Russia's ban on methadone for drug users in Crimea will worsen the HIV/AIDS epidemic and risk public health

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.

Injection Drug Use and Sexual Risk Behaviors Among People who Inject Drugs in Ukraine: A Random-Intercept Latent Transition Analysis

HIV transmission in Ukraine is driven in part by unsafe injection drug use and sexual risk behaviors among people who inject drugs. We performed a random-intercept latent transition analysis on responses to 9 binary injection drug use and sexual behavior items from 1195 people who inject drugs with negative HIV status enrolled in a clustered randomized clinical trial of a social network intervention in Odessa, Donetsk, and Nikolayev, Ukraine. We identified 5 baseline classes: "Social injection/equipment-sharing" (11.7%), "Social injection" (25.9%), "High-risk collective preparation/splitting" (17.0%), "Collective preparation/splitting" (11.3%), and "Dealer-facilitated injection" (34.1%). After 12 months, intervention participants were more likely to transition to the "Collective preparation/splitting" class, which featured the fewest risk behaviors. Transitioning from the "Collective preparation/splitting" to the "Social injection/equipment-sharing" class was associated with HIV acquisition for control participants. Research to illuminate the stability of these patterns and how they may benefit from uniquely tailored programming to reduce unsafe behaviors is needed.

The Relationship Between Intersectional Drug Use and HIV Stigma and HIV Care Engagement Among Women Living with HIV in Ukraine

This study used an intersectional approach to explore the association between enacted and internalized drug use and HIV stigma on HIV care outcomes among HIV-positive women who inject drugs in Ukraine. Surveys were conducted in Kyiv in 2019-2020. Among the 306 respondents, 55% were engaged in HIV care. More than half (52%) of participants not engaged in care reported internalized stigma related to both drug use and HIV status (i.e., intersectional stigma), compared to only 35% of those who were engaged in HIV care. Among those engaged in care, 36% reported intersectional enacted stigma compared to 44% of those not engaged in care; however, this difference was not statistically significant in the univariable analysis (p = 0.06). In the univariable analysis, participants who reported intersectional internalized stigma had 62% lower odds of being engaged in HIV care (OR 0.38, 95% CI 0.22, 0.65, p < 0.001). In the adjusted model, reported intersectional internalized stigma (aOR 0.52, 95% CI 0.30, 0.92, p = 0.026), reported intersectional enacted stigma (aOR 0.47, 95% CI 0.23, 0.95, p = 0.036), and knowing their HIV status for more than 5-years (aOR 2.29, 95% CI 1.35, 3.87, p = 0.002) were significant predictors of HIV care engagement. These findings indicate that interventions to improve HIV care engagement must address women's experiences of both HIV and drug use stigma and the different mechanisms through which stigma operates.

Integrating HIV and substance misuse services: a person-centred approach grounded in human rights

Integrating HIV-related care with treatment for substance use disorder provides an opportunity to better meet the needs of people living with these conditions. People with substance use disorder are rendered especially vulnerable by prevailing policies, structural inequalities, and stigmatisation. In this Series paper we analyse existing literature and empirical evidence from scoping reviews on integration designs for the treatment of HIV and substance use disorder, to understand barriers to and facilitators of care integration and to map ways forward. We discuss how approaches to integration address two core gaps in current models: a failure to consider human rights when incorporating the perspectives of people living with HIV and people who use drugs, and a failure to reflect critically on structural factors that determine risk, vulnerability, health-care seeking, and health equity. We argue that successful integration requires a person-centred approach, which is grounded in human rights, treats both concerns holistically, and reconnects with underlying social, economic, and political inequalities.

Improving healthcare for patients with HIV, tuberculosis and hepatitis C in eastern Europe: a review of current challenges and important next steps

OBJECTIVES

In some eastern European countries, serious challenges exist to meet the HIV-, tuberculosis (TB)- and hepatitis-related target of the United Nations Sustainable Development Goals. Some of the highest incidence rates for HIV and the highest proportion of multi-drug-resistant (MDR) tuberculosis worldwide are found in the region. The purpose of this article is to review the challenges and important next steps to improve healthcare for people living with TB, HIV and hepatitis C (HCV) in eastern Europe.

METHODS

References for this narrative review were identified through systematic searches of PubMed using pre-idientified key word for articles published in English from January 2000 to August 2020. After screening of titles and abstracts 37 articles were identified as relevant for this review. Thirty-eight further articles and sources were identified through searches in the authors' personal files and in Google Scholar.

RESULTS

Up to 50% of HIV/MDR-TB-coinfected individuals in the region die within 2 years of treatment initiation. Antiretroviral therapy (ART) coverage for people living with HIV (PLHIV) and the proportion virological suppressed are far below the UNAIDS 90% targets. In theory, access to various diagnostic tests and treatment of drug-resistant TB exists, but real-life data point towards inadequate testing and treatment. New treatments could provide elimination of viral HCV in high-risk populations but few countries have national programmes.

CONCLUSION

Some eastern European countries face serious challenges to achieve the sustainable development goal-related target of 3.3 by 2030, among others, to end the epidemics of AIDS and tuberculosis. Better integration of healthcare systems, standardization of health care, unrestricted substitution therapy for all people who inject drugs, widespread access to drug susceptibility testing, affordable medicines and a sufficiently sized, well-trained health workforce could address some of those challenges.

Associations between national development indicators and the age profile of people who inject drugs: results from a global systematic review and meta-analysis

BACKGROUND

Globally, an estimated 15·6 million people inject drugs. We aimed to investigate global variation in the age profile of people who inject drugs (PWID), identify country-level factors associated with age of PWID, and assess the association between injecting drug use (IDU) in young people and rates of injecting and sexual risk behaviours at the country level.

METHODS

We derived data from a previously published global systematic review done in April, 2016 (and updated in June, 2017) on the percentage of young PWID, duration of IDU, average age of PWID, average age at IDU initiation, and the percentage of PWID reporting sexual and injecting risk behaviours. We also derived national development indicators from World Bank data. We estimated the percentage of young PWID for each country, using a random-effects meta-analysis (DerSimonian-Laird methodology) and generated pooled regional and global estimates for all indicators of IDU in young people. We used univariable and multivariable generalised linear models to test for associations between the age indicators and country urban population growth, youth unemployment percentage, the percentage of PWID who are female, the percentage of the general population aged 15-24 years, Gini coefficient, opioid substitution therapy coverage (per PWID per year), gross domestic product (GDP) per capita (US$1000), and sexual and injecting risk behaviours.

FINDINGS

In the original systematic review, data on age of PWID was reported in 741 studies across 93 countries. Globally, 25·3% (95% uncertainty interval [UI] 19·6-31·8) of PWID were aged 25 years or younger. The highest percentage of young PWID resided in eastern Europe (43·4%, 95% UI 39·4-47·4), and the lowest percentage resided in the Middle East and north Africa (6·9%, 5·1-8·8). At the country level, in multivariable analysis higher GDP was associated with longer median injecting duration (0·11 years per $1000 GDP increase, 95% CI 0·04-0·18; p=0·002), and older median age of PWID (0·13 years per $1000 increase, 0·06-0·20; p<0·0001). Urban population growth was associated with higher age at IDU initiation (1·40 years per annual percentage change, 0·41-2·40). No associations were identified between indicators of IDU in young people and youth unemployment, Gini coefficient, or opioid substitution therapy coverage provision at the country level. No associations were identified between injecting and sexual risk behaviours and age of PWID.

INTERPRETATION

Variation in the age profile of PWID was associated with GDP and urbanisation. Regions with the highest prevalence of young PWID (aged ≤25 years) had low coverage of interventions to prevent the spread of blood-borne viruses. Data quality highlights the need for improvements in monitoring of PWID populations.

FUNDING

Australian National Drug and Alcohol Research Centre, Australian National Health and Medical Research Council, Open Society Foundation, WHO, the Global Fund, UNAIDS, National Institute for Health Research Health Protection Research Unit for Evaluation of Interventions, Wellcome Trust.

Efficacy of Acupuncture for Treating Opioid Use Disorder in Adults: A Systematic Review and Meta-Analysis

OBJECTIVES

To assess the efficacy of acupuncture in treating opioid use disorder (OUD).

DESIGN

Systematic review and meta-analysis.

METHODS

PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, ProQuest Dissertation and Theses, Allied and Complementary Medicine Database (AMED), Clinicaltrials.gov, and who.int/trialsearch were searched from inception to 23 December 2017. The methodological quality of selected studies and the quality of evidence for outcomes were assessed, respectively, by the Cochrane risk of bias assessment tool and the GRADE approach. Statistical analyses were conducted by RevMan 5.3.

RESULTS

A total of nine studies involving 1063 participants fulfilled the inclusion criteria. The results showed that acupuncture could be more beneficial than no treatment/sham acupuncture in terms of changes in craving for opioid (MD -2.18, 95% CI -3.10 to -1.26), insomnia (MD 2.31, 95% CI 1.97 to 2.65), and depression (SMD -1.50, 95% CI -1.85 to -1.15). In addition, these findings showed that, compared to sham electroacupuncture (EA), EA had differences in alleviating symptoms of craving (SMD -0.50, 95% CI -0.94 to -0.05) and depression (SMD -1.07, 95% CI -1.88 to -0.25) and compared to sham transcutaneous acupoint electrical stimulation (TEAS), TEAS had differences in alleviating symptoms of insomnia (MD 2.31, 95% CI 1.97 to 2.65) and anxiety (MD -1.26, 95% CI -1.60 to -0.92) compared to no treatment/sham TEAS.

CONCLUSIONS

Acupuncture could be effective in treating OUD. Moreover, EA could effectively alleviate symptoms of craving for opioid and depression, and TEAS could be beneficial in improving symptoms of insomnia and anxiety. Nevertheless, the conclusions were limited due to the low-quality and small number of included studies. PROSPERO registration number is CRD42018085063.

Sovereign Rules and Rearrangements: Banning Methadone in Occupied Crimea

In 2014, Russian authorities in occupied Crimea shut down all medication-assisted treatment (MAT) programs for patients with opioid use disorder. These closures dramatically enacted a new political order. As the sovereign occupiers in Crimea advanced new constellations of citizenship and statehood, so the very concept of "right to health" was re-tooled. Social imaginations of drug use helped single out MAT patients as a population whose "right to health," protected by the state, would be artificially restricted. Here, I argue that such acts of medical disenfranchisement should be understood as contemporary acts of statecraft.

Challenges and opportunities for implementation of substance misuse interventions in conflict-affected populations

Alcohol and other drug misuse are significant but neglected public health issues in conflict-affected populations. In this article, we review the literature on the challenges and strategies for implementing substance misuse treatment and prevention services in conflict and post-conflict settings in low- and middle-income countries. We identified nine studies describing interventions in conflict-affected populations residing in Afghanistan, Croatia, India, Kenya, Kosovo, Pakistan, and Thailand. Six of these nine studies focused on refugee populations. Reports revealed challenges to intervention implementation, as well as promising practices and recommendations for future implementation that we characterized as existing in the inner and outer contexts of an implementing organization. Challenges existing in the outer context included low political prioritization, lack of coordination and integration, and limited advocacy for access to substance misuse services. Challenges within the inner context related to competing priorities and a shortage of providers. Resource limitations existed in both the inner and outer contexts. Stigma was a challenge that threatened implementation and utilization of substance use services in situations when substance use interventions were not congruent with the roles, structure, values, and authority of the system or implementing organization. Future research should focus on developing, applying, and evaluating strategies for overcoming these challenges in order to make progress toward meeting the need for substance misuse services in conflict-affected populations.

Injection Drug Use Trajectories among Migrant Populations: A Narrative Review

BACKGROUND

Dual epidemics of injection drug use and blood-borne disease, characterized as "syndemics," are present in a range of settings. Behaviors that drive such syndemics are particularly prevalent among mobile drug-using populations, for whom cross-border migration may pose additional risks.

OBJECTIVES

This narrative review aims to characterize the risk factors for injection drug use initiation associated with migration, employing a risk environment framework and focusing on the San Diego-Tijuana border region as the most dynamic example of these phenomena.

METHODS

Based on previous literature, we divide migration streams into three classes: intra-urban, internal, and international. We synthesized existing literature on migration and drug use to characterize how mobility and migration drive the initiation of injection drug use, as well as the transmission of hepatitis and HIV, and to delineate how these might be addressed through public health intervention.

RESULTS

Population mixing between migrants and receiving communities and the consequent transmission of social norms about injection drug use create risk environments for injection drug use initiation. These risk environments have been characterized as a result of local policy environments, injection drug use norms in receiving communities, migration-related stressors, social dislocation, and infringement on the rights of undocumented migrants.

CONCLUSION

Policies that exacerbate risk environments for migrants may inadvertently contribute to the expansion of epidemics of injection-driven blood-borne disease. Successful interventions that address emerging syndemics in border regions may therefore need to be tailored to migrant populations and distinguish between the vulnerabilities experienced by different migration classes and border settings.

Addressing ethical challenges in HIV prevention research with people who inject drugs

Despite recent advances in HIV prevention and treatment, high HIV incidence persists among people who inject drugs (PWID). Difficult legal and political environments and lack of services for PWID likely contribute to high HIV incidence. Some advocates question whether any HIV prevention research is ethically justified in settings where healthcare system fails to provide basic services to PWID and where implementation of research findings is fraught with political barriers. Ethical challenges in research with PWID include concern about whether research evidence will be translated into practice; concerns that research might exacerbate background risks; and ethical challenges regarding the standard of HIV prevention in research. While these questions arise in other research settings, for research with PWID, these questions are especially controversial. This paper analyses four ethical questions in determining whether research could be ethically acceptable: (1) Can researchers ensure that research does not add to the burden of social harms and poor health experienced by PWID? (2) Should research be conducted in settings where it is uncertain whether research findings will be translated into practice? (3) When best practices in prevention and care are not locally available, what standard of care and prevention is ethically appropriate? (4) Does the conduct of research in settings with oppressive policies constitute complicity? We outline specific criteria to address these four ethical challenges. We also urge researchers to join the call to action for policy change to provide proven safe and effective HIV prevention and harm reduction interventions for PWID around the world.

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.

Critical remarks on strategies aiming to reduce drug related harm: substance misuse and HIV/AIDS in a world in turmoil

In the last decades, the initiatives implemented under the conceptual umbrella of Harm Reduction have gained momentum, with a vigor and scope (both from a geographic and social perspective) never seen before. A more balanced reevaluation could and should rather say such initiatives have resumed, to a large extent, ideas and actions launched much earlier, in the first decades of the 20th century. Notwithstanding, the dissemination of HIV/AIDS in recent years conferred an exceptional visibility and legitimacy to proposals formerly viewed as subsidiary or openly neglected. Nowadays, initiatives inspired by the Harm Reduction philosophy have faced an "identity crisis", not secondary (according to our perspective) to challenges faced by its concepts and operations, but rather as consequence of a world in a turmoil. Such fast-changing dynamics have reconfigured both drug scenes and the patterns and prospects of HIV/AIDS worldwide. This article briefly summarizes some of such recent, ongoing, changes, which have been deeply affecting both concepts and practices to the point of asking for a deep reformulation of most of the initiatives implemented so far.

Impact of opioid substitution therapy on the HIV prevention benefit of antiretroviral therapy for people who inject drugs

OBJECTIVE

A recent meta-analysis suggested that opioid substitution therapy (OST) increased uptake of antiretroviral treatment (ART) and HIV viral suppression. We modelled whether OST could improve the HIV prevention benefit achieved by ART among people who inject drugs (PWID).

METHODS

We modelled how introducing OST could improve the coverage of ART across a PWID population for different baseline ART coverage levels. Using existing data on how yearly HIV-transmission risk is related to HIV plasma viral load, changes in the level of viral suppression across the population were used to project the relative reduction in yearly HIV-transmission risk achieved by ART, with or without OST, compared with if there was no ART - defined here as the prevention effectiveness of ART.

RESULTS

Owing to OST use increasing the chance of being on ART and achieving viral suppression if on ART, the prevention effectiveness of ART for PWID on OST (compared with PWID not on OST) increases by 44, 31, or 20% for a low (20%), moderate (40%), or high (60%) baseline ART coverage, respectively. Improvements in the population-level prevention effectiveness of ART are also achieved across all PWID, compared with if OST was not introduced. For instance, if OST is introduced at 40% coverage, the population-level prevention effectiveness of ART could increase by 27, 20, or 13% for a low (20%), moderate (40%), or high (60%) baseline ART coverage, respectively.

CONCLUSION

OST could improve the HIV prevention benefit of ART; supporting strategies that aim to concurrently scale-up OST with ART.

Late presentation for HIV care across Europe: update from the Collaboration of Observational HIV Epidemiological Research Europe (COHERE) study, 2010 to 2013

Late presentation (LP) for HIV care across Europe remains a significant issue. We provide a cross-European update from 34 countries on the prevalence and risk factors of LP for 2010-2013. People aged ≥ 16 presenting for HIV care (earliest of HIV-diagnosis, first clinic visit or cohort enrollment) after 1 January 2010 with available CD4 count within six months of presentation were included. LP was defined as presentation with a CD4 count < 350/mm(3) or an AIDS defining event (at any CD4), in the six months following HIV diagnosis. Logistic regression investigated changes in LP over time. A total of 30,454 people were included. The median CD4 count at presentation was 368/mm(3) (interquartile range (IQR) 193-555/mm(3)), with no change over time (p = 0.70). In 2010, 4,775/10,766 (47.5%) were LP whereas in 2013, 1,642/3,375 (48.7%) were LP (p = 0.63). LP was most common in central Europe (4,791/9,625, 49.8%), followed by northern (5,704/11,692; 48.8%), southern (3,550/7,760; 45.8%) and eastern Europe (541/1,377; 38.3%; p < 0.0001). There was a significant increase in LP in male and female people who inject drugs (PWID) (adjusted odds ratio (aOR)/year later 1.16; 95% confidence interval (CI): 1.02-1.32), and a significant decline in LP in northern Europe (aOR/year later 0.89; 95% CI: 0.85-0.94). Further improvements in effective HIV testing strategies, with a focus on vulnerable groups, are required across the European continent.

In Their Own Voices: Breaking the Vicious Cycle of Addiction, Treatment and Criminal Justice Among People who Inject Drugs in Ukraine

AIMS

To understand how perceived law enforcement policies and practices contribute to the low rates of utilization of opioid agonist therapies (OAT) among people who inject drugs (PWIDs) in Ukraine.

METHODS

Qualitative data from 25 focus groups (FGs) with 199 opioid-dependent PWIDs in Ukraine examined domains related to lived or learned experiences with OAT, police, arrest, incarceration, and criminal activity were analyzed using grounded theory principles.

FINDINGS

Most participants were male (66%), in their late 30s, and previously incarcerated (85%) mainly for drug-related activities. When imprisoned, PWIDs perceived themselves as being "addiction-free". After prison-release, the confluence of police surveillance, societal stress contributed to participants' drug use relapse, perpetuating a cycle of searching for money and drugs, followed by re-arrest and re-incarceration. Fear of police and arrest both facilitated OAT entry and simultaneously contributed to avoiding OAT since system-level requirements identified OAT clients as targets for police harassment. OAT represents an evidence-based option to 'break the cycle', however, law enforcement practices still thwart OAT capacity to improve individual and public health.

CONCLUSION

In the absence of structural changes in law enforcement policies and practices in Ukraine, PWIDs will continue to avoid OAT and perpetuate the addiction cycle with high imprisonment rates.

Association of patterns of methadone use with antiretroviral therapy discontinuation: a prospective cohort study

BACKGROUND

Methadone maintenance therapy (MMT) is a proven treatment strategy for opioid dependent patients. Although studies have demonstrated that MMT increases contact with the medical system and improves adherence to antiretroviral therapy (ART) in HIV-positive people who inject drugs (PWID), the effect of MMT discontinuation on ART discontinuation has not been well described.

METHODS

We examined the impact of continuous MMT use, MMT non-use and MMT discontinuation on the time to ART discontinuation (defined as 90 days of continuous non-use following previous enrolment) in a community-recruited prospective cohort of HIV-positive PWID followed between May 1996 and May 2013 in Vancouver, Canada. Multivariate Cox proportional hazards regression was used to examine the association between MMT use patterns and time to ART discontinuation while adjusting for socio-demographic confounders.

RESULTS

A total of 794 HIV-positive PWID were included during the study period. In an adjusted analysis, in comparison to those who were continuously on MMT, MMT non-use (Adjusted Hazard Ratio [AHR] = 1.44, 95 % Confidence Interval [CI]: 1.19-1.73) as well as discontinuing MMT (AHR = 1.82, 95 % CI: 1.27-2.60) were both found to be independently associated with time to ART discontinuation.

CONCLUSIONS

This study reinforces the known benefits of MMT use on ART adherence and demonstrates how discontinuation of MMT is independently associated with an increased risk of ART cessation. These data highlight the importance of retaining PWID on MMT.

Responding to the public health consequences of the Ukraine crisis: an opportunity for global health diplomacy

Introduction

Peace and stability in Eastern Europe is now at a crossroads with the rapidly deteriorating foreign policy crisis continuing to unfold in the Ukraine. However, largely overlooked in the context of other foreign policy and diplomatic priorities are the serious public health consequences for the region following the annexation of Crimea and the subsequent decision to ban opioid substitution therapy in the disputed territory.

Discussion

On 1 May 2014, the Republic of Crimea officially announced it would end access to opioid substitution therapy, an essential harm reduction tool recognized by international organizations and virtually all other European countries. The policy development marks a critical reversal in the region’s fight against its growing HIV epidemic and also threatens years of public health gains aimed at providing evidence-based and integrated treatment approaches to combat drug dependence and HIV. Beyond these risks, the Ukrainian conflict could also negatively impact control of other infectious diseases that are converging with HIV and injection drug use, such as multidrug-resistant tuberculosis and hepatitis C virus. The continuing conflict is also likely to have a significant negative impact on Ukraine’s fragile public health system leading to even worse population health outcomes than currently experienced by the country.

Conclusions

In response to this crisis, the application of global health diplomacy principles represents a possible route of advocacy to ensure that HIV prevention, humane treatment of substance using populations, and improving public health outcomes in the region are pursued among concerned international stakeholders. In order to be effective, global health diplomacy efforts must be coordinated and advocated in all forms of diplomatic engagement, including at the core, multistakeholder and informal levels and through existing channels such as the different human rights bodies of the United Nations as well as amongst other actors. Hence, the Ukraine crisis represents a critical moment for the practice and advancement of global health diplomacy in order to ensure global public health priorities are given their rightful place in foreign policy making to hopefully help in bringing resolution to the current conflict.

"Bureaucracy & Beliefs": Assessing the Barriers to Accessing Opioid Substitution Therapy by People Who Inject Drugs in Ukraine

AIMS

Opioid substitution therapy (OST) is an evidence-based HIV prevention strategy for people who inject drugs (PWIDs). Yet, only 2.7% of Ukraine's estimated 310,000 PWIDs receive it despite free treatment since 2004. The multi-level barriers to entering OST among opioid dependent PWIDs have not been examined in Ukraine.

METHODS

A multi-year mixed methods implementation science project included focus group discussions with 199 PWIDs in 5 major Ukrainian cities in 2013 covering drug treatment attitudes and beliefs and knowledge of and experiences with OST. Data were transcribed, translated into English and coded. Coded segments related to OST access, entry, knowledge, beliefs and attitudes were analyzed among 41 PWIDs who were eligible for but had never received OST.

FINDINGS

A number of programmatic and structural barriers were mentioned by participants as barriers to entry to OST, including compulsory drug user registration, waiting lists, and limited number of treatment slots. Participants also voiced strong negative attitudes and beliefs about OST, especially methadone. Their perceptions about methadone's side effects as well as the stigma of being a methadone client were expressed as obstacles to treatment.

CONCLUSIONS

Despite expressed interest in treatment, Ukrainian OST-naïve PWIDs evade OST for reasons that can be addressed through changes in program-level and governmental policies and social-marketing campaigns. Voiced OST barriers can effectively inform public health and policy directives related to HIV prevention and treatment in Ukraine to improve evidence-based treatment access and availability.

Big Events and Risks to Global Substance Using Populations: Unique Threats and Common Challenges

In this commentary, we review a set of "Big Events" from around the world that have adversely impacted substance using populations by first identifying common thematic areas between them, and then describing the unique challenges faced by the diverse and vulnerable populations impacted. The Big Events reviewed are multifaceted and complex in nature, and include the recent global financial crisis, economic and trade sanctions, political transition and its impact on ethnic minorities, colonialism and indigenous communities, and ecological disasters. All have led to immense trauma, displacement, and disruption to critical healthcare services/treatment for people who use drugs, populations who are left underserved in the midst of these crises. It is our hope that through this comparative assessment, global policymakers will proactively identify Big Events and prioritize the development of interventions and policy that meet the unique and immediate needs of substance using population in order to mitigate the significant negative short- and long-term impacts on global public health.