Social support is key to retention in care during Covid-19 pandemic among older people with HIV and substance use disorders in Ukraine

Abstract

Older people with human immunodeficiency virus - HIV (OPWH) defined as ≥50 years old account for a growing proportion of newly diagnosed infections in Ukraine (16% in 2018), but prevalence of substance use disorder among OPWH in Ukraine remains unknown. Ukraine responded to the Covid-19 pandemic with a comprehensive lockdown in late March 2020. Data from a phone survey we conducted among OPWH with substance use disorders (SUD) in Kyiv in May 2020 demonstrated that while OPWH with SUD maintained HIV and SUD therapy throughout Covid-19 lockdown, social support is critical to avoiding treatment interruption for OPWH with SUD. During reopening, reduction of support may lead to OPWH feeling even more isolated. Post-Covid-19 pharmacological approaches to SUD treatment without social support are like vehicles without gas. The research agenda for OPWH patients with SUD going forward must include determining the type of telehealth support that will be optimally effective to retain OPWH including people who inject drugs (PWID), provision of support by lay health workers, and cost effectiveness of such interventions. The lessons learned may be relevant to other countries as well.

Introduction:

Of 4.2 million older people with human immunodeficiency virus – HIV (OPWH) worldwide, defined as ≥50 years old, 80% reside in low- and middle-income settings (Autenrieth et al., 2018) that experience unequal Covid-19 burdens on healthcare. Ukraine is a low-middle income country with increasing HIV incidence and mortality.(UNAIDS, 2016) The HIV epidemic in Ukraine has been primarily driven by injection drug use (IDU),(Booth et al., 2016; Dumchev, Dvoryak, Chernova, Morozova, & Altice, 2017) with transition to a generalized epidemic mainly through sexual contact.(Avert, 2018) In 2017 25% of all new HIV infections in Ukraine were associated with IDU,(UNAIDS, 2018b) with HIV prevalence among people who inject drugs (PWID) estimated at 22.6%.(UNAIDS, 2018a) OPWH account for a growing proportion of newly diagnosed infections in Ukraine (16% in 2018),(Y. Rozanova, O. Zeziulin, I. Zaviriukha, T. Sosidko, O. Gvozdetska, V. Kurpita, T. Kiriazova, K. Gulati, F.L. Altice, S.V. Shenoi 2018) but data on OPWH is sparse concerning comorbidities including substance use disorder (SUD). As OPWH get diagnosed with later stage HIV (52% with CD4<200 among older PWH vs. 35% among younger PWH, p<0.001) and multiple comorbidities, antiretroviral therapy (ART) adherence is essential for preserving long term positive outcomes.(Group et al., 2015; Lifson et al., 2017)

Previous research established the value of social support to improving HIV and addiction treatment adherence in persons with SUD including OPWH across a variety of international settings like the US,(Edelman, Tetrault, & Fiellin, 2014; Polcin & Korcha, 2017), Ukraine, Vietnam, and Indonesia.(Lancaster et al., 2019) However, a recent systematic review concluded that in combination with medication-assisted therapies the utility of social support (via psychosocial interventions) was not consistent.(Dugosh et al., 2016) Given the growing opioid problem in the United States (and elsewhere), expanding access to medication-assisted therapy (MAT) with methadone, buprenorphine, or naltrexone by removing programmatic, administrative, and stigma-related barriers has been a key healthcare goal,(Volkow, Frieden, Hyde, & Cha, 2014; Volkow & Wargo, 2018) social support fading from priority focus.

We have researched lived experiences of OPWH in Ukraine since 2018, exploring the growing cases of HIV infection among older adults,(J. Rozanova, O. Zeziulin, I. Zaviriukha, T. Kiriazova, A. Justice, F.L. Altice, S.V. Shenoi, 2019a) and examining the meaning and implications of receiving an HIV diagnosis in later life.(J. Rozanova, O. Zeziulin, I. Zaviriukha, T. Kiriazova, A. Justice, F.L. Altice, S.V. Shenoi, 2019b) Focus groups we conducted in Kyiv in October-December 2019 with OPWH with SUD, and their HIV and addiction treatment providers helped us appreciate the extent of OPWH’s vulnerability.(J. Rozanova, Zaviriukha, I., Zeziulin, O., Kiriazova, T., Allen, A,, Yariy, V., Mamedova, E., & Shenoi, S. , 2020) Older adults with HIV especially with a history of SUD live with multiple physical and mental comorbidities,(Edelman et al., 2014) and may frequently experience stigma of HIV, substance use, and social exclusion.(J. Rozanova, O. Zeziulin, I. Zaviriukha, T. Kiriazova, A. Justice, F.L. Altice, S.V. Shenoi, 2019b) By their late forties or early fifties, some PWID with HIV may die from these conditions, while others switch to alcohol as their drug of choice (legal and easier to obtain),(Shipunov, 2019) and a minority initiate MAT as respite from procuring street drugs (as patients in Ukraine may receive MAT for free, likewise to ART) or as a means of recovery.(J. Rozanova et al., 2017)

Materials and Methods:

Ukraine responded to the Covid-19 pandemic with a comprehensive lockdown in late March 2020. In May 2020 we surveyed by phone 120 OPWH receiving HIV care in Kyiv, including 50 (42%) patients diagnosed with SUD about how Covid-19 pandemic impacts older patients and their ability to continue HIV and/or addiction treatment. 47% of participants were women; participants’ age ranged from 55–81 years, 96% were prescribed ART, and 72% had comorbidities other than HIV and SUD. We also performed phone interviews with HIV and addiction treatment providers in Kyiv both at the frontlines and at senior executive levels.

How HIV and addiction treatment providers supported OPWH during lockdown:

Our data demonstrated that while OPWH with SUD maintained HIV and SUD therapy throughout the lockdown, there is great anxiety about the availability of treatment services. Providers reported concerns about stability of clinical services given decreased billable patient volume, particularly among social workers, whose salaries are based on a per-patient fee. Simultaneously the amount of non-billable tasks to keep patients in care, increased (e.g., mailing ART to OPWH unable to visit the clinic to obtain refills). Patient and provider responses pointed to the importance of social support that in recent years has become optional alongside pharmacological treatment to SUD. Yet, Covid-19 lockdown demonstrated how support by trusted clinicians providing HIV and addiction treatment services enabled OPWH with SUD to stay in care: they have developed a schedule of frequent informal phone conversations with their clinicians punctuated by infrequent visits to the clinics. However, when lockdown restrictions are lifted OPWH with SUD will need to visit clinics more frequently for check-ups and receiving methadone, but providers may not be able to maintain support at the same level as the early pandemic. But, this support is sorely needed. In our survey a quarter of OPWH with SUD reported having fewer than 2 people including healthcare providers who can support them (with 29% of OPWH never disclosed their HIV status to anybody other than treatment providers), and 61% of OPWH had no treatment supporter. Thus, after the lockdown, OPWH with SUD may feel more isolated and their risk of discontinuing addiction treatment or relapsing to substance use may not be sustained but increase.

Implications for HIV and SUD treatment in Ukraine post-Covid-19:

Examining experiences of OPWH with SUD and their HIV and addiction treatment providers during lockdown provided four insights. While specific to the Ukrainian context, they may have implications for addiction treatment providers and researchers of addictions in other countries, particularly in other low and middle income settings.

First, reviewing OPWH’s adherence to SUD treatment during lockdown may paint an overly optimistic picture, masking social costs of these results. Covid-19 lockdown may disrupt MAT and ART among OPWH with SUD not only while being in place, but also during reopening. After hefty doses of support by clinicians, reduction of support may lead to OPWH feeling even more isolated.

Second, definitions of billable (to the public insurance) services prior to Covid-19 provided to OPWH by clinicians have no provisions for intra- and extramural activities to retain patients in care during pandemics and quarantines. Thus, clinics and care providers risk being financially penalized for efforts to support high-burden OPWH with SUD. Current definitions create disincentives for HIV and addiction treatment providers to take up OPWH patients in comparison to younger groups – which is true for many countries outside of Ukraine, including the United States. The definitions of what constitutes a billable service need to be revised and extended considering the Covid-19 lockdown experience to ensure OPWH with SUD get the support they need.

Third, post-Covid-19 pharmacological approaches to SUD treatment without social support are like vehicles without gas. Availability of MAT post-Covid-19 may not be sufficient to yield good patient outcomes particularly after re-opening after Covid-19 when some of the patients who were temporarily allowed to get take-home MAT, may be required to return to sites more frequently or even daily. Relationships involving MAT providers, OPWH, and their social supports, can offer creative solutions.

Fourth, post-Covid-19 the social support needed by OPWH patients with SUD will exceed support available from their addiction and HIV providers. This is particularly salient given that in many countries including the US and the UK, many front-line clinicians like social workers had their hours significantly cut, or made redundant as routine patient care was suspended during lockdown. This deficit may be mitigated by utilizing lay health workers especially in low and middle income settings, through remote Peer-based interventions to support OPWH with SUD to continue HIV and addiction care. Given Covid-19’s toll on OPWH with SUD, 21% of whom reported having a suicidal ideation and 55% had substantial depressive symptoms, interventions must address mental health in this vulnerable population. OPWH can become an extended network helping one another leverage social and emotional costs of Covid-19 and fostering social belonging.

In sum, examination of Covid-19 lockdown experiences in Ukraine demonstrated that alongside biomedical therapy, social support is critical to avoiding treatment interruption for OPWH with SUD. The research agenda for these patients going forward must include (1) determining the type of telehealth support that will be effective to retain OPWH PWID, (2) provision of support by lay health workers, and (3) the cost effectiveness of such interventions.

Biographical notes on contributors:

Julia Rozanova, PhD, is an Associate Research Scientist at Yale AIDS Program. Sheela Shenoi, MD, is an Assistant Professor in the Yale School of Medicine. Irina Zaviryukha, MD is a Research Scientist at UIPHP. Oleksandr Zeziulin, MD, MPH is a Senior Research Scientist at UIPHP. Tetiana Kiriazova, PhD, MPH, is Executive Director of UIPHP. Elmira Mamedova, MD, is Deputy Medical Director of the Kyiv AIDS Center. Volodymyr Yariy, MD, is Medical Director of the Kyiv Addiction Treatment Clinic “Sociotherapy”.