“Bureaucracy & Beliefs”: Assessing the Barriers to Accessing Opioid Substitution Therapy by People Who Inject Drugs in Ukraine

Aims

Opioid substitution therapy (OST) is an evidence-based HIV prevention strategy for people who inject drugs (PWIDs). Yet, only 2.7% of Ukraine’s estimated 310,000 PWIDs receive it despite free treatment since 2004. The multi-level barriers to entering OST among opioid dependent PWIDs have not been examined in Ukraine.

Methods

A multi-year mixed methods implementation science project included focus group discussions with 199 PWIDs in 5 major Ukrainian cities in 2013 covering drug treatment attitudes and beliefs and knowledge of and experiences with OST. Data were transcribed, translated into English and coded. Coded segments related to OST access, entry, knowledge, beliefs and attitudes were analyzed among 41 PWIDs who were eligible for but had never received OST.

Findings

A number of programmatic and structural barriers were mentioned by participants as barriers to entry to OST, including compulsory drug user registration, waiting lists, and limited number of treatment slots. Participants also voiced strong negative attitudes and beliefs about OST, especially methadone. Their perceptions about methadone’s side effects as well as the stigma of being a methadone client were expressed as obstacles to treatment.

Conclusions

Despite expressed interest in treatment, Ukrainian OST-naïve PWIDs evade OST for reasons that can be addressed through changes in program-level and governmental policies and social-marketing campaigns. Voiced OST barriers can effectively inform public health and policy directives related to HIV prevention and treatment in Ukraine to improve evidence-based treatment access and availability.

Full article at:   http://goo.gl/53ASEL

By:  Martha J. Bojko,1 Alyona Mazhnaya,2 Iuliia Makarenko,3 Ruthanne Marcus,1 Sergii Dvoriak,3 Zahedul Islam,2 andFrederick L. Altice1,4

¹Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut, USA

²ICF International HIV/AIDS Alliance in Ukraine, Kyiv, Ukraine

³Ukrainian Institute for Public Health Policy, Kyiv, Ukraine

⁴Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, Connecticut, USA

Correspondence: Martha J Bojko, PhD, Yale University School of Medicine, Department of Internal Medicine, Section of Infectious Diseases - AIDS Program, 135 College St., Suite 323, New Haven, CT 06510-2483, Mobile (U.S.): +1 (860) 729 04 80, Mobile (Ukraine): +38 (050) 723 15 53

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Prevalence of Depressive Symptoms in Pregnant & Postnatal HIV-Positive Women in Ukraine

BACKGROUND:

Perinatal depression among HIV-positive women has negative implications for HIV-related and other maternal and infant outcomes. The aim of this study was to investigate the burden and correlates of perinatal depression among HIV-positive women in Ukraine, a lower middle income country with one of the largest HIV-positive populations in Europe.

METHODS:

Cross-sectional surveys nested within the Ukraine European Collaborative Study were conducted of HIV-positive women at delivery and between 1 and 12 months postpartum. Depressive symptoms in the previous month were assessed using a self-report screening tool. Other data collected included demographics, antiretroviral therapy (ART)-related self-efficacy, and perceptions of risks/benefits of interventions to prevent mother-to-child transmission (PMTCT). Characteristics of women with and without a positive depression screening test result were compared using Fisher's exact test and χ(2) test for categorical variables.

RESULTS:

A quarter (27 % (49/180) antenatally and 25 % (57/228) postnatally) of participants screened positive for depressive symptoms. Antenatal risk factors were living alone (58 % (7/12) vs 25 % (42/167), being somewhat/terribly bothered by ART side effects (40 % (17/43) vs 23 % (30/129) not /only slightly bothered, p = 0.05) and having lower ART-related self-efficacy (43 % (12/28) vs 23 % (25/110) with higher self-efficacy, p = 0.05). 

Postnatally, single mothers were more likely to screen positive (44 % (20/45) vs 21 % (18/84) of cohabiting and 19 % (19/99) of married women, p < 0.01) as were those unsure of the effectiveness of neonatal prophylaxis (40 % (20/45) vs 18 % (28/154) sure of effectiveness, p < 0.01), those worried that neonatal prophylaxis could harm the baby (30 % (44/146) vs 14 % (10/73) not worried p < 0.01) and those not confident to ask for help with taking ART (48 % (11/23) vs 27 % (10/37) fairly confident and 15 % (4/26) confident that they could do this). 

Of women who reported wanting help for their depressive symptoms, 82 % (37/45) postnatally but only 31 % (12/39) antenatally were already accessing peer counselling, treatment adherence programmes, support groups or social services.

CONCLUSIONS:

A quarter of women screened positive for depression. Results highlight the need for proactive strategies to identify depressive symptoms, and an unmet need for provision of mental health support in the perinatal period for HIV-positive women in Ukraine.

Below:  Responses to three depression screening questions

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By:  Bailey H1, Malyuta R2, Semenenko I2, Townsend CL3, Cortina-Borja M3, Thorne C3; Ukraine European Collaborative Study in EuroCoord.

• 1Population, Policy and Practice Programme, UCL Institute of Child Health, University College London, London, UK. heather.bailey@ucl.ac.uk.
• 2Perinatal Prevention of AIDS Initiative, Odessa, Ukraine.
• 3UCL Institute of Child Health, University College London, London, UK.

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Attitudes Toward Addiction, Methadone Treatment, and Recovery among HIV-Infected Ukrainian Prisoners Who Inject Drugs: Incarceration Effects and Exploration of Mediators

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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By:  Polonsky M1, Rozanova J2, Azbel L3, Bachireddy C4, Izenberg J5, Kiriazova T6, Dvoryak S6, Altice FL2,7,8.

• 1Section of Infectious Diseases, Yale University School of Medicine, 135 College St. Suite 323, New Haven, CT, 06510-2283, USA. maxim.polonsky@yale.edu.
• 2Section of Infectious Diseases, Yale University School of Medicine, 135 College St. Suite 323, New Haven, CT, 06510-2283, USA.
• 3London School of Hygiene and Tropical Medicine, London, UK.
• 4Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
• 5Department of Psychiatry, University of California San Francisco School of Medicine, San Francisco, CA, USA.
• 6Ukrainian Institute on Public Health Policy, Kiev, Ukraine.
• 7Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA.
• 8University of Malaya, Centre of Excellence on Research in AIDS (CERiA), Kuala Lumpur, Malaysia. 
• AIDS Behav. 2016 Mar 24.

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HIV Reduction among Women Who Inject Drugs Can Be Achieved Through Women-Specific Programs and Global Targets: A Model from Ukraine

The International HIV/AIDS Alliance in Ukraine (Alliance) is one of the largest harm reduction programs in the world, and it has been working toward increased coverage of women who inject drugs. In 2009, Alliance supported harm reduction interventions for 150,815 PWID annually (about half the total estimated 2009 PWID population in Ukraine).^3,4 In 2009, Alliance set targets for reaching 60% of PWID and specifically of women who inject drugs. Alliance has used various measures to increase service availability and access for women, who inject drugs throughout Ukraine, including the following: 

• Extension of the minimal harm reduction package of services (which initially included needle and condom distribution, education and counseling, and rapid testing for HIV) to include screening and treatment for sexually transmitted infections through rapid tests for syphilis, gonorrhea, and chlamydia, pregnancy test distribution, and distribution of disinfectants to those involved into sex work. For hardest-to-reach populations, mobile clinics have been procured and equipped with gynecological chairs to allow examination and rapid testing 
• Peer-driven intervention (PDI), a chain-referral model, which includes education and recruitment through outreach. PDI gives PWID per-task nominal rewards to perform the core activities that outreach employees perform—at less expense and greater effectiveness. Alliance Ukraine specifically targeted women who inject drugs as priority group for the PDI intervention to increase coverage of women who inject drugs⁵ 
• Providing economic opportunities for women. Women who used drugs were provided with training and employment opportunities, such as beauty courses, opening of hairdressing practices, etc.
• Introduction of gender-sensitive approaches, such as women-focused outreach and counseling (which considered sex and gender aspects of addiction), structured training activities (educational sessions specifically for women who inject drugs), short-term childcare provided by social workers, case-management (designated time slots for women who inject drugs, group meetings for volunteers from among women who inject drugs and women drug users, counseling by specialists including gynecologists and lawyers), and gender-sensitive organizational policies.⁶

Full article at:   http://goo.gl/lJh3L7

By:   Deshko, Tetiana PhD

International Technical Support Hub, International HIV/AIDS Alliance in Ukraine, Kyiv, Ukraine.

Correspondence to: Tetiana Deshko, PhD, 5 Dymytrova st., building 10A 9th floor, 03680, Kyiv, Ukraine. Tel.: +380 50 387 16 14 (e-mail: deshko@aidsalliance.org.ua).

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Within-Prison Drug Injection among HIV-Infected Ukrainian Prisoners: Prevalence & Correlates of an Extremely High-Risk Behavior

BACKGROUND:

In Ukraine, HIV-infection, injection drug use, and incarceration are syndemic; however, few services are available to incarcerated people who inject drugs (PWIDs). While data are limited internationally, within-prison drug injection (WP-DI) appears widespread and may pose significant challenges in countries like Ukraine, where PWIDs contribute heavily to HIV incidence. To date, WP-DI has not been specifically examined among HIV-infected prisoners, the only persons that can transmit HIV.

METHODS:

A convenience sample of 97 HIV-infected adults recently released from prison within 1-12 months was recruited in two major Ukrainian cities. Post-release surveys inquired about WP-DI and injection equipment sharing, as well as current and prior drug use and injection, mental health, and access to within-prison treatment for HIV and other comorbidities. Logistic regression identified independent correlates of WP-DI.

RESULTS:

Complete data for WP-DI were available for 95 (97.9%) respondents. Overall, 54 (56.8%) reported WP-DI, among whom 40 (74.1%) shared injecting equipment with a mean of 4.4 (range 0-30) other injectors per needle/syringe. Independent correlates of WP-DI were recruitment in Kyiv (AOR 7.46, p=0.003), male gender (AOR 22.07, p=0.006), and active pre-incarceration opioid use (AOR 8.66, p=0.005).

CONCLUSIONS:

Among these recently released HIV-infected prisoners, WP-DI and injection equipment sharing were frequent and involved many injecting partners per needle/syringe. The overwhelming majority of respondents reporting WP-DI used opioids both before and after incarceration, suggesting that implementation of evidence-based harm reduction practices, such as opioid substitution therapy and/or needle/syringe exchange programmes within prison, is crucial to addressing continuing HIV transmission among PWIDs within prison settings. The positive correlation between Kyiv site and WP-DI suggests that additional structural interventions may be useful.

Below:  Overview of injection behaviour before incarceration, within prison, and in the last thirty days

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By:   Izenberg JM1, Bachireddy C1, Wickersham JA1, Soule M1, Kiriazova T2, Dvoriak S3, Altice FL4.

• 1Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA.
• 2Future Without AIDS Foundation, Odessa, Ukraine; Ukrainian Institute on Public Health Policy, Kyiv, Ukraine.
• 3Ukrainian Institute on Public Health Policy, Kyiv, Ukraine.
• 4Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, USA. Electronic address: frederick.altice@yale.edu. 

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Pregnancy Outcomes in HIV-Positive Women in Ukraine, 2000-12 (European Collaborative Study In Eurocoord): An Observational Cohort Study

Women living with HIV are potentially at increased risk of adverse pregnancy outcomes, due to a range of factors, including immunosuppression, use of combination antiretroviral therapy (ART), and injecting drug use. Rates of mother-to-child transmission of HIV in Ukraine have declined to around 2-4%, but little is known about other pregnancy outcomes in this setting. We used data from an observational prospective cohort study to assess pregnancy outcomes among HIV-positive women in Ukraine.

The European Collaborative Study (ECS) in EuroCoord is a continuing cohort study, established in Ukraine in 2000. Eligible women are those with a diagnosis of HIV infection before or during pregnancy (including intrapartum) who deliver liveborn babies at seven sites. Maternal sociodemographic, HIV-related, and delivery (mother and infant) data were collected with study-specific questionnaires. We used Poisson regression models to identify factors associated with preterm delivery (before 37 weeks' gestation) and small weight for gestational age (less than the tenth percentile of weight for gestational age), based on complete cases.

Between January, 2000, and July, 2012, data were collected on 8884 HIV-positive mother and liveborn infant pairs. Median maternal age was 26·5 years (IQR 23·1-30·3). 832 (11%) women had WHO stage 3 or 4 HIV and 1474 (17%) had a history of injecting drug use. 7348 (83%) had received antenatal ART. Among 7435 for whom ART type was available, 4396 (50%) had received zidovudine monotherapy and 2949 (33%) combination ART. Preterm delivery was seen in 780 (9%, 95% CI 8-9) of 8860 births overall and in 77 (9%, 7-11) of 889 babies with small size for gestational age. Factors associated with preterm delivery were history of injecting drug use (adjusted risk ratio 1·64, 95% CI 1·38-1·95), no ART (2·94, 2·43-3·57 vs zidovudine monotherapy), antenatal combination ART (1·40, 1·14-1·73 vs zidovudine monotherapy), WHO stage 4 HIV (2·42, 1·71-3·41 vs WHO stage 1), and being in the most socially deprived group (1·38, 1·11-1·71). Small size for gestational age was associated with history of injecting drug use (adjusted RR 1·39, 95% CI 1·16-1·65), most socially deprived (1·32, 1·09-1·61), no ART (1·60, 1·32-1·94 vs zidovudine monotherapy), and antenatal combination ART (1·33, 1·12-1·60 vs zidovudine monotherapy).

Some risk factors for adverse pregnancy outcomes were directly associated with HIV and treatment and others were shared with the general antenatal population. Monitoring of pregnancy outcomes in Ukraine will be important as use of antenatal combination ART increases.

Via: http://goo.gl/jeSMZG  Purchase full article at: http://goo.gl/loqS9k

By: Bagkeris E1, Malyuta R2, Volokha A3, Cortina-Borja M1, Bailey H1, Townsend CL1, Thorne C4; Ukraine European Collaborative Study in EuroCoord.

• 1Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK.
• 2Perinatal Prevention of AIDS Initiative, Odessa, Ukraine.
• 3Shupyk National Medical Academy of Postgraduate Education, Kiev, Ukraine.
• 4Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK.  

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Sex, Drugs and Prisons: HIV Prevention Strategies for Over 190 000 Clients in Ukraine

One hundred and forty non-governmental organisations implementing human immunodeficiency virus (HIV) prevention programmes among clients, including people who inject drugs, prisoners, female sex workers, men who have sex with men and street children in Ukraine, 2010–2011.

Among enrolled clients, to assess factors associated with HIV testing, HIV retesting within a year of initial testing and HIV seroconversion.

Of 192 487 clients, 42 109 (22%) underwent an initial HIV test (22% were positive). Among HIV-negative clients at baseline, 10 858 (27%) were retested within a year: 317 (3%) of these were HIV-positive. HIV testing and retesting rates were lower among prisoners (0.3%) and others (street children and partners of those in risk groups, 6%), and those who did not receive counselling or services such as condom and needle distribution. Individuals who were not counselled were more likely to seroconvert.

In this large cohort of high-risk groups from Eastern Europe, HIV testing was low and HIV sero-conversion was high. This is of public health concern, bringing into question the overall quality of counselling and how well it is tailored to the specific needs of various risk groups. Qualitative studies to understand the reasons for non-testing are urgently required for designing client-specific interventions.

TABLE 3

Factors associated with HIV seroconversion within a year of initial HIV testing among clients enrolled in HIV prevention programmes in Ukraine, 2010–2011

Read  full article at:  http://ht.ly/SHUWd 

By: O. Denisiuk,1 P. Smyrnov,1 A. M. V. Kumar,2 S. Achanta,3 K. Boyko,1 M. Khogali,4 B. Naik,3 and R. Zachariah4

1 International HIV/AIDS Alliance in Ukraine, Kyiv, Ukraine

2 International Union Against Tuberculosis and Lung Disease, South-East Asia Office, New Delhi, India

3 World Health Organization India Country Office, New Delhi, India

4 Médecins Sans Frontières (MSF), Operational Centre Brussels, Medical Department, Operational Research Unit (LUXOR), MSF-Luxembourg, Luxembourg

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HIV Testing and Diagnosis Rates in Kiev, Ukraine: April 2013 - March 2014

Data from Ukraine on risk factors for HIV acquisition are limited. We describe the characteristics of individuals testing for HIV in the main testing centres of the Ukrainian capital Kiev, including HIV risk factors, testing rates, and positivity rates.

During the study period 6370 individuals tested for HIV, equivalent to a testing rate of 293.2 per 100,000. Of these, 467 (7.8%) were HIV-positive, with the highest proportion positive among 

• 31–35 year olds (11.2%), males (9.4%), 
• people who inject drugs (PWID) (17.9%) 
• and men who have sex with men (MSM) (24.1%). 

Using published population size estimates of MSM, diagnosis rates for MSM ranged from 490.6to 1548.3/100,000. A higher proportion of heterosexual women compared to heterosexual men reported contact with PWID, (16% vs. 4.7%) suggesting a bridging in risk between PWID and their sexual partners.

Collection of HIV risk factor information in Kiev, essential for the purposes of developing effective HIV prevention and response tools, is feasible. The high percentage of MSM among those testing positive for HIV, may indicate a significant level of undisclosed sex between men in national figures.

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By:  Ruth Simmons,1 Ruslan Malyuta,2 Nelli Chentsova,3 Antonia Medoeva,3 Yuri Kruglov,4 Alexander Yurchenko,3 Andrew Copas,1 Kholoud Porter,1,* and CASCADE Collaboration in EuroCoord¶

²Perinatal Prevention of AIDS Initiative, Odessa, Ukraine

³Kyiv City AIDS Center, Kyiv, Ukraine

⁴

1MRC Clinical Trials Unit at University College London, London, United Kingdom

2Perinatal Prevention of AIDS Initiative, Odessa, Ukraine

3Kyiv City AIDS Center, Kyiv, Ukraine

4Institute of Epidemiology, Kyiv, Ukraine

1MRC Clinical Trials Unit at University College London, London, United Kingdom

Fuelling the Epidemics: Challenges Facing HIV, Hepatitis C and Opioid Treatment Services Programmes for PWID in Eastern Ukraine

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Krokodile Injectors in Ukraine: Fueling the HIV Epidemic?

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