International Journal of Drug Policy 18 (2007) 326–328
HIV treatment access and scale-up for delivery of opiate substitution
therapy with buprenorphine for IDUs in Ukraine—programme
description and policy implications
R. Douglas Brucea,∗, Sergey Dvoryakb, Laurie Syllaa, Frederick L. Alticea
aYale University AIDS Program, United States
bUkrainian Institute on Public Health Policy, Ukraine
Received 31 May 2006; received in revised form 7 December 2006; accepted 11 December 2006
Background: Injection drug use (IDU) accounts for 70 percent of HIV cases in Ukraine. Until buprenorphine maintenance therapy (BMT)
was introduced, few effective strategies aimed at achieving reduction in illicit drug use were available as a conduit to anti-retroviral therapy
(ARV) among IDUs.
Description: In October 2005, BMT was scaled-up using Global Fund resources in six regions within Ukraine. Entry criteria included opioid
dependence, HIV-1 seropositivity, age ≥18 years and reported interest in BMT. All sites included a multidisciplinary team. To date, 207
patients have been initiated on BMT.
with ARV. The process for prescription and administration of buprenorphine and ARV is at times cumbersome and constrained by current
Recommendations: More IDU need BMT to improve overall health outcomes. Central to expanding access will be legislative changes to
existing drug policy. Moreover, the cost of buprenorphine is prohibitively expensive. Sustainable substitution therapy in Ukraine requires
lower negotiated prices for buprenorphine, the addition of methadone, or both to the existing formulary for HIV+ drug users.
© 2006 Elsevier B.V. All rights reserved.
Keywords: HIV/AIDS; Buprenorphine; Substitution therapy
Injection drug use (IDU) accounted for 70 percent of HIV
cases in Ukraine between 1987 and 2004 (European centre,
2005). In 2005, Ukraine was home to the fastest growing
HIV epidemic in Europe and one of the most explosive in
the world with over 40,000 individuals infected with HIV,
most of whom are IDUs (UNAIDS/WHO, 2005). There has
arisen a need for the treatment of opioid dependence to
facilitate the expansion of ARVs among HIV-infected IDUs.
∗Corresponding author at: Yale University AIDS Program, 135 College
Street, Suite 323, New Haven, CT 06510-2283, United States.
Tel.: +1 203 737 2883; fax: +1 203 737 4051.
E-mail address: firstname.lastname@example.org (R.D. Bruce).
Although drug treatment programmes existed in Ukraine
prior to opioid substitution therapy (OST), retention in these
programmes was poor with two out of three individuals leav-
ing treatment due partly to limited capacity for treatment and
lack of evidence based treatments in narcological centres
(Dvoryak, 2005). Until November 2006, due to Ukrainian
federal regulations, buprenorphine was the only medication
available for OST. Buprenorphine is a partial opiate agonist
within France (Auriacombe, Fatseas, Dubernet, Daulouede,
& Tignol, 2004). Additionally, ARV access for IDUs is low.
Although not formalized in policy, both clinicians and poli-
cymakers have tended to refuse ARVs to active IDUs, owing
to the perception that IDUs would be poorly adherent. As a
0955-3959/$ – see front matter © 2006 Elsevier B.V. All rights reserved.
R.D. Bruce et al. / International Journal of Drug Policy 18 (2007) 326–328
result, a buprenorphine maintenance treatment (BMT) pro-
gramme was piloted with the goal of bringing HIV-infected
IDUs onto buprenorphine to reduce further transmission of
HIV, and to begin HIV-infected IDUs on ARV treatment.
There are several distinguishing aspects of opioid use pat-
terns in Ukraine. Most IDUs use homemade opioids called
shirka, which is prepared from poppy straw in a common
container that is shared among a group of IDUs. Because
shirka is a solution by nature, those IDUs purchasing ready-
made shirka can buy it in preloaded syringes that tend to be
unsterile. Critically, almost 30 percent of IDU respondents
in Ukraine stated that they shared syringes with other IDUs
(Balakireva, Varban, & Yeremenko, 2003).
OST with sublingual buprenorphine was unavailable in
Ukraine until 2004 when the WHO, UNAIDS and others
recommended OST as a way to address the growing HIV
incidence rate among IDUs (WHO, UNAIDS, & UNODC,
2005). To gain experience and inform future programmes, a
pilot BMT programme was conducted in two cities in 2004.
A total of 70 patients (40 in Kiev and 30 in Kherson) partici-
pated in this 1-year project (Dvoryak, 2005). Following this
feasibility pilot, expansion of OST to additional sites began
as described subsequently.
The national BMT project began in October 2005 and this
report details lessons learned over the first 9 months. There
are 207 patients on BMT in Ukraine and approximately 114
cent) of the HIV-infected individuals on ARVs. This cohort
is disproportionately male (21 percent women), but is con-
sistent with substance use in Ukraine (Booth, Kwiatkowski,
Brewster, Sinitsyna, & Dvoryak, 2006). The average age
is 39 years and the average length of IDU is 16.8 years.
The cohort was recruited through needle exchange sites,
HIV/AIDS healthcare providers and narcological centres
(Ukrainian drug treatment centres).
antibody positive, age >18, opioid dependence, two or more
non-pharmacological drug treatment attempts, and interest
in buprenorphine. HIV-infected IDUs were targeted due to a
Ukraine Ministry of Health order; however, this restriction
was removed in late 2006 to allow both HIV-infected and
HIV-un-infected. The only exclusion criteria is an inability,
in the opinion of the narcologist, to adhere to the required
directly observed method of daily administration which is
required by Ukrainian federal regulations. There is no for-
mal screening or evaluation of this and so it is interpreted
of Health was required to allow expansion of the previous
BMT pilot. Prior to expansion, physicians and staff visited
the Yale University AIDS Program where they underwent an
intensive weeklong training on OST and harm reduction in
HIV-infected IDUs. Subsequently, BMT expansion began in
October 2005 at six sites.
Each BMT is allowed to screen for ongoing substance
struggle to do urine toxicology due to funding limitations.
Despite the project still being in its infancy, several points
and remaining obstacles require discussion. First, after 6
months, retention is approximately 75 percent. This stands
in contrast to drug free programmes (non-OST) in Ukraine
where retention after 6 months is 33.3 percent (Dvoryak,
ity index (ASI) scores on drug use have decreased between
baseline and 6 months consistent with improvements in opi-
oid use over the last 6 months. Specifically, the average score
of drug use by ASI at baseline was 0.3238±0.1208 and
had decreased at 6 months to 0.0944±0.0866. Additionally,
individuals have experienced other personal successes such
as weight gain, improvements in interpersonal relationships,
and obtaining and keeping employment. Third, the average
dose of buprenorphine was approximately 9.3mg, which is
lower than the average dose in the largest prospective cohort
sonal communication with Bruce]. Despite the difference in
dosing, anecdotal reports from Ukraine do not suggest that
reflect the difference in potency between shirka and heroin.
Fourth, potential drug–drug interactions exist and must be
explored. At least one subject reported increased craving
and subjective symptoms of withdrawal every morning. This
subject was on buprenorphine at 10mg/day and also taking
nevirapine for HIV and rifampin for tuberculosis. Under-
standing the shared metabolic pathway of each medication, a
drug–drug interaction is possible (Bruce, Altice, Gourevitch,
& Friedland, 2006). Finally, after the project started, more
HIV-infected IDUs came to the BMT programmes seeking
treatment than programme slots would allow; as a result,
these individuals seeking treatment were turned away and
their names added to a growing list.
tion and eventual expansion of BMT. First, although cheaper
and equally as effective, methadone was unavailable in
Ukraine, until recently. Although recently available in a pilot
project, its future expansion remains to be determined. Sec-
to supervise buprenorphine’s administration. For example,
buprenorphine is administered only in government or com-
munity based treatment centres and only in the presence of
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R.D. Bruce et al. / International Journal of Drug Policy 18 (2007) 326–328
regardless of expertise and safeguards. Third, only narcol-
ogists (physicians with specialized training) can prescribe
buprenorphine. This is an obstacle for integration. Models
of care delivery within the United States allow for integrat-
ing services: a physician can treat opioid dependence with
all buprenorphine is administered daily by direct observation
and is discontinued if the patient is incarcerated, admitted to
an inpatient facility for any treatment (e.g., medical hospi-
talizations), or moves to another city (even temporarily), as
other programmes cannot provide buprenorphine to visiting
patients. To avoid administration on weekends, patients are
given a double dose on Friday with no opportunity for take-
home doses. The reported purpose of these measures is the
prevention of diversion. Ironically, in discussions with the
medical directors of various BMT sites, it is apparent that the
major reason for administrative discharges is for diversion.
In focus groups with patients, the main purpose of diversion
was to create a home supply of buprenorphine to allow ‘days
off’. Such days off are used by patients for various activities
including family holidays. Unfortunately, strict supervision
has a selection bias in some sites towards healthier individu-
als (e.g., do not meet criteria for ARVs). This bias occurred
due to system-level barriers where bringing buprenorphine
to hospitalized patients can be extremely problematic if not
individuals have entered into BMT in Ukraine, with high
levels of retention in treatment, remains promising. The out-
comes of these subjects over the next several years will be
closely monitored. Given the demand for OST, deregulation
is necessary, including a new order from the Ministry of
physicians with adequate training. Buprenorphine should be
chotropic Drugs. Additionally, the availability of methadone
must be addressed. The cost differential between methadone
and buprenorphine is significant: if the money allocated for
as many patients could be treated with methadone [personal
communication with Dvoryak]. Price negotiation which was
successful in lowering ARV prices must be used to lower
the cost of buprenorphine; this will require both national and
international pressure. All changes are desperately needed if
tantly, the estimated goal of 60,000 necessary to impact the
HIV epidemic in Ukraine (WHO et al., 2005). Without such
changes to expand access to substitution therapy in a mean-
ingful way, injection drug use will continue to fuel the HIV
epidemic in Ukraine and will continue to stand in the way of
life-saving anti-retroviral therapy.
The authors would like to thank the National Institute on
Drug Abuse (K23 DA022143, Bruce and K24 DA 017072,
Auriacombe, M., Fatseas, M., Dubernet, J., Daulouede, J. P., & Tignol, J.
(2004). French field experience with buprenorphine. American Journal
on Addictions, 13(Suppl 1), S17–S28.
Balakireva, O. N., Varban, M. Yu., Yeremenko, A. A., et al. (2003). Evalu-
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Basu, S., Smith-Rohrberg, D., Bruce, R. D., & Altice, F. L. (2006). Models
of integrating buprenorphine therapy into HIV care. Clinical Infectious
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Booth, R. E., Kwiatkowski, C. F., Brewster, J. T., Sinitsyna, L., & Dvoryak,
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