Next Steps for Ukraine – Abolition of HIV Registries, Implementation of Routine HIV Testing and Expansion of Services

Booth et al. should be congratulated on a rigorously conducted study with a challenging population. Their work demonstrated that compared to an indigenous leader outreach model, a less-expensive, briefer counseling intervention was equally effective at reducing sexual and injection risk-taking [1].

The data also confirm that learning one's own HIV+ status significantly reduces sexual HIV risk-taking, independently from each intervention. These data are consistent with findings elsewhere where an HIV+ diagnosis alone reduces sexual risk [2]. Knowing one's HIV+ status is essential for accessing life-saving antiretroviral treatment, itself an intervention associated with decreased HIV transmission [3]. On a population level, widespread treatment with antiretroviral medications is a powerful tool in controlling the HIV epidemic among all affected groups [4]. Why then has Ukraine not embarked upon incredibly cost-effective strategies [5] to increase HIV identification through deployment of routine testing?

Routine testing would be most effective if multiple barriers were removed, including name-based registration programs (e.g. HIV and drug dependence) and pre-test counseling. HIV registries and voluntary testing programs stigmatize patients and discourage testing of high-risk individuals, particularly when risk-behaviors are assessed. Moreover, HIV registries and pre-test counseling add significant costs that detract from treatment and prevention, especially in the current global economic climate. In particular, implementation of routine testing could effectively be conducted at existing settings, including where patients are treated for substance abuse, tuberculosis, inpatient services and in newly-created integrated care settings [6]. The criminal justice system would also greatly benefit from routine HIV testing [7] in ways that Booth et al elegantly demonstrated for community outreach and harm reduction programs. These latter sites may serve as sentinel sites for initiating care for HIV and opioid substitution therapy (OST) and greatly contribute to controlling the HIV epidemic.

Though stimulants exist in Ukraine, opioids remain the mainstay of drug dependence. Therefore, wider implementation of OST is urgently needed. While identifying HIV+ status reduces sexual risk-behaviors, OST dramatically reduces injection risk-behaviors [8]. Indeed, since Booth's study, both buprenorphine and methadone have been introduced, but not at a sufficient magnitude to curb the HIV epidemic [9]. Though progress has been made since 2005, considerable legal, political, economic and social barriers continue to impede HIV prevention and treatment efforts. Laws regulating the transportation, storage, and dispensing of opioid treatment therapies currently hamper widespread access. Hospitals rarely offer OST, forcing hospitalized IDUs into agonizing forced-abstinence. Regulations requiring observed, daily OST dosing create a disincentive for patients wanting to return to the workforce. Requirements that physicians dispense OST create unneeded expense and distract them from attending to more complex cases. Laws that ban driver's licenses for OST patients are similarly ill-advised, limiting uptake of OST and further endangering society by encouraging active drug users to remain out of treatment and to drive under the influence of illicit drugs.

In the political and economic arena, ideology and stigma regarding HIV prevention and treatment must be set aside to counter the explosive spread of HIV in Ukraine. Though seemingly daunting, effective HIV containment strategies now exist that will facilitate better health for all Ukrainians. The time to implement them is now.