How methadone is promoting ART adherence for drug users in Ukraine

Globally, it is estimated that 1.65 million people who inject drugs are living with HIV*. Yet access to antiretroviral therapy remains a major problem. At the 24th International Harm Reduction Conference coming up in Malaysia in October, innovative ways in which harm reduction programmes are being shaped to help drug users access the antiretroviral treatment they need will be presented.

Alliance for Public Health, the Alliance's Linking Organisation in Ukraine, will discuss interim findings from a four-year pilot programme that trains peers to support other drug users who test positive for HIV to access antiretroviral treatment (ART).

“When you tell someone they are HIV positive – if you just say to them they need to go to hospital – it is difficult for them,” says Pavlo Smyrnov, a leading harm reduction expert at Alliance for Public Health. “Often this person will be busy thinking about their life, what their HIV status means, and it is likely that they will cope with this news by taking more drugs. But if you do it in a different way, if you say ‘you are HIV positive and this person here is going to help you’, psychologically it is so much better, just to have someone helping you.”

CITI – a model to promote HIV treatment adherance

Alliance for Public Health is the biggest provider of harm reduction services in Ukraine. In 2014 their prevention work constituted the entire national response for injecting drug users. Many of these services are provided by outreach workers in community settings. Before the Community Initiated Treatment Interventions (CITI) pilot began in 2013, those who tested positive to HIV screening at Alliance for Public Health harm reduction centres were referred to government-run clinics for confirmatory testing and treatment. But Alliance for Public Health estimates that around 50,000 people referred through these programmes were failing to get ART, meaning the current system was failing drug users.

“Some people do not like doctors and hospitals, especially stigmatised people such as our clients,” says Smyrnov. “But we were also hearing of doctors telling users they must come off drugs first before they can think about receiving ART. In more extreme cases, we have even heard of doctors asking drug users to give a written statement saying they don’t want to begin ART until they have stopped using drugs.

“It became clear to us that referrals were not really working, so we decided to make treatment our responsibility.”

© the Alliance
CITI will run until 2017 in 11 Ukrainian regions through funding from the Global Fund to Fight AIDS, Malaria and Tuberculosis. Under the scheme, each caseworker supports 30 to 40 people at a time, working with each individual for six months from the time they test positive for HIV. Each client is personally counselled by their caseworker through the process of testing and then registering as HIV positive at a government-run clinic, and will be accompanied by their caseworker on each visit. The caseworkers also work with doctors to ensure drug users receive the services they are entitled to. Drug users who have previously registered at a government clinic for treatment but have not gone on to receive ART are also supported under the scheme.

Further funding from the Alliance’s Innovation Fund has led to the development of CITI+ which extends the period individuals are supported to 18 months through the provision of peer led group sessions, individual counselling sessions, the introduction of family supporters and the issuing of SMS treatment reminders, in order to assess whether caseworkers are able to improve adherence to ART as well as enrolment.

Initial results

Findings show that CITI is working – with people accessing ART within an average of 22 days from initial testing, compared with two years under the referral-only system. 

Many working in harm reduction point to the significance methadone can make to ART adherence for people who use drugs. Methadone can help drug users access and adhere to ART by bringing drug users closer to health services, and by reducing the burden of having to find drugs and buy drugs regularly each day. Methadone helps to bring some stability to many peoples’ lives, and as such it has always been understood to be important in improving access to ART. To investigate this connection more rigorously, the Alliance has been working with researchers from Bristol University and the London School of Hygiene and Tropical Medicine to conduct a systematic review of the impact of methadone on ART access and adherence for people who inject drugs. Preliminary findings of this review were presented at IAS 2015, the International AIDS Society biomedical conference in July. It found opioid substitution therapy (OST) to be associated with a two-fold increase in both ART coverage and adherence and a 17% decrease in the odds of ART discontinuation. This suggests methadone could have a multi-faceted role in improving the lives of drug users who are living with HIV.

What next? Scaling up CITI

Alliance for Public Health is managing a national programme to scale up methadone as current coverage stands at 8,000 people. Research, which will look at the impact of CITI and CITI+ in areas where methadone is and is not available, begins this month with findings expected next year. This evidence will demonstrate the degree to which methadone improves ART adherence, however we know already it is having an impact.

Smyrnov says, “When people are taking methadone it is better because they can be provided with ART at the same time and this makes adherence much easier. You can almost be sure that they are more likely to be adhering. Methadone also stabilises people’s lives so it’s logical that the two should go together. It frees people’s time up, they can actually plan their lives, rather then spending all their time looking for more drugs.”

Alliance for Public Health are the Alliance’s harm reduction experts. Due to their strength in harm reduction programming they manage the Alliance’s Community Action on Harm Reduction programme, through which they are rolling-out the CITI model to other country contexts. Alliance for Public Health also host the Alliance’s global Centre for Drug Use and HIV/Hep C.

Alliance activities at the International Harm Reduction Conference in Malaysia from 18-23 October in Malaysia

*2015 UNODC World Drug Report