HIV treatment access and scale-up for delivery of opiate substitution therapy with buprenorphine for IDUs in Ukraine - programme description and policy implications

Yale University AIDS Program, New Haven, CT 06510-2283, United States. <>
The International journal on drug policy (Impact Factor: 3.19). 09/2007; 18(4):326-8. DOI: 10.1016/j.drugpo.2006.12.011
Source: PubMed


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.
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 >or=18 years and reported interest in BMT. All sites included a multidisciplinary team. To date, 207 patients have been initiated on BMT.
The existing infrastructure allows for further scale-up of and administration of BMT and the possibility of co-administration with ARV. The process for prescription and administration of buprenorphine and ARV is at times cumbersome and constrained by current regulations.
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.

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Available from: Frederick Altice, Jan 09, 2014
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    • "To define the country's regions, we employ the standard four-region approach (Arel, 1995; Kubicek, 2000; Zaller et al., 2014) that divides the country into west, east, north/center, and south. Ukraine first introduced OST with buprenorphine in 2004 (Bruce et al., 2007), followed by methadone's introduction in 2007 (Lawrinson et al., 2008), which has since become the primary OST due to cost. Although OST reduces HIV risk behaviors (Altice et al., 2006; Metzger et al., 1993), increases ART access (Altice et al., 2011; Lucas et al., 2010; Uhlmann et al., 2010) and improves retention in HIV care and HIV treatment outcomes (Altice et al., 2011; Palepu et al., 2006), OST coverage in Ukraine remains inadequate, with only 2.6% of the estimated 310,000 PWIDs receiving treatment (Degenhardt et al., 2013; WHO, 2013; Zaller et al., 2014). "
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    ABSTRACT: Ukraine is experiencing one of the most volatile HIV epidemics globally, fueled primarily by people who inject drugs (PWIDs), and a parallel incarceration epidemic. Opioid substitution therapy (OST) is internationally recognized as one of the most effective forms of treatment for opioid dependence and is among the most effective HIV prevention strategies available, yet efforts to adopt it in Ukraine's Criminal Justice System (CJS) have been thwarted. To understand the reluctance of the Ukrainian CJS to adopt OST despite the overwhelming evidence pointing to its health benefits and improved criminal justice outcomes, we conducted the first survey of Ukrainian prison administrative, medical and custodial staff (N=243) attitudes towards addiction in general, OST, and people living with HIV/AIDS (PLWHA) in representative regions of Ukraine. Results revealed that Ukrainian CJS workers' attitudes toward OST, PLWHA, and drug addiction were universally negative, but differed substantially along geographic and occupational lines. Whereas geographic and cultural proximity to the European Union drove positive attitudes in the west, in the southern region we observed an identifiability effect, as workers who worked directly with prisoners held the most positive attitudes. We also found that knowledge mediated the effect of drug intolerance on OST attitudes. In Ukraine, adoption of OST is more influenced by myths, biases and ideological prejudices than by existing scientific evidence. By elucidating existing attitudes among CJS personnel, this study will help to direct subsequent interventions to address the barriers to implementing evidence-based HIV prevention treatments. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
    Full-text · Article · Dec 2014 · Drug and Alcohol Dependence
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    • "Scale-up of ART and equitable access should be based on a human rights framework. Settings where one may be forced to disclose their involvement in sex work as their involvement in sex work or where one is required to provide a urine sample free of illicit drug chemicals in order to access services, may present significant barriers in ensuring that sex workers and other key populations are able to access services.[61]–[65] Furthermore, conflicting laws and public health policies, such as criminalization of sex work coupled with targeted HIV prevention programs for female sex workers, create confusions and/or risk for health providers and may place sex workers at risk of arrest or violence when accessing HIV prevention programs. "
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    ABSTRACT: Sex workers have endured a high burden of HIV infection in and across HIV epidemics. A comprehensive, community empowerment-based HIV prevention intervention emphasizes sex worker organization and mobilization to address HIV risk and often includes community-led peer education, condom distribution, and other activities. Meta-analysis of such interventions suggests a potential 51% reduction in inconsistent condom use. Mathematical modeling exercises provide theoretical insight into potential impacts of the intervention on HIV incidence and burden in settings where interventions have not yet been implemented.
    Full-text · Article · Feb 2014 · PLoS ONE
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    • "In recognition of this special relationship the World Health Organization , the Joint United Nations Programme on HIV/AIDS, and the United Nations Office on Drugs and Crime, released guidelines to improve coordinated care for TB among PWIDs (World Health Organization, 2008). Among the recommendations is to integrate TB treatment with medication-assisted therapy for opioid dependence, and if indicated, with HIV treatment services (Sylla, Bruce, Kamarulzaman, & Altice, 2007; World Health Organization, 2008). Ukraine, a country facing multiple challenges in the context of volatile epidemics of TB and HIV among PWIDs, faces a number of important challenges in optimizing treatment outcomes for each condition, including the development of multi-drug resistant TB (MDR-TB) (Dubrovina et al., 2008; Granich, 2008; Hurley, 2010; Kruglov et al., 2008; Kruk et al., 2011; Wolfe, Carrieri, & Shepard, 2010). "
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    ABSTRACT: Ukraine's volatile syndemics of tuberculosis (TB) and HIV among people who inject drugs (PWIDs) introduces numerous treatment challenges for each condition, including high mortality and development of multi-drug resistant TB (MDR-TB). A prospective, non-randomized 90-day observational study was conducted in six Ukrainian TB treatment sites to assess the effectiveness of integrating methadone maintenance (MMT) with TB treatment using: (1) 90-day TB treatment retention; (2) time to treatment discontinuation; (3) TB medication adherence; and (4) subject disposition, including mortality. Of the 110 participants enrolled, 57 received MMT and 53 did not (non-MMT). All of the primary outcomes were significantly better in MMT versus non-MMT groups, including 90-day TB treatment completion (89.5% versus 73.6%; p=0.031), time to TB treatment discontinuation (p=0.039) and TB medication adherence (97.1% versus 86.2%; p<0.001) after controlling for death. The major reasons for treatment non-completion in the non-MMT group included death (N=3), administrative discharge from the clinic (N=5), loss to follow-up (N=2), and arrest (N=4). Overall, 90-day mortality was high (8.2%). After controlling for covariates differing between the two groups at baseline, the only independent predictor of completing 90 days of TB treatment was receipt of MMT in an integrated treatment setting (AOR=3.05; 95% CI 1.08-8.66). MMT integrated into inpatient TB treatment significantly improves retention in TB treatment and TB medication adherence among PWIDs. These findings call for policy change to increase the number of MMT sites in TB facilities and make MMT a low-threshold treatment option for opioid dependence in Ukraine.
    Full-text · Article · Nov 2013 · The International journal on drug policy
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