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IAS 2015: Peer-Led Intervention Lowers HIV Infections Among Drug Injectors in Ukraine

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A cluster-randomized trial in Ukraine has shown that a peer education project reduced new HIV infections in people who inject drugs by 41%, researchers reported at the recent 8th Eighth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention in Vancouver.

[Produced in collaboration with Aidsmap.com]

Working with individuals who had an exceptionally high risk of HIV -- each year 1 in 3 became HIV-positive, the intervention is thought to have worked by helping individuals make more use of needle exchange programs, according to presenter Robert Booth of the University of Colorado.

Over the last 15 years Ukraine has experienced a dramatic rise in HIV rates, with new diagnoses doubling each year. The epidemic is concentrated among people who inject drugs, but sexual transmission is now also an important factor.

The hardest-hit part of the country is the southeast, where the study was conducted. In the regions of Odessa, Nikolayev, and Donetsk, just under half of people who inject drugs already have HIV. Of note, Donetsk has since come under the control of pro-Russian separatists, leading to a curtailment of harm reduction services for people who inject drugs.

The injecting practices in Ukraine may have fuelled the spread of HIV. A frequently used drug is liquid poppy straw, which may be bought in pre-loaded syringes from dealers, who are often injectors themselves and who may allow users to extract it from jars directly into their own syringes. In a single day, many recycled needles and syringes can be used to extract the liquid from the jar. Another popular drug, pseudoephedrine, is typically injected in the company of other users, involving multi-person use of both the drug solution and syringes.

The criminalization and police harassment of people who use drugs further exacerbates risk, for example by encouraging people to inject hurriedly. People who inject drugs in Ukraine are a highly stigmatized and marginalized population.

For the study, people in recovery from drug addiction worked as outreach workers. They contacted and recruited 1205 HIV-negative drug injectors.

Half were randomized to receive the control intervention: a counseling and education program that was broadly similar to that typically proposed by the U.S. National Institute on Drug Abuse.

The other half received the same counseling and education plus a peer-based intervention. This involved being trained to recruit and educate their peers on harm reduction practices. The training, led by the outreach workers, was scripted and involved role-play exercises. Each of the peer leaders who had received the training was asked to bring 2 further drug users they knew into the program. The intervention was based on ideas of social learning, social identity, social norms, and social diffusion.

Efforts were made to ensure that all of those recruited -- both the peer leaders and those they recruited -- were still injecting drugs (rather than, for example, being ex-users). This was verified through urine analysis and checking the skin for track marks.

Three-quarters of those recruited were men, their average age was 31, and they had been injecting for around 10 years.

The incidence of HIV was exceptionally high in this population, suggesting that the recruitment methods had been unusually effective in engaging those who need HIV prevention interventions the most. During 1 year of follow-up, 31.8% of initially HIV-negative people who received the control intervention of counseling and education became HIV-positive.

Results were significantly better among those who also received the peer-based intervention, although new infections remained disturbingly frequent. During the year of follow-up, 18.4% became HIV-positive.

After adjustment for other factors that could influence the results, acquiring HIV was associated with older age and injecting more frequently. A counter-intuitive finding was that people who had multiple sexual partners were less likely to acquire HIV, but Booth said that this has been frequently found in Ukrainian studies. He said that people with multiple partners may be more likely to use condoms.

People in the peer intervention group were 41% less likely to acquire HIV. Moreover, they reported 53% and 17% more use of needle exchange programs at 6 and 12 months, respectively.

Political Instability

Tetiana Deshko of the International HIV/AIDS Alliance in Ukraine told the conference that harm reduction interventions in some parts of Ukraine, with the support of international donors, had achieved reductions in HIV incidence among people who inject drugs. But now the political instability and Russian influence, especially in the Donetsk region, threatened the human rights and public health-based approaches that had been introduced.

International advocacy is needed to support services, including harm reduction and opioid substitution therapy, in this war-torn region, she said. Previous conflicts such as those in Transnistria (Moldova) in 1989 and Abkhazia (Georgia) in 1992 also created problems with access to harm reduction, but local activists created innovative ways to deliver services which could be learned from now.

9/8/15

References

R Booth, J Davis, S Dvoryak, et al. Efficacy of a network intervention in reducing HIV incidence among people who inject drugs in Ukraine: preliminary results from a clustered randomized trial. 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, July 19-22, 2015. Abstract TUAC0402.

T Deshko. Fuelling the epidemics: challenges facing HIV, HCV and OST programmes for PWID in Eastern Ukraine. 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, July 19-22, 2015. Presentation WESY0502.