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Smith LR, Perez-Brumer A, Nicholls M, Harris J, Allen Q, Padilla A, Yates A, Samore E, Kennedy R, Kuo I, Lake JE, Denis C, Goodman-Meza D, Davidson P, Shoptaw S, El-Bassel N. A data-driven approach to implementing the HPTN 094 complex intervention INTEGRA in local communities. Implement Sci 2024; 19:39. [PMID: 38831415 PMCID: PMC11149235 DOI: 10.1186/s13012-024-01363-x] [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: 12/11/2023] [Accepted: 04/22/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND HIV burden in the US among people who inject drugs (PWID) is driven by overlapping syndemic factors such as co-occurring health needs and environmental factors that synergize to produce worse health outcomes among PWID. This includes stigma, poverty, and limited healthcare access (e.g. medication to treat/prevent HIV and for opioid use disorder [MOUD]). Health services to address these complex needs, when they exist, are rarely located in proximity to each other or to the PWID who need them. Given the shifting drug use landscapes and geographic heterogeneity in the US, we evaluate a data-driven approach to guide the delivery of such services to PWID in local communities. METHODS We used a hybrid, type I, embedded, mixed method, data-driven approach to identify and characterize viable implementation neighborhoods for the HPTN 094 complex intervention, delivering integrated MOUD and HIV treatment/prevention through a mobile unit to PWID across five US cities. Applying the PRISM framework, we triangulated geographic and observational pre-implementation phase data (epidemiological overdose and HIV surveillance data) with two years of implementation phase data (weekly ecological assessments, study protocol meetings) to characterize environmental factors that affected the viability of implementation neighborhoods over time and across diverse settings. RESULTS Neighborhood-level drug use and geographic diversity alongside shifting socio-political factors (policing, surveillance, gentrification) differentially affected the utility of epidemiological data in identifying viable implementation neighborhoods across sites. In sites where PWID are more geographically dispersed, proximity to structural factors such as public transportation and spaces where PWID reside played a role in determining suitable implementation sites. The utility of leveraging additional data from local overdose and housing response systems to identify viable implementation neighborhoods was mixed. CONCLUSIONS Our findings suggest that data-driven approaches provide a contextually relevant pragmatic strategy to guide the real-time implementation of integrated care models to better meet the needs of PWID and help inform the scale-up of such complex interventions. This work highlights the utility of implementation science methods that attend to the impact of local community environmental factors on the implementation of complex interventions to PWID across diverse drug use, sociopolitical, and geographic landscapes in the US. TRIAL REGISTRATION ClincalTrials.gov, Registration Number: NCT04804072 . Registered 18 February 2021.
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Affiliation(s)
- Laramie R Smith
- School of Medicine, University of California San Diego, 9500 Gilman Drive #0507, La Jolla, CA, 92093-0507, USA.
| | - Amaya Perez-Brumer
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Melanie Nicholls
- School of Social Work, San Diego State University, San Diego, USA
| | - Jayla Harris
- HIV Prevention Trials Network, Family Health International 360, Durham, USA
| | - Qiana Allen
- UTHealth Houston McGovern School of Medicine, Houston, USA
| | - Alan Padilla
- Columbia University, ICAP, Mailman School of Public Health, New York, USA
| | - Autumn Yates
- George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Eliza Samore
- Center for Behavioral and Addiction Medicine at UCLA, Los Angeles, USA
| | - Rebecca Kennedy
- School of Medicine, University of California San Diego, 9500 Gilman Drive #0507, La Jolla, CA, 92093-0507, USA
| | - Irene Kuo
- George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Jordan E Lake
- UTHealth Houston McGovern School of Medicine, Houston, USA
| | - Cecile Denis
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
| | | | - Peter Davidson
- School of Medicine, University of California San Diego, 9500 Gilman Drive #0507, La Jolla, CA, 92093-0507, USA
| | - Steve Shoptaw
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, USA
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Mazhnaya A, Kiriazova T, Chernova O, Tobin K, Owczarzak J. ``Now it is mostly done through stashes, to do it in person one has to trust you'': Understanding the retail injection drug market in Dnipro, Ukraine. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 87:102988. [PMID: 33129134 PMCID: PMC7940550 DOI: 10.1016/j.drugpo.2020.102988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/03/2020] [Accepted: 10/06/2020] [Indexed: 11/19/2022]
Abstract
Little research has been conducted in Ukraine since the 1990s to understand the organization of drug market and its implications for people who inject drugs (PWID). In this study, we explore how PWID perceive the retail drug market in a large Ukrainian city. Qualitative data were obtained during in-depth interviews and analyses included open coding, coding tree development and revision, axial coding, and identification of higher-level domains. Participants' narratives focused on types and forms of drugs available, perceptions about drug quality, methods of buying drugs, and the relationships that are formed and maintained by participating in the drug economy. The described technical organization of the drug market, with multiple contingent combinations of drug types, forms and means of obtaining drugs (hand-to-hand vs stash-based) resulted from diversification and digitalization of the retail injection drug market. The social organization of the drug market in the form of relationships with sellers and drug use partners represented the response to the fundamental problem of uncertainty. The lens of ``transaction cost'' helps explain strategies PWID used to manage uncertainties, including finding reliable and suitable sellers, sending money and picking up the stash under the threat of being stiffed or caught by the police, choosing the product itself, using the intermediaries to outsource risky operations and forming groups to procure and inject together. Our results indicate that the technical and social organization of drug distribution in Ukraine stimulates formation and continuation of relationships and impacts the choices of what, how, and when to inject beyond individual preferences. The policy and practice implications include the need to monitor and understand the retail drug market to develop and deliver more efficient and client-oriented services, incorporate and leverage social networks structure for information sharing and behavior change, pilot and implement drug testing services to assist with management of uncertainties.
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Affiliation(s)
- Alyona Mazhnaya
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, USA.
| | - Tetiana Kiriazova
- Ukrainian Institute on Public Health Policy, 5 Biloruska Street, Kyiv 04050, Ukraine
| | - Olena Chernova
- Ukrainian Institute on Public Health Policy, 5 Biloruska Street, Kyiv 04050, Ukraine
| | - Karin Tobin
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, USA
| | - Jill Owczarzak
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, USA
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Owczarzak J, Nguyen TQ, Mazhnaya A, Phillips SD, Filippova O, Alpatova P, Zub T, Aleksanyan R. Outcome evaluation of a "common factors" approach to develop culturally tailored HIV prevention interventions for people who inject drugs. Drug Alcohol Depend 2019; 199:18-26. [PMID: 30981045 PMCID: PMC6537906 DOI: 10.1016/j.drugalcdep.2019.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 02/05/2019] [Accepted: 02/07/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Current models of HIV prevention intervention dissemination involve packaging interventions developed in one context and training providers to implement that specific intervention with fidelity. Providers rarely implement these programs with fidelity due to perceived incompatibility, resource constraints, and preference for locally-generated solutions. Moreover, such interventions may not reflect local drug markets and drug use practices that contribute to HIV risk. PURPOSE This paper examines whether provider-developed interventions based on common factors of effective, evidence-based behavioral interventions led to reduction in drug-related HIV risk behaviors at four study sites in Ukraine. METHODS We trained staff from eight nongovernmental organizations (NGOs) to develop HIV prevention interventions based on a common factors approach. We then selected four NGOs to participate in an outcome evaluation. Each NGO conducted its intervention for at least N = 130 participants, with baseline and 3-month follow-up assessments. RESULTS At three sites, we observed reductions in the prevalence of both any risk in drug acquisition and any risk in drug injection. At the fourth site, prevalence of any risk in drug injection decreased substantially, but the prevalence of any risk in drug acquisition essentially stayed unchanged. CONCLUSIONS The common factors approach has some evidence of efficacy in implementation, but further research is needed to assess its effectiveness in reducing HIV risk behaviors and transmission. Behavioral interventions to reduce HIV risk developed using the common factors approach could become an important part of the HIV response in low resource settings where capacity building remains a high priority.
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Affiliation(s)
- J Owczarzak
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Hampton House Room 739, Baltimore, MD, 21205-1996, USA; Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, Medical College of Wisconsin, 2071 North Summit Ave, Milwaukee, WI, 53202, USA
| | - TQ Nguyen
- Departments of Mental Health and Biostatistics, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Hampton House 800, Baltimore, MD, 21205, USA; Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, Medical College of Wisconsin, 2071 North Summit Ave, Milwaukee, WI, 53202, USA
| | - A Mazhnaya
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205-1996, USA; Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, Medical College of Wisconsin, 2071 North Summit Ave, Milwaukee, WI, 53202, USA
| | - SD Phillips
- Department of Anthropology, Indiana University, Student Building 130, 701 E. Kirkwood Ave, Bloomington, IN, 47405, USA
| | - O Filippova
- Department of Sociology, V.N. Karazin Kharkiv National University, 6 Svobody Sq, Office 351, Kharkiv, Ukraine
| | - P Alpatova
- Institute of Social-Humanitarian Research, V.N. Karazin Kharkiv National University, 6 Svobody Sq, Office 351, Kharkiv, Ukraine
| | - T Zub
- Department of Sociology, V.N. Karazin Kharkiv National University, 6 Svobody Sq, Office 351, Kharkiv, Ukraine
| | - R Aleksanyan
- Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, Medical College of Wisconsin, 2071 North Summit Ave, Milwaukee, WI, 53202, USA
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Owczarzak J, Phillips SD, Cho W. 'Pure' drug users, commercial sex workers and 'ordinary girls': gendered narratives of HIV risk and prevention in post-Soviet Ukraine. CULTURE, HEALTH & SEXUALITY 2018; 20:1171-1184. [PMID: 29417879 PMCID: PMC6082725 DOI: 10.1080/13691058.2017.1421708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
International best practices call for a gender-responsive approach to HIV prevention for women, including those who use drugs and those who engage in sex work. This paper draws on multiple qualitative data sources collected over five years in Ukraine to explore the notions of gender, women and family that buttress HIV-related programmes for women. Our analysis reveals that service providers often cast women as hapless victims of unfortunate family circumstances and troubled personal relationships that produce sudden poverty, or social strivers who seek access to wealth and privilege at the expense of their health. Women are portrayed as most vulnerable to HIV when they lack a male 'protector'. We argue that the programmes constituted around these stereotypes of women and their vulnerabilities reflect new forms of institutional power that deflect attention away from gendered socio-economic processes that contribute to women's HIV vulnerability, including job insecurity and unemployment, workplace discrimination, unreliable social benefits and power imbalances within their relationships. We explore how to transform HIV prevention efforts to better address the causes of women's increased vulnerability to HIV in Ukraine and in Eastern Europe more generally.
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Affiliation(s)
- Jill Owczarzak
- Department of Health, Behavior and Society, Johns Hopkins School of Public Health, Baltimore, USA
| | | | - Woojeong Cho
- Department of Anthropology, Indiana University, Bloomington, USA
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Mazhnaya A, Tobin KE, Owczarzak J. Association between injection in public places and HIV/HCV risk behavior among people who use drugs in Ukraine. Drug Alcohol Depend 2018; 189:125-130. [PMID: 29913323 DOI: 10.1016/j.drugalcdep.2018.04.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 04/28/2018] [Accepted: 04/30/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND In Eastern Europe and Central Asia new HIV infections occur at a high rate among people who inject drugs (PWID). Injection risk behavior may be associated with injecting in public places. However, there is a lack of studies exploring this association in Ukraine, which has an HIV prevalence 21-42% among PWID. METHODS Data came from a baseline survey of PWID recruited to participate in a behavioral HIV prevention intervention. The association between HIV/HCV injection risk behavior and place of injection (private vs. public) was assessed using multivariable Poisson regression with robust variance estimate. RESULTS Most of the sample was male (73%), > 30 years (56%), and reported opioids as their drug of choice (55%). One in six participants (15.8%, n = 57) reported using a syringe after somebody, and 70% (n = 253) reported injecting in public places within last 30-days. In the adjusted model, injection risk behavior was associated with injecting in public places (PrR: 4.24, 95% CI: 1.76-10.20), unstable housing situation (PrR: 2.46, 95% CI:1.26-4.83), higher than secondary education (PrR:1.82, 95%CI:1.04-3.16), injecting with a sex partner day (PrR:2.13, 95% CI:1.28-3.56), and injecting with a stranger (PrR: 1.47, 95% CI: 0.93-2.31). CONCLUSIONS Injecting in a public place is associated with increased prevalence of risky behavior. Therefore, understanding and addressing place-based context should be part of the national strategy to fight HIV and HCV in Ukraine. National programs would benefit from expanding models to include contextual and structural determinants of health.
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Affiliation(s)
- Alyona Mazhnaya
- Department of Health, Behavior, and Society, Johns Hopkins School of Public Health, 624 N Broadway, Baltimore, MD, 21205, USA.
| | - Karin E Tobin
- Department of Health, Behavior, and Society, Johns Hopkins School of Public Health, 624 N Broadway, Baltimore, MD, 21205, USA.
| | - Jill Owczarzak
- Department of Health, Behavior, and Society, Johns Hopkins School of Public Health, 624 N Broadway, Baltimore, MD, 21205, USA.
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Dumchev K. Imported "Evidence-Based" or Locally Grown Interventions: A False Dichotomy and Some Hard Choices in Implementation Science. Subst Use Misuse 2015; 50:1092-6. [PMID: 25775382 DOI: 10.3109/10826084.2015.1007755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
When public health programs are expanding to new areas or territories, it is often recommended by policy-makers and donors that existing evidence-based practices (EBPs) are to be adapted and implemented. While rationale behind this approach is understandable, proper adaptation to culturally different settings may be no less intensive than development of a new intervention based on the local context. A narrow understanding of implementation science concept may lead to overlooking valuable indigenous practices, which may be summarized into effective and potentially more sustainable models. This paper examines from practical standpoint the process and common caveats in cross-cultural adaptation of EPBs and argues for closer attention to available local experiences.
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