Overview

PEPFAR

Data use for planning, implementation and evaluation of prevention, care and

treatment programs for PWID in Ukraine

Pavlo SmyrnovInternational HIV/AIDS Alliance in Ukraine

AIDS 2014 – Stepping Up The Pace

PEPFAR Overview• Background on HIV epidemic in Ukraine

• Data Action examples– Peer-driven intervention (PDI)– Risk network PDI, Outreach testing– Medication-assisted therapy (MAT)– Community-initiated treatment intervention (CITI)– Integrated care

• Conclusion

HIV epidemic among PWID in Ukraine

Kyiv

Dnipropetrovsk

Donetsk

Mykolaiv

Odesa

Lviv

AR Crimea2007 2008 2009 2011 2013

28.4%

32.8%

21.6% 21.6%

18.1%20.1%

15.0%

9.9%7.2%

3.6%

All PWID Young PWID

• Estimated # of PWID in Ukraine is 310,000• Main injectable drug of abuse – home-made acetylated poppy straw extract (opioid)• Home-made methamphetamine-type drugs are also prevalent

• HIV epidemic started in 1995 among PWID in southern and eastern regions

New cases according toAEM and Spectrum models

19901992

19941996

19982000

20022004

20062008

20102012

20142016

20182020

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

34,755

10,879

4,441

IDU Clients MSW MSMFSW Low-risk males Low-risk females

19951997

19992001

20032005

20072009

20112013

20152017

20190

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

22,557

9,611

1,953

IDUs FSW ClientsMSM Remaining pop

Data: Integrated Bio-Behavioral Surveys (IBBS) and Program data

2007 2008 2009 2011 20130.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

84.1%81.2% 82.6% 81.4% 83.5%

33.1%27.9%

39.4%37.0%

27.7%

IBBS: Past 30 day drug use

Opioids Stimulants

Comparison of IBBS and syringe exchange programs (SEP) data showed that not all PWID have equal access to services

– Only 20% clients of syringe exchange programs (SEP) were women

– Only 30% were teenagers and youth < 25 y.o – Only 1.5% were stimulant users

2007 2008 2009 2011 201371.0%72.0%73.0%74.0%75.0%76.0%77.0%78.0%

IBBS: % Males

2007 2008 2009 2011 201328.0

29.0

30.0

31.0

32.0

33.0

34.0

IBBS: Average age

Action: Peer Driven Intervention (PDI)

• Outreach model for reaching and educating PWID from hidden subpopulations using existing peer networks

• Recruiting coupons are used to invite peers for intervention

• IDUs are taught to share knowledge and can earn rewards for educating peers with bonuses for recruiting young IDUs and women-IDUs

Results• Starting from 2007 ~30 000 new PWID

were reached; coverage increased up to 10 times at some sites

• For most of the clients this was the first contact with harm reduction services

• Worked best with young PWID

Data: Program testing results on all PWID clients in 2011-2013

Not tested; 201506; 63%

Tested once; 81918; 26%

Tested twice or more; 32878; 10%

Error; 1166; 0%Not tested

Tested once

Tested twice or more

Error

Negative; 76,895; 93.8%

Positive; 5,023; 6.2%

Seroconverted; 798; 2.4%

Repeated negative; 32,080; 97.4%

Testing data show low yield of HIV+ in PWID clients

% positive at first test is 4.6%

(Overall prevalence is 18.6%)

Also: Preliminary data from TRIP project in Odesa suggest that in high prevalence settings up to 40% of high risk partners of HIV positive people are also HIV positive and might not be aware about their HIV status.

Action 1: Outreach testing• In the situation of radical decrease of the unit cost the scope and

attractiveness of services will also decrease and may negatively affect number of people who approach services including testing. To deal with this we prioritize outreach by social worker.

• We also propose that social workers will carry rapid tests in outreach routes and assist client in testing. This will greatly increase screening capacity (HIV detection sensitivity) of the projects as tests will be provided at time and location convenient to a client.

• In previous period the testing was limited to time schedule and physical location of doctor and nurse, many doctors were only working between 3 and 6 PM and only at NGO office location, which greatly limited accessibility of HIV testing.

Action 2: Risk Network PDI (RNPDI)

• Active recruitment of HIV positive and their risk networks. In addition to usual post-test counseling routine and referral social/outreach worker will distribute coupons and invite to take part in a survey for a small reward.

• Provide coupons to other positive clients and also for some negative at higher risk. The coupon distribution will stop once we have no more positive participants.

• This will allow actively recruit immediate risk network members of the HIV positive clients, increase screening yield and focus prevention efforts on most at risk for acquiring HIV or most likely transmitting HIV to their partners.

• This approach may increase finding of HIV cases from 4,6% up to 10% of all tested in high prevalence setting (based on data from Odesa pilot). This approach should have maximum effect in high and medium priority regions and may help to identify majority of HIV cases among high risk groups.

Data: MAT effectiveness studies

b a s e l i n e 6 m f o l l o w - u p 1 2 m f o l l o w - u p0%

10%20%30%40%50%60%70%80%90%

100%

80.50%

3.25%

4.81%

94.71%

7.66%

0.00%

home -made opioid use

buprenorphine methadone

b a s e l i n e 6 m f o l l o w - u p 1 2 m f o l l o w - u p0.00

0.05

0.10

0.15

0.20

0.25

0.300.24

0.09

0.04

0.24

0.050.03

as i drug s core


b a s e l i n e 6 m f o l l o w - u p 1 2 m f o l l o w - u p0%

10%

20%

30%

40%

50%

60%

70%55.24%

38.64%

17.59%

58.57%

22.98%

12.52%

de pre ss ion


b a s e l i n e 6 m f o l l o w - u p 1 2 m f o l l o w - u p0.000.020.040.060.080.100.120.140.160.18

0.15

0.08

0.04

0.17

0.02 0.03

b b v -t r aq in jec ti o n sc o r e


b a s e l i n e 6 m f o l l o w - u p 1 2 m f o l l o w - u p0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.350.29

0.25

0.130.19

0.10 0.09

as i me dical s core


b a s e l i n e 6 m f o l l o w - u p 1 2 m f o l l o w - u p0.000.020.040.060.080.100.120.140.160.18

0.15

0.08

0.04

0.17

0.02 0.03

as i le gal s core


Schaub M, Chtenguelov V, Subata E, Weiler G, Uchtenhagen A (2010) Feasibility of buprenorphine and methadone maintenance programmes among users of home made opioids in Ukraine. Int J Drug Policy 21: 229-233.

Action: MAT scale-up in Ukraine

Jan/04

May/0

4

Sep/0

4

Jan/05

May/0

5

Sep/0

5

Jan/06

May/0

6

Sep/0

6

Jan/07

May/0

7

Sep/0

7

Jan/08

May/0

8

Sep/0

8

Jan/09

May/0

9

Sep/0

9

Jan/10

May/1

0

Sep/1

0

Jan/11

May/1

1

Sep/1

1

Jan/12

May/1

2

Sep/1

2

Jan/13

May/1

3

Sep/1

3

Jan/14

May/1

40

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

Total number of MAT clients by medication

Buprenorphine, Ukraine Methadone, Ukraine

Estimated # of injecting opioid users is ~250,000

MAT covers about 3.4% of them

Crimea annexation

Data: HIV care and treatment program

2009 2010 2011 2012 20130

10,000

20,000

30,000

40,000

50,000

60,000

70,000Number of patients on ART

IDU Ukraine

PWH WI D (est )

R eg ist er ed in ca r e

Acti ve med ca r e

Ca r e a nd suppor t

R eceive AR T

R eceive AR T a t 12m*

66,960

46,872

23,436

13,000

6,007

0

163,040

85,696

42,848

52,000

49,777

47,416

Seek-test-treat-retain cascadePWID have disproportionately low access to treatment and care

*no ART retention data on PWID

Action: Community initiated treatment intervention (CITI)

• Short term rapid linkage to treatment intervention which facilitates early treatment access for active drug users.

– locate HIV positive clients in harm reduction and link them to HIV treatment using a case management approach.

– support HIV positive clients up to 6 months into ART (if no support provided through other projects - care and support, ST, integrated services)

– refer to care and support projects or other available resources for long term treatment support.

CITI is mostly focused on linkage to ART with build-in short term adherence support.

CITI preliminary data

PWH WI D (est )

R eg ist er ed in ca r e

Acti ve med ca r e

R eceive AR T

0 10,000 20,000 30,000 40,000 50,000 60,000 70,000

0 100 200 300 400 500 600 700 800 900 1,000

66,960

46,872

23,436

6,007

884

429

429

380

CITI clients All PWID

During first 3 months of CITI implementation in 2014:

• 884 clients were involved

• 429 clients registered in AIDS clinics

• 380 clients started ART• 30 clients started MAT

Conclusion:Prevention effectiveness

2005 2006 2007 2008 2009 2010 2011 2012 -

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

200,000

0

200

400

600

800

1000

1200

Cases among young PWID and coverage by prevention

# PWID covered by prevention# Registered cases among PWID <25 y.o.

• All data sources confirm inverse correlation between increasing coverage of prevention programs and number of new cases among PWID;

• RNPDI, rapid testing in outreach settings, CITI, and other approaches aimed at increasing the service coverage, improving PWID retention in services, and their access to care are key to the success of prevention program in Ukraine

• The effectiveness of prevention programs among PWID in reducing HIV incidence could be easily undermined in case of decreasing coverage or limiting the service package for PWID, which are inevitable in case of the anticipated decline in funding of services for PWID in Ukraine

PEPFAR

THANK YOU FOR ATTENTION!

Data: MAT retention study

Positive TB test is increasing dropout from MAT programs due to legislative requirement for inpatient treatment of active TB cases

Action: Integrated Care

• 6 sites working in TB dispensaries• 2 sites in narcological clinics pilot TB-DOTS• 1 site in narcological clinics provides ART• Implementation guidelines developed

Public Health

Tertiary

SecondaryPrimary

TB STI HIVNarco

Challenges:• Rigid vertical health

care structure• No financial incentives

for providers• Restrictive legislature

Documents

Overview