Optimizing Medication-Assisted Therapy for Opioid Dependence in Ukraine: HIV Impact Modeling and Cost-Effectiveness Evaluation

项目摘要/摘要 乌克兰是东欧和世界上阿片类药物使用率最高的国家之一，造成 特别是涉及传染病的共同发生的流行病造成的大量发病率和死亡率 艾滋病毒，这主要是由注射吸毒引起的。目前对艾滋病毒和阿片类药物问题的反应 乌克兰的使用障碍是不够的。需要新的方法来弥补覆盖差距并优化 病人的结果。阿片类激动剂疗法(OAT)被证明是一种有效和成本效益高的治疗方法 减少与阿片类药物使用有关的危害的干预。自那以后，乌克兰实施了美沙酮疗法。 2008年；然而，在310,000名乌克兰残疾人中，只有2.7%的人领取了OAT，这一比例太低，无法减少 注射毒品介导的艾滋病毒传播。将OAT的可用性扩展到初级医疗保健(PHC)设置 可能会降低进入门槛并增加治疗计划中的保留率。燕麦片的替代品，一个 注射用阿片受体拮抗剂缓释纳曲酮(XR-NTX)是另一种证据 治疗阿片类药物依赖。通过减少对药物的渴求和非法药物的使用，XR-NTX降低了艾滋病毒风险 与安慰剂相比，它可以改善行为，提高生活质量。XR-NXT提供了一种前景看好的替代方案 可能针对不同药物亚群的阿片类药物使用障碍的药物治疗 使用者--特别是那些不能或不愿意接受以激动剂为基础的治疗的人。的主要优势 XR-NTX与口服纳曲酮相比，是每月注射一次，而不是服用 每天。这被证明改善了治疗依从性；然而，坚持治疗仍然是有问题的。 这项研究项目的假设是，新的干预措施：a)将OST的交付扩大到PHC 设施；以及b)与目前相比，乌克兰使用XR-NTX治疗阿片依赖具有成本效益 乌克兰的护理标准。这些干预措施的结果将在患者和人群中进行评估 级别。这项研究将采用数学建模方法：状态转移马尔可夫模型将是 开发用于评估患者水平的结果；以及动态的分区艾滋病毒传播模型将 在人口层面上估计干预措施的效益。这项分析将利用现有的 文献和我最近参与的两项研究：1)形成性研究：试行该条款 乌克兰初级保健机构向阿片类药物使用者提供综合护理的情况(研究期间：2014-2015年)； 2)在乌克兰扩大药物辅助治疗(R01 DA033679，研究周期：2012-2017)。这个 拟议的研究结果可能会导致#年阿片依赖治疗的政策变化。 东欧和中亚，告知未来比较有效性研究的优先事项，并激励 在阿片类药物使用和艾滋病毒负担较高的其他国家进行类似的政策研究。

PROJECT SUMMARY / ABSTRACT Ukraine has one of the highest opioid use prevalence levels in Eastern Europe and worldwide, causing substantial morbidity and mortality through co-occurring epidemics involving infectious diseases, in particular HIV, which is primarily driven by injecting drug use. The current response to the problem of HIV and opioid use disorders in Ukraine is insufficient. Novel approaches are needed to address coverage gaps and optimize patient outcomes. Opioid agonist therapy (OAT) was demonstrated to be an effective and cost-effective intervention in reducing harm associated with opioid use. Ukraine has implemented methadone therapy since 2008; however, only 2.7% of the 310,000 Ukrainian PWIDs are receiving OAT, which is far too low to reduce drug injection-mediated HIV transmission. Expanding OAT availability to primary healthcare (PHC) settings may reduce barriers to entry and increase retention in treatment programs. An alternative to OAT, an injectable opioid receptor antagonist, extended-release naltrexone (XR-NTX) is another evidence-based treatment for opioid dependence. By reducing drug craving and illicit drug use, XR-NTX reduces HIV risk behavior and improves quality of life compared to placebo. XR-NXT offers a promising alternative pharmacological treatment for opioid use disorders that would likely target a different sub-population of drug users – specifically those who cannot or is unwilling to receive agonist-based therapy. The main advantage of XR-NTX in comparison with oral naltrexone is that it is administered as a monthly injection rather than taken daily. This was shown to improve treatment compliance; however, adherence is still problematic. The hypothesis of this research project is that the novel interventions: a) expanding OST delivery to PHC facilities; and b) treating opioid dependence with XR-NTX in Ukraine are cost effective relative to the current standard of care in Ukraine. Outcomes of these interventions will be evaluated at both patient and population levels. The study will employ a mathematical modeling approach: a state transition Markov model will be developed to assess patient-level outcomes; and a dynamic compartmental HIV transmission model will estimate the benefits from the interventions at the population level. The analysis will capitalize on the available literature and two recent studies in which I have been involved: 1) Formative Research: Piloting the Provision of Integrated Care to Opioid Drug Users in Primary Healthcare Facilities in Ukraine (study period: 2014-2015); and 2) Expanding Medication-Assisted Therapies in Ukraine (R01 DA033679, study period: 2012-2017). The results of the proposed study can potentially lead to policy changes in treatment of opioid dependence in Eastern Europe and Central Asia, inform priorities for future comparative effectiveness research, and motivate similar policy research in other countries with high burden of opioid drug use and HIV.