Developing, Implementing, and Pilot Testing an Informed Decision Aid for Opioid Agonist Therapies for Prisoners in Ukraine

Project Summary/Abstract The Eastern European and Central Asian (EECA) region has the most rapidly growing HIV epidemic world-wide, compounded by high rates of incarceration and drug injection.

People who inject drugs (PWID) are concentrated in prisons, a region with some of the highest rates of incarceration, where 70% of PWID experience lifetime incarceration and 36% pass through prisons annually.

Opioid agonist therapies (OAT) with methadone or buprenorphine are evidence- based practices (EBPs) that effectively reduce HIV and HCV transmission in PWID by 54% and 61%, respectively, and reduce death 3-fold.

An OAT pilot of 38 prisoners started in Ukrainian prisons in 2020, yet coverage and scale-up in prisons is low in EECA and modeling data from Ukraine suggests that not only must coverage markedly increase in prisons, but PWID must be retained on it post-release.

The prison environment, however, influences decisions about OAT due to within-prison contextual factors alongside misperceptions that incarceration is treatment.

Informed decision-making aids are evidence-based tools that may facilitate OAT implementation and scale-up in prisons as they guide PWID in deciding whether or not to adopt OAT and what to choose based on personal preferences.

The proposed research seeks to understand the treatment preferences of incarcerated PWID in Ukraine, adapt an informed decision-making aid to these preferences and context, pilot test this aid, and build a mathematical model showing how scale-up of the aid would impact HIV and HCV transmission over a 10-year horizon.

I propose to: 1) Use conjoint-based choice with segmentation analysis with 600 prisoners with opioid use disorder to understand the OAT preferences of prisoners with opioid use disorder in Ukraine.

These findings will guide adaptation of the informed decision-making aid where I will 2) systematically adapt an existing informed decision-making aid for opioid use disorder to the Ukrainian prison context by alpha and beta testing the adapted interactive protype with prisoners (n=25) and providers (n=10), and assess the utility of this implementation tool in changing decisions about OAT using a pre/post design pilot study (n=100); and 3) assess the effectiveness of this informed decision-making aid to scale-up OAT in prisons and its hypothetical impact on HIV and HCV transmission over a 10-year horizon in PWID in Ukraine, using a Markov-based dynamic state-transition model.

These findings, if the informed decision-making aid influences OAT scale-up, can be used to guide adoption of this implementation strategy throughout Eastern European and Central Asian prisons, which have similar structures due to vestiges of the prison system of the former Soviet Union.