A mixed methods exploration of injection drug use risk behaviors and place-based norms in Ukraine.

INTRODUCTION: Despite global reductions in HIV incidence and significant investment in local harm reduction services, Ukraine continues to experience high HIV and HCV prevalence among people who inject drugs (PWID). Place-based factors and social norms affect drug use-related risk factors, but research has paid little attention to the relationship between drug use practices and place in Ukraine, including how these factors may contribute to or protect against HIV/HCV risk. METHODS: This project used a sequential mixed methods design. Between March and August 2018, we interviewed 30 PWID in Dnipro, Ukraine. Participants completed a single in-depth interview in which they described where and with whom they lived; how they generated income; and where, when, how, and with whom they purchased and used drugs. Between May 2019 and March 2020, we recruited 150 PWID in Dnipro to complete a survey that was designed based on interview findings and consisted of three components: an activity space inventory, an egocentric social network inventory, and an HIV risk behavior assessment. RESULTS: Both interview and survey respondents reported consistent use of pharmacies to acquire syringes and nearly universal use of new syringes when injecting. Interview participants reflected that while syringe sharing was previously considered a "common practice," PWID now viewed it as infrequent and unacceptable. However, interview respondents enumerated the contexts in which needle and syringe reuse occurred, including purchasing drugs directly from a dealer and chipping in with other PWID to prepare drugs bought through a stash. CONCLUSION: Participants described relatively easy access to new needles and syringes through pharmacies and expressed strong social sanctioning against reusing needles or syringes. However, equipment sharing behaviors and norms persisted in certain contexts, creating an opportunity for further harm reduction campaigns that incorporate changing norms in these situations to "close the gap" and further reduce HIV and other infections among PWID.

Qualitative exploration of the early experiences of opioid use disorder patients from private clinics after Russia's invasion of Ukraine in five major cities in Ukraine.

Introduction: Following the full-scale invasion of Ukraine by the Russian Federation on 24 February 2022, over 6,000 patients were at risk of potential disruptions in treatment with medications for opioid use disorder (MOUD) in Ukraine. Before 2022, privatized MOUD clinics had emerged, partly driven by restrictive governmental policies and practices in state-funded facilities. Nevertheless, scant information exists regarding their operation and the patient's experiences, especially during crises. This study seeks to elucidate the initial lived experiences of patients utilizing private MOUD clinics, integrating these insights with an analysis of the responding health system during war. Methods: The findings are derived from 20 qualitative semi-structured interviews conducted between March and June 2022, engaging participants from five major Ukrainian cities: Kharkiv, Kyiv, Odesa, Poltava, and Zaporizhzhya. Employing a rapid analysis procedure, we examined the data through descriptive and analytical summaries aligned with the domains of the data collection instrument. Results: Emergent themes encompassed stress and uncertainty following the invasion's onset, challenges accessing MOUD, and consequent perceptions concerning state-funded versus private clinics. The study identified disruptions in the operation of private MOUD clinics across most cities examined. Issues pertaining to MOUD medication availability were linked to dosage reductions at state-funded clinics or pharmacy medication shortages or closures. Despite varied experiences at different MOUD clinics and cities, most participants continued their treatment. Discussion: This qualitative exploration provides a perspective on lived experiences with MOUD treatment at private clinics amidst the initial months of the invasion, illuminating how the early days' stress, access challenges, varied responses from private MOUD clinics, and precarious conditions informed or altered preferences regarding MOUD treatment options. Moreover, these findings corroborate previously documented efforts by myriad stakeholders to mitigate war-related disruptions to MOUD delivery. These insights contribute to the international understanding of health system navigation and resilience during major crises, offering valuable lessons for preparedness development.

The development and initial validation of the Russian version of the BASIS-24.

BACKGROUND: Efficient and linguistically appropriate instruments are needed to assess response to addiction treatment, including severity of addiction/mental health status. This is critical for Russian-speaking persons in Eastern Europe and Central Asia (EECA) where Medications for Opioid Use Disorder (MOUD) remain underscaled to address expanding and intertwined opioid, HIV, HCV and tuberculosis epidemics. We developed and conducted a pilot validation of a Russian version of the 24-item Behavior and Symptom Identification Scale (BASIS-24), an addiction/mental health severity instrument with six subscales, previously validated in English. METHODS: Using the Mapi approach, we reviewed, translated, and back-translated the content to Russian, pilot-tested the Russian-version (BASIS-24-R) among new MOUD patients in Ukraine (N = 283). For a subset of patients (n = 44), test-rest was performed 48 h after admission to reassess reliability of BASIS-24-R. Exploratory principal component analysis (PCA) assessed underlying structure of BASIS-24-R. RESULTS: Cronbach alpha coefficients for overall BASIS-24-R and 5 subscales exceeded 0.65; coefficient for Relationship subscale was 0.42. The Pearson correlation coefficients for overall score and all subscales on the BASIS-24-R exceeded 0.8. Each item loaded onto factors that corresponded with English BASIS-24 subscales ≥ 0.4 in PCA. CONCLUSION: Initial version of BASIS-24-R appears statistically valid in Russian. Use of the BASIS-24-R has potential to guide MOUD treatment delivery in the EECA region and help to align addiction treatment with HIV prevention goals in a region where HIV is concentrated in people who inject opioids and where healthcare professionals have not traditionally perceived MOUD as effective treatment, particularly for those with mental health co-morbidities.

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

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

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.

Factors Associated with Likelihood of Initiating Others into Injection Drug Use Among People Who Inject Drugs in West Virginia.

People who inject drugs (PWID) play a critical role in injection-naïve individuals transitioning to injection drug use. We investigated factors associated with future likelihood of initiating injection-naïve individuals using multivariable logistic regression among 418 PWID in rural Appalachia (Cabell County, West Virginia). Less than 10% reported they were likely to initiate someone in the future. Acquiring syringes from a syringe services program was associated with decreased odds of being likely to initiate someone in the future (adjusted odds ratio [aOR] 0.46, 95% CI 0.23, 0.95), while having previously initiated someone into injection drug use was associated with increased odds (aOR 8.65, 95% CI 4.07, 18.41). Among our sample of PWID in Appalachia, a small proportion reported that they would be likely to initiate an injection-naïve individual in the future. Efforts to reduce injection initiation assistance should focus on this subpopulation of PWID who indicate a willingness to engage in this behavior.

Factors Associated with Sterile Syringe Acquisition among People Who Inject Drugs in West Virginia.

BACKGROUND: Syringe services programs (SSPs) are evidence-based interventions that provide essential overdose and infectious disease prevention resources to people who inject drugs (PWID). Little research has examined factors associated with sterile syringe acquisition at SSPs among rural PWID populations. OBJECTIVES: We aim to identify factors associated with PWID in a rural county in West Virginia having recently acquired sterile syringes at an SSP. METHODS: PWID (n = 420) completed a survey that included measures related to sociodemographics, structural vulnerabilities, and substance use. We used multivariable Poisson regression with robust variance estimation to examine independent associations with sterile syringe acquisition at an SSP. RESULTS: Sixty-five percent of our sample reported having recently acquired sterile syringes at an SSP. Factors associated with recent sterile syringes acquisition at an SSP included: being older (aPR [adjusted prevalence ratio]: 1.011, 95% CI: 1.003-1.019), single (aPR: 0.862, 95% CI: 0.755-0.984), experiencing food insecurity (aPR: 1.233, 95% CI: 1.062-1.431), recently injecting fentanyl (aPR: 1.178, 95% CI: 1.010-1.375) and prescription opioid pain relievers (aPR: 0.681, 95% CI: 0.551-0.842), and recent naloxone acquisition (aPR: 1.360; 95% CI: 1.178-1.569). Receptive syringe sharing was inversely associated with acquiring sterile syringes at an SSP (aPR: 0.852; 95% CI: 0.741-0.979). CONCLUSION: PWID accessing sterile syringes at an SSP was associated with several sociodemographic, structural, and substance use factors. Ensuring rural SSP operations are tailored to local PWID population-level needs is paramount to the prevention of infectious disease outbreaks and overdose fatalities.

Trends in overdose experiences and prevention behaviors among people who use opioids in Baltimore, MD, 2017-2019.

BACKGROUND: Little is known about trends in overdose behaviors. This study explored non-fatal overdose and engagement in overdose prevention behaviors and compared these trends to city-wide overdose fatality rates from 2017 to 2019 in Baltimore, MD. METHODS: The analysis included people who used opioids (PWUO; N = 502) recruited through a community-based study. Enrollment date was used to categorize participants into annual quarters. Logistic regression models examined change in overdose experiences and prevention behaviors with time. Baltimore's fatal overdoses were also mapped over the study period to assess overlaps in trends. RESULTS: The majority of the sample were male(68 %), Black(61 %), reported past 6 months homelessness(56 %), and were on average 45 years old. Most had witnessed(61 %), and 28 % had personally experienced an overdose in the past 6 months. Witnessing overdose marginally increased(aß = 0.182;p = 0.058) while experiencing overdose did not significantly change by enrollment quarter. Most participants had or had been prescribed naloxone(72 %), and one fifth(22 %) regularly carried naloxone, with both access to(aß = 0,408;p = 0.002) and carrying naloxone(aß = 0.302;p = 0.006) increasing over time. Overdose communication remained stable, with 63 % of participants reporting discussing overdose sometimes/often. Among participants who injected (n = 376), regularly injecting alone decreased(aß=-0.207;p = 0.055), and reporting others often/always having naloxone with them when injecting increased over time(aß = 0.573;p < 0.001). CONCLUSIONS: Witnessed overdose marginally increased from 2017 to 2019, aligning with city trends of fatal overdose. Overdose prevention behaviors significantly increased over time. Despite reporting having naloxone or a naloxone prescription, most PWUO did not regularly carry naloxone, and many used alone. Social network diffusion interventions may be a strategy to promote normative overdose prevention behaviors.

Past 12-month nonfatal overdose among people who inject drugs in Ukraine: City-level estimates and risk factors from a cross-sectional study.

BACKGROUND: Nonfatal overdose contributes to high morbidity and is among the strongest proxies for the occurrence of overdose fatality - the leading cause of death among those who use opioids. In Ukraine, a majority of people who inject drugs (PWID) use opioids, but little is known about the relationship between drug market characteristics, nonfatal overdose (NFOD) prevalence, and risk factors for NFOD. METHODS: We used cross-sectional respondent-driven sampling (RDS) data to explore the variability of recent (past 12 months) NFOD among PWID across Ukrainian cities and associations with individual factors. The population-averaged -cross-sectional associations were estimated and compared using generalized linear models for the binary outcome (NFOD vs. not) with robust variance estimates. RESULTS: Recent self-reported NFOD varied between 1% and 14 % across Ukrainian cities. In adjusted analyses, overdose was associated with fewer years of injecting drugs; a higher number of types of drugs used in the past 12 months; using desomorphine, methadone, tramadol, heroin, amphetamine-type drugs or cocaine within past 12 months; using alcohol daily or weekly; recent drug treatment; and history of incarceration. Buying drugs or their ingredients through "stashes" (i.e., drugs secretly hidden in various places) and the perception of drug price increase were associated with higher odds of reporting NFOD. CONCLUSION: The identified risk factors underscore the importance of evidence-based prevention efforts, such as scaling-up opioid agonist therapy, providing naloxone in the community and upon prison release, targeting those most likely to witness overdose and sharing overdose prevention strategies with them, and continuous monitoring of trends and contributing factors.

``Now it is mostly done through stashes, to do it in person one has to trust you'': Understanding the retail injection drug market in Dnipro, Ukraine.

Little research has been conducted in Ukraine since the 1990s to understand the organization of drug market and its implications for people who inject drugs (PWID). In this study, we explore how PWID perceive the retail drug market in a large Ukrainian city. Qualitative data were obtained during in-depth interviews and analyses included open coding, coding tree development and revision, axial coding, and identification of higher-level domains. Participants' narratives focused on types and forms of drugs available, perceptions about drug quality, methods of buying drugs, and the relationships that are formed and maintained by participating in the drug economy. The described technical organization of the drug market, with multiple contingent combinations of drug types, forms and means of obtaining drugs (hand-to-hand vs stash-based) resulted from diversification and digitalization of the retail injection drug market. The social organization of the drug market in the form of relationships with sellers and drug use partners represented the response to the fundamental problem of uncertainty. The lens of ``transaction cost'' helps explain strategies PWID used to manage uncertainties, including finding reliable and suitable sellers, sending money and picking up the stash under the threat of being stiffed or caught by the police, choosing the product itself, using the intermediaries to outsource risky operations and forming groups to procure and inject together. Our results indicate that the technical and social organization of drug distribution in Ukraine stimulates formation and continuation of relationships and impacts the choices of what, how, and when to inject beyond individual preferences. The policy and practice implications include the need to monitor and understand the retail drug market to develop and deliver more efficient and client-oriented services, incorporate and leverage social networks structure for information sharing and behavior change, pilot and implement drug testing services to assist with management of uncertainties.

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.

"You're nobody without a piece of paper:" visibility, the state, and access to services among women who use drugs in Ukraine.

In Ukraine, women constitute a third of all new HIV infections, and injection drug use accounts for nearly half of HIV infections among women. Women who use drugs (WWUD) often have diminished access to drug use treatment, HIV care, and other health and social services or underutilize women-specific services such as maternal health services. While interpersonal and contextual factors diminish access to and utilization of services among WWUD, rules, processes, and bureaucratic structures also systematically exclude women from accessing services and resources. Institutions, bureaucratic processes, and instruments of legibility such as documents regulate who can and cannot access services and raise questions about "deservingness." In this paper, we use the lens of bureaucracy to explore paperwork as a form of structural violence through its production of "legible" citizens, often through reinforcement of gender stereotypes and moral narratives of deservingness. Between December 2017 and October 2018, we interviewed 41 medical and social service providers and 37 WWUD in two Ukrainian cities. Our analysis revealed that requirements for internal passports and residency permits-the primary state apparatus through which rights to services are granted in Ukraine-compelled participants to continually render themselves visible to the state in order to receive services, despite financial, logistical and other challenges that undermined women's ability to obtain documents. These requirements exposed them to new forms of stigma and exclusion, such as reduced opportunities for employment and losing custody of children. Nongovernmental organizations, due to funding cuts, curtailed direct services such as support groups but became liaisons between clients and the state. They enforced new narratives of deservingness, such as the ability to define "good" behavior or reward social relationships with agency staff. Ukraine's current reforms to social safety net institutions present an opportunity to interrogate underlying assumptions about spheres of responsibility for the country's most marginalized and stigmatized groups.

Fentanyl Preference among People Who Inject Drugs in West Virginia.

Background: Overdose fatality rates in rural areas surpass those in urban areas with the state of West Virginia (WV) reporting the highest drug overdose death rate in 2017. There is a gap in understanding fentanyl preference among rural people who inject drugs (PWID). The aim of this study is to investigate factors associated with fentanyl preference among rural PWID in WV. Methods: This analysis uses data from a PWID population estimation study conducted in Cabell County, WV in June-July 2018. Factors associated with fentanyl preference were assessed using multivariable Poisson regression with a robust variance estimate. Results: Among PWID who reported having ever used fentanyl (n = 311), 43.4% reported preferring drugs containing fentanyl. Participants reported high levels of socioeconomic vulnerability, including homelessness (57.9%) and food insecurity (66.9%). Recent increases in drug use and injecting more than one drug in the past 6 months were reported by 27.0% and 84.2% of participants, respectively. In adjusted analyses, fentanyl preference was associated with being younger (PrR:0.98, 95% CI: 0.97-1.00), being female (PrR:1.45, 95% CI:1.14-1.83), being a Cabell county resident (PrR:0.60, 95% CI: 0.45-0.81), increased drug use in the past 6 months (PrR:1.28, 95% CI: 1.01-1.63), and injecting fentanyl in the past 6 months (PrR:1.89, 95% CI: 1.29-2.75). Conclusion: Fentanyl preference is highly prevalent among rural PWID in WV and associated with factors that may exacerbate overdose risks. There is an urgent need for increased access to tailored harm reduction services that address risks associated with fentanyl preference.

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.

Staying hepatitis C negative: A systematic review and meta-analysis of cure and reinfection in people who inject drugs.

BACKGROUND AND AIMS: Direct-acting antivirals (DAAs) are highly effective in treating hepatitis C. However, there is concern that cure rates may be lower, and reinfection rates higher, among people who inject drugs. We conducted a systematic review of treatment outcomes achieved with DAAs in  people who inject drugs (PWID). METHODS: A search strategy was used to identify studies that reported sustained viral response (SVR), treatment discontinuation, adherence or reinfection in recent PWID and/or opioid substitution therapy (OST) recipients. Study quality was assessed using the Newcastle-Ottawa Scale. Meta-analysis of proportions was used to estimate pooled SVR and treatment discontinuation rates. The pooled relative risk of achieving SVR and pooled reinfection rate were calculated using generalized mixed effects linear models. RESULTS: The search identified 8075 references; 26 were eligible for inclusion. The pooled SVR for recent PWID was 88% (95% CI, 83%-92%) and 91% (95% CI 88%-95%) for OST recipients. The relative risk of achieving SVR for recent PWID compared to non-recent PWID was 0.99 (95% CI, 0.94-1.06). The pooled treatment discontinuation was 2% (95% CI, 1%-4%) for both recent PWID and OST recipients. Amongst recent PWID, the pooled incidence of reinfection was 1.94 per 100 person years (95% CI, 0.87-4.32). In OST recipients, the incidence of reinfection was 0.55 per 100 person years (95% CI, 0.17-1.76). CONCLUSIONS: Treatment outcomes were similar in recent PWID compared to non-PWID treated with DAAs. People who report recent injecting or OST recipients should not be excluded from hepatitis C treatment.

Outcome evaluation of a "common factors" approach to develop culturally tailored HIV prevention interventions for people who inject drugs.

BACKGROUND: Current models of HIV prevention intervention dissemination involve packaging interventions developed in one context and training providers to implement that specific intervention with fidelity. Providers rarely implement these programs with fidelity due to perceived incompatibility, resource constraints, and preference for locally-generated solutions. Moreover, such interventions may not reflect local drug markets and drug use practices that contribute to HIV risk. PURPOSE: This paper examines whether provider-developed interventions based on common factors of effective, evidence-based behavioral interventions led to reduction in drug-related HIV risk behaviors at four study sites in Ukraine. METHODS: We trained staff from eight nongovernmental organizations (NGOs) to develop HIV prevention interventions based on a common factors approach. We then selected four NGOs to participate in an outcome evaluation. Each NGO conducted its intervention for at least N = 130 participants, with baseline and 3-month follow-up assessments. RESULTS: At three sites, we observed reductions in the prevalence of both any risk in drug acquisition and any risk in drug injection. At the fourth site, prevalence of any risk in drug injection decreased substantially, but the prevalence of any risk in drug acquisition essentially stayed unchanged. CONCLUSIONS: The common factors approach has some evidence of efficacy in implementation, but further research is needed to assess its effectiveness in reducing HIV risk behaviors and transmission. Behavioral interventions to reduce HIV risk developed using the common factors approach could become an important part of the HIV response in low resource settings where capacity building remains a high priority.

Estimating HIV and HCV prevalence among people who inject drugs in 5 Ukrainian cities using stratification-based respondent driven and random sampling.

BACKGROUND: Ukraine, a country of 45.5 million people, has one of the most volatile HIV and HCV epidemics in the world. In this paper, we estimate the prevalence of HIV and HCV among PWID in five Ukrainian cities. METHODS: A cross-sectional study was conducted in 2014-2015, based on stratified hybrid sampling with random and respondent driven sampling in five cities: Kyiv, Odesa, Mykolaiv, Dnipro and Lviv. Using data on HIV and HCV antibody testing from 1613 respondents, we evaluate selection bias in the sampling methods by analyzing spatial and network patterns of sampling processes. We develop and apply inverse probability weights in order to estimate the HIV and HCV prevalence in each city, as well as in the overall sample. FINDINGS: The aggregate HIV prevalence for the five cities is 35.1% (95% CI: 29.5%-38.5%) but this varied considerably by city: in Kyiv the HIV prevalence is 26.6% (95% CI: 20.3.8%-33.4%), in Odesa - 38.2% (95% CI: 29.8% and 47.1%), in Mykolaiv - 42.0% (95% CI: 34.3%-49.2%), in Dnipro - 58.8% (95% CI: 52.2%-65.8%), and in Lviv 24.6% (95% CI: 18.8%-30.8%). The aggregate HCV prevalence estimate for the five cities is 58.6% (95% CI: 54.9%-61.7%). The highest HCV prevalence is estimated in Kyiv - 84.8% (95% CI: 78.5%-90.1%). HCV prevalence in Odesa is the lowest and estimated to be 36.5% (95% CI: 29.5%-45.1%), in Mykolaiv - 49.1% (95% CI: 41.5%-57.0%), in Dnipro - 56.1% (95% CI: 50.3%-63.4%) and in Lviv 38.5% (95% CI: 31.8%-45.0%). CONCLUSIONS: Monitoring behavioral and health outcomes of PWID on a regular basis is necessary for determining prevention and treatment priorities for HIV and HCV infections in Ukraine and elsewhere. The heterogeneity of the local epidemics provides insights into the best prevention and treatment strategies to be deployed in low-resource settings.

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.

Assessment of barrier severity and willingness to enter opioid agonist treatment among people who inject drugs in Ukraine.

BACKGROUND: Opioid agonist therapies (OAT) in Ukraine were first introduced in 2004 not as addiction treatment, but for HIV prevention. Numerous obstacles have thwarted OAT scale-up, including individual constraints and structural barriers. METHODS: A cross-sectional survey of 1613 opioid dependent people who inject drugs (PWID) were recruited in 2014-2015 using stratified sampling in Kyiv, Odesa, Mykolayiv, Dnipro and Lviv. Analysis was restricted to a subset of 811 PWID who never received OAT. Barriers to OAT were assessed based on reasons why study participants were reluctant to enroll into OAT. A Rasch model from the Item Response Theory was applied to 24 potential barriers, used to score their severity and estimate a latent composite measure for each person's willingness and ability to participate in OAT. RESULTS: The Rasch model confirmed the cumulative nature of barriers with concerns over treatment efficacy, safety and tolerability being more prevalent than barriers related to logistical constraints, opportunity costs and social stigma. If barriers related to treatment perception and logistics were eliminated, the average barrier number would decrease from 10 to 2.2. Participants were more likely to have a higher resistance to OAT entry if they experienced fewer overdoses, did not attain higher education, were not previously incarcerated and if their peers did not have a higher level of resistance to OAT. CONCLUSIONS: Understanding the interdependence of various barriers and attitudes toward OAT can improve the rate of OAT expansion and ameliorate entry into substance abuse treatment programs in Ukraine.

Association between injection in public places and HIV/HCV risk behavior among people who use drugs in Ukraine.

BACKGROUND: In Eastern Europe and Central Asia new HIV infections occur at a high rate among people who inject drugs (PWID). Injection risk behavior may be associated with injecting in public places. However, there is a lack of studies exploring this association in Ukraine, which has an HIV prevalence 21-42% among PWID. METHODS: Data came from a baseline survey of PWID recruited to participate in a behavioral HIV prevention intervention. The association between HIV/HCV injection risk behavior and place of injection (private vs. public) was assessed using multivariable Poisson regression with robust variance estimate. RESULTS: Most of the sample was male (73%), > 30 years (56%), and reported opioids as their drug of choice (55%). One in six participants (15.8%, n = 57) reported using a syringe after somebody, and 70% (n = 253) reported injecting in public places within last 30-days. In the adjusted model, injection risk behavior was associated with injecting in public places (PrR: 4.24, 95% CI: 1.76-10.20), unstable housing situation (PrR: 2.46, 95% CI:1.26-4.83), higher than secondary education (PrR:1.82, 95%CI:1.04-3.16), injecting with a sex partner day (PrR:2.13, 95% CI:1.28-3.56), and injecting with a stranger (PrR: 1.47, 95% CI: 0.93-2.31). CONCLUSIONS: Injecting in a public place is associated with increased prevalence of risky behavior. Therefore, understanding and addressing place-based context should be part of the national strategy to fight HIV and HCV in Ukraine. National programs would benefit from expanding models to include contextual and structural determinants of health.