Daniel Bromberg

Fellowship Site: Ukrainian Institute On Public Health Policy

US Institution: Yale University

Project Title: Adapting and testing an informed decision-making aid for opioid agonist therapy in Ukrainian prisons

Eastern Europe and Central Asia (EECA) has the most rapidly growing HIV epidemic world-wide, compounded by high rates of incarceration and drug injection. Opioid agonist therapies (OAT) like methadone and buprenorphine are highly effective HIV prevention strategies for PWID, yet they are under-scaled in prisons globally, especially in EECA.

OAT was newly introduced in Ukrainian prisons in 2020, with only 38 patients on treatment. While the available evidence suggests that patients would choose to initiate OAT in prisons, given their heightened vulnerabilities, they often don’t do so due to misinformation, prison-specific social pressures, and overconfidence in their ability to prevent relapse post-release. As such, an implementation science theory-informed strategy to increase OAT uptake is urgently needed to address these barriers for PWID in prisons, specifically in the EECA context.

Informed decision-making (IDM) aids are evidence-based tools that may facilitate OAT implementation and scale-up in prisons as they assist PWID in deciding whether to adopt OAT or not and, if so, decide which treatment. IDM aids incorporate evidence and preferences to help prisoners with opioid use disorder (OUD) with two key decisions: 1) whether to initiate OAT in prison; and 2) which type of OAT to select. Such preferences, however, must be empirically assessed in order to understand their impact on adoption. While IDM aids are highly effective tools in health, none are available in the Ukrainian context or for prisoners.

The specific aims for my GHES research are to:

1) To understand the OAT preferences of prisoners with OUD in Ukraine;

2) To systematically adapt an IDM aid for OUD to the Ukrainian prison context;

3) To assess the effectiveness of this IDM implementation tool to scale-up OAT in prisons and its hypothetical impact on HIV and HCV transmission over a 10-year horizon among PWID in Ukraine, using a Markov-based dynamic state-transition model. These findings can be used to guide adoption of this implementation strategy throughout EECA prisons, which have similar structures due to vestiges of the prison system of the former Soviet Union.