The Russian war in Ukraine poses many risks for the spread of HIV, TB and associated conditions, ... more The Russian war in Ukraine poses many risks for the spread of HIV, TB and associated conditions, including possible increases in the numbers of people who inject drugs or engage in sex work in the years ahead. Ukrainian civil society and volunteer efforts have been able to maintain and at times expand services for HIV Key Populations. The extent of mutual-aid and volunteer efforts as well as the continued strength and vitality of harm reduction organizations such as the Alliance for Public Health and the rest of civil society will be crucial resources for postwar efforts to assist Key Populations and prevent the spread of HIV, TB and other diseases. The postwar period will pose great economic and political difficulties for Ukrainians, including large populations of people physically and/or psychically damaged and in pain who might become people who inject drugs. Local and international support for public health and for harm reduction will be needed to prevent potentially large-scale...
Vasylyeva T, Friedman SR, Smyrnov P (2012) "Project Protect" intervention. Testing a ne... more Vasylyeva T, Friedman SR, Smyrnov P (2012) "Project Protect" intervention. Testing a new approach for HIV prevention. Tobacco Control and Public Health in Eastern Europe 2 (Supplement 1, 2nd conference 'Economics, sociology, theory and practice of public health'):s35-s36 BACKGROUND. "Project Protect" aims to find highly infectious individuals through screening for acute/recent infection cases and prevent HIV transmission in the risk networks of these cases through contact tracing of these networks` participants, distributing community alerts about risk of acute infection among them and accurate post-test counseling. METHODS. An ongoing pilot phase of the intervention began in Kriviy Rig and Lviv, Ukraine in November, 2011. Participants are recruited through: 1) screening for cases of acute/recent infection at voluntary counseling and testing (VCT) sites and in partner organizations (including AIDS-Centers) which conduct VCT; 2) visits to drug use venues, ...
Providing HIV healthcare and Treatment as Prevention both depend on diagnosing HIV cases, prefera... more Providing 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. The 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. TRIP tested 1252 people (21% women) in seeds' risk networks; IBBS tested 400 (18% women); Outreach Testing 13,936 (31% ...
Despite global reductions in HIV incidence and mortality, the 15 UNAIDS-designated countries of E... more Despite global reductions in HIV incidence and mortality, the 15 UNAIDS-designated countries of Eastern Europe and Central Asia (EECA) that gained independence from the Soviet Union in 1991 constitute the only region where both continue to rise. HIV transmission in EECA is fuelled primarily by injection of opioids, with harsh criminalisation of drug use that has resulted in extraordinarily high levels of incarceration. Consequently, people who inject drugs, including those with HIV, hepatitis C virus, and tuberculosis, are concentrated within prisons. Evidence-based primary and secondary prevention of HIV using opioid agonist therapies such as methadone and buprenorphine is available in prisons in only a handful of EECA countries (methadone or buprenorphine in five countries and needle and syringe programmes in three countries), with none of them meeting recommended coverage levels. Similarly, antiretroviral therapy coverage, especially among people who inject drugs, is markedly und...
BACKGROUND Opioid agonist treatment (OAT) reduces many of the harms associated with opioid depend... more BACKGROUND Opioid agonist treatment (OAT) reduces many of the harms associated with opioid dependence. We use mathematical modelling to comprehensively evaluate the overall health benefits of OAT in people who inject drugs in Perry County (KY, USA), Kyiv (Ukraine), and Tehran (Iran). METHODS We developed a dynamic model of HIV and hepatitis C virus (HCV) transmission, incarceration, and mortality through overdose, injury, suicide, disease-related and other causes. The model was calibrated to site-specific data using Bayesian methods. We evaluated preventable drug-related deaths (deaths due to HIV, HCV, overdose, suicide, or injury) averted over 2020-40 for four scenarios, added incrementally, compared with a scenario without OAT: existing OAT coverage (setting-dependent; community 4-11%; prison 0-40%); scaling up community OAT to 40% coverage; increasing average OAT duration from 4-14 months to 2 years; and scaling up prison-based OAT. OUTCOMES Drug-related harms contributed differentially to mortality across settings: overdose contributed 27-47% (range of median projections) of preventable drug-related deaths over 2020-40, suicide 6-17%, injury 3-17%, HIV 0-59%, and HCV 2-18%. Existing OAT coverage in Tehran (31%) could have a substantial effect, averting 13% of preventable drug-related deaths, but will have negligible effect (averting <2% of preventable drug-related deaths) in Kyiv and Perry County due to low OAT coverage (<4%). Scaling up community OAT to 40% could avert 12-24% of preventable drug-related deaths, including 13-22% of overdose deaths, with greater effect in settings with significant HIV mortality (Tehran and Kyiv). Improving OAT retention and providing prison-based OAT would have a significant additional effect, averting 27-51% of preventable drug-related deaths. INTERPRETATION OAT can substantially reduce drug-related harms, particularly in settings with HIV epidemics in people who inject drugs. Maximising these effects requires research and investment into achieving higher coverage and provision and longer retention of OAT in prisons and the community. FUNDING UK National Institute for Health Research, US National Institute on Drug Abuse.
People who inject drugs (PWID) remain at high risk of HIV in many countries. The HIV prevention c... more People 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.
In light of the COVID‐19 pandemic, considerable effort is going into identifying and protecting t... more In light of the COVID‐19 pandemic, considerable effort is going into identifying and protecting those at risk. Criminalization, stigmatization and the psychological, physical, behavioural and economic consequences of substance use make people who inject drugs (PWID) extremely vulnerable to many infectious diseases. While relationships between drug use and blood‐borne and sexually transmitted infections are well studied, less attention has been paid to other infectious disease outbreaks among PWID.
Introduction: Alliance for Public Health, the International Charitable Foundation, coordinates HI... more Introduction: Alliance for Public Health, the International Charitable Foundation, coordinates HIV prevention in Non-Governmental Organizations (NGO) working with people who inject drugs (PWID) in Ukraine. We aimed to describe the performance of the differential model of linking PWID to HIV care and treatment (Community Initiated Treatment Intervention – CITI). Methodology: A retrospective cohort study using routine program data was conducted among 8,927 PWID who were tested positive for the first time during January 2016 – June 2017. Study outcomes were enrollment into CITI and initiating antiretroviral treatment (ART). Factors associated with outcomes were estimated by logistic regressions with random effects. Results: Among the study participants, 54% enrolled into CITI and 23% initiated ART. CITI enrolment was associated with being married (adjusted odds ratio (AOR) = 1.17; 95%: 1.02-1.34); less than weekly compared to daily (AOR = 1.31; 95%: 1.13-1.52); less than 5 years of dru...
Introduction: People Who Inject Drugs (PWID) should be offered HIV-testing and harm reduction ser... more Introduction: People Who Inject Drugs (PWID) should be offered HIV-testing and harm reduction services. We assessed the effectiveness of including PWID and their peers in HIV-testing by comparing for a period before (2013-2014) and after their introduction (2015-2017), the a) numbers HIV tested b) number enrolled in harm reduction and c) frequency of HIV-testing. Methodology: An analysis of programme data involved PWID aged ≥ 14 years (1st January 2013-31st December 2017) in Ukraine. Between 2013-2014, HIV-testing (VCT) was done by trained health workers. From 2015, this was Directly Assisted HIV Self-testing (DAST) done by social workers and peers. Optimized HIV case finding (OCF) was introduced (in 2016) as an overlapping strategy with DAST. Results: A total of 844,837 HIV tests were done with 23,427 (2.8%) HIV-positive results. With VCT, there were 164,417 HIV tests compared to 639,685 after engagement of PWID and their peers (>3-fold increase). The highest HIV positive yield ...
Introduction: Viral load is one of the most important determinants for HIV transmission. Identifi... more Introduction: Viral load is one of the most important determinants for HIV transmission. Identification of people with high viral load (PHVL) can be effective in limiting onward HIV transmission. In order to improve the identification of these individuals within risk networks, we determined a) the number of PHVL recruited through risk networks b) their socio-demographic, behavioural and clinical characteristics and c) the characteristics of individuals who referred these PHVL to the study. Methodology: From November 2013 to March 2016, in Odessa, Ukraine, Transmission Reduction Intervention Project (TRIP) was implemented to identify people recently infected with HIV within the risk networks of “seeds” and “venues” where they engaged in risk behaviour. Results: TRIP identified 53 PHVL, of whom 32 (60%) injected drugs; 42 (79%) were unaware of their HIV status; 25 (47%) had more than one sex partner, and only 14 (26%) were using condoms. There were 164 people who referred individuals ...
ObjectivesUkraine has one of the largest HIV epidemics in Europe, with high prevalence among fema... more ObjectivesUkraine has one of the largest HIV epidemics in Europe, with high prevalence among female sex workers (FSWs). We aimed to identify factors associated with HIV testing and receipt of the test result in the last 12 months, HIV prevalence and self-reported positive status among FSWs in Ukraine.MethodsWe used data from an Integrated Bio-Behavioural Survey among FSWs conducted in 2013–2014. The survey methodology combined three sampling strategies: time and location sampling, respondent-driven sampling and key informant recruitment. We used multivariable regression to identify factors associated with self-reported HIV testing in the last 12 months, HIV prevalence and self-reported positive status among FSWs living with HIV. Explored factors included: age, age at first sex, age at entry into sex work, education, marital status, employment status beside sex work, condom use with last paying or non-paying sexual partner, drug or alcohol consumption and sex work venue.ResultsRecent...
People who inject drugs (PWID) experience a high prevalence of incarceration and might be at high... more People who inject drugs (PWID) experience a high prevalence of incarceration and might be at high risk of HIV and hepatitis C virus (HCV) infection during or after incarceration. We aimed to assess whether incarceration history elevates HIV or HCV acquisition risk among PWID. In this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO databases for studies in any language published from Jan 1, 2000 until June 13, 2017 assessing HIV or HCV incidence among PWID. We included studies that measured HIV or HCV incidence among community-recruited PWID. We included only studies reporting original results and excluded studies that evaluated incident infections by self-report. We contacted authors of cohort studies that met the inclusion or exclusion criteria, but that did not report on the outcomes of interest, to request data. We extracted and pooled data from the included studies using random-effects meta-analyses to quantify the associations between recent (past...
As part of a network study of HIV infection among people who inject drugs (PWID) and their contac... more As part of a network study of HIV infection among people who inject drugs (PWID) and their contacts, we discovered a connected subcomponent of 29 uninfected PWID. In the context of a just-declining large epidemic outbreak, this raised a question: What explains the existence of large pockets of uninfected people? Possible explanations include "firewall effects" (Friedman et al., 2000; Dombrowski et al., 2017) wherein the only HIV+ people that the uninfected take risks with have low viral loads; "bottleneck effects" wherein few network paths into the pocket of non-infection exist; low levels of risk behavior; and an impending outbreak. We considered each of these. Participants provided information on their enhanced sexual and injection networks and assisted us in recruiting network members. The largest connected component had 241 members. Data on risk behaviors in the last 6 months were collected at the individual level. Recent infection was determined by LAg (Sedi...
The Russian war in Ukraine poses many risks for the spread of HIV, TB and associated conditions, ... more The Russian war in Ukraine poses many risks for the spread of HIV, TB and associated conditions, including possible increases in the numbers of people who inject drugs or engage in sex work in the years ahead. Ukrainian civil society and volunteer efforts have been able to maintain and at times expand services for HIV Key Populations. The extent of mutual-aid and volunteer efforts as well as the continued strength and vitality of harm reduction organizations such as the Alliance for Public Health and the rest of civil society will be crucial resources for postwar efforts to assist Key Populations and prevent the spread of HIV, TB and other diseases. The postwar period will pose great economic and political difficulties for Ukrainians, including large populations of people physically and/or psychically damaged and in pain who might become people who inject drugs. Local and international support for public health and for harm reduction will be needed to prevent potentially large-scale...
Vasylyeva T, Friedman SR, Smyrnov P (2012) "Project Protect" intervention. Testing a ne... more Vasylyeva T, Friedman SR, Smyrnov P (2012) "Project Protect" intervention. Testing a new approach for HIV prevention. Tobacco Control and Public Health in Eastern Europe 2 (Supplement 1, 2nd conference 'Economics, sociology, theory and practice of public health'):s35-s36 BACKGROUND. "Project Protect" aims to find highly infectious individuals through screening for acute/recent infection cases and prevent HIV transmission in the risk networks of these cases through contact tracing of these networks` participants, distributing community alerts about risk of acute infection among them and accurate post-test counseling. METHODS. An ongoing pilot phase of the intervention began in Kriviy Rig and Lviv, Ukraine in November, 2011. Participants are recruited through: 1) screening for cases of acute/recent infection at voluntary counseling and testing (VCT) sites and in partner organizations (including AIDS-Centers) which conduct VCT; 2) visits to drug use venues, ...
Providing HIV healthcare and Treatment as Prevention both depend on diagnosing HIV cases, prefera... more Providing 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. The 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. TRIP tested 1252 people (21% women) in seeds' risk networks; IBBS tested 400 (18% women); Outreach Testing 13,936 (31% ...
Despite global reductions in HIV incidence and mortality, the 15 UNAIDS-designated countries of E... more Despite global reductions in HIV incidence and mortality, the 15 UNAIDS-designated countries of Eastern Europe and Central Asia (EECA) that gained independence from the Soviet Union in 1991 constitute the only region where both continue to rise. HIV transmission in EECA is fuelled primarily by injection of opioids, with harsh criminalisation of drug use that has resulted in extraordinarily high levels of incarceration. Consequently, people who inject drugs, including those with HIV, hepatitis C virus, and tuberculosis, are concentrated within prisons. Evidence-based primary and secondary prevention of HIV using opioid agonist therapies such as methadone and buprenorphine is available in prisons in only a handful of EECA countries (methadone or buprenorphine in five countries and needle and syringe programmes in three countries), with none of them meeting recommended coverage levels. Similarly, antiretroviral therapy coverage, especially among people who inject drugs, is markedly und...
BACKGROUND Opioid agonist treatment (OAT) reduces many of the harms associated with opioid depend... more BACKGROUND Opioid agonist treatment (OAT) reduces many of the harms associated with opioid dependence. We use mathematical modelling to comprehensively evaluate the overall health benefits of OAT in people who inject drugs in Perry County (KY, USA), Kyiv (Ukraine), and Tehran (Iran). METHODS We developed a dynamic model of HIV and hepatitis C virus (HCV) transmission, incarceration, and mortality through overdose, injury, suicide, disease-related and other causes. The model was calibrated to site-specific data using Bayesian methods. We evaluated preventable drug-related deaths (deaths due to HIV, HCV, overdose, suicide, or injury) averted over 2020-40 for four scenarios, added incrementally, compared with a scenario without OAT: existing OAT coverage (setting-dependent; community 4-11%; prison 0-40%); scaling up community OAT to 40% coverage; increasing average OAT duration from 4-14 months to 2 years; and scaling up prison-based OAT. OUTCOMES Drug-related harms contributed differentially to mortality across settings: overdose contributed 27-47% (range of median projections) of preventable drug-related deaths over 2020-40, suicide 6-17%, injury 3-17%, HIV 0-59%, and HCV 2-18%. Existing OAT coverage in Tehran (31%) could have a substantial effect, averting 13% of preventable drug-related deaths, but will have negligible effect (averting <2% of preventable drug-related deaths) in Kyiv and Perry County due to low OAT coverage (<4%). Scaling up community OAT to 40% could avert 12-24% of preventable drug-related deaths, including 13-22% of overdose deaths, with greater effect in settings with significant HIV mortality (Tehran and Kyiv). Improving OAT retention and providing prison-based OAT would have a significant additional effect, averting 27-51% of preventable drug-related deaths. INTERPRETATION OAT can substantially reduce drug-related harms, particularly in settings with HIV epidemics in people who inject drugs. Maximising these effects requires research and investment into achieving higher coverage and provision and longer retention of OAT in prisons and the community. FUNDING UK National Institute for Health Research, US National Institute on Drug Abuse.
People who inject drugs (PWID) remain at high risk of HIV in many countries. The HIV prevention c... more People 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.
In light of the COVID‐19 pandemic, considerable effort is going into identifying and protecting t... more In light of the COVID‐19 pandemic, considerable effort is going into identifying and protecting those at risk. Criminalization, stigmatization and the psychological, physical, behavioural and economic consequences of substance use make people who inject drugs (PWID) extremely vulnerable to many infectious diseases. While relationships between drug use and blood‐borne and sexually transmitted infections are well studied, less attention has been paid to other infectious disease outbreaks among PWID.
Introduction: Alliance for Public Health, the International Charitable Foundation, coordinates HI... more Introduction: Alliance for Public Health, the International Charitable Foundation, coordinates HIV prevention in Non-Governmental Organizations (NGO) working with people who inject drugs (PWID) in Ukraine. We aimed to describe the performance of the differential model of linking PWID to HIV care and treatment (Community Initiated Treatment Intervention – CITI). Methodology: A retrospective cohort study using routine program data was conducted among 8,927 PWID who were tested positive for the first time during January 2016 – June 2017. Study outcomes were enrollment into CITI and initiating antiretroviral treatment (ART). Factors associated with outcomes were estimated by logistic regressions with random effects. Results: Among the study participants, 54% enrolled into CITI and 23% initiated ART. CITI enrolment was associated with being married (adjusted odds ratio (AOR) = 1.17; 95%: 1.02-1.34); less than weekly compared to daily (AOR = 1.31; 95%: 1.13-1.52); less than 5 years of dru...
Introduction: People Who Inject Drugs (PWID) should be offered HIV-testing and harm reduction ser... more Introduction: People Who Inject Drugs (PWID) should be offered HIV-testing and harm reduction services. We assessed the effectiveness of including PWID and their peers in HIV-testing by comparing for a period before (2013-2014) and after their introduction (2015-2017), the a) numbers HIV tested b) number enrolled in harm reduction and c) frequency of HIV-testing. Methodology: An analysis of programme data involved PWID aged ≥ 14 years (1st January 2013-31st December 2017) in Ukraine. Between 2013-2014, HIV-testing (VCT) was done by trained health workers. From 2015, this was Directly Assisted HIV Self-testing (DAST) done by social workers and peers. Optimized HIV case finding (OCF) was introduced (in 2016) as an overlapping strategy with DAST. Results: A total of 844,837 HIV tests were done with 23,427 (2.8%) HIV-positive results. With VCT, there were 164,417 HIV tests compared to 639,685 after engagement of PWID and their peers (>3-fold increase). The highest HIV positive yield ...
Introduction: Viral load is one of the most important determinants for HIV transmission. Identifi... more Introduction: Viral load is one of the most important determinants for HIV transmission. Identification of people with high viral load (PHVL) can be effective in limiting onward HIV transmission. In order to improve the identification of these individuals within risk networks, we determined a) the number of PHVL recruited through risk networks b) their socio-demographic, behavioural and clinical characteristics and c) the characteristics of individuals who referred these PHVL to the study. Methodology: From November 2013 to March 2016, in Odessa, Ukraine, Transmission Reduction Intervention Project (TRIP) was implemented to identify people recently infected with HIV within the risk networks of “seeds” and “venues” where they engaged in risk behaviour. Results: TRIP identified 53 PHVL, of whom 32 (60%) injected drugs; 42 (79%) were unaware of their HIV status; 25 (47%) had more than one sex partner, and only 14 (26%) were using condoms. There were 164 people who referred individuals ...
ObjectivesUkraine has one of the largest HIV epidemics in Europe, with high prevalence among fema... more ObjectivesUkraine has one of the largest HIV epidemics in Europe, with high prevalence among female sex workers (FSWs). We aimed to identify factors associated with HIV testing and receipt of the test result in the last 12 months, HIV prevalence and self-reported positive status among FSWs in Ukraine.MethodsWe used data from an Integrated Bio-Behavioural Survey among FSWs conducted in 2013–2014. The survey methodology combined three sampling strategies: time and location sampling, respondent-driven sampling and key informant recruitment. We used multivariable regression to identify factors associated with self-reported HIV testing in the last 12 months, HIV prevalence and self-reported positive status among FSWs living with HIV. Explored factors included: age, age at first sex, age at entry into sex work, education, marital status, employment status beside sex work, condom use with last paying or non-paying sexual partner, drug or alcohol consumption and sex work venue.ResultsRecent...
People who inject drugs (PWID) experience a high prevalence of incarceration and might be at high... more People who inject drugs (PWID) experience a high prevalence of incarceration and might be at high risk of HIV and hepatitis C virus (HCV) infection during or after incarceration. We aimed to assess whether incarceration history elevates HIV or HCV acquisition risk among PWID. In this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO databases for studies in any language published from Jan 1, 2000 until June 13, 2017 assessing HIV or HCV incidence among PWID. We included studies that measured HIV or HCV incidence among community-recruited PWID. We included only studies reporting original results and excluded studies that evaluated incident infections by self-report. We contacted authors of cohort studies that met the inclusion or exclusion criteria, but that did not report on the outcomes of interest, to request data. We extracted and pooled data from the included studies using random-effects meta-analyses to quantify the associations between recent (past...
As part of a network study of HIV infection among people who inject drugs (PWID) and their contac... more As part of a network study of HIV infection among people who inject drugs (PWID) and their contacts, we discovered a connected subcomponent of 29 uninfected PWID. In the context of a just-declining large epidemic outbreak, this raised a question: What explains the existence of large pockets of uninfected people? Possible explanations include "firewall effects" (Friedman et al., 2000; Dombrowski et al., 2017) wherein the only HIV+ people that the uninfected take risks with have low viral loads; "bottleneck effects" wherein few network paths into the pocket of non-infection exist; low levels of risk behavior; and an impending outbreak. We considered each of these. Participants provided information on their enhanced sexual and injection networks and assisted us in recruiting network members. The largest connected component had 241 members. Data on risk behaviors in the last 6 months were collected at the individual level. Recent infection was determined by LAg (Sedi...
Uploads
Papers by Pavlo Smyrnov