Integration of health services improves multiple healthcare outcomes among HIV-infected people who inject drugs in Ukraine

Abstract

Background

People who inject drugs (PWID) experience poor outcomes and fuel HIV epidemics in middle-income countries in Eastern Europe and Central Asia. We assess integrated/co-located (ICL) healthcare for HIV-infected PWID, which despite international recommendations, is neither widely available nor empirically examined.

Methods

A 2010 cross-sectional study randomly sampled 296 HIV-infected opioid-dependent PWID from two representative HIV-endemic regions in Ukraine where ICL, non-co-located (NCL) and harm reduction/outreach (HRO) settings are available. ICL settings provide onsite HIV, addiction, and tuberculosis services, NCLs only treat addiction, and HROs provide counseling, needles/syringes, and referrals, but no opioid substitution therapy (OST). The primary outcome was receipt of quality healthcare, measured using a quality healthcare indicator (QHI) composite score representing percentage of eight guidelines-based recommended indicators met for HIV, addiction and tuberculosis treatment. The secondary outcomes were individual QHIs and health-related quality-of-life (HRQoL).

Results

On average, ICL-participants had significantly higher QHI composite scores compared to NCL- and HRO-participants (71.9% versus 54.8% versus 37.0%, p < 0.001) even after controlling for potential confounders. Compared to NCL-participants, ICL-participants were significantly more likely to receive antiretroviral therapy (49.5% versus 19.2%, p < 0.001), especially if CD4 ≤ 200 (93.8% versus 62.5% p < 0.05); guideline-recommended OST dosage (57.3% versus 41.4%, p < 0.05); and isoniazid preventive therapy (42.3% versus 11.2%, p < 0.001). Subjects receiving OST had significantly higher HRQoL than those not receiving it (p < 0.001); however, HRQoL did not differ significantly between ICL- and NCL-participants.

Conclusions

These findings suggest that OST alone improves quality-of-life, while receiving care in integrated settings collectively and individually improves healthcare quality indicators for PWID.

Introduction

From 1999 to 2009, HIV incidence decreased 19% globally, but increased 25% in Eastern Europe and Central Asia (UNAIDS, 2010). In Ukraine (Kruglov et al., 2008), as throughout the region, this epidemic is concentrated among people who inject drugs (PWID; Cohen, 2010, Mathers et al., 2007). To help address this crisis, Ukraine first introduced opioid substitution therapy (OST) in 2004 with buprenorphine (Bruce et al., 2007), adding methadone in 2007 (Lawrinson et al., 2008, Schaub et al., 2010). For PWID, OST enhances quality of life (Nosyk et al., 2011) and reduces injection-related HIV risk behaviors (Gowing et al., 2008), while improving antiretroviral (ART) access (Altice et al., 2011, Uhlmann et al., 2010) and adherence (Malta et al., 2010) and viral suppression (Altice et al., 2011, Roux et al., 2009) among those infected with HIV. Modeling data from Ukraine confirm OST as the most efficacious and cost-effective intervention for injection-related and transitional HIV epidemics compared to harm reduction or ART provision alone (Alistar et al., 2011, Degenhardt et al., 2010).

HIV-infected PWID experience intertwined co-morbidities that complicate care and contribute to poor outcomes, including tuberculosis, viral hepatitis, mental illness, active drug use and HIV itself (Altice et al., 2010). Recognition of HIV/AIDS and addiction as chronic, co-occurring illnesses necessitates a fundamental re-design of healthcare delivery for these conditions (Colvin, 2011, McLellan et al., 2000, Scandlyn, 2000, Siegel and Lekas, 2002). To address this complex challenge, models of integrated healthcare have been proposed and developed (Basu et al., 2006, Sylla et al., 2007) and are advocated by the World Health Organization despite a lack of empiric evidence (Kerr et al., 2004, World Health Organization, 2008). Lack of service integration results in insufficient coordination and cross-training, problematic pharmacokinetic interaction management and logistical hurdles that undermine holistic healthcare provision (Altice et al., 2010, Wolfe et al., 2010). Integration, ranging from simple service co-location to unified cross-disciplinary case-management, seeks to alleviate many of these barriers, and in the process, increase medication adherence and viral suppression that ultimately decreases HIV transmission and viral resistance (Altice et al., 2010, Sylla et al., 2007). The extent to which integrated healthcare improves health outcomes, however, has not been examined in middle-income countries that struggle to optimize limited healthcare resources, despite increased OST availability (Lekhan et al., 2010, Rechel et al., 2012, Wolfe et al., 2010).

Research in high-income countries supports healthcare integration for PWID (Turner et al., 2005), including those with HIV. Similar to the U.S. and former Soviet Union (FSU) countries, drug treatment in Ukraine is limited and where available, often separate from general healthcare settings, resulting in siloed care for PWID. As a result, fewer than 5% of Ukrainian HIV-infected PWID receive ART (Wolfe et al., 2010). New integrated/co-located (ICL) clinics for HIV-infected PWID were first introduced in 2008, providing ART, OST, case management and primary care, including screening and treatment for tuberculosis (TB), in a single location (Curtis, 2010). Their impact on health-related outcomes, however, has not yet been assessed. The availability of integrated healthcare delivery and OST in Ukraine make this setting unique for examining the extent to which integrated healthcare could abrogate the burgeoning region-wide HIV epidemic.