Dual motivational model of pre-exposure prophylaxis use intention: model testing among men who have sex men in Ukraine.

The Dual Motivational Model of pre-exposure prophylaxis (PrEP) use intention (DMM) is a new theoretical model recently tested among men who have sex with men (MSM) in the United States. The model posits that there are two main motivational pathways to use PrEP: the Protection Motivation Pathway and the Expectancy Motivation Pathway. The Protection Motivation Pathway suggests that the intention to use PrEP is triggered by the desire to protect oneself from HIV, while the Expectancy Motivation Pathway suggests that PrEP use intention is triggered by the expectation to have better sexual experiences on PrEP. Although both motivators have been tested separately, only the DMM of PrEP use intention suggests that both pathways simultaneously influence an individual's intention to use PrEP. We used data from 1078 MSM in Ukraine to test the DMM. Results show that the relationship of the pathways is similar among Ukrainian and American MSM. Potential explanations for minor differences may be related to cultural and contextual differences, and the different trajectories for PrEP roll-out. Successful validation of the DMM for PrEP use intention as a theoretical model suggests that it may be applied to other cultures contemplating PrEP use delivery to target health promotion among high risk MSM.

Pre-exposure Prophylaxis Among Men Who have Sex with Men: Dual Motivational Model of Intention to Use Pre-exposure Prophylaxis.

Men who have sex with men (MSM) account for most new HIV infections in the United States. Despite representing a fraction of the population, MSM make up an estimated 65% of new infections. To address this epidemic, pre-exposure prophylaxis (PrEP) is recommended to supplement condom use. Despite its effectiveness, PrEP uptake among MSM is low. Few studies have employed theoretical approaches to understand PrEP use intention. Incorporating factors like safe sex fatigue, expectation of better sexual experiences, and perceived risk are proposed in this dual motivational path model of PrEP use intention. This model hypothesized that PrEP use intention is influenced by two key pathways: (1) protection motivation pathway, and (2) sexual expectancy pathway. Data were collected using social networking applications from 402 MSM. The model was tested using structural equation modeling. We elaborate the complex decision-making process proposed by this novel theoretical model and discuss its practical implications.

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.

The Influence of Medication Attitudes on Utilization of Antiretroviral Therapy (ART) in Indonesian Prisons.

Negative attitudes toward HIV medications may restrict utilization of antiretroviral therapy (ART) in Indonesian prisons where many people living with HIV (PLH) are diagnosed and first offered ART. This mixed-method study examines the influence of medication attitudes on ART utilization among HIV-infected Indonesian prisoners. Randomly-selected HIV-infected male prisoners (n = 102) completed face-to-face in-depth interviews and structured surveys assessing ART attitudes. Results show that although half of participants utilized ART, a quarter of those meeting ART eligibility guidelines did not. Participants not utilizing ART endorsed greater concerns about ART efficacy, safety, and adverse effects, and more certainty that ART should be deferred in PLH who feel healthy. In multivariate analyses, ART utilization was independently associated with more positive ART attitudes (AOR = 1.09, 95 % CI 1.03-1.16, p = 0.002) and higher internalized HIV stigma (AOR = 1.03, 95 % CI 1.00-1.07, p = 0.016). Social marketing of ART is needed to counteract negative ART attitudes that limit ART utilization among Indonesian prisoners.

High rates of deferring antiretroviral treatment for patients with HIV and substance use disorders: Results from a national sample of HIV physicians in Ukraine.

BACKGROUND: HIV incidence and mortality are increasing in Ukraine despite their reductions globally, in part due to suboptimal antiretroviral therapy (ART) coverage in key populations of people with HIV (PWH) where the epidemic is concentrated. As physicians are gatekeepers to ART prescription, stigma and discrimination barriers are understudied as a key to meeting HIV treatment targets in key populations. METHODS: A national sample (N = 204) of ART-prescribing physicians in Ukraine were surveyed between August and November 2019. Participants underwent a series of randomized, hypothetical HIV clinical scenarios and decided whether to initiate or defer (or withhold) ART. Scenarios varied based on 5 distinct CD4 counts (CD4: 17, 176, 305, 470, or 520 cells/mL) and 10 different PWH key populations. Z scores and McNemar's test for paired samples were used to assess differences between key populations and CD4 count. Feeling thermometers were used to assess stigma-related measures toward key populations among physicians. RESULTS: Physicians were highly experienced (mean = 19 years) HIV treaters, female (80.4%), and trained in infectious diseases (76.5%). Patients who drink alcohol (range: 21.6%-23.5%) or use (PWUD range: 16.7%-20.1%) or inject (PWID range: 15.5%-20.1%) drugs were most likely to have ART deferred, even at AIDS-defining CD4 counts. PWID maintained on methadone, however, were significantly (p<0.001) less likely to have ART deferred compared with those who were not (range: 7.8%-12.7%) on methadone. Men who have sex with men (range: 5.4%-10.8%), transgender women (range: 4.9%-11.3%), sex workers (range: 3.9%-10.3%),and having an HIV-uninfected sex partner (range: 3.9%-9.3%) had the lowest likelihood of ART deferral. Increasing levels of stigma (i.e., feeling thermometers) towards a key population was correlated with ART deferral (i.e., discrimination). CONCLUSIONS: Despite international and Ukrainian guidelines recommending ART prescription for all PWH, irrespective of risk or CD4 count, ART deferral by experienced HIV experts remains high in certain key populations, especially in PWH and substance use disorders. Strategies that initiate ART immediately after diagnosis (i.e., rapid start antiretroviral therapy), independent of risk group, should be prioritized to truly mitigate the current epidemic.

The impact of emergency guidance to the COVID-19 pandemic on treatment entry, retention and mortality among patients on methadone in Ukraine.

BACKGROUND AND AIMS: Ukraine's Ministry of Health released urgent COVID-19 guidelines, allowing for early implementation of take-home dosing (THD) for opioid agonist therapies (OAT) such as methadone. Enrollment in OAT and retention in the program are the most effective HIV prevention strategies for people who inject drugs (PWID). This study aimed to evaluate the impact of Ukraine's COVID-19 emergency guidance on OAT treatment enrollment, retention on treatment and mortality. DESIGN AND SETTING: Using Ukraine's national OAT registry for 252 governmental clinics across 25 regions, we conducted a 12-month comparative prospective cohort survival analysis. This study compared newly enrolled methadone patients within the initial 6 months following the COVID-19 guidance (COVID) with patients from the preceding year (pre-COVID) in a country with high adult HIV prevalence (1.2%) that is concentrated in PWID. PARTICIPANTS: In the nation-wide sample of newly enrolled PWID in Ukraine, comprising 2798 individuals, 1423 were in the COVID cohort and 1375 were in the pre-COVID cohort. The majority were male (86.7%), with an average age of 39.3 years. MEASUREMENTS: Primary outcomes were average monthly enrollment per cohort, treatment retention and mortality, with internal time-dependent predictors, including THD and optimal (> 85 mg) methadone dosing. RESULTS: Relative to the pre-COVID period, the monthly average patient enrollment was statistically significantly higher during the COVID period (283.7 versus 236.0; P < 0.0001), where patients were more likely to transition to THD and achieve optimal dosing earlier. Significant differences were observed in the proportions of person-months on THD (41 versus 13%, P < 0.0001) and optimal dosing (38 versus 31%, P < 0.0001) between the COVID and pre-COVID cohorts. Predictors of treatment retention, expressed as adjusted hazard ratios (aHR), included early THD [aHR = 1.90, 95% confidence interval (CI) = 1.47-2.45], early optimal dosing (aHR = 1.71, 95% CI = 1.37-2.13) and prior methadone treatment (aHR = 1.39, 95% CI = 1.15-1.68). These factors persisted, respectively, in the pre-COVID (aHR = 2.28, 95% CI = 1.41-3.70; aHR = 1.84, 95% CI = 1.32-2.56; and aHR = 1.36, 95% CI = 1.06-1.74) and COVID (aHR = 1.91, 95% CI = 1.40-2.59; aHR = 1.61, 95% CI = 1.20-2.16; and aHR = 1.49, 95% CI = 1.08-1.94) cohorts. Survival did not differ significantly between the two prospective cohorts. CONCLUSION: Ukraine's prompt adoption of early take-home dosing for opioid agonist therapies, such as methadone, following the emergency COVID-19 guidance appears to have increased enrollment into methadone and improved treatment retention for people who inject drugs without adverse effects on patient survival.

Work readiness and barriers to employment during COVID-19 for individuals with Neurofibromatosis Type 1 (NF1).

BACKGROUND: The global COVID-19 pandemic has directly impacted individuals with rare diseases who are attempting to maintain or obtain employment. Individuals with Neurofibromatosis Type 1 are especially at risk due to their disease. OBJECTIVE: The current study compared the impact that generalized anxiety and quality of life had on work readiness and potential barriers that individuals with NF1 had in gaining and maintaining employment during the COVID-19 pandemic to a sample of healthy individuals using a moderating mediation analysis. METHODS: A total of 213 individuals (105 NF1; 108 Healthy individuals) were recruited to complete a cross-sectional study in which a series of work-related assessments were completed. RESULTS: Generalized anxiety had an indirect effect on work readiness, fully mediated by barriers, with higher anxiety associated with more barriers, in turn negatively correlating with work readiness; quality of life partially mediated the effect of barriers on work readiness and was negatively associated with the former and positively with the latter. CONCLUSION: Quality of life was a mediator of the relationship between perceived employment barriers and work readiness for the healthy individuals group only. The results imply that anxiety and quality of life are significant mediators and require consideration in terms of evaluation and facilitation of employment maintenance and acquisition.

Feasibility of a remotely monitored blood alcohol concentration device to facilitate treatment motivation.

Background: Consistent monitoring of blood alcohol concentration through breathalyzers is critical for identifying reoccurrence. Little research has effectively utilized convenient wireless enabled breathalyzers that can measure blood alcohol concentration while enhancing treatment motivation for outpatient care. The current study attempted to understand the impact of wireless breathalyzers on treatment motivation and self-efficacy in remaining sober for individuals diagnosed with alcohol use disorder in an outpatient treatment facility. Methods: Participants were assigned to one of two conditions: the experimental breathalyzer and the treatment as usual group. The groups were assessed by the University of Rhode Island Change Assessment (URICA), and on self-efficacy, measured by the Alcohol Abstinence Self-Efficacy Scale (AASE). The evaluation period took place over three months with a six-week follow-up evaluation. During the entirety of the evaluation period and post-study follow up, interviews occurred. Results: As a secondary analysis, the URICA's motivational scores were higher for participants receiving the experimental intervention at a two-month evaluation and at the six-week follow-up. The AASE's temptation to reoccurrence scores significantly reduced over time for both groups. The confidence to resist temptation was not significant. Three major themes emerged from the interviews, including the benefit of the breathalyzer facilitating their treatment, ease of device use, and technical issues. Conclusions: The insights gained from this study will be important to develop cost-effective ancillary interventions for comprehensive alcohol dependence treatment. On-going monitoring enabled by new technology allows treatment providers to take an individualized disease-management approach as well as facilitating timely interventions by the treatment provider.

Aligning public health and public safety: Probation as a touchpoint to identify and link patients with opioid use disorder to opioid agonist treatment.

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.

Development and validation of a new scale to measure chronic suicidal ideation: The Chronic Suicidal Ideation Inventory-5 (CSI-5).

OBJECTIVE: Little is known about characteristics that differentiate acute from chronic suicidal ideation. Studies have been hampered by the lack of a formal operational definition or measurement tool for chronic suicidal ideation (CSI). We sought to adapt a standardized measure of obsessive-compulsive thinking to rate chronic suicidal ideation in a mood disorder inpatient cohort. METHOD: We devised a novel self-report instrument, based on constructs related to obsessive-compulsive thinking and the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), as applied to preoccupations with suicidal thoughts and their persistence over 24 months in a previously described cohort of 97 inpatients with mood disorder. Exploratory factor analysis and principal components analysis were used to establish the factor structure of the instrument, and Cronbach's alpha and McDonald's omega were calculated to determine internal consistency of the scale. RESULTS: Significant Pearson correlations with individual scale items and total CSI-5 scores were evident in relation to the 2-, 6-, 12- and 24-month periods preceding the index hospitalization. A one-factor solution explained 75% of the variance in total CSI-5 scores. Cronbach's alpha was 0.914, and McDonalds's omega was 0.916. CSI-5 scores were not significantly associated with current depression severity scores or actual past suicide attempts. CONCLUSIONS: This 5-item adaptation of Y-BOCS-type questions provides an internally consistent and reliable assessment of chronic suicidal ideation in patients with mood disorder. The integrated assessment of time occupied by suicidal thoughts, activity interference, associated distress, efforts to resist suicidal thoughts, and degree of control over suicidal thinking provides a cohesive framework for understanding chronic suicidal ideation.

The Spanish Version of the Video Game Functional Assessment-Revised.

It is estimated that 16.8 million in Spain (41% female) are involved in gaming, and approximately 8.3% of Spanish gamers are problematic gamers (i.e., endorsing five or more of the nine criteria for Internet Gaming Disorder [IGD]). Given the high prevalence of IGD in Spain, this study evaluated construct validity and concurrent validity of the Spanish Version of the Video Game Functional Assessment-Revised (SP-VGFA-R), by examining the correlational coefficients with the nine-item Internet Gaming Disorder Scale-Short-Form (IGDS9-SF). A total of 434 adults 18 years of age or older participated in the study (15.1% female). Results showed that the SP-VGFA-R was positively and significantly associated with the IGDS9-SF (bivariate coefficients ranging from 0.411 to 0.610). Four distinct factors in the SP-VGFA-R were identified in confirmatory factor analysis, including (a) social attention, (b) tangible/intangible rewards, (c) escape/avoidance of demands or pain, and (d) sensory stimulation. Other findings showed that IGDS9-SF scores increased as (a) the escape/avoidance of demands or pain function increased and (b) two or more function scores increased. The SP-VGFA-R can be used in combination with the IGDS9-SF to assess Spanish gamers with IGD internationally, and to develop evidence-based behavioral interventions.

A pilot implementation study to scale-up methadone in incarcerated persons with opioid use disorder and retain them on treatment after release in Moldova.

BACKGROUND: Eastern Europe and Central Asia have intertwined HIV and incarceration epidemics, concentrated in people who inject drugs. Moldova is one of the few countries in this region that offers methadone within prisons, but uptake and post-release retention remains suboptimal. Screening, brief intervention, and referral to treatment (SBIRT) procedures are a potential implementation strategy to address this problem. METHODS: From June 1, 2017 to March 3, 2018, we conducted a 2-stage SBIRT strategy in nine prisons and four pre-trial detention facilities in Moldova among incarcerated persons with opioid use disorder (OUD; N = 121) and within 90 days of release. Survey results were analyzed to evaluate the effect of the SBIRT strategy on the uptake of and post-release retention on methadone maintenance treatment (MMT). RESULTS: Among the 121 screened with OUD, 27 were on MMT at baseline within the prison and this number increased to 41 after the two-step SBIRT intervention, reflecting a 51.9% increase over baseline. Eleven (78.6%) of the 14 participants that newly started MMT did so only after completing both SBIRT sessions. The brief intervention did not significantly improve knowledge about methadone but did improve attitudes towards it. Among the 41 participants who received methadone during this trial, 40 (97.6%) were retained 6 months after release; the one participant not retained was on methadone at the time of the intervention and had planned to taper off. CONCLUSION: The SBIRT strategy significantly improved participant attitudes, but treatment initiation mostly occurred after completing both sessions, including soon after release, but remained low overall. Work within the Moldovan prison subculture to dispel negative myths and misinformation is needed to further scale-up OAT in Moldova.

Multi-level implementation factors that influence scale-up of methadone maintenance treatment in Moldovan prisons: A qualitative study.

INTRODUCTION: People who inject drugs (PWID) are overrepresented in prison populations, especially in the Eastern European and Central Asian region (EECA), where HIV incidence and mortality continue to rise. Modeling data suggest that methadone maintenance treatment (MMT) scale-up in prison with continuation after release could substantially reduce new HIV infections. Moldova, one of four countries in the EECA to have introduced MMT in prisons, has faced challenges with its scale-up. METHOD: To improve implementation of MMT in Moldovan prisoners, we analyzed the qualitative interviews of 44 recently released Moldovan prisoners with opioid use disorder who either accepted or rejected MMT while incarcerated; these 44 were among a subset of 56 participants in a quantitative survey who had complete interview data. After translating and back-translating interviews, we used content analysis to identify key barriers and facilitators to MMT uptake. RESULTS: Our qualitative analyses revealed that positive attitudes toward methadone facilitated treatment uptake, yet the study identified three thematic barriers as to why PWID do not accept MMT while in prison, including: 1) negative personal attitudes toward MMT; 2) stigmatization of MMT by informal hierarchies within prison; and 3) distrust of the formal prison hierarchy (i.e., administration), which provides MMT. CONCLUSION: Overall, the social forces of the two prisoner hierarchies and distrust between them appeared to outweigh the perceived benefits of MMT and impacted MMT uptake. Here we provide strategies to promote MMT more effectively in prison settings.

Preliminary analysis of self-reported quality health indicators of patients on opioid agonist therapy at specialty and primary care clinics in Ukraine: A randomized control trial.

International agencies recommend integrating addiction treatment into primary care for people who inject drugs (PWID) with opioid use disorder (OUD). Empirical data supporting integration that incorporates comprehensive health outcomes, however, are not known. For this randomized controlled trial in Ukraine, adult PWID with OUD were randomized to receive opioid agonist therapy (OAT) in specialty addiction treatment clinics (SATC) or to primary care clinics (PCCs). For those randomized to PCC, they were subsequently allocated to PCCs where clinicians received pay-for-performance (P4P) incentives (PCC with P4P) or not (PCC without P4P). Participating cities had one of each of the three intervention sites to control for geographic variation. Ongoing tele-education specialty training (OAT, HIV, tuberculosis) was provided to all PCCs. While the primary outcome for the parent trial focuses on patient medical record data, this preliminary analysis focuses on assessment of self-reported achievement of nationally recommended quality health indicators (QHIs) which is summed as a composite QHI score. Secondary outcomes included specialty and primary care QHI subscores. This study occurred from 01/20/2018-11/1/2020 with 818 of 990 randomized participants having complete self-reported data for analysis. Relative to SATC (treatment as usual), the mean composite QHI score was 12.7 (95% CI: 10.1-15.3; p<0.001) percentage points higher at PCCs; similar and significantly higher scores were observed in PCCs compared to SATCs for both primary care (PCC vs SATC: 18.4 [95% CI: 14.8-22.0; p<0.001] and specialty (PCC vs SATC: 5.9 [95% CI: 2.6-9.2; p<0.001] QHI scores. Additionally, the mean composite QHI score was 4.6 (95% CI: 2.0-7.2; p<0.001) points higher in participants with long term (>3 months) experience with OAT compared to participants newly initiating OAT. In summary, PWID with OUD receive greater primary care and specialty healthcare services when receiving OAT at PCCs supported by tele-education relative to treatment as usual provided in SATCs. Clinical trial registration: This trial was registered at clinicaltrials.gov and can be found using the following registration number: NCT04927091.

Drug injection within prison in Kyrgyzstan: elevated HIV risk and implications for scaling up opioid agonist treatments.

Purpose Within-prison drug injection (WPDI) is a particularly high HIV risk behavior, yet has not been examined in Central Asia. A unique opportunity in Kyrgyzstan where both methadone maintenance treatment (MMT) and needle-syringe programs (NSP) exist allowed further inquiry into this high risk environment. The paper aims to discuss these issues. Design/methodology/approach A randomly selected, nationally representative sample of prisoners within six months of release in Kyrgyzstan completed biobehavioral surveys. Inquiry about drug injection focused on three time periods (lifetime, 30 days before incarceration and during incarceration). The authors performed bivariate and multivariable generalized linear modeling with quasi-binomial distribution and logit link to determine the independent correlates of current WPDI. Findings Of 368 prisoners (13 percent women), 109 (35 percent) had ever injected drugs, with most (86 percent) reporting WPDI. Among those reporting WPDI, 34.8 percent had initiated drug injection within prison. Despite nearly all (95 percent) drug injectors having initiated MMT previously, current MMT use was low with coverage only reaching 11 percent of drug injectors. Two factors were independently correlated with WPDI: drug injection in the 30 days before the current incarceration (AOR=12.6; 95%CI=3.3-48.9) and having hepatitis C infection (AOR: 10.1; 95%CI=2.5-41.0). Originality/value This study is the only examination of WPDI from a nationally representative survey of prisoners where both MMT and NSP are available in prisons and in a region where HIV incidence and mortality are increasing. WPDI levels were extraordinarily high in the presence of low uptake of prison-based MMT. Interventions that effectively scale-up MMT are urgently required as well as an investigation of the environmental factors that contribute to the interplay between MMT and WPDI.

Patient preferences and extended-release naltrexone: A new opportunity to treat opioid use disorders in Ukraine.

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.

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.

Pre-incarceration police harassment, drug addiction and HIV risk behaviours among prisoners in Kyrgyzstan and Azerbaijan: results from a nationally representative cross-sectional study.

INTRODUCTION: The expanding HIV epidemic in Azerbaijan and Kyrgyzstan is concentrated among people who inject drugs (PWID), who comprise a third of prisoners there. Detention of PWID is common but its impact on health has not been previously studied in the region. We aimed to understand the relationship between official and unofficial (police harassment) detention of PWID and HIV risk behaviours. METHODS: In a nationally representative cross-sectional study, soon-to-be released prisoners in Kyrgyzstan (N=368) and Azerbaijan (N=510) completed standardized health assessment surveys. After identifying correlated variables through bivariate testing, we built multi-group path models with pre-incarceration official and unofficial detention as exogenous variables and pre-incarceration composite HIV risk as an endogenous variable, controlling for potential confounders and estimating indirect effects. RESULTS: Overall, 463 (51%) prisoners reported at least one detention in the year before incarceration with an average of 1.3 detentions in that period. Unofficial detentions (13%) were less common than official detentions (41%). Optimal model fit was achieved (X (2)=5.83, p=0.44; Goodness of Fit Index (GFI) GFI=0.99; Comparative Fit Index (CFI) CFI=1.00; Root Mean Square Error of Approximation (RMSEA) RMSEA=0.00; PCLOSE=0.98) when unofficial detention had an indirect effect on HIV risk, mediated by drug addiction severity, with more detentions associated with higher addiction severity, which in turn correlated with increased HIV risk. The final model explained 35% of the variance in the outcome. The effect was maintained for both countries, but stronger for Kyrgyzstan. The model also holds for Kyrgyzstan using unique data on within-prison drug injection as the outcome, which was frequent in prisoners there. CONCLUSIONS: Detention by police is a strong correlate of addiction severity, which mediates its effect on HIV risk behaviour. This pattern suggests that police may target drug users and that such harassment may result in an increase in HIV risk-taking behaviours, primarily because of the continued drug use within prisons. These findings highlight the important negative role that police play in the HIV epidemic response and point to the urgent need for interventions to reduce police harassment, in parallel with interventions to reduce HIV transmission within and outside of prison.

Determinants of willingness to enroll in opioid agonist treatment among opioid dependent people who inject drugs in Ukraine.

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.

Intersecting epidemics of HIV, HCV, and syphilis among soon-to-be released prisoners in Kyrgyzstan: Implications for prevention and treatment.

BACKGROUND: Central Asia is afflicted with increasing HIV incidence, low antiretroviral therapy (ART) coverage and increasing AIDS mortality, driven primarily by people who inject drugs (PWID). Reliable data about HIV, other infectious diseases, and substance use disorders in prisoners in this region is lacking and could provide important insights into how to improve HIV prevention and treatment efforts in the region. METHODS: A randomly sampled, nationwide biobehavioural health survey was conducted in 8 prisons in Kyrgyzstan among all soon-to-be-released prisoners; women were oversampled. Consented participants underwent computer-assisted, standardized behavioural health assessment surveys and testing for HIV, HCV, HBV, and syphilis. Prevalence and means were computed, and generalized linear modelling was conducted, with all analyses using weights to account for disproportionate sampling by strata. RESULTS: Among 381 prisoners who underwent consent procedures, 368 (96.6%) were enrolled in the study. Women were significantly older than men (40.6 vs. 36.5; p=0.004). Weighted prevalence (%), with confidence interval (CI), for each infection was high: HCV (49.7%; CI: 44.8-54.6%), syphilis (19.2%; CI: 15.1-23.5%), HIV (10.3%; CI: 6.9-13.8%), and HBV (6.2%; CI: 3.6-8.9%). Among the 31 people with HIV, 46.5% were aware of being HIV-infected. Men, compared to women, were significantly more likely to have injected drugs (38.3% vs.16.0%; p=0.001). Pre-incarceration and within-prison drug injection, primarily of opioids, was 35.4% and 30.8%, respectively. Independent correlates of HIV infection included lifetime drug injection (adjusted odds ratio [AOR]=38.75; p=0.001), mean number of years injecting (AOR=0.93; p=0.018), mean number of days experiencing drug problems (AOR=1.09; p=0.025), increasing duration of imprisonment (AOR=1.08; p=0.02 for each year) and having syphilis (AOR=3.51; p=0.003), while being female (AOR=3.06; p=0.004) and being a recidivist offender (AOR=2.67; p=0.008) were independently correlated with syphilis infection. CONCLUSION: Drug injection, syphilis co-infection, and exposure to increased risk during incarceration are likely to be important contributors to HIV transmission among prisoners in Kyrgyzstan. Compared to the community, HIV is concentrated 34-fold higher in prisoners. A high proportion of undiagnosed syphilis and HIV infections presents a significant gap in the HIV care continuum. Findings highlight the critical importance of evidence-based responses within prison, including enhanced testing for HIV and sexually transmitted infections, to stem the evolving HIV epidemic in the region.