Transformation of the HIV treatment cascade for people who inject drugs in Ukraine

Background:Ukraine's HIV epidemic, the second-largest in Europe, is concentrated among people who inject drugs (PWID), primarily opioids. Between 2014 and 2021, Ukraine has scaled up opioid agonist therapies (OAT) considerably.Methods:We conducted a large cross-sectional biobehavioral survey of PWID in 2020-2021 to compare to an equivalent survey from 2014 to 2015 using representative sampling approaches including random sampling and RDS of PWID with opioid dependence, recruiting those who were: currently on OAT; previously on OAT; and never on OAT. Only PWID who tested positive for HIV were assessed for the proportion linked to care, prescribed antiretroviral therapy (ART), and adherent to ART.Results:Comparing samples from 2021 (N = 2027) to 2014 (N = 1613), there were differences in HIV diagnosis (92.6 vs. 90%), linkage to care (86.5 vs. 85.3%), prescription of ART (95.8 vs. 78.9%), and adherence to ART (93.6 vs. 85.7%), for those patients who had previously been on OAT. In a subanalysis from the 2020 to 2021 sample, having ever touched the OAT treatment system (currently or previously on OAT) had significantly better outcomes at each step of the cascade relative to those who had never been on OAT.Interpretation:Although OAT had previously been demonstrated to improve HIV treatment outcomes along the HIV care cascade, findings here suggest that OAT has scaled-up along with higher levels of engagement in the HIV care cascade over time. Importantly, but not previously described, is the finding that touching the OAT treatment system, irrespective of retention on treatment contributes to improved HIV treatment outcomes for each step of the cascade.