44% lower with 1 network female; 61% lower with 2 network females; and 72% lower with 3 network females.

CONCLUSIONS

A greater number of women in an injection network, coupled with the provision of risk-reduction strategies, is associated with HIV risk-mitigation, though the mechanisms through which this occurs remain unclear. Findings can support new research and practice directions that prioritize women who inject drugs and more thoughtfully support their health and wellbeing.

Cross-sectional HIV and HCV cascades of care across the regions of Ukraine between 2019 and 2020: findings from the CARE cohort

INTRODUCTION

Eastern Europe is facing major HIV and hepatitis C (HCV) epidemics, with many people living with HIV (PLHIV) and HIV/HCV coinfection living in Ukraine. Despite the previous progress towards care quality improvement, the ongoing war in Ukraine is disrupting HIV and HCV care.

METHODS

We described an HIV cascade of care (CoC) in PLHIV from two clinical sites and an HCV CoC for anti-HCV-positive PLHIV from six sites in Ukraine, enrolled in the CARE cohort between 1 January 2019 and 1 June 2020. The cross-sectional HIV CoC and HCV CoC are described at study enrolment.

RESULTS

Of 1028 PLHIV, 1014 (98.6%, 95% confidence interval [CI] 97.7-99.3) were on antiretroviral therapy (ART), and 876 (86.4% of those on ART, 95% CI 84.1-88.4) were virologically suppressed. Of 894 participants on ART >6 months, 90.8% (95% CI 88.7-92.6) were virologically suppressed (HIV-RNA <200 copies/ml). Of 2040 anti-HCV-positive PLHIV, 417 (20.4%, 95% CI 18.7-22.3) were ever tested for HCV-RNA prior to enrolment, ranging from 4.9% to 54.4% across sites, and 13.5% were currently HCV-RNA positive. One hundred and eighteen persons (7.3% of ever chronically infected) had received HCV treatment, and 25 persons (1.6% of ever chronically infected) were cured, with variations across sites (0%-7.5%). The site diagnosing 54.4% of people with chronic HCV was the only one providing free RNA testing for all anti-HCV-positive persons, while the intra-country differences in treatment coverage were driven by the number of available direct-acting antiviral (DAA) courses.

CONCLUSIONS

Over 98% of PLHIV in care in both CARE sites in Ukraine were receiving ART, and the target of 90% virally suppressed was achieved in persons >6 months on ART. Only one of six HIV/HCV study sites tested over 50% anti-HCV-positive PLHIV for HCV-RNA and treated over 25% of eligible persons. While free HCV-RNA testing and DAA treatment are paramount to achieving HCV elimination targets, they remained a challenge in Ukraine in 2019-2020. The extent of the HIV and HCV care disruption during the war will be further assessed in the CARE cohort and compared with the pre-war findings.

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

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

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.

Assessing the influence of conflict on the dynamics of sex work and the HIV and HCV epidemics in Ukraine: protocol for an observational, ethnographic, and mathematical modeling study

BACKGROUND

Armed conflict erupted in eastern Ukraine in 2014 and still continues. This conflict has resulted in an intensification of poverty, displacement and migration, and has weakened the local health system. Ukraine has some of the highest rates of HIV and Hepatitis C (HCV) in Europe. Whether and how the current conflict, and its consequences, will lead to changes in the HIV and HCV epidemic in Ukraine is unclear. Our study aims to characterize how the armed conflict in eastern Ukraine and its consequences influence the pattern, practice, and experience of sex work and how this affects HIV and HCV rates among female sex workers (FSWs) and their clients.

METHODS

We are implementing a 5-year mixed methods study in Dnipro, eastern Ukraine. Serial mapping and size estimation of FSWs and clients will be conducted followed by bio-behavioral cross-sectional surveys among FSWs and their clients. The qualitative component of the study will include in-depth interviews with FSWs and other key stakeholders and participant diaries will be implemented with FSWs. We will also conduct an archival review over the course of the project. Finally, we will use these data to develop and structure a mathematical model with which to estimate the potential influence of changes due to conflict on the trajectory of HIV and HCV epidemics among FSW and clients.

DISCUSSION

The limited data that exists on the effect of conflict on disease transmission provides mixed results. Our study will provide rigorous, timely and context-specific data on HIV and HCV transmission in the setting of conflict. This information can be used to inform the design and delivery of HIV and HCV prevention and care services.

Challenges and opportunities for implementation of substance misuse interventions in conflict-affected populations

Alcohol and other drug misuse are significant but neglected public health issues in conflict-affected populations. In this article, we review the literature on the challenges and strategies for implementing substance misuse treatment and prevention services in conflict and post-conflict settings in low- and middle-income countries. We identified nine studies describing interventions in conflict-affected populations residing in Afghanistan, Croatia, India, Kenya, Kosovo, Pakistan, and Thailand. Six of these nine studies focused on refugee populations. Reports revealed challenges to intervention implementation, as well as promising practices and recommendations for future implementation that we characterized as existing in the inner and outer contexts of an implementing organization. Challenges existing in the outer context included low political prioritization, lack of coordination and integration, and limited advocacy for access to substance misuse services. Challenges within the inner context related to competing priorities and a shortage of providers. Resource limitations existed in both the inner and outer contexts. Stigma was a challenge that threatened implementation and utilization of substance use services in situations when substance use interventions were not congruent with the roles, structure, values, and authority of the system or implementing organization. Future research should focus on developing, applying, and evaluating strategies for overcoming these challenges in order to make progress toward meeting the need for substance misuse services in conflict-affected populations.

Molecular epidemiology reveals the role of war in the spread of HIV in Ukraine

Ukraine has one of the largest HIV epidemics in Europe, historically driven by people who inject drugs (PWID). The epidemic showed signs of stabilization in 2012, but the recent war in eastern Ukraine may be reigniting virus spread. We investigated the movement of HIV-infected people within Ukraine before and during the conflict. We analyzed HIV-1 subtype-A pol nucleotide sequences sampled during 2012-2015 from 427 patients of 24 regional AIDS centers and used phylogeographic analysis to reconstruct virus movement among different locations in Ukraine. We then tested for correlations between reported PWID behaviors and reconstructed patterns of virus spread. Our analyses suggest that Donetsk and Lugansk, two cities not controlled by the Ukrainian government in eastern Ukraine, were significant exporters of the virus to the rest of the country. Additional analyses showed that viral dissemination within the country changed after 2013. Spearman correlation analysis showed that incoming virus flow was correlated with the number of HIV-infected internally displaced people. Additionally, there was a correlation between more intensive virus movement and locations with a higher proportion of PWID practicing risky sexual behaviors. Our findings suggest that effective prevention responses should involve internally displaced people and people who frequently travel to war-affected regions. Scale-up of harm reduction services for PWID will be an important factor in preventing new local HIV outbreaks in Ukraine.

Crisis management by HIV/AIDS non-governmental organisations in the post-Euromaidan Ukraine led to opening new horizons

Purpose

Civil society played a significant role during and after the 2014 revolution in Ukraine, which led to the resignation of President Yanukovich and his government and triggered a series of political, economic and social changes. In some areas, particularly by HIV and tuberculosis, the critical gaps threatened the emergence of a public health catastrophe. The purpose of this paper is to describe how civil society expands and strengthens its role in complex crisis situations, self-regulating and re-adjusting own aims and strategy by using the case of non-governmental organisations (NGOs) active in HIV prevention in high-risk groups and harm reduction.

Design/methodology/approach

The paper presents the analysis of the case of Alliance of Public Health, one of the principal recipients of the Global Fund to Fight Tuberculosis, AIDS and Malaria in 2014-2016, during and after the Euromaidan Revolution in Ukraine.

Findings

In the post-Euromaidan era, NGO sector has been able to sustain the response to the HIV/AIDS epidemic at a stable level despite significant limitations of resources and the overall fragile situation. Special efforts have been undertaken to continue activities in the conflict zone in the east of the country. Furthermore, NGOs managed to extend beyond their usual responsibilities, bridging the gaps in deteriorating public health and social systems, including taking the leadership in medical procurement; advocating for national plans development; and supplying medical goods to the uncontrolled territories in the east of the country.

Originality/value

This paper is one of the first exploring the role of non-governmental sector in HIV/AIDS programmes in resource-scarce situation of political, social and economic crisis. Case description of the strategies and activities applied in the situation gives the possibility to reflect on raising the effectiveness of the response to existing and emerging public health issues in complex crisis, as well on the potential for HIV/AIDS prevention and treatment advocacy to grow into global health diplomacy.

In Their Own Voices: Breaking the Vicious Cycle of Addiction, Treatment and Criminal Justice Among People who Inject Drugs in Ukraine

AIMS

To understand how perceived law enforcement policies and practices contribute to the low rates of utilization of opioid agonist therapies (OAT) among people who inject drugs (PWIDs) in Ukraine.

METHODS

Qualitative data from 25 focus groups (FGs) with 199 opioid-dependent PWIDs in Ukraine examined domains related to lived or learned experiences with OAT, police, arrest, incarceration, and criminal activity were analyzed using grounded theory principles.

FINDINGS

Most participants were male (66%), in their late 30s, and previously incarcerated (85%) mainly for drug-related activities. When imprisoned, PWIDs perceived themselves as being "addiction-free". After prison-release, the confluence of police surveillance, societal stress contributed to participants' drug use relapse, perpetuating a cycle of searching for money and drugs, followed by re-arrest and re-incarceration. Fear of police and arrest both facilitated OAT entry and simultaneously contributed to avoiding OAT since system-level requirements identified OAT clients as targets for police harassment. OAT represents an evidence-based option to 'break the cycle', however, law enforcement practices still thwart OAT capacity to improve individual and public health.

CONCLUSION

In the absence of structural changes in law enforcement policies and practices in Ukraine, PWIDs will continue to avoid OAT and perpetuate the addiction cycle with high imprisonment rates.

Drug Treatment as HIV Prevention Among Women and Girls Who Inject Drugs From a Global Perspective: Progress, Gaps, and Future Directions

Although there have been significant reductions in the number of new HIV infections globally from 2009 to 2013, incidence remains unacceptably high for persons who use drugs. In many settings, women and girls who inject drugs (WWID) with HIV/AIDS experience poor treatment access, including evidence-based practices like antiretroviral therapy and drug treatment. Medication-assisted therapies (MAT) for substance use disorders are especially inaccessible, which in their absence, increases HIV transmission risk. Irrespective of setting or culture, drug treatment using MAT is not only effective but also cost-effective at reducing opioid use and linked injection and sexual risks. Data presented here for WWID address their access to MAT for opioid addiction and to treatments being developed that address the relationship, family, and vocational needs of this group. The most glaring finding is that globally, WWID frequently are excluded in surveys or studies with an impressive lack of disaggregated data by gender when surveying access to MAT—even in wealthy countries. Despite this, there have been some striking improvements in implementing drug treatment as prevention, notably in Iran and China. Still, real barriers remain for women and girls to accessing drug treatment, other harm reduction services, and antiretroviral therapy. Development and/or implementation of interventions that facilitate women and girls engaging in drug treatment that address their roles within society, work, and family/relationships, and outcome evaluation of these interventions are crucial.