Humanitarian crises exacerbate challenges to accessing HIV care. Older people with HIV (OPWH, aged ≥ 50 years) may seek additional support with HIV care, which often requires disclosing their HIV status to healthcare providers, family, or friends. We sought to understand how crises, including COVID-19 and the war with the Russian Federation, have changed OPWH disclosure behaviours over time. We surveyed OPWH in Kyiv, Ukraine, by phone at four-time points: May–June 2020 (Wave 1), January–February 2021 (Wave 2), January–February 2022 (Wave 3) and May–June 2022 (Wave 4). Participants’ responses were compared longitudinally. The primary outcome was new HIV status disclosure, and the independent variables were living conditions (living alone, not living alone) and HIV care support. Other variables analysed were age, gender, comorbidities, social support, depressive and anxiety symptoms, time since diagnosis, and history of addiction. A mixed-effects multivariable logistic regression model was used to assess the relationship between HIV status disclosure and independent variables. Of the 123 participants recruited, 90 OPWH completed the survey across all four-time points, of which 46 (51.1

Ukraine has the highest HIV prevalence in Europe at 1.2%. Antiretroviral therapy (ART) coverage is significantly lower among older people living with HIV(OPWH)(50+). OPWH have more challenges in treatment versus younger individuals. They often receive late diagnoses and require management of opportunistic infections and other chronic conditions. Russia's full-scale invasion in 2022 disrupted PWH by affecting the economy and healthcare services that lost 35,000 clinicians since the invasion. Peer support helps re-engage and retain OPWH in HIV care, especially during crises. The Peer-Run Optimal Support for Treatment (PROST) intervention was developed using the ADAPT-ITT framework. This process involved a multidisciplinary team, including OPWH, HIV clinicians, clinical psychologists, and social workers who work with OPWH. From February 2023 to April 2024, we tested the PROST intervention at Kyiv's largest HIV clinic to evaluate its feasibility, acceptability, and preliminary effectiveness among out-of-care clients (OOC) with no-ART-refill for over 90 days and ART-naïve OPWH. Enrolled participants were randomized 2:1 into PROST or treatment as usual (TAU) group. Both arms were surveyed, and HIV clinical data were extracted at baseline, 3 and 6-month follow-up. Study enrolled 56 OOC and 37 newly diagnosed ART-naïve OPWH. The mean age was 56.4 years (SD=5.6) and 55 % were women; randomization worked with no significant difference between the PROST vs TAU arm on any characteristic. Study retention rates at three and six months were 93.5% and 91.4%, respectively, with similar rates in both the PROST and TAU arms. At month three, the proportion of OOC achieving viral suppression (VS)(< 200 copies) was significantly higher in the PROST arm compared to TAU (63.4% vs. 53.3%; p< 0.001). No significant benefits were observed in the ART-naïve group. For OOC at month six, being in the PROST arm and experiencing reduced depression symptoms was associated with VS (OR=0.15, 95% CI: 0.02–0.94, p=0.042). PROST intervention may decrease depressive symptoms and help to achieve VS, including undetectable viral loads among OOC OPWH. A fully powered trial is necessary to confirm whether PROST can mitigate the negative effects of poor mental health on VS in this population. Sheela Shenoi, MD MPH, Merck Pharmaceuticals: My spouse worked for Merck 1997-2007 and retains company stock in his retirement account. There is no conflict of interest with this work.

The overlapping COVID-19 crisis and the war starting in 2022 threaten front-line healthcare workers’ mental health, well-being and job retention in Ukraine. This paper provides a synopsis of a panel discussion held by the Global Mental Health Humanitarian Coalition in May 2022 and expert consultations with clinicians between December 2022 and February 2023 on these challenges. The crises created new problems and exacerbated many pre-existing difficulties. We found that healthcare workers had needed to mobilise previously untapped strengths, including portable emergency medical documents and bespoke local psychosocial support services, amid the costs and pressures of ongoing healthcare reforms.

Background A substantial number of older adults succumb soon after HIV diagnosis despite ART. We explored the causes, risk factors and circumstances before death among older adults acquring HIV. Methods We recruited individuals newly diagnosed at our centre from 2016-2020 and analysed data of those who died. Patients were stratified to older (≥50 years) or younger (<50 years) based on their age at diagnosis and attributes were compared. The Cox proportional multivariable model was used to identify factors associated with all-cause mortality. Results Among 75 deaths reported, the majority of deaths were AIDS-related and late presentation was common in both age groups. The majority of deaths occurred in the first 12 months after care presentation and over two-thirds in both groups disengaged from care prior to death. Older age remained an independent factor associated with death after adjusting for confounders including opportunistic infections, late presentation to care, ART initiation and chronic comorbidities at presentation. Conclusion Most causes of death in our setting were AIDS-related and associated with late care presentation both in young and older individuals, although older age at diagnosis remained an independent risk factor. Our findings highlight the urgent need to encourage prompt ART initiation following diagnosis, especially in older adults.

Background HIV incidence and mortality are increasing in Ukraine despite their reductions globally, in part due to suboptimal antiretroviral therapy (ART) coverage in key populations of people with HIV (PWH) where the epidemic is concentrated. As physicians are gatekeepers to ART prescription, stigma and discrimination barriers are understudied as a key to meeting HIV treatment targets in key populations. Methods A national sample (N = 204) of ART-prescribing physicians in Ukraine were surveyed between August and November 2019. Participants underwent a series of randomized, hypothetical HIV clinical scenarios and decided whether to initiate or defer (or withhold) ART. Scenarios varied based on 5 distinct CD4 counts (CD4: 17, 176, 305, 470, or 520 cells/mL) and 10 different PWH key populations. Z scores and McNemar’s test for paired samples were used to assess differences between key populations and CD4 count. Feeling thermometers were used to assess stigma-related measures toward key populations among physicians. Results Physicians were highly experienced (mean = 19 years) HIV treaters, female (80.4%), and trained in infectious diseases (76.5%). Patients who drink alcohol (range: 21.6%-23.5%) or use (PWUD range: 16.7%-20.1%) or inject (PWID range: 15.5%-20.1%) drugs were most likely to have ART deferred, even at AIDS-defining CD4 counts. PWID maintained on methadone, however, were significantly (p<0.001) less likely to have ART deferred compared with those who were not (range: 7.8%-12.7%) on methadone. Men who have sex with men (range: 5.4%-10.8%), transgender women (range: 4.9%-11.3%), sex workers (range: 3.9%-10.3%),and having an HIV-uninfected sex partner (range: 3.9%-9.3%) had the lowest likelihood of ART deferral. Increasing levels of stigma (i.e., feeling thermometers) towards a key population was correlated with ART deferral (i.e., discrimination). Conclusions Despite international and Ukrainian guidelines recommending ART prescription for all PWH, irrespective of risk or CD4 count, ART deferral by experienced HIV experts remains high in certain key populations, especially in PWH and substance use disorders. Strategies that initiate ART immediately after diagnosis (i.e., rapid start antiretroviral therapy), independent of risk group, should be prioritized to truly mitigate the current epidemic.

Background:In resource-limited settings, HIV-related services are often targeted to younger key populations, although increasing reports have found that adults >= 50 years now account for among the highest increase in new HIV diagnosis. We assessed the proportion of new HIV infections among older adults (>= 50 years) and compared their sociodemographics, risk behaviors, and HIV-related outcomes to newly diagnosed younger adults (<50 years).Methods:This retrospective analysis included all new HIV diagnosis from 2016 to 2019 at the University of Malaya Medical Centre, Malaysia. Trends of HIV diagnosis was assessed using join point regression analysis, and characteristics between the older and younger adults were compared using chi(2) test or Mann-Whitney U test. Kaplan-Meier analysis and log-rank test were used to compare the survival probability in both age groups.Results:From a total of 594 new HIV diagnosis between 2016 and 2019, 11.5% (N = 68) were among older adults with an annual percent increase of 5.50%. Older adults were more likely ethnic Indians (P < 0.001), acquired HIV through heterosexual contact (P = 0.001), had late presentation to care (P = 0.003), and multimorbidity (P < 0.001). Immunological responses after 12 months on antiretroviral therapy were comparable in both the groups. Older adults had a higher probability of death compared with younger adults (adjusted hazard ratio 1.81, 95% confidence interval: 1.02 to 3.23, P = 0.043) after adjusting for sex, mode of HIV transmission, late presentation to care, antiretroviral therapy initiation, and multimorbidity.Conclusion:Older adults diagnosed with HIV were associated with late care presentation and increased mortality. There is an urgent need to enhance uptake of HIV testing and linkage to care among older individuals in our setting.

Contrary to apocalyptic expectations, in Ukraine up to 90% of staff in addiction and HIV care facilities (unless physically destroyed) have remained in post since the start of the Russian invasion in February 2022. Ukraine provides insights into the sources of this resilience as well as its limits and costs. In February 2022, Ukraine was a low/middle-income country of 42 million people, of whom 260 000 were living with HIV (PLWH) and over 347 000 injected drugs (PWID) [1]. Through prior efforts, 83% of PLWH were on antiretroviral therapy (ART), and 5% of PWID received opioid substitution treatment (OST) [2, 3]. When the Russian invasion began, experts predicted rapid collapse of HIV and addiction treatment [4, 5], but instead, clinicians have been stalwart in providing continued patient care. Despite nearly a quarter of the population fleeing Ukraine since 2022 [6], in addiction and HIV care facilities remaining physically intact ~80% to 90% of clinicians remain in post [7]. For example, in Kramatorsk (20 km from the front), with one addiction treatment facility destroyed, the remaining four continue daily care, serving 290 in-patients (reduced from 450 beds pre-war) and 141 OST patients. Of 25 HIV care sites of the Donetsk region (where active combat is ongoing), 14 sites are currently still working full-time. After the doctor of the Avdiivka city site (7 km from the front) was wounded, the nurse was evacuated from Avdiivka, but she continues to provide treatment remotely for all 205 patients registered at the site, including organizing the delivery of OST and ART to 40 HIV PWID patients who remain in Avdiivka. With escalating safety risks and intermittent interruption to electricity, internet and other necessities, how have HIV and addiction care facilities endured? First, per testimonies from Ukrainian healthcare workers who participated in the Global Mental Health Humanitarian Coalition panel in May 2022 [8], clinicians value their jobs, challenging as they may be, especially as stable employment is scarce during humanitarian crisis. As an addiction doctor from Chernihiv stated, ‘a medical worker is a profession of the soul, the kindness of the heart and 100% dedication, thus most people stay working. Furthermore, times are hard, and people hold on to any job’. Her counterpart from Kherson echoed by saying ‘healthcare workers have a special way of thinking. There was a time in the 1990s when doctors had no money for food, but patients were assisted. Healthcare workers will treat patients even in the face of a threat to own life’. Since 2015, Ukraine has implemented healthcare reform, including operational restructuring and cost reduction, leading to painful staff cuts by 10% to 20% across addiction and HIV clinics [9, 10]. Coronavirus disease 2019 (Covid-19) pandemic gave temporary respite, with the Ukrainian Ministry of Health slowing the cuts and introducing Covid-19 bonus payments for frontline staff providing critical care (including HIV and addiction treatment) [11, 12]. Relatively small in absolute terms ($200/month maximum), this bonus could exceed 200% of frontline clinicians' modest salary [13]. Bonuses dwindled in 2021, but restarted intermittently during the war through the advocacy of clinical directors and political goodwill of local authorities, providing financial and also moral buoy to clinicians. Despite initial frontline staff shortages in March–April 2022, when some personnel evacuated and others could not access the workplace because of transportation disruptions, many clinicians returned to Ukraine and resumed work throughout the summer [14]. When Ukraine reclaimed territories near Kherson and Zaparizhzhia in October 2022, most internally displaced clinicians returned to their posts. For example, in Kherson, all staff of a local AIDS clinic consisting of a doctor, two nurses and a laboratory technician fled the city during the active combat, but everyone returned when the facility was re-opened on 9 November 2022. Continuing work in their field (as opposed to the uncertainty experienced by Ukrainian refugees abroad) was a key motivator. Second, a supportive working environment, with clinic directors genuinely recognizing clinicians' contributions, is another powerful motivator for coping with adversity. During Covid-19, frontline healthcare staff in many countries felt disenchanted that the public and administrative applause to ‘Our Heroes’ lacked political and financial follow-through [15]. In contrast, during the war, medical directors of Ukrainian addiction and HIV clinics developed bespoke ways to acknowledge their staff's contributions. For example, when clinicians Kyiv lived on clinic premises without going home for 3 days or longer to provide round-the-clock services, medical directors stayed with their staff, equally shouldering every burden. In Kherson, an HIV clinic director who left Ukraine when the city was occupied continued working by Zoom without salary, supporting her staff and patients until the clinic reopened. This authentic ‘being there together’, complemented by patients' overwhelming gratitude, fostered reciprocal empathy among colleagues, lowering the risk of burnout. However, although buoyant, Ukrainian clinicians and facilities are not immortal. Over time, destruction grows, and territory where life is possible shrinks. Literature defines a resilient healthcare system as able to ‘adapt to challenges and changes at different system levels, to maintain high-quality care’ [16]. Learnings from Ukraine suggest this may obscure when medics become expendable, and put the onus on individuals and facilities to absorb all shocks. Inadvertently, it downplays the government's responsibility to mitigate the crisis and protect and support essential workers. Resilience during the crisis can trap clinicians in compulsory altruism [17], working over and above the call of duty to save vulnerable patients, until the point where the staff eventually collapse. Furthermore, as with vulnerable patients who cannot leave dangerous places because of limited resources and eldercare responsibilities, the same is true for clinicians. As the humanitarian crisis continues, there is a real danger that resilience is assumed to be ever-extendable and able to absorb growing workloads under shrinking resources, and regarded as a default for HIV and addiction treatment facilities. Yet, there is still time to help as meaningful work performs a therapeutic function for medics, with Ukrainian clinical leaders keeping their organisations alive despite adversity. Insights from the research evidence and learnings from Ukrainian HIV and addiction clinicians' coping in recent years suggest three recommendations. First recommendation: extending the timeline of the ongoing healthcare reform in Ukraine, as previously agreed before the Russian invasion. The last phase of reform aims to reconfigure many addiction and HIV clinics from January 2024, subsuming some staff into special departments in larger hospitals and passing other functions to primary care facilities. Extending the timeline would allow clinicians to meet increased patient care demands during the humanitarian crisis, lessen immediate job security concerns and incorporate learnings from crisis adaptations to ensure the reform's long-term success. Second recommendation: establishment by the Ukrainian Ministry of Health of a re-employment pathway for clinicians of destroyed clinics, including nationwide co-ordination of available posts, and allowing HIV and addiction care facilities to open additional positions and hire new staff. This could alleviate staff burnout and permit clinicians from war-destroyed facilities to follow their transferred patients, with the latter benefitting from continuity of care from medics with whom they already have rapport and trust. One option could be increasing the number of mobile care teams, following the model used by the Public Health Alliance, whose care vans visit de-occupied rural areas to deliver hepatitis C treatment [18]. With support from the Ministry of Health, re-deployed clinicians could provide addiction, HIV and other infectious diseases treatment to people living in communities where clinics have been destroyed, helping to curb the epidemics. Third recommendation: support by the Ukrainian Ministry of Health for regular professional development activities for clinicians across all facilities. From a humanitarian perspective, each facility risks becoming an island and training activities can increase social support and alleviate burnout risks, while giving clinicians opportunities to learn from each other's empirically tested coping strategies. International partners' donation of laptops, power-banks and light-generating devices to clinics across Ukraine has facilitated online access. Additional paid leave and/or travel funding to clinicians from regions with active hostilities would support in-person participation while also giving respite. The achievement of Ukrainian addiction and HIV care clinicians to maintain capacity during a crisis should inspire medics and planners elsewhere. Just as previous wars led to advances in anesthesiology and surgery with clinicians learning from a massive evidence base [19], so too lessons from Ukraine have the potential to reduce the human costs to healthcare resilience. Julia Rozanova: Conceptualization (lead); funding acquisition (lead); investigation (equal); methodology (equal); project administration (equal); writing—original draft (lead); writing—review and editing (equal). Irina Zaviryukha: Conceptualization (equal); data curation (equal); funding acquisition (equal); investigation (equal); methodology (equal); project administration (equal); validation (equal); writing—original draft (equal); writing—review and editing (equal). Alexandra A. Deac: Conceptualization (equal); data curation (equal); investigation (equal); methodology (equal); project administration (equal); resources (supporting); software (lead); writing—original draft (equal); writing—review and editing (equal). Oleksandr Zeziulin: Conceptualization (equal); data curation (equal); formal analysis (equal); funding acquisition (equal); investigation (equal); methodology (equal); project administration (equal); resources (equal); software (supporting); supervision (equal); validation (equal); writing—review and editing (equal). Tetiana Kiriazova: Conceptualization (supporting); data curation (supporting); funding acquisition (equal); investigation (equal); methodology (equal); validation (equal); writing—review and editing (equal). Valerie Earnshaw: Conceptualization (supporting); funding acquisition (equal); investigation (equal); methodology (equal); validation (equal); writing—review and editing (equal). Katherine M. Rich: Conceptualization (equal); data curation (equal); formal analysis (equal); investigation (equal); methodology (equal); validation (equal); writing—review and editing (equal). Sheela V. Shenoi: Conceptualization (supporting); funding acquisition (equal); investigation (equal); methodology (equal); supervision (equal); writing—review and editing (equal). Harry Skipper: Conceptualization (supporting); resources (supporting); validation (equal); writing—review and editing (equal). Volodymyr Yariy: Conceptualization (equal); investigation (equal); resources (equal); validation (equal); writing—review and editing (equal). Sir John Strang: Conceptualization (lead); investigation (equal); methodology (equal); writing—review and editing (equal). We thank HIV and addiction treatment providers from Kherson, Zaporizhzhia, Odesa, Donetsk, Zhytomyr, Dnipro and Kyiv regions, with whom we have worked on clinical studies for many years, for sharing with us their testimonies of experiences being a clinician in Ukraine during the war. We have written this article on their behalf. This article is dedicated to medics quietly doing their job amidst the roaring crises. None.

Abstract Humanitarian crises impact mental health, yet data lacks among older individuals. We explored how Covid-19 and the Russian invasion has impacted older people with HIV (OPWH, ≥50 years) in Ukraine. We surveyed a longitudinal cohort of 123 OPWH (50% female) during four periods: April-June 2020 (Wave 1), December 2020-February 2021 (Wave 2), December 2021–February 2022 (Wave 3), and July–September 2022 (Wave 4). The primary outcomes were depressive (PHQ9>5) and anxiety symptoms (GAD7>5). Factors associated with these symptoms were assessed using a mixed effects logistic regression model that included gender, time since HIV diagnosis, history of a substance use disorder (SUD), history of another chronic condition, HIV disclosure, living alone, and social support. Logistical regression controlling for SUD assessed factors associated with resilience (BRS). During Wave 4, OPWH were offered free psychological counseling through our project. Across all Waves, women were more likely than men to have mild to severe anxiety and depressive symptoms, but also to have higher resilience, and to accept psychological counseling during the war. Comorbid SUD and other chronic conditions increased likelihood of anxiety, and longer time since HIV diagnosis increased likelihood of depressive symptoms. Unlike women, men showed distress discussing “Social Support” topic during the war. OPWH with SUD had higher resilience across all waves. While female OPWH had more depressive and anxiety symptoms during the crises they have higher resilience, social support, and help acceptance, suggesting bespoke approaches are needed to assist male and female OPWH in humanitarian settings.

Background: The war in Ukraine has posed significant challenges to the healthcare system. This paper draws upon expert consultations, held between December 2022 and February 2023, focused on HIV/AIDS, addiction, and mental health service delivery during the first year of this war, and following the Global Mental Health Humanitarian Coalition panel discussion in May 2022. Objectives: This commentary presents the experiences of frontline healthcare workers in Ukraine, challenges, and local adaptations to meet the increased mental health needs of healthcare providers. We aimed to document the adaptations made in the addiction healthcare system and to acknowledge the changes in vulnerabilities and lessons learned. Results: Burnout among healthcare providers delivering addiction, HIV/AIDS and mental health services became more visible after the second half of 2022. Challenges included increased workload, contextual threats, lack of job relocation strategies, and money-follow-the-patient policies. Recommendations: The lessons from the first year of war in Ukraine hold significant generalizability to other contexts. These include enabling bottom-up approaches to tailoring services and allowing healthcare providers to respond to the dynamics of war in an effective and active manner. Other recommendations include departmental-specific resources and strategies, particularly as vulnerable groups and challenges are unstable in humanitarian contexts. Conclusions: Globally and in Ukraine, healthcare workers need more than applause. Along with monetary incentives, other strategies to prevent burnout, ensure sustainable capacity building, job relocation opportunities, and bespoke adaptations are imperative to protect healthcare providers' wellbeing and overall public health.

In a short period, the COVID-19 pandemic and the time that has followed has disrupted all aspects of lives from research to healthcare and caused the world to react and adapt just as rapidly. For vulnerable populations such as the uniquely growing proportion of older people with HIV (OPWH) in the low- and middle-income (LMIC) country of Ukraine, the situation is particularly pressing. In Ukraine, instead of experiencing a "new normal" with the rest of the Western world, the people were left with something even worse: war. Adaptations made during the pandemic provided a host of reliable and simple tools that ultimately allowed this research to go forward even in a post-pandemic, war-torn nation. In the first study of its kind, phone surveys were conducted with 123 OPWH receiving HIV care in Kyiv to better understand how the current socio-political landscape impacted OPWH in this resource-scarce environment. This chapter synthesises responses to the benefits and challenges of adapting traditional methods of rapport building and phone surveys to meet the demands of new realities. This model of revitalising vintage methodologies in modern ways has allowed the continuation of engagement with vulnerable people and can be replicated in similarly turbulent climates.

Supplemental Digital Content is Available in the Text. Background: In resource-limited settings, HIV-related services are often targeted to younger key populations, although increasing reports have found that adults ≥50 years now account for among the highest increase in new HIV diagnosis. We assessed the proportion of new HIV infections among older adults (≥50 years) and compared their sociodemographics, risk behaviors, and HIV-related outcomes to newly diagnosed younger adults (<50 years). Methods: This retrospective analysis included all new HIV diagnosis from 2016 to 2019 at the University of Malaya Medical Centre, Malaysia. Trends of HIV diagnosis was assessed using join point regression analysis, and characteristics between the older and younger adults were compared using χ2 test or Mann–Whitney U test. Kaplan–Meier analysis and log-rank test were used to compare the survival probability in both age groups. Results: From a total of 594 new HIV diagnosis between 2016 and 2019, 11.5% (N = 68) were among older adults with an annual percent increase of 5.50%. Older adults were more likely ethnic Indians (P < 0.001), acquired HIV through heterosexual contact (P = 0.001), had late presentation to care (P = 0.003), and multimorbidity (P < 0.001). Immunological responses after 12 months on antiretroviral therapy were comparable in both the groups. Older adults had a higher probability of death compared with younger adults (adjusted hazard ratio 1.81, 95% confidence interval: 1.02 to 3.23, P = 0.043) after adjusting for sex, mode of HIV transmission, late presentation to care, antiretroviral therapy initiation, and multimorbidity. Conclusion: Older adults diagnosed with HIV were associated with late care presentation and increased mortality. There is an urgent need to enhance uptake of HIV testing and linkage to care among older individuals in our setting.

HIV incidence continues to increase in Eastern Europe and Central Asia (EECA), in large part due to non-sterile injection drug use, especially within prisons. Therefore, medication-assisted therapy with opioid agonists is an evidence-based HIV-prevention strategy. The Kyrgyz Republic offers methadone within its prison system, but uptake remains low. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a framework for identifying people who would potentially benefit from methadone, intervening to identify OUD as a problem and methadone as a potential solution, and providing referral to methadone treatment. Using an SBIRT framework, we screened for OUD in Kyrgyz prisons among people who were within six months of returning to the community (n = 1118). We enrolled 125 people with OUD in this study, 102 of whom were not already engaged in methadone treatment. We conducted a pre-release survey followed by a brief intervention (BI) to address barriers to methadone engagement. Follow-up surveys immediately after the intervention and at 1 month, 3 months, and 6 months after prison release assessed methadone attitudes and uptake. In-depth qualitative interviews with 12 participants explored factors influencing methadone utilization during and after incarceration. Nearly all participants indicated favorable attitudes toward methadone both before and after intervention in surveys; however, interest in initiating methadone treatment remained very low both before and after the BI. Qualitative findings identified five factors that negatively influence methadone uptake, despite expressed positive attitudes toward methadone: (1) interpersonal relationships, (2) interactions with the criminal justice system, (3) logistical concerns, (4) criminal subculture, and (5) health-related concerns.

Background:People with HIV in the United States are aging, with risk for negative health outcomes from social isolation. PositiveLinks is a mobile health (mHealth) intervention that includes an anonymous Community Message Board (CMB) for peer-to-peer conversations. We investigated differences in CMB usage and social support between younger (<50 years) and older (≥50) members.Methods:We assessed the relationship between age groups and app use using chi-square tests. CMB posts were analyzed qualitatively to categorize forms of social support. To have a visual understanding of this relationship, we created a network diagram to display interactions among PL members.Results:Among 87 participants, 31 (42.5%) were in the older age group. Older members launched the app more often at 6 months (445.5 vs. 240.5 mean launches per participant, p ≤ 0.001) and 12 months (712.3 vs. 292.6 launches, p ≤ 0.001) compared with younger members. Older members also demonstrated more CMB posts at 6 months (47.4 vs. 7.6 mean posts per participant, p = 0.02) and 12 months (77.5 vs. 10.6 posts, p = 0.04). Of 1861 CMB posts, 7% sought support and 72% provided support. In addition, the network visualization showed that four participants, who were in the older age group, had more post generation than others and most of their posts provided support.Conclusions:Older PL members demonstrated significantly more app use than younger members, including CMB posts for social support. This durable app engagement indicates that mHealth can enable social connection among people living with chronic disease across the lifespan.

Background Efficient and linguistically appropriate instruments are needed to assess response to addiction treatment, including severity of addiction/mental health status. This is critical for Russian-speaking persons in Eastern Europe and Central Asia (EECA) where Medications for Opioid Use Disorder (MOUD) remain underscaled to address expanding and intertwined opioid, HIV, HCV and tuberculosis epidemics. We developed and conducted a pilot validation of a Russian version of the 24-item Behavior and Symptom Identification Scale (BASIS-24), an addiction/mental health severity instrument with six subscales, previously validated in English. Methods Using the Mapi approach, we reviewed, translated, and back-translated the content to Russian, pilot-tested the Russian-version (BASIS-24-R) among new MOUD patients in Ukraine (N = 283). For a subset of patients (n = 44), test-rest was performed 48 h after admission to reassess reliability of BASIS-24-R. Exploratory principal component analysis (PCA) assessed underlying structure of BASIS-24-R. Results Cronbach alpha coefficients for overall BASIS-24-R and 5 subscales exceeded 0.65; coefficient for Relationship subscale was 0.42. The Pearson correlation coefficients for overall score and all subscales on the BASIS-24-R exceeded 0.8. Each item loaded onto factors that corresponded with English BASIS-24 subscales ≥ 0.4 in PCA. Conclusion Initial version of BASIS-24-R appears statistically valid in Russian. Use of the BASIS-24-R has potential to guide MOUD treatment delivery in the EECA region and help to align addiction treatment with HIV prevention goals in a region where HIV is concentrated in people who inject opioids and where healthcare professionals have not traditionally perceived MOUD as effective treatment, particularly for those with mental health co-morbidities.

Ukraine imposed a COVID-19 lockdown in March 2020. From April to June 2020, we surveyed 123 older people with HIV (OPWH) by phone to assess their mental health, engagement in HIV and other healthcare, and substance use using standardised scales. Variables of key interest were symptoms of depression and symptoms of anxiety. Univariate and multivariable Firth logistic regression models were built to assess factors associated with: (1) symptoms of depression, and (2) symptoms of anxiety. Findings indicated high suicidal ideation (10.6%); 45.5% met the screening criteria for moderate to severe depression; and 35.0% met the criteria for generalised anxiety disorder (GAD). Independent correlates of having moderate to severe depression included being female (AOR: 2.83, 95%CI = 1.19–7.05), having concerns about potential barriers to HIV treatment (AOR: 8.90, 95%CI = 1.31–104.94), and active drug use (AOR: 34.53, 95%CI = 3.02–4885.85). Being female (AOR: 5.30, 95%CI = 2.16–14.30) and having concerns about potential barriers to HIV treatment (AOR: 5.33, 95%CI = 1.22–28.45) were independently correlated with GAD, and over half (58.5%) were willing to provide peer support to other OPWH. These results highlight the impact of the COVID-19 restrictions in Ukraine on mental health for OPWH and support the need to screen for psychiatric and substance use disorders, potentially using telehealth strategies.

Background: The Kyrgyz Republic (Kyrgyzstan) is one of few countries in Eastern Europe and Central Asia to provide methadone within its prisons, but uptake of this program has been suboptimal, in part because methadone uptake may have personal or social risks and consequences. Decision aids are evidence-based strategies that are designed to inform the patient's choice by objectively providing information that incorporates patient preferences. Methods: We conducted qualitative interviews in Kyrgyz and Russian with currently and formerly incarcerated people ( n = 36) in Kyrgyzstan from October 2016 to September 2018. Interviews explored factors influencing methadone utilization in prisons. Transcripts were coded by five researchers using content analysis. A secondary thematic analysis was conducted to determine factors specific to initiation or continuation of methadone treatment in prisons. Results: We identified six interrelated themes affecting an individual's decision to initiate or continue methadone treatment: 1) informal prison governance (incarcerated people governing themselves); 2) informal prison economy; 3) perceived and objective benefits of methadone treatment; 4) perceived and objective side effects of methadone treatment; 5) distrust of formal prison administration (medical and correctional staff); and 6) desire for a "cure " from addiction. Conclusion: Respondents' perceptions about benefits, side effects, and addiction as a curable disease are not consistent with the available evidence. An evidence-based, informed decision-making aid would need to address the six themes identified here, of which several are specific to the Kyrgyz prison context. Unlike decision aids elsewhere, the unique aspects of incarceration itself alongside the informal governance system strongly present within Kyrgyz prisons will need to be incorporated into decisional processes to promote HIV prevention and treatment in a region with high rates of HIV transmission and mortality.

INTRODUCTION:The Eastern Europe and Central Asian (EECA) region has the highest increase in HIV incidence and mortality globally, with suboptimal HIV treatment and prevention. All EECA countries (except Russia) are low and middle-income (LMIC). While LMIC are home to 80% of all older people living with HIV (OPWH), defined as ≥50 years, extant literature observed that newly diagnosed OPWH represent the lowest proportion in EECA relative to all other global regions. We examined HIV diagnoses in OPWH in Ukraine, a country emblematic of the EECA region. METHODS:We analysed incident HIV diagnoses from 2015-2018 and mortality trends from 2016-2018 for three age groups: 1) 15-24 years; 2) 25-49 years; and 3) ≥50 years. AIDS was defined as CD4<200cells/mL. Mortality was defined as deaths per 1000 patients newly diagnosed with HIV within the same calendar year. Mortality rates were calculated for 2016, 2017, and 2018, compared to age-matched general population rates, and all-cause standardized mortality ratios (SMRs) were calculated. RESULTS:From 2015-2018, the proportion of OPWH annually diagnosed with HIV increased from 11.2% to 14.9% (p<0.01). At the time of diagnosis, OPWH were also significantly (p<0.01) more likely to have AIDS (43.8%) than those aged 25-49 years (29.5%) and 15-24 years (13.3%). Newly diagnosed OPWH had the same-year mortality ranging from 3 to 8 times higher than age-matched groups in the Ukrainian general population. CONCLUSIONS:These findings suggest a reassessment of HIV testing, prevention and treatment strategies in Ukraine is needed to bring OPWH into focus. OPWH are more likely to present with late-stage HIV and have higher mortality rates. Re-designing testing practices is especially crucial since OPWH are absent from targeted testing programs and are increasingly diagnosed as they present with AIDS-defining symptoms. New strategies for linkage and treatment programs should reflect the distinct needs of this target population.

Low- and middle-income countries are home to 80% of older people with HIV (OPWH). Ukrainian OPWH experience higher mortality and decreased antiretroviral therapy (ART) initiation than younger patients, but there is little data examining OPWH’s perspectives around new diagnosis and impact on care. In this study, we examined accounts of 30 newly diagnosed OPWH in Ukraine, exploring challenges faced in the peri-diagnosis period. Themes emerged representing the longitudinal coping process: OPWH (1) viewed themselves as low risk before diagnosis; (2) experienced HIV diagnosis as a traumatic event challenging their self-image; (3) used disclosure to seek support among a small circle of family, friends, or health care providers; (4) avoided disclosure to outsiders including primary care providers for fears of stigma and breaches in confidentiality; (5) viewed age as an asset; and (6) used HIV diagnosis as starting point for growth. These findings highlight the need for age-specific programming to increase HIV knowledge and coping, increase screening, and improve long-term planning.

BackgroundHIV incidence in Eastern Europe and Central Asia (EECA) continues to increase, primarily among people who inject drugs (PWID) and people in prisons. In Kyrgyzstan, an estimated 35% of people in prison are PWID, and 10% have been diagnosed with HIV. In 2008, Kyrgyzstan became the first country in EECA to provide free and voluntary methadone in prisons. We examine the impact of this national program on methadone within prison as well as linkage to and retention in treatment upon release to the community.MethodsAdministrative data from a national methadone registry with de-identified information were assessed retrospectively. We examined the delivery of methadone services, including the duration of treatment both within prison and after release, for all prisoners who were prescribed methadone in Kyrgyz prisons from 2008 to 2018. Reasons for discontinuing methadone, HIV status and methadone dose are also analyzed.ResultsBetween 2008 and 2018, nine of Kyrgyzstan's 16 prisons offered methadone, and 982 incarcerated people initiated methadone within prison. Prisoners prescribed methadone were mostly male (96.2%), in their mid-30s (mean=34.9 years), and had been incarcerated for a relatively long time (mean = 44.1 months); their mean treatment duration in prison was 12.5 months, and 31.6% had HIV. A subsample (N = 645; 65.7%) of these were released to the community. Of these 645 people, 356 (55.2%) were not taking methadone at the time of release, 128 (19.8%) were on methadone and continued it after release, and the remainder (N=161, 25.0%) were on methadone at the time of release, but subsequently discontinued it, most within the first 7 days after release. Among those continuing methadone, 14.8% (N=19) remained on treatment ≥ 12 months. Independent correlates of linkage to methadone after release included positive HIV status (adjusted hazard ratio (aHR)=1.55; p = 0.033), receipt of methadone before their incarceration (aHR=2.01; p = 0.039), and receipt of methadone at the time of release (aHR = 20.81; p<0.001).ConclusionThis is the first evaluation of within-prison methadone treatment in EECA. Uptake of methadone within prison and retention in treatment after release were both low. Continuous maintenance of treatment throughout incarceration is an opportunity to optimize HIV prevention and link patients to methadone post-release.

BACKGROUND AND AIMS:Ukraine's HIV epidemic remains concentrated among opioid-dependent people who inject drugs (PWID) where opioid agonist therapies (OAT) like methadone (MMT) and buprenorphine (BMT) maintenance treatments are the most cost-effective HIV prevention strategies, but remain under-scaled. This study aimed to measure the association between dose and type of OAT prescribed and treatment retention.DESIGN:Observational longitudinal cohort study.PARTICIPANTS AND SETTING:Patients (n = 15 290) prescribed OAT throughout Ukraine from 2004 through 2016.MEASUREMENTS:Data were analyzed using time-event strategies to estimate cumulative treatment retention, defined as time to OAT discontinuation. Cumulative retention proportions at 1, 12 and 36 months were assessed for outcomes. Cox regression with log-rank likelihood assessed independent predictors of treatment discontinuation.FINDINGS:The proportion prescribed high (MMT: > 85 mg; BMT: ≥ 16 mg), medium (MMT: > 40-85 mg; BMT: > 6-15 mg) and low (MMT: ≤ 40 mg; BMT: ≤ 6 mg) dosages was 25, 43 and 32%, respectively. Retention was significantly higher for BMT than MMT both at 12 (89 versus 75%) and 36 months (80 versus 56%). Although dosing levels for BMT did not influence retention, increasing dosages for MMT were significantly associated with higher retention rates at 1 (90, 96, 99%), 12 (59, 78, 91%) and 36 (34, 59, 79%) months, respectively. Independent predictors associated with 12-month OAT discontinuation were medium [adjusted hazard ratio (aHR) = 2.23; 95% confidence limit (CL) = 1.95-2.54] and low (aHR = 4.96; 95% CL = 4.37-5.63) OAT dosage relative to high dosage, male sex (aHR = 1.27; 95% CL = 1.14-1.41), MMT relative to BMT prescription (aHR = 1.57; 95% CL = 1.32-1.87) and receiving OAT in general (aHR = 1.22; 95% CL = 1.02-1.46) or tuberculosis (aHR = 1.43; 95% CL = 1.10-1.85) hospitals, relative to specialty addiction treatment and AIDS center settings. Lower dosages contributed more to dropout especially at 1 month (aHR 3.12; 95% CL = 2.21-4.41 and aHR 7.71; 95% CL = 5.51-10.79 for medium and low dosages, respectively). Younger age was significantly associated with OAT discontinuation only at 36 months (aHR = 1.08; 95% CI = 1.02-1.15).CONCLUSIONS:Higher dosages of opioid agonist therapies, especially for methadone maintenance treatment patients, appear to be associated with higher levels of treatment retention in Ukraine.