Daniel J. Bromberg

Background: Ukraine's HIV epidemic, the second-largest in Europe, is concentrated among people who inject drugs (PWID), primarily opioids. Between 2014 and 2021, Ukraine has scaled up opioid agonist therapies (OAT) considerably. Methods: We conducted a large cross-sectional biobehavioral survey of PWID in 2020–2021 to compare to an equivalent survey from 2014 to 2015 using representative sampling approaches including random sampling and RDS of PWID with opioid dependence, recruiting those who were: currently on OAT; previously on OAT; and never on OAT. Only PWID who tested positive for HIV were assessed for the proportion linked to care, prescribed antiretroviral therapy (ART), and adherent to ART. Results: Comparing samples from 2021 (N = 2027) to 2014 (N = 1613), there were differences in HIV diagnosis (92.6 vs. 90%), linkage to care (86.5 vs. 85.3%), prescription of ART (95.8 vs. 78.9%), and adherence to ART (93.6 vs. 85.7%), for those patients who had previously been on OAT. In a subanalysis from the 2020 to 2021 sample, having ever touched the OAT treatment system (currently or previously on OAT) had significantly better outcomes at each step of the cascade relative to those who had never been on OAT. Interpretation: Although OAT had previously been demonstrated to improve HIV treatment outcomes along the HIV care cascade, findings here suggest that OAT has scaled-up along with higher levels of engagement in the HIV care cascade over time. Importantly, but not previously described, is the finding that touching the OAT treatment system, irrespective of retention on treatment contributes to improved HIV treatment outcomes for each step of the cascade.

The incidence and mortality of human immunodeficiency viruses (HIVs) are rising in Eastern Europe and Central Asia (EECA), particularly among people who inject drugs. Opioid agonist therapies (OATs), such as methadone or buprenorphine, are the most effective treatments for opioid use disorder and serve as a key HIV-prevention strategy in EECA. OAT uptake across the region, however, has been limited. The Kyrgyz Republic was the first Central Asian country to initiate OAT and remains a pioneer in the region. To understand the progression of OAT scale-up, all legislations related to drug policies or methadone in the Kyrgyz Republic were analyzed from the country’s founding to March 2023 and compared with policies in neighboring countries, particularly Kazakhstan and Tajikistan. Concurrently, local news coverage and policy reports were also assessed. OAT has been available in the Kyrgyz Republic since 2001, initially as a pilot project funded by international donors, and then with gradually increasing state support. Since its inception, the methadone program has evolved and influenced neighboring countries in Central Asia, despite numerous political challenges. The Kyrgyz Republic has expanded access to methadone, revised clinical protocols, and increased the number of distribution sites in communities and the carceral system to ensure broader access, aiming for program sustainability. While methadone policies and implementation in the Kyrgyz Republic have advanced earlier and more expansively than in neighboring countries, some challenges persist. Based on the findings, the suggestions provided may support the sustainable scale-up of methadone programs, enabling continued growth and improvement.

Introduction: Stigma has undermined the scale‐up of evidence‐based HIV prevention and treatment. Negative beliefs influence clinicians’ discriminatory behaviour and ultimately have wide‐ranging effects across the HIV prevention and treatment continuum. Stigma among clinicians can be mitigated in several ways, including through interpersonal contact. In this study, we test whether interactions with people who inject drugs (PWID) influence attitudes of both direct and indirect providers of opioid agonist therapies (OATs) within the same primary care clinics (PCCs) where OAT is newly introduced.Methods: In a cluster randomized controlled trial integrating OAT and HIV care into PCCs in Ukraine, clinicians at 24 integrated care sites (two sites in 12 regions) from January 2018 to August 2022 completed a structured survey at baseline, 12 and 24 months. The survey included feeling thermometers and standardized scales related to clinician attitudes towards patients and evidence‐based care. Nested linear mixed‐effects models were used to examine changes in mean scores over three timepoints for both direct and indirect clinicians.Results: There were fewer significant changes in any of the scales for direct providers (n = 87) than for indirect providers (n = 155). Direct providers became less tough‐minded about substance use disorders (p = 0.002), had less negative opinions about PWID (p = 0.006) and improved their beliefs regarding OAT maintenance (pp = 0.004). Indirect providers reported improvements in most stigma constructs, including a significant decrease in prejudice (pp = 0.001), shame (p = 0.007) and fear (p = 0.001) towards PWID.Conclusions: Integrating OAT services within primary settings was associated with significantly reduced stigma constructs and improved attitudes towards PWID, possibly through increased intergroup contact between PWID and general clinical staff. Unlike most stigma reduction interventions, re‐engineering clinical processes so that PWID receive their care in PCCs emerges as a multilevel stigma reduction intervention through the integration of specialized services in PCCs. Integration influences different types of stigma, and has positive effects not only on health outcomes, but also improves clinician attitudes and efficiently reduces clinician stigma.

HIV incidence and mortality are increasing in Eastern Europe and Central Asia and are concentrated in people who inject drugs. Maintenance with opioid agonist therapies (OAT) like methadone or buprenorphine is the best treatment for opioid use disorder and a key HIV-prevention strategy in the region. In Kazakhstan, the scale-up of methadone has been minimal since methadone’s introduction in 2008 and has been supported through international charitable organizations. As the Republic of Kazakhstan is designated to assume financial and administrative oversight of OAT, legislative gains can ensure treatment continuity and scale-up. Here, we review legislative barriers to OAT scale-up in Kazakhstan using an implementation science lens. We review legislative, political, and cultural barriers that undermine the efficient distribution and allocation of medications and impose burdensome clinical and administrative demands on patients and clinicians. Legislative reform is required to support further OAT expansion. We therefore provide policy recommendations to overcome these barriers to increase access to this life-saving, life-prolonging, evidence-based medical treatment. Minimally, these include increased numbers of clinical sites and patients at these sites; re-engineering OAT delivery across the country and directly to patients; introducing newer formulations of OAT; and creating an open bidding process to procure treatment medications.

Background: People in criminal justice settings (CJS) have high rates of opioid use disorder (OUD) and HIV. Probation is part of the CJS and congregates many individuals with high rates of mental health and substance use disorders relative to the general population; nevertheless, probation remains a major improvement to incarceration. As a steppingstone to full decarceration efforts, community supervision settings like probation can be leveraged as “touchpoints” to identify and link people with OUD (and other co-morbid conditions) to treatment and reduce criminal activity. Methodology: To determine the feasibility of a modified screening, brief intervention and referral to treatment (SBIRT) strategy to link probationers to opioid agonist therapies (OAT) in the newly created probation system in Ukraine, we conducted a single-arm SBIRT intervention in eight probation centers in four Ukrainian administrative regions. For those screening positive for OUD, interest in OAT was assessed before and after a brief intervention. Those interested in OAT were referred to community OAT services. Participants with OUD also underwent HIV testing. Principal findings: Of the 1,298 consecutive individuals screened, 208 (16.0%) met criteria for opioid dependence. Of these, 122 (58.7%) enrolled in brief intervention, of which 54 (44.3%) had HIV and 14 (25.9%) of these were newly diagnosed. After the brief intervention, interest in starting OAT increased significantly from a median of 7.0 to 8.0 (P = <0.001) using a 10-point scale. Thirty (N = 30; 24.6%) of the enrolled participants initiated OAT and 21 of these (70%) were retained in treatment for 6 months. Significance: The prevalence of OUD (and HIV) is high among people in probation in Ukraine. SBIRT can identify a large number of people eligible for OAT, many of whom were willing to initiate and remain on OAT. Integrating SBIRT into probation can potentially assist with OAT scale-up and help address HIV prevention efforts.

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.

Methadone treatment is prescribed by evidence-based medicine as the most effective tool for the treatment of opioid addiction. Its implementation into high-need prison settings worldwide has been met with challenges, particularly in Eastern Europe and Central Asia where the opioid epidemic continues to expand. To address these impasses to intervention translation, we turn to post-structural approaches to policy analysis. These approaches open space for (re)thinking the ways that translated interventions emerge locally, by treating policy texts as social practices that make interventions in specific, sometimes unexpected, ways. We leverage Carol Bacchi’s post-structuralist analytic framework to interrogate how the object of methadone is constituted in Kyrgyz prisons through an analysis of the national legislative document, the “Government Program,” which provides the legislative basis for opioid addiction treatment administration in the Kyrgyz Republic. Rather than the medicalized methadone for the treatment of opioid use disorder, contained in the distinct objectivization of methadone emerging from this policy text, is the previously unexamined assumption that methadone is a particular type of governance. We describe a methadone object tied up with the shifting social structures that govern Kyrgyz prisons, divided between formal (state-run) and informal (prisoner-run) governance. In Kyrgyz prisons, where opioid policy discourse produces a divide between formal and informal governance, methadone emerges as a tool of the formal prison administration to regain control of the prisons from the practices of prisoner subculture. Although this study takes the Kyrgyz case as an example, the enactment of methadone as formal governance is likely to resonate throughout Eastern Europe and Central Asia, where there is a strong legacy of self-governing prisons. We conclude with a call for global health policymakers to consider how opioid addiction treatment is constituted within local governing relations, in ways that may depart sharply from the evidence base.