title: Factors associated with physical and sexual violence by police among people who inject drugs in Ukraine: implications for retention on opioid agonist therapy.
abstract: Ukraine's volatile HIV epidemic, one of the largest in Eastern Europe and Central Asia, remains concentrated in people who inject drugs (PWID). HIV prevalence is high (21.3% to 41.8%) among the estimated 310,000 PWID. Opioid agonist therapy (OAT) is the most cost-effective HIV prevention strategy there, yet OAT services are hampered by negative attitudes and frequent harassment of OAT clients and site personnel by law enforcement. This paper examines the various types of police violence that Ukrainian PWID experience and factors associated with the different types of violence, as well as the possible implications of police harassment on OAT retention.
  
  
  
  In 2014 to 2015, we conducted a cross-sectional survey in five Ukrainian cities with 1613 PWID currently, previously and never on OAT, using a combination of respondent-driven sampling, as well as random sampling. We analysed correlates of police violence by multiple factors, including by gender, and their effects on duration of OAT retention. Self-reported physical and sexual violence by police were the two primary outcomes, while retention on OAT was used as a secondary outcome.
  
  
  
  Overall, 1033 (64.0%) PWID reported being physically assaulted by police, which was positively correlated with currently or previously being on OAT (69.1% vs. 60.2%; p<0.01). HIV prevalence rates were higher in those receiving OAT than those not on OAT (47.6% vs. 36.1%; p<0.01). Police violence experiences differed by sex, with men experiencing significantly more physical violence, while women experienced more sexual violence (65.9% vs. 42.6%; p<0.01). For PWID who had successfully accessed OAT, longer OAT retention was significantly correlated both with sexual assault by police and fewer non-fatal overdoses.
  
  
  
  Police violence is a frequent experience among PWID in Ukraine, particularly for those accessing OAT, an evidence-based primary and secondary HIV prevention strategy. Police violence experiences, however, were different for men and women, and interventions with police that address these sexual differences and focus on non-violent interactions with PWID to improve access and retention on OAT are crucial for improving HIV prevention and treatment goals for Ukraine.
authors.affiliation: AIDS Program, Section of Infectious Diseases, Yale University School of Medicine New Haven, CT, USA; okutsa@umich.eduruthanne.marcus@yale.edu.
authors.forename: Oksana
authors.initials: O
authors.lastname: Kutsa
authors.affiliation: AIDS Program, Section of Infectious Diseases, Yale University School of Medicine New Haven, CT, USA; okutsa@umich.eduruthanne.marcus@yale.edu.
authors.forename: Ruthanne
authors.initials: R
authors.lastname: Marcus
authors.affiliation: AIDS Program, Section of Infectious Diseases, Yale University School of Medicine New Haven, CT, USA.
authors.forename: Martha J
authors.initials: MJ
authors.lastname: Bojko
authors.affiliation: AIDS Program, Section of Infectious Diseases, Yale University School of Medicine New Haven, CT, USA.
authors.forename: Alexei
authors.initials: A
authors.lastname: Zelenev
authors.affiliation: ICF Alliance for Public Health, Kiev, Ukraine.
authors.forename: Alyona
authors.initials: A
authors.lastname: Mazhnaya
authors.affiliation: Ukrainian Institute on Public Health Policy, Kiev, Ukraine.
authors.forename: Sergii
authors.initials: S
authors.lastname: Dvoriak
authors.affiliation: ICF Alliance for Public Health, Kiev, Ukraine.
authors.forename: Sergii
authors.initials: S
authors.lastname: Filippovych
authors.affiliation: AIDS Program, Section of Infectious Diseases, Yale University School of Medicine New Haven, CT, USA.|Division of Epidemiology of Microbial Diseases, Yale University School of Public Health New Haven, CT, USA.
authors.forename: Frederick L
authors.initials: FL
authors.lastname: Altice
mesh_terms: D000328:Adult; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000523:psychology; D006801:Humans; D008297:Male; D016495:Police / Q000331:legislation & jurisprudence / Q000523:psychology; D015995:Prevalence; D012742:Sex Offenses / Q000331:legislation & jurisprudence; D015819:Substance Abuse, Intravenous / Q000453:epidemiology / Q000523:psychology*; D014455:Ukraine / Q000453:epidemiology; D000078329:Workforce
chemical_list: D000701:Analgesics, Opioid
keywords: HIV; Ukraine; buprenorphine; methadone; opioid agonist therapy; police violence; substance use disorders