MOAC204

Opioid Substitution Therapy (OST) with Buprenorphine in Ukraine – Way to Prevent HIV/AIDS among IDUs: 

Opioid Substitution Therapy (OST) with Buprenorphine in Ukraine – Way to Prevent HIV/AIDS among IDUs Sergii Dvoriak MD, PhD Ukrainian Institute on Public Health Policy 4th IAS Conference on HIV Pathogenesis, Treatment and Prevention 23 July, 2007 Sydney, Australia

Acknowedgement : 

Acknowedgement Dr. O.Lebega - The AIDS Alliance in Ukraine O.Morozova, MA - The AIDS Alliance in Ukraine Dr. A.Viyevskiy – Kyiv City Narcology Hospital Dr. O.Yurchenko – Kyiv City AIDS Center Dr. L.Vlasenko – NGO ‘Virtus’, Dnipropetrovsk Dr. M.Skorokhodov – Donetsk Narcology Dispensary Dr. A.Mandebura – Crimea Republican Narcology Dispensary Dr. I.Blizhevskaya - Kherson Narcology Dispensary Dr. I.Podolyan - Odessa Narcology Dispensary Dr. K.Dumchev – Vinnitsa Narcology Dispensary Dr. V.Shtengelov – Ukrainian Institute on Public Health Policy Dr. I.Grishayeva – The WHO, Ukraine Dr. A.Uchtnengagen – Zurich University, Switzerland Український інститут досліджень політики щодо громадського здоров’я Ukrainian Institute on Public Health Policy

Drug statistics in Ukraine, 1990-2006: 

Drug statistics in Ukraine, 1990-2006 No IDU size estimations were held in 1990; Number of individuals officially registered with drug-related disorders was 123’400 in 2006; Estimated number of IDUs in Ukraine (2005-2006) is 325’000 – 425’000 Український інститут досліджень політики щодо громадського здоров’я Ukrainian Institute on Public Health Policy

Prevalence of IDUs in Ukraine (MoH data): 

Prevalence of IDUs in Ukraine (MoH data)

HIV transmission in Ukraine: 

HIV transmission in Ukraine Injection of drugs From mother to child Sexual Undetermined Data of the Ukrainian AIDS Center Український інститут досліджень політики щодо громадського здоров’я Ukrainian Institute on Public Health Policy *Note: Practices of HIV testing among IDUs, people with STDs, pregnant women and blood donors had been changing in 1996-2003.

Relationship between IDU and HIV: 

Relationship between IDU and HIV Український інститут досліджень політики щодо громадського здоров’я Ukrainian Institute on Public Health Policy

Political context: 

Political context

Joint Mission of WHO/UNAIDS/UNODC on SMT in Ukraine (November, 2004): 

Joint Mission of WHO/UNAIDS/UNODC on SMT in Ukraine (November, 2004) ~ 30-40% of IDUs depended from opiates should have access to SMT for get influence on both epidemics – drug use and HIV. For Ukraine, where estimated number of IDUs is 325 – 425 thousands, the need in SMT is between 60 - 200 thousands courses

UNDP Pilot Project. SMT with Buprenorphine (Addnok) 2004-2005: 

UNDP Pilot Project. SMT with Buprenorphine (Addnok) 2004-2005 Kyiv – 57 clients (2 fem.) Kherson – 30 clients (1 fem.) CRITERIA: Opioid dependence (ICD-10). Two or more previous unsuccessful treatment attempts (drug-free) 18 or older Readiness for the program Український інститут досліджень політики щодо громадського здоров’я Ukrainian Institute on Public Health Policy

WHO-multi-site prospective study Evaluating the Efficacy of ST in Opioid Dependence and HIV/AIDS: 

WHO-multi-site prospective study Evaluating the Efficacy of ST in Opioid Dependence and HIV/AIDS

Overview of the Study : 

Overview of the Study This was a prospective observational study with assessments at baseline, and 3- and 6- month follow-ups All assessments are related to the period of one month prior to interview The main aims of outcome evaluation were to explore changes in the following domains: Health Status and well being of individuals in substitution treatment, Community/ Social benefits, And also Programme performance

General Protocol of the Study (2003): 

General Protocol of the Study (2003) Dr. Vladimir Poznyak, Management of Substance Abuse, Department of Mental Health and Substance Abuse, WHO, Geneva Professor Ambros Uchtenhagen, Research Institute of Mental Health and Addiction, Zurich, Switzerland Professor Robert Ali, WHO Collaborating Centre for the Treatment of Drug and Alcohol problems, University of Adelaide (Australia)

Slide13: 

Data collection Sites/ Clinics involved in the study: Regional Narcology Dispensary of Kherson Region; Kiev City Narcology Hospital State data collection time frame: April 2004 – December 2004 December 2004- May 2005

Demographics, Drug Use & Treatment History: 

Demographics, Drug Use & Treatment History

Demographics at treatment entry: 

Demographics at treatment entry

Drug Use Lifetime (ASI – Lite): 

Drug Use Lifetime (ASI – Lite) * Most common route of administration = intravenous

Changes in Well Being and Health Status and Social/Community BenefitsSome data from Poland and Lithuania are demonstrated also: 

Changes in Well Being and Health Status and Social/Community Benefits Some data from Poland and Lithuania are demonstrated also

Drug Use last 30 days (ASI – Lite): 

Drug Use last 30 days (ASI – Lite)

Drug Use last 30 days (ASI – Lite): 

Drug Use last 30 days (ASI – Lite)

Other opioid (poppy straw) use in the last 30 days: 

Other opioid (poppy straw) use in the last 30 days

Amphetamine use in the last 30 days: 

Amphetamine use in the last 30 days

Health Status: 

Health Status *Range

Health Status: 

Health Status

Quality of life: WHOQOL-bref: 

Quality of life: WHOQOL-bref

Quality of life: WHOQOL-bref: 

Quality of life: WHOQOL-bref

Quality of Life – Physical Domain(WHOQOL-BREF): 

Quality of Life – Physical Domain (WHOQOL-BREF)

Quality of Life – Psychological Domain: 

Quality of Life – Psychological Domain

Quality of Life – Social Domain: 

Quality of Life – Social Domain

Blood Borne Virus Risk BehaviourBBV-Traq *: 

Blood Borne Virus Risk Behaviour BBV-Traq * * Blood Born Virus Transmission Assessment Questionnaire

Blood Borne Virus Risk Behavior (BBV-Traq): 

Blood Borne Virus Risk Behavior (BBV-Traq)

Blood Borne Virus Risk Behavior – Injecting Practices (BBV-TRAQ): 

Blood Borne Virus Risk Behavior – Injecting Practices (BBV-TRAQ)

Criminal and Employment Activity: 

Criminal and Employment Activity * OTI= Opiate Treatment Index- section two [Max score = 16].

Community /Social benefits Self reported criminal involvement (OTI): 

Community /Social benefits Self reported criminal involvement (OTI)

Programme Performance : 

Programme Performance * Refers to those still receiving maintenance treatment

Order of MoH # 161 of April 13, 2005: 

Order of MoH # 161 of April 13, 2005 To start SMT implementation for opioid addicts with co-morbiding HIV/AIDS in following treatment organizations:… To use for this purpose buprenorphine (Addnok) which will be provided as humanitarian aid by International Charity Organization International HIV/AIDS Alliance in Ukraine / GFATM To monitor the treatment and find best models for spreading this method to all regions of Ukraine

‘The HIV/AIDS Alliance in Ukraine’ (GF-Funding) Project /2005-06/: 

‘The HIV/AIDS Alliance in Ukraine’ (GF-Funding) Project /2005-06/ Pilot Sites: Kyiv – 2 sites; Donetsk, Dnipropetrovsk, Odesa, Simpheropol, Mykolayiv, Vinnitsa, Poltava, Kherson Start of BMT – October 2005 Purpose: to broad access to ARV for HIV+ IDUs Total number of patients > 200 persons

Development of SMT Programs in Ukraine,2003 - 2007 yy.: 

Development of SMT Programs in Ukraine, 2003 - 2007 yy. Український інститут досліджень політики щодо громадського здоров’я Ukrainian Institute on Public Health Policy

Slide38: 

Substitution maintenance therapy with ADDNOK medication in Kyiv on the basis of KCNCH “Sociotherapy” (Adherence to SMT program)

National Project “Overcoming HIV/AIDS Epidemic in Ukraine“ financing GFATM – The HIV/AIDS Alliance in Ukraine: 

National Project “Overcoming HIV/AIDS Epidemic in Ukraine“ financing GFATM – The HIV/AIDS Alliance in Ukraine Український інститут досліджень політики щодо громадського здоров’я Ukrainian Institute on Public Health Policy

Monitoring and Evaluation of the pilot phase : 

Monitoring and Evaluation of the pilot phase HIV+ and HIV- IDUs N – 200 clients in 6 sites sites Instruments: 1. For monitoring: Eligibility checklist, Patient recruitment table, Staffing table /SASQ (The Staff attitude and satisfaction questionnaire);  Focus groups   2. For evaluation: ASI-5 - Addiction Severity Index, 5 th edition (computerized version), BBV-TRAQ questionnaire (Blood borne virus transmission risk assessment questionnaire) (With baseline and 6 month follow-up data)                     

Demographics: 

Demographics

Drug use - Lifetime (ASI – Lite): 

Drug use - Lifetime (ASI – Lite)

Drug use – Previous 30 days (ASI – Lite): 

Drug use – Previous 30 days (ASI – Lite) * Preliminary data

Drug use – Previous 30 days (ASI – Lite): 

Drug use – Previous 30 days (ASI – Lite)

Addiction severity index - 5: 

Addiction severity index - 5 * Preliminary data

Addiction severity index - 5: 

Addiction severity index - 5

Blood Borne Virus Risk Behavior (BBV-Traq): 

Blood Borne Virus Risk Behavior (BBV-Traq) * Preliminary data

Blood Borne Virus Risk Behavior (BBV-Traq): 

Blood Borne Virus Risk Behavior (BBV-Traq)

Buprenorphine in tablets: 

Buprenorphine in tablets 2004y - 36 000tbls = ~ $50 000 2005y - 96 000tbls = ~$125 000 2006y - 432 000tbls =~$475 000

Cost of Buprenorphine (Addnok): 

Cost of Buprenorphine (Addnok) Український інститут досліджень політики щодо громадського здоров’я Ukrainian Institute on Public Health Policy

Total expenditure on SMT development in Ukraine (per patient data): 

Total expenditure on SMT development in Ukraine (per patient data) 197 patients at the end of January 2006 (project duration to date - 4 months) Substance cost – $42 000. Cost of infrastructure development projects – $266 000 Total expenditures – $308 000 Total expends per patient a month – $390. Український інститут досліджень політики щодо громадського здоров’я Ukrainian Institute on Public Health Policy

Conclusions: 

Conclusions Buprenorphine (Addnok) is effective for SMT: retention in Tx; reduction of opioids use; health status & quality of life improvement; reduction of risky behavior; decrease of criminal involvement. In phase of stabilization an effective dose of buprenorphine is ~ 8-10 mg/day. Ukrainian data are similar to Poland, Lithuania etc Political context is still ambivalent and not supportive. Public health decision-makers still are not active in terms of development of SMT in Ukraine and influencing HIV-epidemic. The country needs a new strategy and practice regarding SMT to promptly respond on the epidemic challenges. Firstly to broad access to SMT providing methadone ST.

Slide53: 

Thank you for your attention!