Integration of health services improves multiple healthcare outcomes among HIV-infected people who inject drugs in Ukraine
Introduction
From 1999 to 2009, HIV incidence decreased 19% globally, but increased 25% in Eastern Europe and Central Asia (UNAIDS, 2010). In Ukraine (Kruglov et al., 2008), as throughout the region, this epidemic is concentrated among people who inject drugs (PWID; Cohen, 2010, Mathers et al., 2007). To help address this crisis, Ukraine first introduced opioid substitution therapy (OST) in 2004 with buprenorphine (Bruce et al., 2007), adding methadone in 2007 (Lawrinson et al., 2008, Schaub et al., 2010). For PWID, OST enhances quality of life (Nosyk et al., 2011) and reduces injection-related HIV risk behaviors (Gowing et al., 2008), while improving antiretroviral (ART) access (Altice et al., 2011, Uhlmann et al., 2010) and adherence (Malta et al., 2010) and viral suppression (Altice et al., 2011, Roux et al., 2009) among those infected with HIV. Modeling data from Ukraine confirm OST as the most efficacious and cost-effective intervention for injection-related and transitional HIV epidemics compared to harm reduction or ART provision alone (Alistar et al., 2011, Degenhardt et al., 2010).
HIV-infected PWID experience intertwined co-morbidities that complicate care and contribute to poor outcomes, including tuberculosis, viral hepatitis, mental illness, active drug use and HIV itself (Altice et al., 2010). Recognition of HIV/AIDS and addiction as chronic, co-occurring illnesses necessitates a fundamental re-design of healthcare delivery for these conditions (Colvin, 2011, McLellan et al., 2000, Scandlyn, 2000, Siegel and Lekas, 2002). To address this complex challenge, models of integrated healthcare have been proposed and developed (Basu et al., 2006, Sylla et al., 2007) and are advocated by the World Health Organization despite a lack of empiric evidence (Kerr et al., 2004, World Health Organization, 2008). Lack of service integration results in insufficient coordination and cross-training, problematic pharmacokinetic interaction management and logistical hurdles that undermine holistic healthcare provision (Altice et al., 2010, Wolfe et al., 2010). Integration, ranging from simple service co-location to unified cross-disciplinary case-management, seeks to alleviate many of these barriers, and in the process, increase medication adherence and viral suppression that ultimately decreases HIV transmission and viral resistance (Altice et al., 2010, Sylla et al., 2007). The extent to which integrated healthcare improves health outcomes, however, has not been examined in middle-income countries that struggle to optimize limited healthcare resources, despite increased OST availability (Lekhan et al., 2010, Rechel et al., 2012, Wolfe et al., 2010).
Research in high-income countries supports healthcare integration for PWID (Turner et al., 2005), including those with HIV. Similar to the U.S. and former Soviet Union (FSU) countries, drug treatment in Ukraine is limited and where available, often separate from general healthcare settings, resulting in siloed care for PWID. As a result, fewer than 5% of Ukrainian HIV-infected PWID receive ART (Wolfe et al., 2010). New integrated/co-located (ICL) clinics for HIV-infected PWID were first introduced in 2008, providing ART, OST, case management and primary care, including screening and treatment for tuberculosis (TB), in a single location (Curtis, 2010). Their impact on health-related outcomes, however, has not yet been assessed. The availability of integrated healthcare delivery and OST in Ukraine make this setting unique for examining the extent to which integrated healthcare could abrogate the burgeoning region-wide HIV epidemic.
Section snippets
Study design
From October to December, 2010, a cross-sectional survey of 296 HIV-infected PWID meeting criteria for opioid dependence and having injected ≥2 years was conducted in two profoundly HIV-impacted Ukrainian regions (Kiev and Dnipropetrovsk).
Study sites
Subjects were recruited from three different settings within each region: integrated and fully co-located (ICL); non-co-located (NCL); and harm reduction and outreach (HRO) sites. Subjects receiving no services were excluded from this study. OST in Ukraine,
Respondent characteristics
Response rate was high (98.7%) across sites. The sample, presented in Fig. 1 and Table 1, is comprised mostly of men (66%) in their mid-30s (mean 35.7 years). ICL participants were significantly older than NCL (mean 36.9 versus 34.4 years, p < 0.01) subjects and had injected opioids longer than NCL or HRO (mean: 14.4 versus 11.0 versus 8.6 years) participants; however, ICL and NCL participants had been on OST the same duration (mean = 31.8 months). ICL subjects were significantly more likely to be
Discussion
To our knowledge, this is the first empiric evaluation of different models for providing care to HIV-infected PWID in Eastern Europe or any middle-income country, including assessment of integrated and co-located care, in a region where HIV treatment outcomes are comparatively poor. Compared to other at-risk groups, HIV-infected PWID are less likely to access HIV-related healthcare (Andersen et al., 2000, Celentano et al., 2001, Korthuis et al., 2004, Strathdee et al., 1998) and more likely to
Role of funding source
The International HIV/AIDS Alliance (Ukraine), Open Society Institute, and World Health Organization provided funds for the completion of this study. Salary and research (R01 DA029910 and R01 DA33679) oversight as well as career development support for FLA (K24 DA0170720) was also provided by the National Institutes on Drug Abuse. Additional support was provided by the National Institutes of Health Medical Science Training Program (GM07205) for JMI and CB. JMI received funding from the Yale
Contributors
Authors CB, MCS, JMI, SD, KD, and FLA designed the study and wrote the protocol. CB undertook the statistical analysis with oversight by FLA, and author CB wrote the first draft of the manuscript. All authors had full access to the data and contributed to and have approved the final manuscript.
Conflicts of interest
All authors declare they have no conflicts of interest.
Acknowledgements
In addition to the funding sources mentioned above, we would like to acknowledge Tiaira Winn, Artem Kopelev, and Maua Herme for their help with data management, Zahed Islam from Alliance Ukraine for technical guidance and assistance, and the Ukrainian Institute on Public Health Policy for their logistical and translation assistance.
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