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AbstractIntroductionPeople who inject drugs (PWID) remain at high risk of HIV in many countries. The HIV prevention cascades have been proposed to replicate the success of the treatment cascades and reinvigorate the prevention programmes through improved monitoring, planning and delivery. We adapted the cascade framework to the PWID context in Ukraine, assessed gaps and analysed factors associated with achieving "access" and "effective use" outcomes.MethodsSelf‐reported data on the use of prevention services and risk behaviours from the 2017 integrated bio‐behavioural survey among PWID in Ukraine were used to construct cascades for needle/syringe and condom programmes (NSP and CP). Socio‐demographic and behavioural variables were evaluated as potential correlates of cascade outcomes.ResultsThe NSP cascade analysis included 7815 HIV‐negative PWID. Motivation to use clean syringes was not assessed and assumed at 100%. Access to clean syringes through NSP in the past 12 months was reported by 2789 participants (35.7%). Effective use of syringes (no sharing in the past 30 days) was reported by 7405 participants (94.8%). NSP access was higher among women, individuals older than 44, and mixed drug users; while effective use was reported more frequently by men and opioid users, with no difference by age. The CP cascade analysis included 6606 (85%) of the HIV‐negative PWID who had sex in the past three months. Of those, 2282 (34.5%) received condoms, and 1708 (25.9%) reported consistent use with all partners in the past three months. Older PWID and mixed‐drug users accessed condoms more frequently; whereas younger subgroups and opioid users used them more consistently.ConclusionsOverall, the cascade framework was useful to describe the status of HIV prevention among PWID in Ukraine and to identify areas for improvement in the programming and evaluation of HIV prevention. Access to needle/syringe and condom programmes was substantially below the recommended levels. Effective use of clean syringes was reported by a vast majority of PWID, although likely affected by self‐report bias; whereas consistent condom use was infrequent. Socio‐demographic and behavioural variables showed significant associations in NSP and CP cascade analyses, with little consistency between the access and effective use outcomes.

AbstractIntroductionPeople who inject drugs (PWID) in Ukraine have high prevalences of HIV and hepatitis C (HCV). Since the turn of the century, various organizations have funded non‐governmental organizations (NGOs) in Ukraine to provide PWID with needles and syringes, condoms, HIV and HCV testing, and improve linkage to opioid agonist therapy (OAT) and HIV treatment. We investigated whether contact with these NGOs was associated with improved HIV prevention and treatment outcomes among PWID.MethodsFive rounds of respondent‐driven sampled integrated bio‐behavioural survey data (2009 [N = 3962], 2011 [N = 9069], 2013 [N = 9502], 2015 [N = 9405], and 2017 [N = 10076]) among PWID in Ukraine (including HIV/HCV testing and questionnaires) were analysed using mixed‐effect logistic regression models (mixed‐effects: city, year). These regression models assessed associations between being an NGO client and various behavioural, OAT, HIV testing and HIV treatment outcomes, adjusting for demographic characteristics (age, gender, lifetime imprisonment, registration in a drug abuse clinic, education level). We also assessed associations between being an NGO client and being HIV positive or HCV positive, likewise adjusting for demographic characteristics (as above).ResultsNGO clients were more likely to have received HIV testing ever (adjusted odds ratio [aOR] 5.37, 95% confidence interval [95% CI]: 4.97 to 5.80) or in the last year (aOR 3.37, 95% CI: 3.20 to 3.54), to have used condoms at last sexual intercourse (aOR 1.37, 95% CI: 1.30 to 1.44) and sterile needles at last injection (aOR 1.37, 95% CI: 1.20 to 1.56), to be currently (aOR 4.19, 95% CI: 3.48 to 5.05) or ever (aOR 2.52, 95% CI: 2.32 to 2.74) on OAT, and to have received syringes (aOR 109.89, 95% CI: 99.26 to 121.66) or condoms (aOR 54.39, 95% CI: 50.17 to 58.96) in the last year. PWID who were HIV positive (aOR 1.40, 95% CI: 1.33 to 1.48) or HCV positive (aOR 1.57, 95% CI: 1.49 to 1.65) were more likely to have contact with NGOs, with HIV positive PWID in contact with NGOs being more likely to be registered at AIDS centres (aOR 2.34, 95% CI: 1.88 to 2.92) and to be on antiretroviral therapy (aOR 1.60, 95% CI: 1.40 to 1.83).ConclusionsContact with PWID targeted NGOs in Ukraine is associated with consistently better preventive, HIV testing and HIV treatment outcomes, suggesting a beneficial impact of harm reduction NGO programming.

AbstractIntroductionPeople who inject drugs (PWID) in Ukraine have high prevalences of HIV and hepatitis C virus (HCV). Non‐governmental organizations (NGOs) provide PWID with needles/syringes, condoms, HIV/HCV testing and linkage to opioid agonist treatment (OAT) and antiretroviral therapy (ART). We estimated their impact and cost‐effectiveness among PWID.MethodsA dynamic HIV and HCV transmission model among PWID was calibrated using data from four national PWID surveys (2011–2017). The model assumed 37–49% coverage of NGOs among community PWID, with NGO contact reducing injecting risk and increasing condom use and recruitment onto OAT and ART. We estimated the historic (1997–2021) and future (2022–2030, compared to no NGO activities from 2022) impact of NGOs in terms of the proportion of HIV/HCV infections averted and changes in HIV/HCV incidence. We estimated the future impact of scaling‐up NGOs to 80% coverage with/without scale‐up in OAT (5–20%) and ART (64–81%). We estimated the cost per disability‐adjusted life‐year (DALY) averted of current NGO provision over 2022–2041 compared to NGO activities stopping over 2022–2026, but restarting after that till 2041. We assumed average unit costs of US$80–90 per person‐year of NGO contact for PWID.ResultsWith existing coverage levels of NGOs, the model projects that NGOs have averted 20.0% (95% credibility interval: 13.3–26.1) and 9.6% (5.1–14.1) of new HIV and HCV infections among PWID over 1997–2021, respectively, and will avert 31.8% (19.6–39.9) and 13.7% (7.5–18.1) of HIV and HCV infections over 2022–2030. With NGO scale‐up, HIV and HCV incidence will decrease by 54.2% (43.3–63.8) and 30.2% (20.5–36.2) over 2022–2030, or 86.7% (82.9–89.3) and 39.8% (31.4–44.8) if OAT and ART are also scaled‐up. Without NGOs, HIV and HCV incidence will increase by 51.6% (23.6–76.3) and 13.4% (4.8–21.9) over 2022–2030. Current NGO provision over 2022–2026 will avert 102,736 (77,611–137,512) DALYs when tracked until 2041 (discounted 3% annually), and cost US$912 (702–1222) per DALY averted; cost‐effective at a willingness‐to‐pay threshold of US$1548/DALY averted (0.5xGDP).ConclusionsNGO activities have a crucial preventative impact among PWID in Ukraine which should be scaled‐up to help achieve HIV and HCV elimination. Disruptions could have a substantial detrimental impact.

AbstractIntroductionProviding HIV healthcare and Treatment as Prevention both depend on diagnosing HIV cases, preferably soon after initial infection. We hypothesized that tracing risk networks recruits higher proportions of undiagnosed positives than outreach‐based testing or respondent‐driven sampling (RDS) in Odessa, Ukraine.MethodsThe Transmission Reduction Intervention Project (TRIP) used risk network tracing to recruit sexual and injection networks of recently‐infected and longer‐term infected (LTs) seeds (2013 to 2016). Integrated Biobehavioural Surveillance (IBBS) (2013) used RDS to recruit people who inject drugs (PWID). Outreach Testing tested PWID for HIV at community outreach sites (2013 to 2016). Proportions of undiagnosed positives among those tested were compared TRIP versus IBBS; TRIP versus Outreach Testing and between TRIP arms. Costs were compared across the projects.ResultsTRIP tested 1252 people (21% women) in seeds' risk networks; IBBS tested 400 (18% women); Outreach Testing 13,936 (31% women). TRIP networks included a higher proportion of undiagnosed positives (14.6%) than IBBS (5.0%) or Outreach Testing (2.4%); odds ratio (OR) 3.25 (95% CI 2.07, 5.12) versus IBBS and 7.03 (CI 5.95, 8.31) versus Outreach Testing respectively. Findings remained significant in analyses stratified by sex and when PWID in TRIP networks were compared with Outreach Testing and IBBS. Within TRIP, recently‐infected participants' networks contained higher proportions of undiagnosed positives (16.3%) than LTs' networks (12.2%); OR 1.41 (CI 1.01, 1.95). TRIP located undiagnosed positives less expensively than did RDS or Outreach Testing.ConclusionsTRIP's recruiting techniques, including prioritizing networks of the recently infected, find undiagnosed HIV‐positive people efficiently. They should be integrated with standard practice to improve case‐finding. Research should test these techniques in other socio‐epidemiologic contexts.Clinical trial registryRegistered ClinicalTrials.gov: NCT01827228.

AbstractIntroductionThis paper examines the extent to which an intervention succeeded in locating people who had recently become infected with HIV in the context of the large‐scale Ukrainian epidemic. Locating and intervening with people who recently became infected with HIV (people with recent infection, or PwRI) can reduce forward HIV transmission and help PwRI remain healthy.MethodsThe Transmission Reduction Intervention Project (TRIP) recruited recently‐infected and longer‐term infected seeds in Odessa, Ukraine, in 2013 to 2016, and asked them to help recruit their extended risk network members. The proportions of network members who were PwRI were compared between TRIP arms (i.e. networks of recently‐infected seeds vs. networks of longer‐term infected seeds) and to the proportion of participants who were PwRI in an RDS‐based Integrated Biobehavioral Surveillance of people who inject drugs in 2013.ResultsThe networks of PwRI seeds and those of longer‐term infected seeds had similar (2%) proportions who were themselves PwRI. This was higher than the 0.25% proportion in IBBS (OR = 7.80; p = 0.016). The odds ratio among the subset of participants who injected drugs was 11.17 (p = 0.003). Cost comparison analyses using simplified ingredients‐based methods found that TRIP spent no more than US $4513 per PwRI located whereas IBBS spent $11,924.ConclusionsFurther research is needed to confirm these results and improve TRIP further, but our findings suggest that interventions that trace the networks of people who test HIV‐positive are a cost‐effective way to locate PwRI and reduce HIV transmission and should therefore be implemented.