title: Integration of health services improves multiple healthcare outcomes among HIV-infected people who inject drugs in Ukraine.
abstract: BACKGROUND
  People who inject drugs (PWID) experience poor outcomes and fuel HIV epidemics in middle-income countries in Eastern Europe and Central Asia. We assess integrated/co-located (ICL) healthcare for HIV-infected PWID, which despite international recommendations, is neither widely available nor empirically examined.
  
  
  METHODS
  A 2010 cross-sectional study randomly sampled 296 HIV-infected opioid-dependent PWID from two representative HIV-endemic regions in Ukraine where ICL, non-co-located (NCL) and harm reduction/outreach (HRO) settings are available. ICL settings provide onsite HIV, addiction, and tuberculosis services, NCLs only treat addiction, and HROs provide counseling, needles/syringes, and referrals, but no opioid substitution therapy (OST). The primary outcome was receipt of quality healthcare, measured using a quality healthcare indicator (QHI) composite score representing percentage of eight guidelines-based recommended indicators met for HIV, addiction and tuberculosis treatment. The secondary outcomes were individual QHIs and health-related quality-of-life (HRQoL).
  
  
  RESULTS
  On average, ICL-participants had significantly higher QHI composite scores compared to NCL- and HRO-participants (71.9% versus 54.8% versus 37.0%, p<0.001) even after controlling for potential confounders. Compared to NCL-participants, ICL-participants were significantly more likely to receive antiretroviral therapy (49.5% versus 19.2%, p<0.001), especially if CD4 ≤ 200 (93.8% versus 62.5% p<0.05); guideline-recommended OST dosage (57.3% versus 41.4%, p<0.05); and isoniazid preventive therapy (42.3% versus 11.2%, p<0.001). Subjects receiving OST had significantly higher HRQoL than those not receiving it (p<0.001); however, HRQoL did not differ significantly between ICL- and NCL-participants.
  
  
  CONCLUSIONS
  These findings suggest that OST alone improves quality-of-life, while receiving care in integrated settings collectively and individually improves healthcare quality indicators for PWID.
authors.affiliation: Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, USA.
authors.forename: Chethan
authors.initials: C
authors.lastname: Bachireddy
authors.affiliation: Massachussetts General Hospital, Department of Psychiatry, Boston, USA.
authors.forename: Michael C
authors.initials: MC
authors.lastname: Soule
authors.affiliation: Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, USA.
authors.forename: Jacob M
authors.initials: JM
authors.lastname: Izenberg
authors.affiliation: Ukrainian Institute on Public Health Policy, Kyiv, Ukraine.
authors.forename: Sergey
authors.initials: S
authors.lastname: Dvoryak
authors.affiliation: Centers for Disease Control and Prevention, Kyiv, Ukraine.
authors.forename: Konstantin
authors.initials: K
authors.lastname: Dumchev
authors.affiliation: Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, USA; Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, USA. Electronic address: frederick.altice@yale.edu.
authors.forename: Frederick L
authors.initials: FL
authors.lastname: Altice
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000379:methods; D019033:Delivery of Health Care, Integrated / Q000379:methods*; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy*; D006801:Humans; D008297:Male; D011788:Quality of Life; D015819:Substance Abuse, Intravenous / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy*; D016896:Treatment Outcome; D014455:Ukraine / Q000453:epidemiology
keywords: Buprenorphine; HIV/AIDS; Health services delivery; Integrated healthcare; International health; Methadone; Opioid substitution therapy; Quality healthcare indicators; Substance abuse