Impact of war on HIV-related healthcare services and health workers in eastern Ukraine: a qualitative study.

The 2022 Russian invasion of Ukraine has caused serious challenges for healthcare workers (HCWs) and HIV-related healthcare services. This study assessed the effects of the invasion on HCWs wellbeing and on continuity of HIV services, using in-depth interviews with HCWs from facilities offering HIV antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) services in the Donetsk region of Eastern Ukraine. A directed content analysis, with both inductive and deductive approaches, was conducted. Ten HCWs (6 [60%] doctors, 4 [40%] nurses; 9 [90%] female) were interviewed. Six respondents were displaced from their homes and worksites, and all described stress and threats to emotional wellbeing. HCWs used online consultations, encrypted mobile communication, and multi-month dispensing to support continuity of ART and PrEP services. They noted immediate needs for psychological and financial support, and access to laptop computers and mobile communications to ensure continuity of HIV services. Priorities for restoration of services include repair of health facilities, restoration of laboratory services and supply chains, and return of personnel and patients. HCWs made innovative, rapid adaptations to HIV services to keep ART and PrEP services running, demonstrating the resolve of Ukrainian HCWs to maintain continuity of HIV services despite the disruptions of war.

Does HIV index testing bring patients into treatment at earlier stages of HIV disease? Results from a retrospective study in Ukraine.

BACKGROUND: Over one-third of people living with HIV (PLH) in Ukraine are not on treatment. Index testing services, which link potentially exposed partners (named partners) of known PLH (index patients) with testing and treatment services, are being scaled in Ukraine and could potentially close this gap. METHODS: This retrospective study included patient data from 14,554 adult PLH who initiated antiretroviral treatment (ART) between October 2018 and May 2021 at one of 35 facilities participating in an intervention to strengthen index testing services. Mixed effects modified Poisson models were used to assess differences between named partners and other ART initiators, and an interrupted time series (ITS) analysis was used to assess changes in ART initiation over time. RESULTS: Compared to other ART initiators, named partners were significantly less likely to have a confirmed TB diagnosis (aRR = 0.56, 95% CI = 0.40, 0.77, p < 0.001), a CD4 count less than 200 cells/mm3 (aRR = 0.84, 95% CI = 0.73, 0.97, p = 0.017), or be categorized as WHO HIV stage 4 (aRR = 0.68, 9% CI = 0.55, 0.83, p < 0.001) at the time of ART initiation, and were significantly more likely to initiate ART within seven days of testing for HIV (aRR = 1.36, 95% CI = 1.22, 1.50, p < 0.001). Our ITS analysis showed a modest 2.34% (95% CI = 0.26%, 4.38%; p = 0.028) month-on-month reduction in mean ART initiations comparing the post-intervention period to the pre-intervention period, although these results were likely confounded by the COVID epidemic. CONCLUSION: Our findings suggest that index testing services may be beneficial in bringing PLH into treatment at an earlier stage of HIV disease and decreasing delays between HIV testing and ART initiation, potentially improving patient outcomes and retention in the HIV care cascade.

Distinctive model for HIV index testing (IT) in Eastern Europe: results of Ukraine's physician-led, integrated IT programme.

OBJECTIVES: The effectiveness of HIV index testing (IT) in Eastern Europe has not been described. This study reports the performance of a scaled IT programme in Ukraine. DESIGN: This observational study included clients enrolled in IT services in 2020, and used routinely collected data from programme registers and the national electronic health record system. SETTING: The study covered 39 public-sector health facilities where IT services were integrated into medical visits for persons living with HIV (PLHIV) already enrolled in HIV care. PARTICIPANTS: Participants included PLHIV with both recent (<6 months) and previously established (≥6 months) HIV diagnoses. INTERVENTION: Ukraine's physician-led IT model involves a cascade of steps including voluntary informed consent, partner elicitation, selection of partner notification method and follow-up with clients to ensure partners are notified, tested for HIV and linked to HIV prevention and treatment services, as needed. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcomes included contact index, testing, index and HIV case-finding index disaggregated by index client (IC) subgroups, including people with current or past injection drug use (PWID) and men who have sex with men (MSM). RESULTS: Of 14 525 ICs offered index testing, 51.9% accepted, of whom 98.3% named at least one sexual, injection or biological child partner. In total, 14.9% of ICs were PWID and 3.5% were MSM. Clients named 8448 unique partners (contact index=1.14). HIV case finding averaged 0.14 cases per client, and was highest among clients with recent HIV diagnosis (0.29) and among PWID (0.23), and lower among clients with established HIV diagnosis (0.07). More than 90% of all partners with new HIV diagnoses were linked to care. CONCLUSIONS: There was a high case-finding index among ICs with recent HIV and high linkage to care for all partners, demonstrating the effectiveness of this integrated, physician-led model implemented in 39 health facilities in Ukraine.

Profile of partners who completed HIV testing and received a new HIV diagnosis in Ukraine's HIV index testing program: a retrospective cohort study to inform program improvement.

BACKGROUND: Approximately one-third of people living with HIV in Ukraine are unaware of their HIV status. Index testing (IT) is an evidence-based HIV testing strategy that supports voluntary notification of partners with HIV risk, so they can receive HIV testing, prevention, and treatment services. METHODS: Ukraine scaled up IT services in 2019. This observational study of Ukraine's IT program covered 39 health facilities located in 11 regions with high HIV burden. The study used routine program data from January-December 2020 to describe the profile of named partners and explore index client (IC) and partner factors associated with two outcomes: 1) completing testing; and 2) HIV case finding. Analysis used descriptive statistics and multilevel linear mixed regression models. RESULTS: The study included 8,448 named partners, of whom 6,959 had unknown HIV status. Among them,72.2% completed HIV testing and 19.4% of those tested were newly diagnosed with HIV. Two-thirds of all new cases were among partners of ICs who were recently diagnosed and enrolled in care (< 6 months), while one third were among partners of established ICs. In adjusted analysis, partners of ICs with unsuppressed HIV viral load (VL) were less likely to complete HIV testing (adjusted odds ratio [aOR] = 0.11, p < 0.001), but more likely to receive a new HIV diagnosis (aOR = 1.92, p < 0.001). Partners of ICs who cited injection drug use or having a known HIV + partner as their own reason for testing were more likely to receive a new HIV diagnosis (aOR = 1.32, p = 0.04 and aOR = 1.71, p < 0.001 respectively). Involving providers in the partner notification process was associated with completed testing (aOR = 1.76, p = 0.001) and HIV case finding (aOR = 1.64, p < 0.01), compared with notification by ICs. CONCLUSION: HIV case detection was highest among partners of recently diagnosed ICs, but IT participation among established ICs still yielded an important share of all newly-identified HIV cases. Areas for improvement in Ukraine's IT program include completing testing for partners of ICs with unsuppressed HIV VL, with history of injection drug use or discordant partnerships. Using intensified follow-up for the sub-groups at risk of incomplete testing may be practical. Greater use of provider-assisted notification could also accelerate HIV case finding.

Factors Associated With Delayed Contraceptive Implant Removal in Ethiopia.

BACKGROUND: In 2009, the Government of Ethiopia initiated the implant scale-up initiative, which expanded contraceptive access by training health extension workers (HEWs) to insert single-rod etonogestrel contraceptive implants (Implanon) at rural health posts. Removals were provided by referrals to higher levels of the health system. However, little was known about whether women were getting their implants removed at the recommended 3-year postinsertion date or what barriers they faced to removal. METHODS: Between June and July 2016, 1,860 Ethiopian women, who had a 1-rod etonogestrel implant inserted by either an HEW or another health care provider between 3 and 6 years prior, were surveyed. We describe the characteristics of the sample and use multivariable logistic regression to predict factors associated with keeping implants inserted beyond 3 years. RESULTS: Women who had received their implants from HEWs were significantly more likely to report keeping them inserted for more than 3 years (adjusted odds ratio=2.50; 95% confidence interval=1.19, 5.24), compared with those who got their implant from another health care provider. Women who reported distance to the facility or transportation as a barrier were also significantly more likely to keep their implant for more than 3 years. Married and educated women were less likely to keep their implants for an extended duration. Among women who had their implant for 3 years or less, women who had had it inserted by an HEW were significantly more likely to report that the provider was unable or refused to provide removal as a barrier. DISCUSSION: Efforts to expand lower level and community-based access to contraceptive implants that do not ensure reliable access to removals at the same level as insertions may lead to women using implants beyond the recommended duration.

'I won't be able to go home being pregnant': sex work and pregnancy in Dhaka, Bangladesh.

Sex workers report high rates of unintended pregnancy that are inconsistent with widespread reports of condom use. Greater understanding of the implications of an unintended pregnancy and barriers to contraceptive use is needed to better meet the broader sexual and reproductive health needs of this population. We conducted in-depth interviews with 20 women sex workers in Dhaka, Bangladesh. Findings reveal that most women are trying to conform to societal norms and protect their reputations. They fear pregnancy would reveal that they are having unsanctioned sex and that they are sex workers. This could lead to ostracism from families and society, resulting in homelessness and abandonment by partners. Pregnancy may affect a sex worker's ability to work and leave her unable to meet financial obligations. All study participants were using condoms but most acknowledged they could not use them consistently. They had all tried other contraceptive methods, notably injectables and the pill, but some noted experience of side-effects, difficulties in adherence and the desire to use other methods. Understanding the context of sex workers' lives is an important step in informing stakeholders about the range of services needed to improve their sexual and reproductive health.

Understanding the Broader Sexual and Reproductive Health Needs of Female Sex Workers in Dhaka, Bangladesh.

CONTEXT: Little is known about the sexual and reproductive health care needs of female sex workers in Dhaka, Bangladesh. METHODS: Survey data were collected from 354 hotel-based and 323 street-based female sex workers using a venue-based stratified cluster sampling approach. In addition, in-depth interviews were conducted with 20 female sex workers recruited from drop-in centers. We calculated unmet need for family planning and examined fertility desires, use of condoms and other contraceptive methods, experiences with gender-based violence, sexual and reproductive health service needs, and preferences on where to receive services. RESULTS: The prevalence of unmet need was 25% among hotel-based female sex workers and 36% among street-based female sex workers. Almost all participants reported having used condoms in the past 30 days, and 44% of hotel-based sex workers and 30% of street-based sex workers reported dual method use during that period. Condom use was inconsistent, however, and condom breakage and nonuse for extra money were common. Many women reported experiencing gender-based violence. Sexual and reproductive health services had been obtained by 64% of hotel-based and 89% of street-based sex workers in the past six months; drop-in centers were their preferred site for receiving health services. CONCLUSIONS: Female sex workers in Dhaka need family planning and other sexual and reproductive health services and prefer receiving them from drop-in centers.

Meeting the Contraceptive Needs of Key Populations Affected by HIV in Asia: An Unfinished Agenda.

Like all women, women living with and at risk of acquiring HIV have the right to determine the number and timing of their pregnancies and to safely achieve their reproductive intentions. Yet, many women in Asia affected by HIV lack access to family planning services and experience disproportionately high rates of unintended pregnancy and abortion. Programs that have succeeded in promoting condom use and providing HIV prevention and treatment services in this region have largely missed the opportunity to address the contraceptive needs of the key populations they serve. The importance of better linkages between family planning and HIV policies and programs is now widely recognized by global health policymakers and donors. However, to date, most of the efforts to improve these linkages have been conducted in Africa. Greater attention is needed to the developing, implementing, and evaluating of integrated family planning/HIV approaches that are tailored to the political, cultural, and public health context in Asia. In this paper, we describe the use of and need for family planning among key populations affected by HIV in Asia, discuss the challenges to effectively addressing of these needs, and offer recommendations for strengthening the linkages between family planning and HIV policies and programs in the region.