Plan to combat growing HIV epidemic in Ukraine

In the past decade, an epidemic of HIV has swept through Ukraine, fueled mostly by intravenous drug use. Of Ukraine’s approximately 390,000 intravenous drug users as many as half are HIV-infected — and the epidemic is now spreading beyond the drug using community into the broader population. Ukraine’s HIV prevalence is now the highest in Europe.

In a study published in the March issue of PLoS-Medicine, researchers at Stanford University and the Veterans Affairs Palo Alto Health Care System demonstrate that the most effective way to combat the spreading disease is a combined program of drug substitution — providing methadone for opiate users, for instance — and anti-retroviral therapy for those already infected.

“HIV is spreading in Eastern Europe more quickly than in any other part of the world,” said Margaret Brandeau, PhD, the Coleman F. Fung Professor of Engineering at Stanford and senior author of the study. “Our study shows that substitution therapy for injection drug users is an inexpensive and effective means of curbing HIV transmission in the region.”

The study could not be more well-timed. The government of Ukraine recently endorsed a bold, new law that advances a human-rights approach to the HIV crisis in an effort to address the growing concern. The law includes substitution therapy and needle exchanges for intravenous drug users, as well as confidentiality guarantees and health-care services for victims of sexual violence and for adolescents, among other provisions.

Ironically, however, in the very same month the government passed the law, methadone-substitution therapy patients and non-governmental health organizations reported a dramatic shift in policy by Ukraine’s Ministry of Interior that included withholding such treatments for intravenous drug users pending “voluntary” surveys related to their health and HIV status.

“At a time when hope should be on the rise thanks to the new HIV law, the ministry’s new policy direction has had a chilling effect on treatment programs,” said Sabina Alistar, lead author of the study and a doctoral student of management science and engineering at the School of Engineering.

Using sophisticated computer modeling, the Stanford researchers examined the rate of HIV transmission and the relative success of treatment and prevention efforts in Ukraine. They used Ukraine country-level data and current HIV trends in Ukraine to make rational assumptions about possible future trends and scenarios.

The research team included current drug users who receive methadone-substitution therapy, drug users who do not receive substitution therapy and non-drug users. The researchers then measured the effects of various combinations of drug substitution and anti-retroviral therapy upon factors such as health-care costs, quality of life, the prevalence of HIV and infections averted.

With no further intervention, the researchers calculated that HIV prevalence will reach 67.2 percent of intravenous drug users in 20 years. The Stanford study then showed that providing drug-substitution to just 25 percent of intravenous drug users today could lower that figure to 53.1 percent, while averting 4,700 new infections.

The results demonstrate a clear and compelling conclusion: methadone substitution by itself is a highly cost-effective method for addressing the growing HIV epidemic in Ukraine. However, the research went further to calculate that if health officials administer a joint program of methadone substitution and anti-retroviral treatment they would be able to prevent the most infections and deliver the greatest overall health benefit, not only for those already infected or those who inject drugs but also for uninfected individuals and those who do not inject drugs.

“Not only does drug substitution therapy work, but it is remarkably cost-effective when you consider total costs of treating and caring for a growing HIV-infected community,” said Alistar.

“Providing effective drug substitution therapy and HIV antiretroviral therapy together to the injection-drug-using community protects the entire population — it actually prevents more infections in non-drug users than in the drug-using community,” said co-author Douglas K. Owens, MD, a senior investigator at the VA-Palo Alto and professor of medicine at Stanford’s School of Medicine.

The key for government and health policy makers in Ukraine, said the study’s authors, is not to choose one approach or the other — expanding access to antiretroviral therapy or drug substitution therapy — but to find the right balance between the two. Accomplishing such a balance, however, has been difficult.

“With the stigma attached to injection drug use, the necessary balance is getting harder to achieve,” said Brandeau. “In an epidemic like this, governments in Ukraine — and elsewhere in Eastern Europe — should be expanding drug substitution programs, not restricting or ending them.”

“Cutting back on drug substitution is exactly the wrong thing to do in a time of growing threat from the disease,” added Alistar. “There is a profound negative effect of restricting drug substitution, not just in the community of injection drug users, but also in the wider Ukraine population.”

While the study was specific to Ukraine, the authors say that the results can be applied to other nations in Central Asia and Eastern Europe experiencing similar increases in transmission.

“These conclusive results can and should inform HIV policy throughout Eastern Europe where the disease is spreading almost as rapidly as in Ukraine,” said Brandeau.

Provided by Stanford University Medical Center