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IntroductionDaily oral HIV pre‐exposure prophylaxis (PrEP) with tenofovir/emtricitabine (TDF/FTC) is recommended for people who inject drugs (PWID) but coverage is low. The real‐life effectiveness of PrEP among PWID is unknown as previous studies were conducted in controlled settings and mainly relied on self‐report. Analysis of PrEP metabolites—tenofovir diphosphate (TFVdp) and emtricitabine triphosphate (FTCtp)—offers an objective measure of adherence.MethodsTo analyse longitudinal patterns of PrEP adherence among PWID in Ukraine, we used data from a community‐based implementation trial conducted in Kyiv between July 2020 and March 2021 to test the efficacy of SMS reminders to improve adherence. Among 199 enrolled participants, 156 (78.4%) were retained through 6 months. Based on TFVdp/FTCtp levels assessed at 3 and 6 months, we identified groups with various adherence patterns (adherent at ≥2 doses/week, improved, worsened, non‐adherent). Correlates of adherence were analysed using multinomial logistic regression.ResultsMost participants (53.8%, n = 84/156) had no detectable metabolites at both assessments; 7.1% (n = 11/156) were consistently taking ≥2 doses/week; 1.3% (n = 2/156) were consistently taking ≥4 doses/week; 13.5% (n = 21/156) exhibited improved and 21.8% (n = 34/156) had worsened adherence at 6 compared to 3 months. “White coat compliance” (increased dosing prior to assessment) was common. Consistent adherence was associated with SMS reminders, younger age, employment, lower income, longer injection drug use duration, recent high‐risk injecting (receptive syringe sharing, using pre‐filled syringe, back‐ or front‐loading, container sharing), absence of overdose in the past 6 months, perceived HIV risk through sexual intercourse and higher PrEP self‐efficacy. Alcohol consumption was associated with inconsistent PrEP use. Groups with improved and worsened adherence did not differ.ConclusionsDaily oral PrEP may not achieve the desired effectiveness among PWID as a standalone intervention, calling for testing of alternative PrEP formulations and innovative integrated risk reduction strategies, especially in the context of HIV epidemics associated with injection drug use in eastern Europe and central Asia and the public health crisis in Ukraine caused by the war with Russia. SMS reminders may be effective among PWID who prioritize PrEP. Our findings offer practical guidance in identifying PWID who are likely to benefit from PrEP and those who need additional support.
IntroductionDaily oral HIV pre‐exposure prophylaxis (PrEP) with tenofovir/emtricitabine (TDF/FTC) is recommended for people who inject drugs (PWID) but coverage is low. The real‐life effectiveness of PrEP among PWID is unknown as previous studies were conducted in controlled settings and mainly relied on self‐report. Analysis of PrEP metabolites—tenofovir diphosphate (TFVdp) and emtricitabine triphosphate (FTCtp)—offers an objective measure of adherence.MethodsTo analyse longitudinal patterns of PrEP adherence among PWID in Ukraine, we used data from a community‐based implementation trial conducted in Kyiv between July 2020 and March 2021 to test the efficacy of SMS reminders to improve adherence. Among 199 enrolled participants, 156 (78.4%) were retained through 6 months. Based on TFVdp/FTCtp levels assessed at 3 and 6 months, we identified groups with various adherence patterns (adherent at ≥2 doses/week, improved, worsened, non‐adherent). Correlates of adherence were analysed using multinomial logistic regression.ResultsMost participants (53.8%, n = 84/156) had no detectable metabolites at both assessments; 7.1% (n = 11/156) were consistently taking ≥2 doses/week; 1.3% (n = 2/156) were consistently taking ≥4 doses/week; 13.5% (n = 21/156) exhibited improved and 21.8% (n = 34/156) had worsened adherence at 6 compared to 3 months. “White coat compliance” (increased dosing prior to assessment) was common. Consistent adherence was associated with SMS reminders, younger age, employment, lower income, longer injection drug use duration, recent high‐risk injecting (receptive syringe sharing, using pre‐filled syringe, back‐ or front‐loading, container sharing), absence of overdose in the past 6 months, perceived HIV risk through sexual intercourse and higher PrEP self‐efficacy. Alcohol consumption was associated with inconsistent PrEP use. Groups with improved and worsened adherence did not differ.ConclusionsDaily oral PrEP may not achieve the desired effectiveness among PWID as a standalone intervention, calling for testing of alternative PrEP formulations and innovative integrated risk reduction strategies, especially in the context of HIV epidemics associated with injection drug use in eastern Europe and central Asia and the public health crisis in Ukraine caused by the war with Russia. SMS reminders may be effective among PWID who prioritize PrEP. Our findings offer practical guidance in identifying PWID who are likely to benefit from PrEP and those who need additional support.
IntroductionGlobally, stark inequities exist in access to HIV treatment and prevention. The eastern European and central Asian region is experiencing the sharpest rise in new HIV acquisition and deaths in the world, with low rates of treatment and prevention services, especially for key and vulnerable populations who face a range of human rights‐related barriers to HIV prevention and treatment.MethodsAn implementation learning evaluation approach was used to examine the implementation of the Breaking Down Barriers initiative targeting key and vulnerable populations in Ukraine. Between September 2022 and April 2023, researchers conducted 23 key informant interviews with individuals from the Ukrainian government, implementing organizations and human rights experts. Using a concurrent triangulation design, researchers and key informants, in a process of co‐creation, sought to describe programme accomplishments, challenges and innovations in implementation, between 2021 and 2023, including periods before and after Russia's February 2022 full‐scale invasion.ResultsEight rights‐based interventions related to HIV were identified in Global Fund programme documents and key informant interviews as making up the core of the Breaking Down Barriers initiative in Ukraine. These included programmes seeking to: eliminate stigma and discrimination; ensure the non‐discriminatory provision of medical care; promote rights‐based law enforcement practices; expand legal literacy (“know your rights”); increase access to justice; improve laws, regulations and policies; reduce gender discrimination, harmful gender norms and violence against women and girls; and mobilize communities for advocacy. These programmes received US$5.9 million in funding. Key informants reported that significant progress had been made addressing human rights barriers and scaling up interventions, both before and after Russia's invasion. Programme implementors adopted innovative approaches, including using paralegals, hotlines and other community‐led interventions, to ensure that key and vulnerable populations, including displaced individuals, were able to access prevention and care.ConclusionsAn implementation learning evaluation approach examining programmes addressing human rights barriers to HIV services, designed as a process of co‐creation between researchers, programme implementors, government officials and human rights experts, can provide a robust assessment of programme outputs, outcomes and evidence of impact, despite a challenging operational environment.
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