Determinants of psychological distress during the COVID-19 pandemic among people who use drugs in Montreal, Canada.

INTRODUCTION: Limited data exists on psychological impacts of the COVID-19 pandemic among people who use drugs (PWUD). This study aimed to determine the prevalence and correlates of severe psychological distress (PD) among PWUD in Montreal around the beginning of the pandemic. METHODS: We conducted a rapid assessment study from May to December 2020 among PWUD recruited via a community-based cohort of people who inject drugs in Montreal (Hepatitis C cohort [HEPCO], N = 128) and community organisations (N = 98). We analysed self-reported data on changes in drug use behaviours and social determinants since the declaration of COVID-19 as a public health emergency, and assessed past-month PD using the Kessler K6 scale. Multivariable logistic regression was conducted to examine correlates of PD distress (score ≥13). RESULTS: Of 226 survey participants, a quarter (n = 56) were screened positive for severe PD. In multivariable analyses, age (1-year increment) (adjusted odds ratio = 0.94, 95% confidence interval [0.90, 0.98]) and a decrease in non-injection drug use versus no change (0.26 [0.07, 0.92]) were protective against severe PD, while positive associations were found for any alcohol use in the past 6 months (3.73 [1.42, 9.78]), increased food insecurity (2.88 [1.19, 6.93]) and both moving around between neighbourhoods more (8.71 [2.63, 28.88]) and less (3.03 [1.18, 7.74]) often compared to no change. DISCUSSION AND CONCLUSIONS: This study documented a high prevalence of severe PD among PWUD during the COVID-19 pandemic compared with pre-COVID-19 data. Social determinants such as food insecurity and mobility issues, alongside demographic and substance use-related factors, were linked to distress. Evidence-based risk mitigation strategies for this population could reduce negative consequences in future pandemics or disruptions.

HCV treatment initiation in the era of universal direct acting antiviral coverage - Improvements in access and persistent barriers.

BACKGROUND: Barriers to HCV treatment initiation persisted after the introduction of direct-acting antivirals (DAAs) in Canada among people who inject drugs (PWID); whether DAA universal coverage lifted these barriers remain unknown. We assessed the evolution of HCV treatment initiation and associated factors among PWID in Montreal, Canada, comparing eras of IFN-based regimens (2011-2013), of DAA restricted access (2014-02/2018), and universal coverage (03/2018-03/2020). METHODS: We included chronically HCV-infected participants followed in a community-based PWID cohort in Montreal, Canada between 2011 and 03/2020 and collected data at 3-month intervals. Time-updated Cox regressions were conducted to examine 9 variables of interest associated with treatment initiation overall and for each of the three eras. RESULTS: Of 276 participants, 126 initiated treatment during follow-up. Yearly initiation increased from 3% in 2011 to 19% in 2016, and 54% in 2018. PWID aged >40 (vs. ≤40) were twice as likely to initiate treatment in 2014-02/2018 (HR: 2.02 95%CI: [1.24-3.28]) but not in other periods (2011-2013: 0.55 [0.25-1.22]; 03/2018-03/2020: 1.14 [0.59-2.22])). Odds of initiation were lower for men than women in all periods, with women three times more likely to be treated under universal coverage (0.30 [0.11-0.77] vs 2011-2013: 0.67 [0.25-1.78] and 2014-02/2018: 0.75 [0.42-1.35]). Recent incarceration was negatively associated with initiation throughout all periods (2011-2013: 0.57 [0.13-2.43]; 2014-03/2018: 0.39 [0.17-0.91]; 03/2018-03/2020: 0.25 [0.07-0.83]). Barriers associated with high injection frequency appear to have diminished since DAA introduction (2014-02/2018: 0.71 [0.42-1.20]; 03/2018-03/2020: 1.05 [0.52-2.11] vs. 2011-2013: 0.26 [0.08-0.88]). Contact with a primary care physician and engagement in opioid agonist therapy were positively associated with treatment initiation, though estimates were attenuated under universal coverage relative to previous eras. CONCLUSION: Treatment initiation rates have increased since the introduction of universal DAA coverage, though barriers such as incarceration persist.

Ageing and older people who use illicit opioids, cocaine or methamphetamine: a scoping review and literature map.

AIMS: To provide an overview of research literature on ageing and older people who use illicit opioids and stimulants by documenting the conceptual frameworks used and content areas that have been investigated. METHODS: We conducted a scoping review of literature relating to ageing and older people who use illicit stimulants and opioids, defining 'older' as 40 years and above. Primary studies, secondary studies and editorials were included. Searches were conducted in PubMed and Embase in July 2020 and March 2021; the Cochrane library was searched in November 2021. Charted data included methodological details, any conceptual frameworks explicitly applied by authors and the content areas that were the focus of the publication. We developed a hierarchy of content areas and mapped this to provide a visual guide to the research area. RESULTS: Of the 164 publications included in this review, only 16 explicitly applied a conceptual framework. Seven core content areas were identified, with most publications contributing to multiple content areas: acknowledgement of drug use among older people (n = 64), health status (n = 129), health services (n = 109), drug use practices and patterns (n = 84), social environments (n = 74), the criminal legal system (n = 28) and quality of life (n = 15). CONCLUSIONS: The literature regarding older people who use illicit drugs remains under-theorized. Conceptual frameworks are rarely applied and few have been purposely adapted to this population. Health status and health services access and use are among the most frequently researched topics in this area.

A rapid review of the impacts of "Big Events " on risks, harms, and service delivery among people who use drugs: Implications for responding to COVID-19.

BACKGROUND: "Big Events" are major disruptions to physical, political, and economic environments that can influence vulnerability to drug-related harms. We reviewed the impacts of Big Events with relevance to the COVID-19 pandemic on drug-related risk and harms and access to drug treatment and harm reduction services. METHODS: We conducted a rapid review of quantitative, qualitative, and mixed methods literature relating to the following Big Events: respiratory infection pandemics, natural disasters, financial crises, and heroin shortages. Included studies reported data on changes to risks, harms, and/or service provisioning for people who use illicit drugs (other than cannabis) in the context of these Big Events. Searches were conducted in PubMed in May 2020, and two reviewers screened studies for inclusion. Peer-reviewed studies published in English or French were included. We used a narrative synthesis approach and mapped risk pathways identified in the literature. RESULTS: No studies reporting on respiratory infection pandemics were identified. Twelve studies reporting on natural disaster outcomes noted marked disruption to drug markets, increased violence and risk of drug-related harm, and significant barriers to service provision caused by infrastructure damage. Five studies of the 2008 global financial crisis indicated increases in the frequency of drug use and associated harms as incomes and service funding declined. Finally, 17 studies of heroin shortages noted increases in heroin price and adulteration, potentiating drug substitutions and risk behaviors, as well as growing demand for drug treatment. CONCLUSION: Current evidence reveals numerous risk pathways and service impacts emanating from Big Events. Risk pathway maps derived from this literature provide groundwork for future research and policy analyses, including in the context of the COVID-19 pandemic. In light of the findings, we recommend responding to the pandemic with legislative and financial support for the flexible delivery of harm reduction services, opioid agonist treatment, and mental health care.

The real-world impact of dosing of methadone and buprenorphine in retention on opioid agonist therapies in Ukraine.

BACKGROUND AND AIMS: Ukraine's HIV epidemic remains concentrated among opioid-dependent people who inject drugs (PWID) where opioid agonist therapies (OAT) like methadone (MMT) and buprenorphine (BMT) maintenance treatments are the most cost-effective HIV prevention strategies, but remain under-scaled. This study aimed to measure the association between dose and type of OAT prescribed and treatment retention. DESIGN: Observational longitudinal cohort study. PARTICIPANTS AND SETTING: Patients (n = 15 290) prescribed OAT throughout Ukraine from 2004 through 2016. MEASUREMENTS: Data were analyzed using time-event strategies to estimate cumulative treatment retention, defined as time to OAT discontinuation. Cumulative retention proportions at 1, 12 and 36 months were assessed for outcomes. Cox regression with log-rank likelihood assessed independent predictors of treatment discontinuation. FINDINGS: The proportion prescribed high (MMT: > 85 mg; BMT: ≥ 16 mg), medium (MMT: > 40-85 mg; BMT: > 6-15 mg) and low (MMT: ≤ 40 mg; BMT: ≤ 6 mg) dosages was 25, 43 and 32%, respectively. Retention was significantly higher for BMT than MMT both at 12 (89 versus 75%) and 36 months (80 versus 56%). Although dosing levels for BMT did not influence retention, increasing dosages for MMT were significantly associated with higher retention rates at 1 (90, 96, 99%), 12 (59, 78, 91%) and 36 (34, 59, 79%) months, respectively. Independent predictors associated with 12-month OAT discontinuation were medium [adjusted hazard ratio (aHR) = 2.23; 95% confidence limit (CL) = 1.95-2.54] and low (aHR = 4.96; 95% CL = 4.37-5.63) OAT dosage relative to high dosage, male sex (aHR = 1.27; 95% CL = 1.14-1.41), MMT relative to BMT prescription (aHR = 1.57; 95% CL = 1.32-1.87) and receiving OAT in general (aHR = 1.22; 95% CL = 1.02-1.46) or tuberculosis (aHR = 1.43; 95% CL = 1.10-1.85) hospitals, relative to specialty addiction treatment and AIDS center settings. Lower dosages contributed more to dropout especially at 1 month (aHR 3.12; 95% CL = 2.21-4.41 and aHR 7.71; 95% CL = 5.51-10.79 for medium and low dosages, respectively). Younger age was significantly associated with OAT discontinuation only at 36 months (aHR = 1.08; 95% CI = 1.02-1.15). CONCLUSIONS: Higher dosages of opioid agonist therapies, especially for methadone maintenance treatment patients, appear to be associated with higher levels of treatment retention in Ukraine.

Treating opioid dependence with extended-release naltrexone (XR-NTX) in Ukraine: Feasibility and three-month outcomes.

BACKGROUND: Although opioid agonist treatments (OAT) with methadone or buprenorphine are available to treat opioid use disorders (OUD) in Ukraine, OAT acceptability and coverage remains low. Extended-release naltrexone (XR-NTX) that recently became available as another treatment option provides new opportunities for treating OUDs in this region and we aimed to test its feasibility. METHODS: Patients with OUD (N=135) and interested in treatment with XR-NTX were initiated on monthly XR-NTX injections and monitored for three months. Correlates of 3-month retention on XR-NTX and drug use at each time-point using self-reports and urine drug testing (UDT) were assessed. RESULTS: Of the 134 participants initiated XR-NTX, 101 (75%) completed three months, defined as 4 consecutive XR-NTX injections. Independent factors negatively associated with retention in XR-NTX treatment included previous maintenance with OAT (aOR=0.3; 95%CI=0.1-0.9) and extrinsic help-seeking treatment motivation (aOR=0.7; 95%CI=0.5-0.9). Of these 101 participants completing three months of treatment, opioid use markedly reduced using self-report (67%% to 22%; p>0.001) and UDT (77% to 24%; p<0.001) outcomes over time. Alcohol, marijuana and stimulant use, however, remained unchanged. Craving for opioids and symptoms of depression also significantly decreased, while health-related quality of life scores improved over time. No adverse side effects were reported during the period of observation. CONCLUSION: The first introduction of XR-NTX in Ukraine among persons with OUD resulted in high levels of retention, marked reductions in opioid use and improved quality of life. These descriptive results suggest that XR-NTX treatment is feasible and well-tolerated over a 3-month period in Ukraine.

Transitioning from interferon-based to direct antiviral treatment options: A potential shift in barriers and facilitators of treatment initiation among people who use drugs?

BACKGROUND: Multiple barriers for accessing hepatitis C virus (HCV) treatment were identified during the interferon-based (IFN) treatment era for people who inject drugs (PWID). Whether these barriers persist since the introduction of IFN-free direct-acting antiviral (DAA) agents in Canada remains to be documented. This study examined temporal trends in HCV treatment initiation and associated factors during the transition from INF-based to all-oral DAA regimens. METHODS: The study population was drawn from a prospective cohort of PWID in Montreal, Canada. At three-month/one-year intervals between 2011 and 2017, participants with chronic HCV infection completed an interviewer-administered questionnaire on socio-demographic characteristics, drug use and health service utilisation, including HCV treatment. Time-updated Cox multivariate regression models, stratified by DAA + INF (2011-2013) and all-oral DAA (2014-2017) availability periods, were conducted to examine associations between time to HCV treatment initiation and associated barriers and facilitators. RESULTS: Of 308 participants (85% male, median age 42 [IQR: 33, 50]), 80 (26%) initiated HCV treatment during 915 person-years (PY). Incidence rates increased from 1.6 /100 PY (95%CI:0.9-2.6) in 2011 to 12.7 (10.6-15.1) in 2017 (p-trend = 0.0012). In multivariate analyses, visiting a primary care physician (2011-2013: aHR = 3.63[1.21-10.9]; 2014-2017: 2.52[1.10-5.77]) and frequent injection (0.23[0.05-0.99] and 0.49[0.24-0.99]) were consistently associated with treatment initiation. Participants aged >40 (2.27[1.24-4.13]), receiving opioid agonist therapy (OAT) (2.17[1.19-3.94]), and reporting prior HCV treatment (3.00[1.75-5.15]) were more likely to initiate treatment in the all-oral DAA period. CONCLUSION: Treatment initiation increased between 2011 and 2017, but still remains low among PWID. Primary care visiting was a key facilitator regardless of the period, while engagement in OAT and health services, indicated by prior HCV treatment, increased the likelihood of treatment initiation in the DAA era. These findings suggest that access to health services is essential but not enough to scale up treatment in this population.

Opioid Agonist Treatment and Improved Outcomes at Each Stage of the HIV Treatment Cascade in People Who Inject Drugs in Ukraine.

BACKGROUND: The HIV treatment cascade is a crucial tool to guide HIV prevention and treatment strategies. The extent to which opioid agonist treatments (OATs) such as methadone and buprenorphine influence this cascade was examined in a nationwide study of people who inject drugs (PWID) in Ukraine. SETTING: Cross-sectional stratified survey of PWID followed by HIV and hepatitis C virus testing in 5 Ukrainian cities. METHODS: Opioid-dependent PWID (N = 1613) were sampled from January 2014 to March 2015. Analysis was confined to 520 participants with HIV, with 184 (35.4%) prescribed OAT. Weighted logistic regression models were used to assess independent factors associated with the 5 steps in the HIV treatment cascade. RESULTS: Compared with PWID not on OAT (N = 336), participants who prescribed OAT (N = 184) were significantly more likely to be diagnosed (91% vs. 71%), linked (81% vs. 52%), and retained (69% vs. 35%) in HIV care, and prescribed (56% vs. 31%) and optimally (>95% of doses) adherent to antiretroviral therapy (41% vs. 22%). Receiving OAT contributed most as an independent factor with every step of the cascade. Other steps in the HIV treatment cascade were influenced by age, depression, and geographical variability. CONCLUSIONS: OAT remains an essential and effective strategy to not only treat patients with opioid use disorder, but also a crucial strategy to engage PWID in care to meet UNAIDS 90-90-90 targets. Geographical differences suggest local structural impediments. With low OAT coverage prescribed for 2.9% of the estimated 347,000 PWID in Ukraine, OAT expansion requires strategic interventions that target the individual, clinical care settings, policies, and funding.

The Effectiveness and Cost-Effectiveness of Hepatitis C Screening for Migrants in the EU/EEA: A Systematic Review.

Chronic hepatitis C (HCV) is a public health priority in the European Union/European Economic Area (EU/EEA) and is a leading cause of chronic liver disease and liver cancer. Migrants account for a disproportionate number of HCV cases in the EU/EEA (mean 14% of cases and >50% of cases in some countries). We conducted two systematic reviews (SR) to estimate the effectiveness and cost-effectiveness of HCV screening for migrants living in the EU/EEA. We found that screening tests for HCV are highly sensitive and specific. Clinical trials report direct acting antiviral (DAA) therapies are well-tolerated in a wide range of populations and cure almost all cases (>95%) and lead to an 85% lower risk of developing hepatocellular carcinoma and an 80% lower risk of all-cause mortality. At 2015 costs, DAA based regimens were only moderately cost-effective and as a result less than 30% of people with HCV had been screened and less 5% of all HCV cases had been treated in the EU/EEA in 2015. Migrants face additional barriers in linkage to care and treatment due to several patient, practitioner, and health system barriers. Although decreasing HCV costs have made treatment more accessible in the EU/EEA, HCV elimination will only be possible in the region if health systems include and treat migrants for HCV.

The effectiveness and cost-effectiveness of screening for latent tuberculosis among migrants in the EU/EEA: a systematic review.

BackgroundMigrants account for a large and growing proportion of tuberculosis (TB) cases in low-incidence countries in the European Union/European Economic Area (EU/EEA) which are primarily due to reactivation of latent TB infection (LTBI). Addressing LTBI among migrants will be critical to achieve TB elimination. Methods: We conducted a systematic review to determine effectiveness (performance of diagnostic tests, efficacy of treatment, uptake and completion of screening and treatment) and a second systematic review on cost-effectiveness of LTBI screening programmes for migrants living in the EU/EEA. Results: We identified seven systematic reviews and 16 individual studies that addressed our aims. Tuberculin skin tests and interferon gamma release assays had high sensitivity (79%) but when positive, both tests poorly predicted the development of active TB (incidence rate ratio: 2.07 and 2.40, respectively). Different LTBI treatment regimens had low to moderate efficacy but were equivalent in preventing active TB. Rifampicin-based regimens may be preferred because of lower hepatotoxicity (risk ratio = 0.15) and higher completion rates (82% vs 69%) compared with isoniazid. Only 14.3% of migrants eligible for screening completed treatment because of losses along all steps of the LTBI care cascade. Limited economic analyses suggest that the most cost-effective approach may be targeting young migrants from high TB incidence countries. Discussion: The effectiveness of LTBI programmes is limited by the large pool of migrants with LTBI, poorly predictive tests, long treatments and a weak care cascade. Targeted LTBI programmes that ensure high screening uptake and treatment completion will have greatest individual and public health benefit.

The effectiveness and cost-effectiveness of screening for active tuberculosis among migrants in the EU/EEA: a systematic review.

BACKGROUND: The foreign-born population make up an increasing and large proportion of tuberculosis (TB) cases in European Union/European Economic Area (EU/EEA) low-incidence countries and challenge TB elimination efforts. Methods: We conducted a systematic review to determine effectiveness (yield and performance of chest radiography (CXR) to detect active TB, treatment outcomes and acceptance of screening) and a second systematic review on cost-effectiveness of screening for active TB among migrants living in the EU/EEA. Results: We identified six systematic reviews, one report and three individual studies that addressed our aims. CXR was highly sensitive (98%) but only moderately specific (75%). The yield of detecting active TB with CXR screening among migrants was 350 per 100,000 population overall but ranged widely by host country (110-2,340), migrant type (170-1,192), TB incidence in source country (19-336) and screening setting (220-1,720). The CXR yield was lower (19.6 vs 336/100,000) and the numbers needed to screen were higher (5,076 vs 298) among migrants from source countries with lower TB incidence (≤ 50 compared with ≥ 350/100,000). Cost-effectiveness was highest among migrants originating from high (> 120/100,000) TB incidence countries. The foreign-born had similar or better TB treatment outcomes than those born in the EU/EEA. Acceptance of CXR screening was high (85%) among migrants. Discussion: Screening programmes for active TB are most efficient when targeting migrants from higher TB incidence countries. The limited number of studies identified and the heterogeneous evidence highlight the need for further data to inform screening programmes for migrants in the EU/EEA.

Concurrent drug injection during opioid agonist treatment among people who inject drugs in Ukraine.

Ongoing drug use during opioid agonist treatment (OAT) negatively affects treatment and health outcomes, and increases treatment dropout. This study aimed to examine correlates of concurrent illicit drug use among OAT patients in Ukraine. A random sample of 434 patients currently on OAT receiving buprenorphine (BMT) or methadone maintenance treatment (MMT) from five cities in Ukraine were assessed for factors associated with self-reported concurrent illicit drug use during OAT using a multivariable logistic regression. Among 434 OAT patients, 100 (23%) reported concurrent drug injecting in the previous 30 days; 28% of these were injecting ≥20 days. While 100 (100%) of these injected opioids, 24 (24%) injected stimulants; 40 (40%) met criteria for polysubstance use disorder that included opioids, stimulants and alcohol. Independent correlates of concurrent drug injection included: being on MMT vs. BMT (aOR = 2.8, 95%CI = 1.4-5.8), lower OAT dosage (aOR = 1.7, 95%CI = 1.1-2.7), more severe addiction severity (aOR = 2.3, 95%CI = 1.4-3.8), younger age of injection initiation (aOR = 2.3, 95%CI = 1.3-3.9), and presence of alcohol use disorder (aOR = 2.1, 95%CI = 1.3-3.5); participants living with parents were negatively associated with concurrent drug injection. Concurrent drug use was prevalent among OAT patients in Ukraine indicating the urgent needs for tailored interventions and changes in OAT program design and implementation. Results highlight the importance of prescribing an adequate OAT dosage, and discrepancies between MMT and BMT programs in Ukraine addressing needs of OAT patients with specific characteristics such as severe opioid and alcohol dependence.

A qualitative assessment of attitudes about and preferences for extended-release naltrexone, a new pharmacotherapy to treat opioid use disorders in Ukraine.

Numerous individual barriers, including negative attitudes toward opioid agonist therapies (OAT), have undermined HIV prevention efforts in Ukraine where the epidemic is concentrated in people who inject drugs (PWID). The recent availability of extended-release naltrexone (XR-NTX), an opioid antagonist, provides new opportunities for treatment and prevention, but little is known about patient preferences. We conducted qualitative analysis using focus groups (FG) of PWID recruited based on OAT experience: currently, previously, and never on OAT in five Ukrainian cities. FG included 199 PWID in 25 focus groups. Focus group transcripts were coded and analyzed using a modified grounded theory approach to identify common themes and domains related to attitudes about and preferences for XR-NTX, relative to other treatments. Interest in XR-NTX was supported if supervised opioid withdrawal and psychological support were assured. Other factors supporting XR-NTX included a focus on younger PWID early in their injection career and motivated for recovery. Perceptions of recovery included not receiving psychoactive medications like methadone or buprenorphine. With more information, XR-NTX could be a viable option for PWID in Ukraine, especially if concerns regarding withdrawal and psychological support are adequately addressed.

Addressing hepatitis C in the foreign-born population: A key to hepatitis C virus elimination in Canada.

Hepatitis C virus (HCV) is the leading cause of death from infectious disease in Canada. Immigrants are an important group who are at increased risk for HCV; they account for a disproportionate number of all HCV cases in Canada (~30%) and have approximately a twofold higher prevalence of HCV (~2%) than those born in Canada. HCV-infected immigrants are more likely to develop cirrhosis and hepatocellular carcinoma and are more likely to have a liver-related death during a hospitalization than HCV-infected non-immigrants. Several factors, including lack of routine HCV screening programs in Canada for immigrants before or after arrival, lack of awareness on the part of health practitioners that immigrants are at increased risk of HCV and could benefit from screening, and several patient- and health system-level barriers that affect access to health care and treatment likely contribute to delayed diagnosis and treatment uptake. HCV screening and engagement in care among immigrants can be improved through reminders in electronic medical records that prompt practitioners to screen for HCV during clinical visits and implementation of decentralized community-based screening strategies that address cultural and language barriers. In conclusion, early screening and linkage to care for immigrants from countries with an intermediate or high prevalence of HCV would not only improve the health of this population but will be key to achieving HCV elimination in Canada. This article describes the unique barriers encountered by the foreign-born population in accessing HCV care and approaches to overcoming these barriers.

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.

Willingness to pay for opioid agonist treatment among opioid dependent people who inject drugs in Ukraine.

BACKGROUND: In the context of decreasing external and limited Ukrainian governmental funding for opioid agonist treatments (OAT) for opioid dependent people who inject drugs in Ukraine, information on sustainable financial models is needed. METHODS: Data on 855 opioid dependent people who inject drugs (PWID) were drawn from a cross-sectional nationwide survey of 1613 PWID. They comprised 434 participants who were receiving OAT and 421 who were on OAT in the past or have never been on OAT and were interested in receiving the treatment. Multivariate logistic regression was used to examine factors associated with willingness-to-pay (WTP) for OAT, stratified by OAT experience. Variation in the price which respondents were willing to pay for OAT and its effect on their monthly income among PWID with different OAT experience were assessed as a continuous variable using one-way ANOVA and Kruskal-Wallis test. RESULTS: Overall, 378 (44%) expressed WTP for OAT. Factors independently associated with WTP differed by OAT experience. Among those using OAT, independent predictors of WTP included: city (Dnipro - aOR=1.9; 95%CI=1.1-4.8 and Lviv - (aOR=2.2; 95%CI=1.1-4.8) compared to those elsewhere in Ukraine), higher income (aOR=1.8; 95%CI=1.2-2.7) and receiving psychosocial counseling (aOR=1.8; 95%CI=1.2-2.7). Among those who had previously been on OAT, positive attitude towards OAT (aOR=1.3; 95%CI=1.1-1.6) and family support of OAT (aOR=2.5; 95%CI=1.1-5.7) were independently associated with WTP. Among PWID who had never been on OAT, being male (aOR=2.2; 95%CI=1.1-4.2), younger age (aOR=1.9; 95%CI=1.2-3.2), higher income (aOR=2.0; 95%CI=1.2-3.4) and previous unsuccessful attempts to enter OAT (aOR=2.3; 95%CI=1.1-4.7) were independently associated with WTP. PWID were willing to commit a large percentage of their monthly income for OAT, which, however, varied significantly based on OAT experience: current OAT: 37% of monthly income, previous OAT: 53%, and never OAT: 60% (p-value=0.0009). CONCLUSIONS: WTP for OAT was substantial among PWID in Ukraine, supporting the implementation of self-pay or co-payment programs. Such strategies, however, must remain affordable, provide better access to OAT, and consider specific needs of PWID.

Trends in Injection Risk Behaviors among People Who Inject Drugs and the Impact of Harm Reduction Programs in Ukraine, 2007-2013.

The study examined trends in injection risk behaviors among people who inject drugs (PWIDs) and assessed the impact of harm reduction programs in Ukraine during 2007-2013. We performed a secondary analysis of the data collected in serial cross-sectional bio-behavioral surveillance surveys administered with PWIDs in Ukraine in 2007, 2008, 2011, and 2013. Using data from 14 Ukrainian cities, we assessed short-term trends in injection risk behaviors with the Cochran-Armitage test for trend and multivariable logistic regression models, adjusted for age, sex, region, marital status, education level, occupation, age at injection drug use initiation, experience of overdose, and self-reported HIV status. The overall test for trend indicated a statistically significant decrease over time for sharing needle/syringe during the last injection (p < 0.0001), sharing needle/syringe at least once in the last 30 days (p < 0.0001), and using a common container for drug preparation (p < 0.0001). The prevalence of injecting drugs from pre-loaded syringes was high (61.0%) and did not change over the study period. After adjusting for all significant confounders and comparing to 2007, the prevalence of sharing needle/syringe during the last injection was unchanged in 2008 (OR = 1.06, 95% CI = 0.92, 1.21), and declined in 2011 (OR = 0.18, 95% CI = 0.15, 0.22) and 2013 (OR = 0.17, 95% CI = 0.14, 0.21). Sharing needles/syringes in the last 30 days significantly decreased when compared to that in 2007 (2008: OR = 0.81, 95% CI = 0.74, 0.89; 2011: OR = 0.43, 95% CI = 0.38, 0.47; and 2013: OR = 0.31, 95% CI = 0.27, 0.35). The prevalence of using common instruments for drug preparation also decreased compared to that in 2007 (2008: OR = 0.88, 95% CI = 0.85, 0.91; 2011: OR = 0.85, 95% CI = 0.85, 0.90; and 2013: OR = 0.74, 95% CI = 0.71, 0.76). The observed reduction in the prevalence of injection risk behavior over time is encouraging. Our findings suggest that prevention programs in Ukraine have positive impact and provide support for governmental expansion of these programs.

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.

The Future of Opioid Agonist Therapies in Ukraine: A Qualitative Assessment of Multilevel Barriers and Ways Forward to Promote Retention in Treatment.

Opioid agonist therapies (OAT) to treat opioid addiction in people who inject drugs (PWID) began in Ukraine in 2004. Scale-up of OAT, however, has been hampered by both low enrollment and high attrition. To better understand the factors influencing OAT retention among PWID in Ukraine, qualitative data from 199 PWIDs were collected during 25 focus groups conducted in five Ukrainian cities from February to April 2013. The experiences of PWID who were currently or previously on OAT or currently trying to access OAT were analyzed to identify entry and retention barriers encountered. Transcribed data were analyzed using a grounded theory approach. Individual beliefs about OAT, particularly misaligned treatment goals between clients and providers, influenced PWID's treatment seeking behaviors. Multiple programmatic and structural issues, including inconvenient hours and treatment site locations, complicated dosing regimens, inflexible medication dispensing guidelines, and mistreatment by clinic and medical staff also strongly influenced OAT retention. Findings suggest the need for both programmatic and policy-level structural changes such as revising legal regulations covering OAT dispensing, formalizing prescription dosing policies and making OAT more available through other sites, including primary care settings as a way to improve treatment retention. Quality improvement interventions that target treatment settings could also be deployed to overcome healthcare delivery barriers. Additional patient education and medical professional development around establishing realistic treatment goals as well as community awareness campaigns that address the myths and fears associated with OAT can be leveraged to overcome individual, family and community-level barriers.