Martha J. Bojko

Men’s Extramarital Sex, Marital Relationships and Sexual Risk in Urban Poor Communities in India

The objectives of this paper are to (1) understand the nature of men’s extramarital sexuality in three low income communities in Mumbai, India; (2) explore the associations between marital relationships and extramarital sex; and (3) assess the implications of the research results for intervention. Results are based on survey data collected from 2,408 randomly selected men from the three study communities and a matched subset of 260 randomly selected men and their wives who responded to a female version of the mens survey. These surveys produced a unique data set, which allows sociodemographic, attitudinal and behavioral variables from husband and wife and variables that are the product of husband and wife interaction to be utilized to predict mens extramarital sex through multiple sequential logistic regression analysis. Results indicate that mens extramarital sex is significantly associated with husbands and wifes age, wifes perception of domestic violence, husbands education and place of birth, husbands alcohol use, wifes willingness to engage in marital sex, and types of marital sexual acts. These results confirm the need to move from the individual to the couple as the unit of research and the need for intervention to reduce the risk of HIV/STI transmission within marriage both in India and internationally.

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, Ukraines volatile and expanding HIV epidemic is still being fueled by PWIDs, primarily using opioids (2). Among the ~375,000–425,000 PWIDs, HIV prevalence ranges from 21.3%–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 internationally recognized as the most effective treatment for opioid dependence (5); newer data suggest 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 programs (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 scaled-to-need, “combination interventions” promoting HIV prevention and treatment for PWIDs. Harm reduction programs 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) programs using BMT began that year (8); MMT commenced in 2008 (9). In 2008, international donors funded creation of integrated care services for PWIDs through pilot programs in Kyiv, Dnipropetrovsk, Mykolaiv and Odessa that simultaneously provided 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 behaviors, increasing access to ART, and improving HIV treatment access, retention and other outcomes (5), less 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 Healths 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 the 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 program 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 stakeholder groups, including law enforcement, local government, and healthcare providers (18). In order to forge ahead on the earlier adopted progressive path and remain an innovative regional leader of HIV prevention and treatment for PWIDs, there is an urgent need for the Ukrainian government to redress the gaps and barriers in HIV policy and provision of prevention and treatment services for PWIDs. Ukraines current OST program is heavily dependent on funding from the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM), due to expire in 2016, and the 2011 decision to cancel its next funding cycle due to insufficient funds potentially jeopardizes future OST services in Ukraine unless Ukraines Ministry of Health opts to subsidize it. Without governmental financial support, HIV prevention and treatment will revert back to nihilist strategies extant in nearby Russia where HIV prevention and treatment efforts among PWIDs are inconsistent with evidence-based care and human rights mandates (11). Expanding MAT for PWIDs and working with clients, providers and stakeholders to make these programs culturally relevant and logistically acceptable in the Ukrainian context is an opportunity to increase access to and retention in services while also raising community and stakeholder awareness of the societal and public health benefits of these evidence-based interventions. Mathematical modeling confirms MAT expansion as the most cost-effectiveness HIV prevention and treatment strategy in Ukraines transitioning HIV epidemic and importantly, expanding MAT coverage to 25% of PWIDs along with ART coverage to 80% of HIV-infected persons who need it would avert 8,300 new HIV infections annually (3). It is crucial that Ukraine treats drug dependence not as a crime but humanely as a chronic, relapsing disease similarly to any other chronic medical condition that affects individuals, regardless of age, socio-economic status, political affiliation, or sexual orientation and which requires consistent, evidence-based treatment options adapted to the Ukrainian cultural context and understood and accepted by all stakeholders. An HIV epidemic fueled by PWIDs is no longer “somebody elses problem.” The Ministry of Healths recent willingness to revisit Order No. 200 as well as the June 2012 submission to the Ukrainian government of a new national drug strategy prepared by the Ukrainian State Drug Control Committee and UNODC (19) are hopeful signs that Ukraine is moving forward. A progressive path remains the only solution for improving the health of the individual, the healthcare system and Ukrainian society. Anything less will set Ukraine on a downward trajectory that will reverse its many recent gains, including the secondary benefits to its neighbors who have similarly adopted evidence-based HIV prevention and treatment strategies that are consistent with public health and human rights.

“Bureaucracy & Beliefs”: Assessing the barriers to accessing opioid substitution therapy by people who inject drugs in Ukraine

Abstract Aims: Opioid substitution therapy (OST) is an evidence-based HIV prevention strategy for people who inject drugs (PWIDs). Yet, only 2.7% of Ukraine’s estimated 310,000 PWIDs receive it despite free treatment since 2004. The multi-level barriers to entering OST among opioid-dependent PWIDs have not been examined in Ukraine. Methods: A multi-year mixed methods implementation science project included focus group discussions with 199 PWIDs in five major Ukrainian cities in 2013 covering drug treatment attitudes, beliefs, knowledge and experiences with OST. Data were transcribed, translated into English and coded. Coded segments related to OST access, entry, knowledge, beliefs and attitudes were analyzed among 41 PWIDs who were eligible for but had never received OST. Findings: A number of programmatic and structural barriers were mentioned by participants as barriers to entry to OST, including compulsory drug user registration, waiting lists and limited number of treatment slots. Participants also voiced strong negative attitudes and beliefs about OST, especially methadone. Their perceptions about methadone’s side effects as well as the stigma of being a methadone client were expressed as obstacles to treatment. Conclusions: Despite expressed interest in treatment, Ukrainian OST-naïve PWIDs evade OST for reasons that can be addressed through changes in program-level and governmental policies and social-marketing campaigns. Voiced OST barriers can effectively inform public health and policy directives related to HIV prevention and treatment in Ukraine to improve evidence-based treatment access and availability.

In their own voices: breaking the vicious cycle of addiction, treatment and criminal justice among people who inject drugs in Ukraine

Abstract Aims: To understand how perceived law enforcement policies and practices contribute to the low rates of utilisation of opioid agonist therapies (OAT) like methadone and buprenorphine among people who inject drugs (PWIDs) in Ukraine. Methods: Qualitative data from 25 focus groups (FGs) with 199 opioid-dependent PWIDs in Ukraine examined domains related to lived or learned experiences with OAT, police, arrest, incarceration and criminal activity and were analysed using grounded theory principles. Findings: Most participants were male (66%), in their late 30s, and previously incarcerated (85%), mainly for drug-related activities. When imprisoned, PWIDs perceived themselves as being “addiction-free”. After prison-release, the confluence of police surveillance and societal stress contributed to participants’ drug use relapse, perpetuating a cycle of searching for money and drugs, followed by re-arrest and re-incarceration. Fear of police and arrest both facilitated OAT entry and simultaneously contributed to avoiding OAT since system-level requirements identified OAT clients as targets for police harassment. OAT represents an evidence-based option to “break the cycle”; however, law enforcement practices still thwart OAT capacity to improve individual and public health. Conclusion: In the absence of structural changes in law enforcement policies and practices in Ukraine, PWIDs will continue to avoid OAT and perpetuate the addiction cycle with high imprisonment rates.

Determinants of willingness to enroll in opioid agonist treatment among opioid dependent people who inject drugs in Ukraine

BACKGROUND Coverage with opioid agonist treatments (OAT) that include methadone and buprenorphine is low (N=8400, 2.7%) for the 310,000 people who inject drugs (PWID) in Ukraine. In the context of widespread negative attitudes toward OAT in the region, patient-level interventions targeting the barriers and willingness to initiate OAT are urgently needed. METHODS A sample of 1179 PWID with opioid use disorder not currently on OAT from five regions in Ukraine was assessed using multivariable logistic regression for independent factors related to willingness to initiate OAT, stratified by their past OAT experience. RESULTS Overall, 421 (36%) PWID were willing to initiate OAT. Significant adjusted odds ratios (aOR) for covariates associated with the willingness to initiate OAT common for both groups included: higher injection frequency (previously on OAT: aOR=2.7; never on OAT: aOR=1.8), social and family support (previously on OAT: aOR=2.0; never on OAT: aOR=2.0), and positive attitude towards OAT (previously on OAT: aOR=1.3; never on OAT: aOR=1.4). Among participants previously on OAT, significant correlates also included: HIV-negative status (aOR=2.6) and depression (aOR=2.7). Among participants never on OAT, however, living in Kyiv (aOR=4.8) or Lviv (aOR=2.7), previous imprisonment (aOR=1.5), registration at a Narcology service (aOR=1.5) and recent overdose (aOR=2.6) were significantly correlated with willingness to initiate OAT. CONCLUSIONS These findings emphasize the need for developing interventions aimed to eliminate existing negative preconceptions regarding OAT among PWID with opioid use disorder in Ukraine, which should be tailored to meet the needs of specific characteristics of PWID in geographically distinct setting based upon injection frequency, prior incarceration, and psychiatric and HIV status.

The Future of Opioid Agonist Therapies in Ukraine: A Qualitative Assessment of Multilevel Barriers and Ways Forward to Promote Retention in Treatment

Opioid agonist therapies (OAT) to treat opioid addiction in people who inject drugs (PWID) began in Ukraine in 2004. Scale-up of OAT, however, has been hampered by both low enrollment and high attrition. To better understand the factors influencing OAT retention among PWID in Ukraine, qualitative data from 199 PWIDs were collected during 25 focus groups conducted in five Ukrainian cities from February to April 2013. The experiences of PWID who were currently or previously on OAT or currently trying to access OAT were analyzed to identify entry and retention barriers encountered. Transcribed data were analyzed using a grounded theory approach. Individual beliefs about OAT, particularly misaligned treatment goals between clients and providers, influenced PWIDs treatment seeking behaviors. Multiple programmatic and structural issues, including inconvenient hours and treatment site locations, complicated dosing regimens, inflexible medication dispensing guidelines, and mistreatment by clinic and medical staff also strongly influenced OAT retention. Findings suggest the need for both programmatic and policy-level structural changes such as revising legal regulations covering OAT dispensing, formalizing prescription dosing policies and making OAT more available through other sites, including primary care settings as a way to improve treatment retention. Quality improvement interventions that target treatment settings could also be deployed to overcome healthcare delivery barriers. Additional patient education and medical professional development around establishing realistic treatment goals as well as community awareness campaigns that address the myths and fears associated with OAT can be leveraged to overcome individual, family and community-level barriers.

Factors associated with physical and sexual violence by police among people who inject drugs in Ukraine: implications for retention on opioid agonist therapy

Ukraines volatile HIV epidemic, one of the largest in Eastern Europe and Central Asia, remains concentrated in people who inject drugs (PWID). HIV prevalence is high (21.3% to 41.8%) among the estimated 310,000 PWID. Opioid agonist therapy (OAT) is the most cost‐effective HIV prevention strategy there, yet OAT services are hampered by negative attitudes and frequent harassment of OAT clients and site personnel by law enforcement. This paper examines the various types of police violence that Ukrainian PWID experience and factors associated with the different types of violence, as well as the possible implications of police harassment on OAT retention.

Sexual Health, Marital Sex, and Sexual Risk in Urban Poor Communities in India

Marital sex has been an unaddressed component of sexual risk. This article explores marital sex and its link to men’s extramarital sexual behavior in 3 economically marginal communities in Mumbai, India. Using in-depth interviews with women, men, and couples, qualitative results are presented on first night experiences, ability of women to refuse their husbands’ demands for sex, sexual communication, and sexual pleasure associated with marital sex. Using regression analysis of survey data for 260 couples, the quantitative results indicate that greater sexual satisfaction for both men and women is significantly related to men’s lesser involvement in extramarital sex. These results provide a basis for a couples’ intervention effort that can yield greater marital and sexual communication and reduction in sexual risk.

Willingness to pay for opioid agonist treatment among opioid dependent people who inject drugs in Ukraine

BACKGROUND In the context of decreasing external and limited Ukrainian governmental funding for opioid agonist treatments (OAT) for opioid dependent people who inject drugs in Ukraine, information on sustainable financial models is needed. METHODS Data on 855 opioid dependent people who inject drugs (PWID) were drawn from a cross-sectional nationwide survey of 1613 PWID. They comprised 434 participants who were receiving OAT and 421 who were on OAT in the past or have never been on OAT and were interested in receiving the treatment. Multivariate logistic regression was used to examine factors associated with willingness-to-pay (WTP) for OAT, stratified by OAT experience. Variation in the price which respondents were willing to pay for OAT and its effect on their monthly income among PWID with different OAT experience were assessed as a continuous variable using one-way ANOVA and Kruskal-Wallis test. RESULTS Overall, 378 (44%) expressed WTP for OAT. Factors independently associated with WTP differed by OAT experience. Among those using OAT, independent predictors of WTP included: city (Dnipro - aOR=1.9; 95%CI=1.1-4.8 and Lviv - (aOR=2.2; 95%CI=1.1-4.8) compared to those elsewhere in Ukraine), higher income (aOR=1.8; 95%CI=1.2-2.7) and receiving psychosocial counseling (aOR=1.8; 95%CI=1.2-2.7). Among those who had previously been on OAT, positive attitude towards OAT (aOR=1.3; 95%CI=1.1-1.6) and family support of OAT (aOR=2.5; 95%CI=1.1-5.7) were independently associated with WTP. Among PWID who had never been on OAT, being male (aOR=2.2; 95%CI=1.1-4.2), younger age (aOR=1.9; 95%CI=1.2-3.2), higher income (aOR=2.0; 95%CI=1.2-3.4) and previous unsuccessful attempts to enter OAT (aOR=2.3; 95%CI=1.1-4.7) were independently associated with WTP. PWID were willing to commit a large percentage of their monthly income for OAT, which, however, varied significantly based on OAT experience: current OAT: 37% of monthly income, previous OAT: 53%, and never OAT: 60% (p-value=0.0009). CONCLUSIONS WTP for OAT was substantial among PWID in Ukraine, supporting the implementation of self-pay or co-payment programs. Such strategies, however, must remain affordable, provide better access to OAT, and consider specific needs of PWID.

Why People Who Inject Drugs Voluntarily Transition Off Methadone in Ukraine

Methadone maintenance therapy (MMT) treats opioid use disorder among people who inject drugs (PWID). To understand why PWID may voluntarily discontinue MMT, we analyzed data from 25 focus groups conducted in five Ukrainian cities from February to April 2013 with 199 participants who were currently, previously, or never on MMT. Using constant comparison method, we uncovered three themes explaining why PWID transition off MMT: (a) purposeful resistance to rigid social control associated with how MMT is delivered and to power asymmetries in provider–patient relationships, (b) self-management of a PWID’s “wounded identity” that is common in socially stigmatized and physically sick persons—MMT serves as a reminder of their illness, and (c) the quest for a “normal life” uninterrupted by daily MMT site visits, harassment, and time inefficiencies, resources, and social capital. Focusing on holistic principles of recovery would improve addiction treatment and HIV prevention in Ukraine and globally.