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

BACKGROUND: Patterns of movement, heterogeneity of context, and individual space-time patterns affect health, and individuals' movement throughout the landscape is shaped by addiction, meeting basic needs, and maintaining relationships. Place and social context enable or constrain behavior and individuals use social networks and daily routines to accomplish individual goals and access resources. METHODS: This article explores drug use as part of daily routines and daily paths among people who inject drugs in Dnipro City, Ukraine. Between March and August 2018, we interviewed 30 people who inject drugs living in Dnipro City, Ukraine. Study participants completed a single interview that lasted between 1 and 2 hours. During the interview, participants described their daily routine and daily path using a printed map of Dnipro as a prompt. Participants were asked to draw important sites; give time estimates of arrival and departure; and annotate on the map the points, paths, and areas most prominent or important to them. Participants also described to what extent their daily routines were planned or spontaneous, how much their daily path varied over time, and how drug use shaped their daily routine. RESULTS: We identified 3 major types of daily routine: unpredictable, predictable, and somewhat predictable. Participants with unpredictable daily routines had unreliable sources of income, inconsistent drug suppliers and drug use site, and dynamic groups of people with whom they socialized and used drugs. Participants with predictable daily routines had reliable sources of income, a regular drug dealer or stash source, and a stable group of friends or acquaintances with whom they bought and/or used drugs. Participants with somewhat predictable daily routines had some stable aspects of their daily lives, such as a steady source of income or a small group of friends with whom they used drugs, but also experienced circumstances that undermined their ability to have a routinized daily life, such as changing drug use sites or inconsistent income sources. CONCLUSIONS: Greater attention needs to be paid to the daily routines of people who use drugs to develop and tailor interventions that address the place-based and social contexts that contribute to drug-use related risks.

``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.

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.

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

BACKGROUND: Opioid agonist treatments (OAT) are widely-used, evidence-based strategies for treating opioid dependence and reducing HIV transmission. The positive benefits of OAT are strongly correlated with time spent in treatment, making retention a key indicator for program quality. This study assessed patient retention and associated factors in Ukraine, where OAT was first introduced in 2004. METHODS: Data from clinical records of 2916 patients enrolled in OAT at thirteen sites from 2005 to 2012 were entered into an electronic monitoring system. Survival analysis methods were used to determine the probability of retention and its correlates. RESULTS: Twelve-month retention was 65.8%, improving from 27.7% in 2005, to 70.9% in 2011. In multivariable analyses, the correlates of retention were receiving medium and high doses of medication (compared to low doses, dropout aHR=0.57 for both medium and high doses), having not been tested for HIV and tuberculosis (compared to not being tested, dropout aHR=4.44 and 3.34, respectively), and among those who were tested-a negative TB test result (compared to receiving a positive test result, dropout aHR=0.67). CONCLUSION: Retention in Ukrainian OAT programs, especially in recent years, is comparable to other countries. The results confirm the importance of adequate OAT dosing (≥60mg of methadone, ≥8mg of buprenorphine). Higher dosing, however, will require interventions that address negative attitudes toward OAT by patients and providers. Interruption of OAT, in the case developing tuberculosis, should incorporate continuity of OAT for TB patients through integrated care delivery systems.

Trials and tribulations of conducting bio-behavioral surveys in prisons: implementation science and lessons from Ukraine.

Purpose - Ukraine is home to Europe's worst HIV epidemic, overwhelmingly fueled by people who inject drugs who face harsh prison sentences. In Ukraine, HIV and other infectious diseases are concentrated in prisons, yet the magnitude of this problem had not been quantified. The purpose of this paper is to evaluate the systematic health survey of prisoners in the former Soviet Union (FSU). Design/methodology/approach - Qualitative interviews were carried out with research and prison administrative staff to assess the barriers and facilitators to conducting a bio-behavioral survey in Ukrainian prisons. Findings - Crucial barriers at the institutional, staff, and participant level require addressing by: first, ensuring Prison Department involvement at every stage; second, tackling pre-conceived attitudes about drug addiction and treatment among staff; and third, guaranteeing confidentiality for participants. Originality/value - The burden of many diseases is higher than expected and much higher than in the community. Notwithstanding the challenges, scientifically rigorous bio-behavioral surveys are attainable in criminal justice systems in the FSU with collaboration and careful consideration of this specific context.