At the crossroads: HIV prevention and treatment for people who inject drugs in U kraine

By 2009, HIV incidence decreased globally by 19% while rates in Eastern Europe and Central Asia increased by 25%, primarily among people who inject drugs (PWIDs) (1). Regionally, Ukraine and Russia account for 90% of new HIV infections and while there is evidence that the HIV epidemic is transitioning to a generalized epidemic, Ukraine's volatile and expanding HIV epidemic is still being fueled by PWIDs, primarily using opioids (2). Among the ~375,000–425,000 PWIDs, HIV prevalence ranges from 21.3%–41.8% and PWIDS account for nearly 70% of all cumulative and 56% of new HIV infections (3, 4). Medication-assisted therapies (MAT), especially methadone (MMT) and buprenorphine maintenance treatment (BMT), are internationally recognized as the most effective treatment for opioid dependence (5); newer data suggest extended-release naltrexone is also effective (6). MAT also remains among the most effective primary and secondary HIV prevention strategies available, especially when used as part of a “combination intervention” approach integrated with needle/syringe exchange programs (NSEPs), antiretroviral therapy (ART); peer education and outreach; expanded HIV testing; and contextual promotion of public policies and other structural changes conducive to promote public health (7). Within the region, Ukraine initially implemented relatively progressive, but insufficiently scaled-to-need, “combination interventions” promoting HIV prevention and treatment for PWIDs. Harm reduction programs including outreach and peer education, condom distribution, voluntary HIV testing, and NSEPs were started in Ukraine in the late 1990s, followed by ART expansion in 2004. Pilot opioid substitution therapy (OST) programs using BMT began that year (8); MMT commenced in 2008 (9). In 2008, international donors funded creation of integrated care services for PWIDs through pilot programs in Kyiv, Dnipropetrovsk, Mykolaiv and Odessa that simultaneously provided treatment for HIV, tuberculosis and OST (10). Unlike nearby Russia where HIV prevention and treatment efforts for PWIDs are flailing and OST is legislatively banned (11), Ukraine has made progress, but is now at a crossroads. While MAT is highly effective in reducing HIV risk behaviors, increasing access to ART, and improving HIV treatment access, retention and other outcomes (5), less than 2% of PWIDs in Ukraine are currently receiving this critical therapy despite available, funded OST slots (12). It is unclear if this inertia is due to inadequate commitment or insufficient funding, but data suggest that recent Ukrainian efforts to expand MAT services for PWIDs have been hindered by multiple structural barriers including restricted access to services, human rights abuses, police harassment including arrest, detention and incarceration, and unsupportive policy or social environments (13, 14). For example, the Ukrainian Ministry of Health's 2012 order No. 200 (15), which newly requires PWIDs to provide documentation of two failed detoxification attempts before being admitted to OST, abrogates recent attempts to expand OST. Detoxification of chronically dependent PWIDs is associated with death, suffering and wasted time, energy, and resources for patients who would otherwise benefit from it (16). In addition, both OST clients and medical staff must adhere to the strict legal controls which regulate the distribution of methadone in Ukraine: any legal violations of the “About Narcotics Turnover” law is treated seriously and even technical errors made by medical staff can result in arrest and detention. Police also create additional difficulties for OST clients and threaten medical staff (14). As a result, most medical facilities fear establishing OST sites within their clinics (17). These seemingly incipient negative trends in HIV policy and programming in Ukraine place at odds an evidence-based HIV policy foundation with new and emerging national laws, legislation, and policies now hindering responsiveness to policy and changing epidemic patterns. A 2011 HIV policy evaluation confirmed that at both the national and local levels, “implementation, coordination, and collaboration are often left to individual personalities and interests of those involved” and that many of the structural barriers to HIV program planning revolve around a lack of detailed operational guidelines or implementation plans, inadequate strategic planning, insufficient resources to implement laws and regulations, and a lack of awareness and acceptance of legal protections for vulnerable populations among key stakeholder groups, including law enforcement, local government, and healthcare providers (18). In order to forge ahead on the earlier adopted progressive path and remain an innovative regional leader of HIV prevention and treatment for PWIDs, there is an urgent need for the Ukrainian government to redress the gaps and barriers in HIV policy and provision of prevention and treatment services for PWIDs. Ukraine's current OST program is heavily dependent on funding from the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM), due to expire in 2016, and the 2011 decision to cancel its next funding cycle due to insufficient funds potentially jeopardizes future OST services in Ukraine unless Ukraine's Ministry of Health opts to subsidize it. Without governmental financial support, HIV prevention and treatment will revert back to nihilist strategies extant in nearby Russia where HIV prevention and treatment efforts among PWIDs are inconsistent with evidence-based care and human rights mandates (11). Expanding MAT for PWIDs and working with clients, providers and stakeholders to make these programs culturally relevant and logistically acceptable in the Ukrainian context is an opportunity to increase access to and retention in services while also raising community and stakeholder awareness of the societal and public health benefits of these evidence-based interventions. Mathematical modeling confirms MAT expansion as the most cost-effectiveness HIV prevention and treatment strategy in Ukraine's transitioning HIV epidemic and importantly, expanding MAT coverage to 25% of PWIDs along with ART coverage to 80% of HIV-infected persons who need it would avert 8,300 new HIV infections annually (3). It is crucial that Ukraine treats drug dependence not as a crime but humanely as a chronic, relapsing disease similarly to any other chronic medical condition that affects individuals, regardless of age, socio-economic status, political affiliation, or sexual orientation and which requires consistent, evidence-based treatment options adapted to the Ukrainian cultural context and understood and accepted by all stakeholders. An HIV epidemic fueled by PWIDs is no longer “somebody else's problem.” The Ministry of Health's recent willingness to revisit Order No. 200 as well as the June 2012 submission to the Ukrainian government of a new national drug strategy prepared by the Ukrainian State Drug Control Committee and UNODC (19) are hopeful signs that Ukraine is moving forward. A progressive path remains the only solution for improving the health of the individual, the healthcare system and Ukrainian society. Anything less will set Ukraine on a downward trajectory that will reverse its many recent gains, including the secondary benefits to its neighbors who have similarly adopted evidence-based HIV prevention and treatment strategies that are consistent with public health and human rights.