BACKGROUND: Russia's full-scale war in Ukraine since 24-Feb-2022 has greatly disrupted OAT services for PWIDs, especially in high HIV burden southeastern regions, leading to internal displacement. Our study seeks to assess how the war and internal relocation affect OAT retention, critical for HIV prevention among PWIDs.
METHODS: We conducted a two-year comparative cohort survival analysis using Ukraine's national OAT registry from 252 clinics across 25 regions. The study compared local OAT patients in conflict-remote regions with conflict-affected regions and internally displaced patients. Regions were clustered into frontline, target, and remote based on conflict-related metrics: numbers of air raids, explosions, artillery attacks, and percentages of internally displaced population. The primary outcome, treatment retention, was assessed considering time-dependent displacement status, medication type (methadone vs. buprenorphine), OAT dose (optimal (methadone: =90mg; buprenorphine: =16mg) vs. suboptimal), dispensation strategy (daily vs. THD: take-home dosing), age, sex, inject drug duration, HIV-status.
RESULTS: The nationwide sample of PWID receiving OAT as of 23-Feb-2022 comprised 17,265 individuals, with 4,953 (28.7%) in frontline, 8,786 ( 50.9%) in target, and 3,526 (20.4%) in remote regions. Most were male (84.6%), averaging 38.9±7.5 years old. From 24-Feb-2022 through 01-Jan-2024, 519 (0.03%) individuals underwent internal relocation, and 5,040 (29.2%) experienced treatment dropout. Compared to the local patient cohort in remote regions, patients local to target and frontline regions had elevated risk of treatment discontinuation (adjusted hazard ratios (aHR):1.31, 95%CI:1.27-1.35; aHR:6.92, 95%CI:6.87-6.97, respectively). Internally displaced patients in target, frontline, and remote regions faced significantly greater dropout risk than local patients in conflict-distant regions (aHR:5.95, 95%CI:5.80-6.03; aHR:6.80, 95%CI:6.73-6.87; aHR:16.79, 95%CI:16.61-16.95, respectively). The dropout risk for internally displaced patients in remote areas mirrored that of patients in frontline regions. Predictors of higher treatment retention included optimal dosing (aHR:0.79, 95%CI:0.76-0.82), THD (aHR:0.72, 95%CI:0.68-0.76), and receiving methadone (aHR:0.88, 95%CI:0.84-0.92). Females and people with HIV had a heightened risk of treatment discontinuation (aHR:1.17, 95%CI:1.13-1.21; aHR:1.07, 95%CI:1.04-1.11).
CONCLUSIONS: Russia’s full-scale war in Ukraine increased the risk of OAT discontinuation for patients in conflict-affected regions and all internally displaced patients, undermining HIV prevention efforts among PWIDs. Further research on national OAT service preparedness for disasters is crucial for uninterrupted care for key populations.