Modeling the impact and cost-effectiveness of opioid agonist treatments to reduce the negative consequences of incarceration on HIV and TB transmission in Eastern Europe and Central Asia

全球艾滋病毒发病率和死亡率有所下降，但东欧和中亚有所上升 （EECA），其中艾滋病毒流行病主要由注射毒品（IDU）推动，主要是阿片类药物。 此外，结核病越来越多地与艾滋病毒感染和注射吸毒有关，结核病发病率不断上升， EECA艾滋病毒感染者（PWH）的死亡原因。在EECA中，对吸毒的严厉定罪导致 注射毒品者（PWID）的监禁率非常高，他们的艾滋病毒和结核病被放大， 艾滋病的高危行为和过度拥挤的结核病。我们来自全球荟萃分析的新数据显示， 在PWID中，监禁增加了81%的艾滋病毒感染风险，我们在乌克兰的研究结果表明， 在PWID中，55%的新艾滋病毒感染可归因于发生在以下人群中的高危行为： 最近或曾经被监禁过。此外，我们最近的统计分析表明， 在乌克兰，与多年监禁密切相关，特别是在感染艾滋病毒的PWID中。 2004年在残疾妇女中解决监禁、艾滋病毒和结核病传播的有效战略 EECA应包括使用美沙酮或丁丙诺啡的阿片类激动剂治疗（OAT）。这些有效 治疗减少了注射频率和感染艾滋病毒的风险。OAT还可以改善艾滋病毒和结核病 治疗结果，减少犯罪活动，因此也可以减少艾滋病毒和结核病的传播， 减少监禁的有害影响，提高OAT本身的预防效益。扩大 社区和监狱中的OAT如果与扩大艾滋病毒和结核病治疗相联系，将特别有效。 该项目的目的是开发和测试新的建模策略，以评估影响和成本- 在乌克兰和吉尔吉斯斯坦的刑事司法环境中扩大OAT的有效性， 相当可观的数据。为全面评估审裁处在监狱所带来的效益，我们亦会估计 在这两个国家，监禁与艾滋病毒和结核病在PWID和普通人群中的传播有关。我们将 基于我们现有的实施科学研究（R 01 DA 029910，MATLINK战略）的数据， 我们已经向患有OUD的囚犯提供（乌克兰）或扩大（吉尔吉斯斯坦）OAT，包括 在发布后与OAT联系，以捕捉这一特定的高风险时期。我们将使用数据的结果， MATLINK和相关研究，并收集成本数据，以预测扩大规模的影响和成本效益 以监狱为基础的审裁处（使用MATLINK），与释放后的社区审裁处挂钩， 预防艾滋病毒在艾滋病感染者和一般人群中传播的好处，以及通过以下途径获得的次级好处： 改善艾滋病毒和结核病治疗结果，减少监禁。调查结果可用于指导政策 在整个EECA和其他艾滋病毒集中在PWID的环境中。

HIV incidence and mortality has decreased globally, but has increased in Eastern Europe and Central Asia (EECA), where the HIV epidemics are fueled primarily by injecting drug use (IDU), mostly of opioids. Furthermore, TB is increasingly linked to HIV infection and IDU, with TB rates increasing and being the main cause of death among people with HIV (PWH) in EECA. Harsh criminalization of drug use in EECA results in extraordinarily high incarceration rates of people who inject drugs (PWID), whose HIV and TB are amplified by high risk behaviors for HIV and overcrowding for TB. Our new data from a global meta-analysis shows that incarceration increases HIV acquisition risk 81% in PWID, and our findings from Ukraine suggest that 28%– 55% of new HIV infections among PWID are attributable to the heightened risk behavior that occurs among PWID recently or ever incarcerated. Furthermore, our recent statistical analyses suggest that the burden of TB in Ukraine is strongly associated with years of incarceration, particularly among PWID with HIV. An effective strategy for tackling the syndemics of incarceration, HIV and TB transmission among PWID in EECA should include opioid agonist treatments (OAT) with methadone or buprenorphine. These effective treatments reduce the frequency of injecting and the risk of HIV acquisition. OAT also improves HIV and TB treatment outcomes and reduces criminal activity, and so could also reduce HIV and TB transmission through reducing the detrimental effect of incarceration and improving the preventative benefits of OAT itself. Scaled up OAT in the community and prison would be especially effective if linked with HIV and TB treatment scale-up. The aim of this project is to develop and testing new modeling strategies to evaluate the impact and cost- effectiveness of scaling-up OAT in criminal justice settings in Ukraine and Kyrgyzstan where we have collected considerable data. To capture the full benefits of OAT in prison, we will also estimate the contribution of incarceration to HIV and TB transmission among PWID and the general population in both countries. We will build on data from our existing implementation science research (R01 DA029910, the MATLINK strategy), in which we have introduced (Ukraine) or expanded (Kyrgyzstan) OAT provision to prisoners with OUD, including linkage to OAT following release to capture this particular high-risk period. We will use data on outcomes from MATLINK and related studies and collected cost data to project the impact and cost-effectiveness of scaling-up prison-based OAT (using MATLINK) with linkage to community OAT after release, incorporating the direct prevention benefits on HIV transmission in PWID and general population and secondary benefits through improving HIV and TB treatment outcomes and reducing incarceration. Findings can be used to guide policies throughout EECA and other settings where HIV is concentrated in PWID.