Will the Russian war in Ukraine unleash larger epidemics of HIV, TB and associated conditions and diseases in Ukraine?

The Russian war in Ukraine poses many risks for the spread of HIV, TB and associated conditions, including possible increases in the numbers of people who inject drugs or engage in sex work in the years ahead. Ukrainian civil society and volunteer efforts have been able to maintain and at times expand services for HIV Key Populations. The extent of mutual-aid and volunteer efforts as well as the continued strength and vitality of harm reduction organizations such as the Alliance for Public Health and the rest of civil society will be crucial resources for postwar efforts to assist Key Populations and prevent the spread of HIV, TB and other diseases. The postwar period will pose great economic and political difficulties for Ukrainians, including large populations of people physically and/or psychically damaged and in pain who might become people who inject drugs. Local and international support for public health and for harm reduction will be needed to prevent potentially large-scale increases in infectious disease and related mortality.

Hepatitis C Virus in people with experience of injection drug use following their displacement to Southern Ukraine before 2020.

BACKGROUND: Due to practical challenges associated with genetic sequencing in low-resource environments, the burden of hepatitis C virus (HCV) in forcibly displaced people is understudied. We examined the use of field applicable HCV sequencing methods and phylogenetic analysis to determine HCV transmission dynamics in internally displaced people who inject drugs (IDPWID) in Ukraine. METHODS: In this cross-sectional study, we used modified respondent-driven sampling to recruit IDPWID who were displaced to Odesa, Ukraine, before 2020. We generated partial and near full length genome (NFLG) HCV sequences using Oxford Nanopore Technology (ONT) MinION in a simulated field environment. Maximum likelihood and Bayesian methods were used to establish phylodynamic relationships. RESULTS: Between June and September 2020, we collected epidemiological data and whole blood samples from 164 IDPWID (PNAS Nexus.2023;2(3):pgad008). Rapid testing (Wondfo® One Step HCV; Wondfo® One Step HIV1/2) identified an anti-HCV seroprevalence of 67.7%, and 31.1% of participants tested positive for both anti-HCV and HIV. We generated 57 partial or NFLG HCV sequences and identified eight transmission clusters, of which at least two originated within a year and a half post-displacement. CONCLUSIONS: Locally generated genomic data and phylogenetic analysis in rapidly changing low-resource environments, such as those faced by forcibly displaced people, can help inform effective public health strategies. For example, evidence of HCV transmission clusters originating soon after displacement highlights the importance of implementing urgent preventive interventions in ongoing situations of forced displacement.

Phylodynamics and migration data help describe HIV transmission dynamics in internally displaced people who inject drugs in Ukraine.

Internally displaced persons are often excluded from HIV molecular epidemiology surveillance due to structural, behavioral, and social barriers in access to treatment. We test a field-based molecular epidemiology framework to study HIV transmission dynamics in a hard-to-reach and highly stigmatized group, internally displaced people who inject drugs (IDPWIDs). We inform the framework by Nanopore generated HIV pol sequences and IDPWID migration history. In June-September 2020, we recruited 164 IDPWID in Odesa, Ukraine, and obtained 34 HIV sequences from HIV-infected participants. We aligned them to publicly available sequences (N = 359) from Odesa and IDPWID regions of origin and identified 7 phylogenetic clusters with at least 1 IDPWID. Using times to the most recent common ancestors of the identified clusters and times of IDPWID relocation to Odesa, we infer potential post-displacement transmission window when infections likely to happen to be between 10 and 21 months, not exceeding 4 years. Phylogeographic analysis of the sequence data shows that local people in Odesa disproportionally transmit HIV to the IDPWID community. Rapid transmissions post-displacement in the IDPWID community might be associated with slow progression along the HIV continuum of care: only 63% of IDPWID were aware of their status, 40% of those were in antiviral treatment, and 43% of those were virally suppressed. Such HIV molecular epidemiology investigations are feasible in transient and hard-to-reach communities and can help indicate best times for HIV preventive interventions. Our findings highlight the need to rapidly integrate Ukrainian IDPWID into prevention and treatment services following the dramatic escalation of the war in 2022.

Unified European support framework to sustain the HIV cascade of care for people living with HIV including in displaced populations of war-struck Ukraine.

Ukraine is one of the countries in Europe most affected by HIV. The escalation of open war on the European continent has affected HIV care in Ukraine in an unprecedented way. Treating physicians in Europe have little experience on how to handle HIV-specific care under these circumstances. A framework is urgently needed that both defines and sets out strategies to handle the specific challenges for emergency support for people living with HIV, both those staying in Ukraine and those becoming displaced. The optimal allocation of the few available medical resources, primarily antiretroviral therapy, is necessary to best prevent individual morbidity and achieve population transmission control. Professional HIV networks play a central role to create, optimise, and execute support strategies. Through a rapid literature review we identified the key strategies needed to create a support framework, adapted to Ukraine's HIV epidemiology. We produce a unified support framework aiming to reduce the inevitable impact on Ukraine's HIV care cascade now, and when rebuilding it after the war.

Modelling the intervention effect of opioid agonist treatment on multiple mortality outcomes in people who inject drugs: a three-setting analysis.

BACKGROUND: Opioid agonist treatment (OAT) reduces many of the harms associated with opioid dependence. We use mathematical modelling to comprehensively evaluate the overall health benefits of OAT in people who inject drugs in Perry County (KY, USA), Kyiv (Ukraine), and Tehran (Iran). METHODS: We developed a dynamic model of HIV and hepatitis C virus (HCV) transmission, incarceration, and mortality through overdose, injury, suicide, disease-related and other causes. The model was calibrated to site-specific data using Bayesian methods. We evaluated preventable drug-related deaths (deaths due to HIV, HCV, overdose, suicide, or injury) averted over 2020-40 for four scenarios, added incrementally, compared with a scenario without OAT: existing OAT coverage (setting-dependent; community 4-11%; prison 0-40%); scaling up community OAT to 40% coverage; increasing average OAT duration from 4-14 months to 2 years; and scaling up prison-based OAT. OUTCOMES: Drug-related harms contributed differentially to mortality across settings: overdose contributed 27-47% (range of median projections) of preventable drug-related deaths over 2020-40, suicide 6-17%, injury 3-17%, HIV 0-59%, and HCV 2-18%. Existing OAT coverage in Tehran (31%) could have a substantial effect, averting 13% of preventable drug-related deaths, but will have negligible effect (averting <2% of preventable drug-related deaths) in Kyiv and Perry County due to low OAT coverage (<4%). Scaling up community OAT to 40% could avert 12-24% of preventable drug-related deaths, including 13-22% of overdose deaths, with greater effect in settings with significant HIV mortality (Tehran and Kyiv). Improving OAT retention and providing prison-based OAT would have a significant additional effect, averting 27-51% of preventable drug-related deaths. INTERPRETATION: OAT can substantially reduce drug-related harms, particularly in settings with HIV epidemics in people who inject drugs. Maximising these effects requires research and investment into achieving higher coverage and provision and longer retention of OAT in prisons and the community. FUNDING: UK National Institute for Health Research, US National Institute on Drug Abuse.

Operationalizing the HIV prevention cascade for PWID using the integrated bio-behavioural survey data from Ukraine.

INTRODUCTION: People who inject drugs (PWID) remain at high risk of HIV in many countries. The HIV prevention cascades have been proposed to replicate the success of the treatment cascades and reinvigorate the prevention programmes through improved monitoring, planning and delivery. We adapted the cascade framework to the PWID context in Ukraine, assessed gaps and analysed factors associated with achieving "access" and "effective use" outcomes. METHODS: Self-reported data on the use of prevention services and risk behaviours from the 2017 integrated bio-behavioural survey among PWID in Ukraine were used to construct cascades for needle/syringe and condom programmes (NSP and CP). Socio-demographic and behavioural variables were evaluated as potential correlates of cascade outcomes. RESULTS: The NSP cascade analysis included 7815 HIV-negative PWID. Motivation to use clean syringes was not assessed and assumed at 100%. Access to clean syringes through NSP in the past 12 months was reported by 2789 participants (35.7%). Effective use of syringes (no sharing in the past 30 days) was reported by 7405 participants (94.8%). NSP access was higher among women, individuals older than 44, and mixed drug users; while effective use was reported more frequently by men and opioid users, with no difference by age. The CP cascade analysis included 6606 (85%) of the HIV-negative PWID who had sex in the past three months. Of those, 2282 (34.5%) received condoms, and 1708 (25.9%) reported consistent use with all partners in the past three months. Older PWID and mixed-drug users accessed condoms more frequently; whereas younger subgroups and opioid users used them more consistently. CONCLUSIONS: Overall, the cascade framework was useful to describe the status of HIV prevention among PWID in Ukraine and to identify areas for improvement in the programming and evaluation of HIV prevention. Access to needle/syringe and condom programmes was substantially below the recommended levels. Effective use of clean syringes was reported by a vast majority of PWID, although likely affected by self-report bias; whereas consistent condom use was infrequent. Socio-demographic and behavioural variables showed significant associations in NSP and CP cascade analyses, with little consistency between the access and effective use outcomes.

Challenges posed by COVID-19 to people who inject drugs and lessons from other outbreaks.

INTRODUCTION: In light of the COVID-19 pandemic, considerable effort is going into identifying and protecting those at risk. Criminalization, stigmatization and the psychological, physical, behavioural and economic consequences of substance use make people who inject drugs (PWID) extremely vulnerable to many infectious diseases. While relationships between drug use and blood-borne and sexually transmitted infections are well studied, less attention has been paid to other infectious disease outbreaks among PWID. DISCUSSION: COVID-19 is likely to disproportionally affect PWID due to a high prevalence of comorbidities that make the disease more severe, unsanitary and overcrowded living conditions, stigmatization, common incarceration, homelessness and difficulties in adhering to quarantine, social distancing or self-isolation mandates. The COVID-19 pandemic also jeopardizes essential for PWID services, such as needle exchange or substitution therapy programmes, which can be affected both in a short- and a long-term perspective. Importantly, there is substantial evidence of other infectious disease outbreaks in PWID that were associated with factors that enable COVID-19 transmission, such as poor hygiene, overcrowded living conditions and communal ways of using drugs. CONCLUSIONS: The COVID-19 crisis might increase risks of homelessnes, overdoses and unsafe injecting and sexual practices for PWID. In order to address existing inequalities, consultations with PWID advocacy groups are vital when designing inclusive health response to the COVID-19 pandemic.

Phylodynamics Helps to Evaluate the Impact of an HIV Prevention Intervention.

Assessment of the long-term population-level effects of HIV interventions is an ongoing public health challenge. Following the implementation of a Transmission Reduction Intervention Project (TRIP) in Odessa, Ukraine, in 2013-2016, we obtained HIV pol gene sequences and used phylogenetics to identify HIV transmission clusters. We further applied the birth-death skyline model to the sequences from Odessa (n = 275) and Kyiv (n = 92) in order to estimate changes in the epidemic's effective reproductive number (Re) and rate of becoming uninfectious (δ). We identified 12 transmission clusters in Odessa; phylogenetic clustering was correlated with younger age and higher average viral load at the time of sampling. Estimated Re were similar in Odessa and Kyiv before the initiation of TRIP; Re started to decline in 2013 and is now below Re = 1 in Odessa (Re = 0.4, 95%HPD 0.06-0.75), but not in Kyiv (Re = 2.3, 95%HPD 0.2-5.4). Similarly, estimates of δ increased in Odessa after the initiation of TRIP. Given that both cities shared the same HIV prevention programs in 2013-2019, apart from TRIP, the observed changes in transmission parameters are likely attributable to the TRIP intervention. We propose that molecular epidemiology analysis can be used as a post-intervention effectiveness assessment tool.

People with high HIV viral load within risk networks: who are these people and who refers them best?

Introduction: Viral load is one of the most important determinants for HIV transmission. Identification of people with high viral load (PHVL) can be effective in limiting onward HIV transmission. In order to improve the identification of these individuals within risk networks, we determined a) the number of PHVL recruited through risk networks b) their socio-demographic, behavioural and clinical characteristics and c) the characteristics of individuals who referred these PHVL to the study. Methodology: From November 2013 to March 2016, in Odessa, Ukraine, Transmission Reduction Intervention Project (TRIP) was implemented to identify people recently infected with HIV within the risk networks of "seeds" and "venues" where they engaged in risk behaviour. Results: TRIP identified 53 PHVL, of whom 32 (60%) injected drugs; 42 (79%) were unaware of their HIV status; 25 (47%) had more than one sex partner, and only 14 (26%) were using condoms. There were 164 people who referred individuals into the study; 33 of them (20%) referred PHVL. In terms of referrers, those with lower than secondary level of education, not living with a sex partner, and reporting regular condom use were significantly more likely (p < 0.05) to refer PHVL. Most PHVL (38, 72%) and their referrers (27, 82%) were found through venues. Conclusions: In Odessa city, PHVL are at high risk of transmitting HIV as the majority inject drugs, do not know their HIV status, and have unprotected sex and/or multiple partners. Targeting these individuals for HIV prevention, harm reduction and initiation of antiretroviral treatment (ART) is urgent.

Social network approaches to locating people recently infected with HIV in Odessa, Ukraine.

INTRODUCTION: This paper examines the extent to which an intervention succeeded in locating people who had recently become infected with HIV in the context of the large-scale Ukrainian epidemic. Locating and intervening with people who recently became infected with HIV (people with recent infection, or PwRI) can reduce forward HIV transmission and help PwRI remain healthy. METHODS: The Transmission Reduction Intervention Project (TRIP) recruited recently-infected and longer-term infected seeds in Odessa, Ukraine, in 2013 to 2016, and asked them to help recruit their extended risk network members. The proportions of network members who were PwRI were compared between TRIP arms (i.e. networks of recently-infected seeds vs. networks of longer-term infected seeds) and to the proportion of participants who were PwRI in an RDS-based Integrated Biobehavioral Surveillance of people who inject drugs in 2013. RESULTS: The networks of PwRI seeds and those of longer-term infected seeds had similar (2%) proportions who were themselves PwRI. This was higher than the 0.25% proportion in IBBS (OR = 7.80; p = 0.016). The odds ratio among the subset of participants who injected drugs was 11.17 (p = 0.003). Cost comparison analyses using simplified ingredients-based methods found that TRIP spent no more than US $4513 per PwRI located whereas IBBS spent $11,924. CONCLUSIONS: Further research is needed to confirm these results and improve TRIP further, but our findings suggest that interventions that trace the networks of people who test HIV-positive are a cost-effective way to locate PwRI and reduce HIV transmission and should therefore be implemented.

HIV testing behaviour and HIV prevalence among female sex workers in Ukraine: findings from an Integrated Bio-Behavioural Survey, 2013-2014.

OBJECTIVES: Ukraine has one of the largest HIV epidemics in Europe, with high prevalence among female sex workers (FSWs). We aimed to identify factors associated with HIV testing and receipt of the test result in the last 12 months, HIV prevalence and self-reported positive status among FSWs in Ukraine. METHODS: We used data from an Integrated Bio-Behavioural Survey among FSWs conducted in 2013-2014. The survey methodology combined three sampling strategies: time and location sampling, respondent-driven sampling and key informant recruitment. We used multivariable regression to identify factors associated with self-reported HIV testing in the last 12 months, HIV prevalence and self-reported positive status among FSWs living with HIV. Explored factors included: age, age at first sex, age at entry into sex work, education, marital status, employment status beside sex work, condom use with last paying or non-paying sexual partner, drug or alcohol consumption and sex work venue. RESULTS: Recent HIV testing was low overall with only 63.2% of FSWs reported having tested and received their test result in the last 12 months prior to the survey. HIV prevalence was 7.1% overall, but only 45.0% of FSWs living with HIV were aware of their HIV status. Testing in the last 12 months with receipt of test result was less common among FSWs who used drugs ever in life (adjusted OR (AOR) 0.7, 95% CI 0.6 to 0.9), women soliciting clients indoors (AOR 0.8, 95% CI 0.7 to 0.9) and those not using a condom with last paying sexual partner (AOR 0.3, 95% CI 0.2 to 0.5). HIV positivity was associated with history of ever using drugs (AOR 2.3, 95% CI 1.4 to 3.6) and soliciting clients outdoors (AOR 1.5, 95% CI 1.1 to 2.0). Women working indoors were less aware of their positive status (AOR 0.1, 95% CI 0.1 to 0.9). CONCLUSION: HIV prevalence is high among FSWs in Ukraine, and testing and knowledge of one's status remain insufficient. HIV testing programmes need to expand with strategies to reach specific subgroups of FSWs.

A Network Intervention to Locate Newly HIV Infected Persons Within MSM Networks in Chicago.

Individuals with recent/acute HIV-infection have an increased likelihood of disease transmission. To evaluate effectiveness of identifying recent infections, we compared networks of recently and long-term HIV-infected individuals. The Transmission Reduction Intervention Project included two separate arms of recruitment, networks of recently HIV-infected individuals and networks of long-term HIV-infected individuals. Networks of each were recruited and tested for HIV and syphilis infection. The per-seed yield ratios of recruitment were compared between arms. Overall, 84 (41.6%) of 202 participants were identified as HIV-positive. HIV prevalence was higher (p < 0.001) among networks of recent seeds (33/96, 34.4%) compared to long-term seeds (6/31, 19.4%). More individuals were identified with active syphilis infection (p = 0.007) among networks of recent seeds (15/96, 15.6%), compared to networks of long-term seeds (3/31, 9.7%). Network-based recruitment of recently HIV-infected individuals was more effective at identifying HIV and syphilis infection. Allocation of public health resources may be improved by targeting interventions toward networks of recently HIV-infected individuals.

Linking intravenous drug users to treatment through non-governmental organizations in Ukraine: how well is it working?

INTRODUCTION: Alliance for Public Health, the International Charitable Foundation, coordinates HIV prevention in Non-Governmental Organizations (NGO) working with people who inject drugs (PWID) in Ukraine. We aimed to describe the performance of the differential model of linking PWID to HIV care and treatment (Community Initiated Treatment Intervention - CITI). METHODOLOGY: A retrospective cohort study using routine program data was conducted among 8,927 PWID who were tested positive for the first time during January 2016 - June 2017. Study outcomes were enrollment into CITI and initiating antiretroviral treatment (ART). Factors associated with outcomes were estimated by logistic regressions with random effects. RESULTS: Among the study participants, 54% enrolled into CITI and 23% initiated ART. CITI enrolment was associated with being married (adjusted odds ratio (AOR) = 1.17; 95%: 1.02-1.34); less than weekly compared to daily (AOR = 1.31; 95%: 1.13-1.52); less than 5 years of drug use compared to > 14 years (AOR = 1.73; 95%: 1.40-2.13), and having no criminal records (AOR = 1.30; 95%: 1.12-1.50). Factors of non-ART initiation were male gender (AOR = 1.33; 95%: 1.16-1.53); being single (AOR = 1.48; 95%: 1.21-1.82); drug use duration > 14 years compared to < 5 years (AOR = 1.38; 95%: 1.03-1.85), unemployment (AOR = 1.45; 95%: 1.15-1.83) and history of incarceration (AOR = 1.21; 95%: 1.003-1.45). CONCLUSION: Mobilizing the NGO community and PWID to engage in outreach HIV testing activity and harm reduction for key populations has succeeded in opening the gateway to prevention, care and ART for thousands of PWID in Ukraine.

Engaging people who inject drugs and their peers in HIV testing and harm reduction in Ukraine: do they make a difference?

INTRODUCTION: People Who Inject Drugs (PWID) should be offered HIV-testing and harm reduction services. We assessed the effectiveness of including PWID and their peers in HIV-testing by comparing for a period before (2013-2014) and after their introduction (2015-2017), the a) numbers HIV tested b) number enrolled in harm reduction and c) frequency of HIV-testing. METHODOLOGY: An analysis of programme data involved PWID aged ≥ 14 years (1st January 2013-31st December 2017) in Ukraine. Between 2013-2014, HIV-testing (VCT) was done by trained health workers. From 2015, this was Directly Assisted HIV Self-testing (DAST) done by social workers and peers. Optimized HIV case finding (OCF) was introduced (in 2016) as an overlapping strategy with DAST. RESULTS: A total of 844,837 HIV tests were done with 23,427 (2.8%) HIV-positive results. With VCT, there were 164,417 HIV tests compared to 639,685 after engagement of PWID and their peers (>3-fold increase). The highest HIV positive yield (20%) was when OCF was included. With increasing HIV-testing caseload, a progressive decrease in enrollment in harm reduction was seen (85% in 2014 to 47% in 2017, X2 for trend P < 0.001). OCF resulted in enrollment into harm reduction of 2722 HIV-positives, which was 35% higher than through DAST alone (7,5%). HIV re-testing almost doubled with DAST. CONCLUSION: Active engagement of PWID and their peers in HIV-testing increased uptake of HIV-testing. Including OCF has a synergistic effect in HIV-positive yield. Strategies are urgently needed to ensure that individuals who are HIV tested are enrolled in harm reduction.

Incarceration history and risk of HIV and hepatitis C virus acquisition among people who inject drugs: a systematic review and meta-analysis.

BACKGROUND: People who inject drugs (PWID) experience a high prevalence of incarceration and might be at high risk of HIV and hepatitis C virus (HCV) infection during or after incarceration. We aimed to assess whether incarceration history elevates HIV or HCV acquisition risk among PWID. METHODS: In this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO databases for studies in any language published from Jan 1, 2000 until June 13, 2017 assessing HIV or HCV incidence among PWID. We included studies that measured HIV or HCV incidence among community-recruited PWID. We included only studies reporting original results and excluded studies that evaluated incident infections by self-report. We contacted authors of cohort studies that met the inclusion or exclusion criteria, but that did not report on the outcomes of interest, to request data. We extracted and pooled data from the included studies using random-effects meta-analyses to quantify the associations between recent (past 3, 6, or 12 months or since last follow-up) or past incarceration and HIV or HCV acquisition (primary infection or reinfection) risk among PWID. We assessed the risk of bias of included studies using the Newcastle-Ottawa Scale. Between-study heterogeneity was evaluated using the I2 statistic and the P-value for heterogeneity. FINDINGS: We included published results from 20 studies and unpublished results from 21 studies. These studies originated from Australasia, western and eastern Europe, North and Latin America, and east and southeast Asia. Recent incarceration was associated with an 81% (relative risk [RR] 1·81, 95% CI 1·40-2·34) increase in HIV acquisition risk, with moderate heterogeneity between studies (I2=63·5%; p=0·001), and a 62% (RR 1·62, 95% CI 1·28-2·05) increase in HCV acquisition risk, also with moderate heterogeneity between studies (I2=57·3%; p=0·002). Past incarceration was associated with a 25% increase in HIV (RR 1·25, 95% CI 0·94-1·65) and a 21% increase in HCV (1·21, 1·02-1·43) acquisition risk. INTERPRETATION: Incarceration is associated with substantial short-term increases in HIV and HCV acquisition risk among PWID and could be a significant driver of HCV and HIV transmission among PWID. These findings support the need for developing novel interventions to minimise the risk of HCV and HIV acquisition, including addressing structural risks associated with drug laws and excessive incarceration of PWID. FUNDING: Engineering and Physical Sciences Research Council, National Institute for Health Research, National Institutes of Health.

Pockets of HIV Non-infection Within Highly-Infected Risk Networks in Athens, Greece.

As part of a network study of HIV infection among people who inject drugs (PWID) and their contacts, we discovered a connected subcomponent of 29 uninfected PWID. In the context of a just-declining large epidemic outbreak, this raised a question: What explains the existence of large pockets of uninfected people? Possible explanations include "firewall effects" (Friedman et al., 2000; Dombrowski et al., 2017) wherein the only HIV+ people that the uninfected take risks with have low viral loads; "bottleneck effects" wherein few network paths into the pocket of non-infection exist; low levels of risk behavior; and an impending outbreak. We considered each of these. Participants provided information on their enhanced sexual and injection networks and assisted us in recruiting network members. The largest connected component had 241 members. Data on risk behaviors in the last 6 months were collected at the individual level. Recent infection was determined by LAg (SediaTM Biosciences Corporation), data on recent seronegative tests, and viral load. HIV RNA was quantified using Artus HI Virus-1 RG RT-PCR (Qiagen). The 29 members of the connected subcomponent of uninfected participants were connected (network distance = 1) to 17 recently-infected and 24 long-term infected participants. Fourteen (48%) of these 29 uninfected were classified as "extremely high risk" because they self-reported syringe sharing and had at least one injection partner with viral load >100,000 copies/mL who also reported syringe sharing. Seventeen of the 29 uninfected were re-interviewed after 6 months, but none had seroconverted. These findings show the power of network research in discovering infection patterns that standard individual-level studies cannot. Theoretical development and exploratory network research studies may be needed to understand these findings and deepen our understanding of how HIV does and does not spread through communities. Finally, the methods developed here provide practical tools to study "bottleneck" and "firewall" network hypotheses in practice.

Network Research Experiences in New York and Eastern Europe: Lessons for the Southern US in Understanding HIV Transmission Dynamics.

PURPOSE: This paper presents an overview of different kinds of risk and social network methods and the kinds of research questions each can address. RECENT FINDINGS: It also reviews what network research has discovered about how network characteristics are associated with HIV and other infections, risk behaviors, preventive behaviors, and care, and discusses some ways in which network-based public health interventions have been conducted. Based on this, risk and social network research and interventions seem both feasible and valuable for addressing the many public health and social problems raised by the widespread use of opioids in the US South.

Molecular Analysis of Human Immunodeficiency Virus Type 1 (HIV-1)-Infected Individuals in a Network-Based Intervention (Transmission Reduction Intervention Project): Phylogenetics Identify HIV-1-Infected Individuals With Social Links.

Background: The Transmission Reduction Intervention Project (TRIP) is a network-based intervention that aims at decreasing human immunodeficiency virus type 1 (HIV-1) spread. We herein explore associations between transmission links as estimated by phylogenetic analyses, and social network-based ties among persons who inject drugs (PWID) recruited in TRIP. Methods: Phylogenetic trees were inferred from HIV-1 sequences of TRIP participants. Highly supported phylogenetic clusters (transmission clusters) were those fulfilling 3 different phylogenetic confidence criteria. Social network-based ties (injecting or sexual partners, same venue engagement) were determined based on personal interviews, recruitment links, and field observation. Results: TRIP recruited 356 individuals (90.2% PWID) including HIV-negative controls; recently HIV-infected seeds; long-term HIV-infected seeds; and their social network members. Of the 150 HIV-infected participants, 118 (78.7%) were phylogenetically analyzed. Phylogenetic analyses suggested the existence of 13 transmission clusters with 32 sequences. Seven of these clusters included 14 individuals (14/32 [43.8%]) who also had social ties with at least 1 member of their cluster. This proportion was significantly higher than what was expected by chance. Conclusions: Molecular methods can identify HIV-infected people socially linked with another person in about half of the phylogenetic clusters. This could help public health efforts to locate individuals in networks with high transmission rates.

Molecular epidemiology reveals the role of war in the spread of HIV in Ukraine.

Ukraine has one of the largest HIV epidemics in Europe, historically driven by people who inject drugs (PWID). The epidemic showed signs of stabilization in 2012, but the recent war in eastern Ukraine may be reigniting virus spread. We investigated the movement of HIV-infected people within Ukraine before and during the conflict. We analyzed HIV-1 subtype-A pol nucleotide sequences sampled during 2012-2015 from 427 patients of 24 regional AIDS centers and used phylogeographic analysis to reconstruct virus movement among different locations in Ukraine. We then tested for correlations between reported PWID behaviors and reconstructed patterns of virus spread. Our analyses suggest that Donetsk and Lugansk, two cities not controlled by the Ukrainian government in eastern Ukraine, were significant exporters of the virus to the rest of the country. Additional analyses showed that viral dissemination within the country changed after 2013. Spearman correlation analysis showed that incoming virus flow was correlated with the number of HIV-infected internally displaced people. Additionally, there was a correlation between more intensive virus movement and locations with a higher proportion of PWID practicing risky sexual behaviors. Our findings suggest that effective prevention responses should involve internally displaced people and people who frequently travel to war-affected regions. Scale-up of harm reduction services for PWID will be an important factor in preventing new local HIV outbreaks in Ukraine.

Risk network approaches to locating undiagnosed HIV cases in Odessa, Ukraine.

INTRODUCTION: Providing HIV healthcare and Treatment as Prevention both depend on diagnosing HIV cases, preferably soon after initial infection. We hypothesized that tracing risk networks recruits higher proportions of undiagnosed positives than outreach-based testing or respondent-driven sampling (RDS) in Odessa, Ukraine. METHODS: The Transmission Reduction Intervention Project (TRIP) used risk network tracing to recruit sexual and injection networks of recently-infected and longer-term infected (LTs) seeds (2013 to 2016). Integrated Biobehavioural Surveillance (IBBS) (2013) used RDS to recruit people who inject drugs (PWID). Outreach Testing tested PWID for HIV at community outreach sites (2013 to 2016). Proportions of undiagnosed positives among those tested were compared TRIP versus IBBS; TRIP versus Outreach Testing and between TRIP arms. Costs were compared across the projects. RESULTS: TRIP tested 1252 people (21% women) in seeds' risk networks; IBBS tested 400 (18% women); Outreach Testing 13,936 (31% women). TRIP networks included a higher proportion of undiagnosed positives (14.6%) than IBBS (5.0%) or Outreach Testing (2.4%); odds ratio (OR) 3.25 (95% CI 2.07, 5.12) versus IBBS and 7.03 (CI 5.95, 8.31) versus Outreach Testing respectively. Findings remained significant in analyses stratified by sex and when PWID in TRIP networks were compared with Outreach Testing and IBBS. Within TRIP, recently-infected participants' networks contained higher proportions of undiagnosed positives (16.3%) than LTs' networks (12.2%); OR 1.41 (CI 1.01, 1.95). TRIP located undiagnosed positives less expensively than did RDS or Outreach Testing. CONCLUSIONS: TRIP's recruiting techniques, including prioritizing networks of the recently infected, find undiagnosed HIV-positive people efficiently. They should be integrated with standard practice to improve case-finding. Research should test these techniques in other socio-epidemiologic contexts. CLINICAL TRIAL REGISTRY: Registered ClinicalTrials.gov: NCT01827228.