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The Effect of Opioid Agonist Maintenance Therapy on Healthcare Utilization and

Engagement among HIV-infected People Who Inject Drugs in Ukraine

C. Bachireddy1, J. Izenberg2, M. Soule3, S. Dvoryak4, F. Altice5

1Harvard Medical School, Brigham and Women's Hospital, Internal Medicine, Boston,

United States, 2University of California San Francisco, Psychiatry, San Francisco, United States, 3Harvard Medical School, Massachusetts General Hospital McLean, Psychiatry, Boston, United States, 4Ukrainian Institute on Public Health Policy, Kyiv, Ukraine, 5Yale University School of Medicine, Internal Medicine, New Haven, United

States

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No conflicts of interest to declare

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Background

• Despite decreasing HIV incidence and mortality globally, Eastern Europe and Central Asia face an increasing HIV epidemic driven by injection drug use.

• Ukraine is home to Europe’s most volatile HIV epidemic with an adult HIV prevalence of 1.1%

• Both OAT and ART provision are essential to stemming the IDU-driven HIV epidemic.

• Despite the introduction of OAT in Ukraine in 2004, only 2.7% of PWID access OAT, and among HIV-infected PWID, only 5% receive ART.

• HIV-infected PWID are much less likely to be on ART and engaged in chronic care and much more likely to transmit HIV than their counterparts who do not suffer from addiction.

• Instead, PWID often inappropriately utilize acute emergency services for substance abuse-related complaints, a behavior that can strain resource-poor health systems.

• In this study, we evaluate the effect of OAT on utilization of medical services and engagement in HIV care.

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Methods• Cross-sectional study of

healthcare utilization in the past six months among 296 randomly sampled HIV-infected opioid-dependent PWID in 9 clinics in 2010 across Ukraine.

• Therapeutic on OAT if on for at least 3 consecutive months prior to the past six months or as not taking OAT if not on any in the past nine months. Based on this criterion, 24 individuals were excluded.

n Total OAT No OAT p-valueMean age in years (SD) 270 35.5 (6.92) 35.28 (6.9) 35.92 (7) 0.47Female 268 33.58% 31.82% 36.96% 0.4Employment Status 246 <0.001unemployed 43.50% 48.85% 30.56%part time 47.15% 39.08% 66.67%full time 9.35% 12.07% 2.78%

Income Below Poverty 271 60.89% 51.98% 77.66% <0.001Married 272 26.84% 30.51% 20.00% 0.062Housing Status 270lives alone 10.37% 7.43% 15.79% 0.031lives with others 89.63% 92.57% 84.21%Education 271 0.385none 0.74% 0.56% 1.06%lower secondary 18.82% 16.38% 23.40%upper secondary 68.27% 71.75% 61.70%university 12.18% 11.30% 13.83%Co-morbiditieshepatitis C 272 59.19% 67.80% 43.16% <0.001Time in Prison 248 3.21 (5.79) 4.07 (6.81) 1.51 (2.10) <0.001Lifetime injection (yrs) 176 11.03 (7.86) 12.34 (8.06) 8.61 (6.88) <0.001OD ever 270 52.96% 43.50% 70.97% <0.001Time since HIV dx (yrs) 268 5.53 5.38 5.62 0.611

Table 1: Basic Characteristics

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Results

Substance Abuse

Those on OAT had more years of opioid injection but were less likely to have injected in the past 30 days, to have engaged in poly- substance abuse, to have drug problems currently, or to have ever overdosed on drugs (p< 0.01).

n Total OAT No OAT p-value

IDU p30d 271 53.14% 32.95% 90.53% <0.001

Mean total injection p30 144 19.42 (20.79) 11.78 (18.05) 24.58 (21.02) <0.001

Mean injections per day 144 0.65 (0.69) 0.39 (0.60) 0.82 (0.70) <0.001

Daily IDU 271 20.66% 10.23% 40.00% <0.001

Polysubstance use 260 46.92% 35.76% 66.32% <0.001

Stimulant use 259 11% 2% 25% <0.001

Hazardous EtOH 242 23.55% 18.63% 33.33% 0.011

$ spent on drugs p30d 271 146 USD 11 USD 397 USD <0.001

Drug problems p30d 260 3.03 (6.74) 1.81 (5.69) 5.5 (7.95) <0.001

Table 2: Substance Abuse on OAT

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Total Visits Ambulatory Emergency Hospital0

1

2

3

4

5

3.27

1.78 2.77

0.53

1.94

0.59

4.57

0.34

OATNo OAT

★★

★

★

★ p<0.05

# Symptoms PHQ-9 SF-36 QoL SF-36 Mental SF-36 Physical0

10

20

30

40

50

7.75 9.26

44.1839.47

44.3

10.46 11.52

37.227.61

40.33 OATNo OAT

★ p<0.05

Figure 1: Healthcare Utilization in the Prior 6 Months and OAT

Figure 2: Patient-reported Outcomes and OAT

★★

★★★★

★

★

★★

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Results

Despite higher rates of incarceration and more years of opioid injection, those therapeutic on OAT were less likely to engage in HIV risk behaviors or to seek emergency care than those not on OAT and more likely to engage in HIV care with fewer overall symptoms and improved quality of life.

HIV EngagementThose on OAT and those on OAT for longer periods of time were more likely to be engaged in HIV care, as evidenced by higher rates of ART (37% v 26%, p=0.08), recent CD4 testing (82% v 60%, p< 0.01), and recent TB testing (95% v 71%, p< 0.01).

Patient-reported Outcomes

Those on OAT reported fewer symptoms (10.46 v 7.75, p< 0.01), improved depression scores (p<0.01) and improved quality of life (p<0.01).

Limitations

Cross-sectional design and potential for recall and social desirability biases.

Conclusions