Shifting from an inpatient to outpatient centered model through transforming the TB financing in ex-Soviet countries.

INTRODUCTION: In former Soviet Union countries, tuberculosis (TB) financing largely relies on a hospital-centered model. The World Health Organization favors transformation to ambulatory treatment since it is cheaper and patient-centered. We explored policy and decision maker's perspectives on: a) enabling factors for transformation in Armenia and b) challenges and ways forward in doing so in Ukraine and Tajikistan. METHODOLOGY: Qualitative study of key informants from government, donors and the national TB program. RESULTS: 52 informants with a mean service record of 20 years were involved. Key enablers in Armenia included collaborative partnership and political will, carefully selecting an adapted financing scheme that avoided financial penalization of hospitals and health workers, and use of operational research. The operational challenges in Ukraine and Tajikistan hovered around the lack of technical capacity and guidance on "how to implement" alternative financing. Shortcomings in strategic planning, uncertainty/fear that existing hospital funding would be cut and reluctance to change were highlighted. Suggested ways forwards to change the current paradigm included country-level technical assistance, capacity building, regional exchanges and operational research. CONCLUSIONS: the perspectives of "those who decide" on transforming TB financing have been highlighted. Taking these perspectives on-board is vital for achieving the end-TB goals.

A country-wide evaluation of infection control for tuberculosis in health-care facilities in Armenia.

INTRODUCTION: Infection control at health facilities is an important part of TB control programmes. To assess the implementation of tuberculosis infection control (TB IC) measures and barriers hindering their implementation in TB health care facilities (HCFs) in Armenia; to report the feasibility of using the WHO recommended checklist. METHODOLOGY: A cross-sectional survey using WHO TB-IC checklist and direct observations was conducted between January and May 2018. RESULTS: The survey included all 62 TB institutions in Armenia. TB HCFs in Armenia had implemented some recommended TB IC measures: offering IC training to staff (48%), shortening time to diagnosing TB to less than one day (29%) and ensuring good ventilation (60%). N95 respirators were available in all HCFs. However, barriers that hindered implementation of TB IC measures were: lack of training, a different incentive model for primary care doctors versus TB doctors and lack of space and poor conditions of the building. CONCLUSION: The use of the standardized WHO checklist in this first evaluation of TB IC measures in Armenia was found to be useful and feasible in identifying areas of weak IC implementation and barriers to achieving good infection control. Other TB programs may benefit from the use of this model of assessment, based on the WHO checklist.

Linking intravenous drug users to treatment through non-governmental organizations in Ukraine: how well is it working?

INTRODUCTION: Alliance for Public Health, the International Charitable Foundation, coordinates HIV prevention in Non-Governmental Organizations (NGO) working with people who inject drugs (PWID) in Ukraine. We aimed to describe the performance of the differential model of linking PWID to HIV care and treatment (Community Initiated Treatment Intervention - CITI). METHODOLOGY: A retrospective cohort study using routine program data was conducted among 8,927 PWID who were tested positive for the first time during January 2016 - June 2017. Study outcomes were enrollment into CITI and initiating antiretroviral treatment (ART). Factors associated with outcomes were estimated by logistic regressions with random effects. RESULTS: Among the study participants, 54% enrolled into CITI and 23% initiated ART. CITI enrolment was associated with being married (adjusted odds ratio (AOR) = 1.17; 95%: 1.02-1.34); less than weekly compared to daily (AOR = 1.31; 95%: 1.13-1.52); less than 5 years of drug use compared to > 14 years (AOR = 1.73; 95%: 1.40-2.13), and having no criminal records (AOR = 1.30; 95%: 1.12-1.50). Factors of non-ART initiation were male gender (AOR = 1.33; 95%: 1.16-1.53); being single (AOR = 1.48; 95%: 1.21-1.82); drug use duration > 14 years compared to < 5 years (AOR = 1.38; 95%: 1.03-1.85), unemployment (AOR = 1.45; 95%: 1.15-1.83) and history of incarceration (AOR = 1.21; 95%: 1.003-1.45). CONCLUSION: Mobilizing the NGO community and PWID to engage in outreach HIV testing activity and harm reduction for key populations has succeeded in opening the gateway to prevention, care and ART for thousands of PWID in Ukraine.

Anxiety, depression, and quality of life among HIV positive injection drug users in Ukraine, 2017.

INTRODUCTION: People who inject drugs (PWID) are one of the key populations most vulnerable to HIV infection, with 28 times higher prevalence compared to the rest of the population. PWID are known to have many physical, psychological and lifestyle challenges that can influence access to care. Depression is common among PWID living with HIV. It has major effect on health-related quality of life (HRQoL) and is influencing adherence to antiretroviral therapy. This study was conducted to explore how anxiety and depression affect HRQoL among HIV-positive PWID in Ukraine. It will provide knowledge for the further policy development. METHODOLOGY: A descriptive cross-sectional study using data from interviewer- administrated questionnaires was performed. The questionnaire was based on the Hospital Anxiety and Depression Scale. The questionnaire on HRQoL was based on the SF-36. RESULTS: Among the 90 HIV positive PWID 74% (67) and 61% (55) had anxiety and depression scores higher than 7 respectively, indicating that most patients had mental health problems. Average scores for general health (40), role limitations due to physical (44) and emotional health (34), vitality (41) and mental health (45) had mean scores less than 50 along with total physical (43) and mental health scores (35). Having an HIV positive partner or partner with unknown HIV status increases anxiety in HIV positive PWID. CONCLUSION: There are increased depressive and anxiety symptoms and poorer QoL among HIV-positive PWID in Ukraine. Strategies focusing on psychosocial support addressing QoL as part of HIV care could improve health outcomes for these comorbid and debilitating conditions.

Engaging people who inject drugs and their peers in HIV testing and harm reduction in Ukraine: do they make a difference?

INTRODUCTION: People Who Inject Drugs (PWID) should be offered HIV-testing and harm reduction services. We assessed the effectiveness of including PWID and their peers in HIV-testing by comparing for a period before (2013-2014) and after their introduction (2015-2017), the a) numbers HIV tested b) number enrolled in harm reduction and c) frequency of HIV-testing. METHODOLOGY: An analysis of programme data involved PWID aged ≥ 14 years (1st January 2013-31st December 2017) in Ukraine. Between 2013-2014, HIV-testing (VCT) was done by trained health workers. From 2015, this was Directly Assisted HIV Self-testing (DAST) done by social workers and peers. Optimized HIV case finding (OCF) was introduced (in 2016) as an overlapping strategy with DAST. RESULTS: A total of 844,837 HIV tests were done with 23,427 (2.8%) HIV-positive results. With VCT, there were 164,417 HIV tests compared to 639,685 after engagement of PWID and their peers (>3-fold increase). The highest HIV positive yield (20%) was when OCF was included. With increasing HIV-testing caseload, a progressive decrease in enrollment in harm reduction was seen (85% in 2014 to 47% in 2017, X2 for trend P < 0.001). OCF resulted in enrollment into harm reduction of 2722 HIV-positives, which was 35% higher than through DAST alone (7,5%). HIV re-testing almost doubled with DAST. CONCLUSION: Active engagement of PWID and their peers in HIV-testing increased uptake of HIV-testing. Including OCF has a synergistic effect in HIV-positive yield. Strategies are urgently needed to ensure that individuals who are HIV tested are enrolled in harm reduction.