At the crossroads: HIV prevention and treatment for people who inject drugs in Ukraine.

By 2009, HIV incidence decreased globally by 19% while rates in Eastern Europe and Central Asia increased by 25%, primarily among people who inject drugs (PWIDs) [1]. Regionally, Ukraine and Russia account for 90% of new HIV infections, and while there is evidence that the HIV epidemic is transitioning to a generalized epidemic, Ukraine’s volatile and expanding HIV epidemic is still being fuelled by PWIDs, primarily using opioids [2]. Among the approximately 375 000–425 000 PWIDs, HIV prevalence ranges from 21.3 to 41.8% and PWIDS account for nearly 70% of all cumulative and 56% of new HIV infections [3,4]. Medication-assisted therapies (MAT), especially methadone (MMT) and buprenorphine maintenance treatment (BMT), are recognized internationally as the most effective treatment for opioid dependence [5]; newer data suggest that extended-release naltrexone is also effective [6]. MAT also remains among the most effective primary and secondary HIV prevention strategies available, especially when used as part of a ‘combination intervention’ approach integrated with needle/syringe exchange programmes (NSEPs); antiretroviral therapy (ART); peer education and outreach; expanded HIV testing; and contextual promotion of public policies and other structural changes conducive to promote public health [7]. Within the region, Ukraine initially implemented relatively progressive, but insufficiently scaledto-need, ‘combination interventions’ promoting HIV prevention and treatment for PWIDs. Harm reduction programmes, including outreach and peer education, condom distribution, voluntary HIV testing and NSEPs, were started in Ukraine in the late 1990s, followed by ART expansion in 2004. Pilot opioid substitution therapy (OST) programmes using BMT began during that year [8]; MMT commenced in 2008 [9]. In 2008, international donors funded the creation of integrated care services for PWIDs through pilot programmes in Kyiv, Dnipropetrovsk, Mykolaiv and Odesa that provided simultaneous treatment for HIV, tuberculosis and OST [10]. Unlike nearby Russia, where HIV prevention and treatment efforts for PWIDs are flailing and OST is legislatively banned [11], Ukraine has made progress, but is now at a crossroads. While MAT is highly effective in reducing HIV risk behaviours, increasing access to ART and improving HIV treatment access, retention and other outcomes [5], fewer than 2% of PWIDs in Ukraine are currently receiving this critical therapy despite available, funded OST slots [12]. It is unclear if this inertia is due to inadequate commitment or insufficient funding, but data suggest that recent Ukrainian efforts to expand MAT services for PWIDs have been hindered by multiple structural barriers, including restricted access to services, human rights abuses, police harassment including arrest, detention and incarceration and unsupportive policy or social environments [13,14]. For example, the Ukrainian Ministry of Health’s 2012 Order No. 200 [15], which newly requires PWIDs to provide documentation of two failed detoxification attempts before being admitted to OST, abrogates recent attempts to expand OST. Detoxification of chronically dependent PWIDs is associated with death, suffering and wasted time, energy and resources for patients who would otherwise benefit from it [16]. In addition, both OST clients and medical staff must adhere to the strict legal controls which regulate the distribution of methadone in Ukraine: any legal violations of the ‘About Narcotics Turnover’ law is treated seriously, and even technical errors made by medical staff can result in arrest and detention. Police also create additional difficulties for OST clients and threaten medical staff [14]. As a result, most medical facilities fear establishing OST sites within their clinics [17]. These seemingly incipient negative trends in HIV policy and programming in Ukraine place at odds an evidence-based HIV policy foundation with new and emerging national laws, legislation and policies now hindering responsiveness to policy and changing epidemic patterns. A 2011 HIV policy evaluation confirmed that, at both national and local levels, ‘implementation, coordination, and collaboration are often left to individual personalities and interests of those involved’ and that many of the structural barriers to HIV programme planning revolve around a lack of detailed operational guidelines or implementation plans, inadequate strategic planning, insufficient resources to implement laws and regulations and a lack of awareness and acceptance of legal protections for vulnerable populations among key EDITORIAL bs_bs_banner