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

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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.