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Background: A substantial number of older adults succumb soon after HIV diagnosis despite ART. We explored the causes, risk factors and circumstances before death among older adults acquring HIV., Methods: We recruited individuals newly diagnosed at our centre from 2016-2020 and analysed data of those who died. Patients were stratified to older (≥50 years) or younger (<50 years) based on their age at diagnosis and attributes were compared. The Cox proportional multivariable model was used to identify factors associated with all-cause mortality., Results: Among 75 deaths reported, the majority of deaths were AIDS-related and late presentation was common in both age groups. The majority of deaths occurred in the first 12 months after care presentation and over two-thirds in both groups disengaged from care prior to death. Older age remained an independent factor associated with death after adjusting for confounders including opportunistic infections, late presentation to care, ART initiation and chronic comorbidities at presentation., Conclusion: Most causes of death in our setting were AIDS-related and associated with late care presentation both in young and older individuals, although older age at diagnosis remained an independent risk factor. Our findings highlight the urgent need to encourage prompt ART initiation following diagnosis, especially in older adults., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: HIV incidence and mortality are increasing in Ukraine despite their reductions globally, in part due to suboptimal antiretroviral therapy (ART) coverage in key populations of people with HIV (PWH) where the epidemic is concentrated. As physicians are gatekeepers to ART prescription, stigma and discrimination barriers are understudied as a key to meeting HIV treatment targets in key populations., Methods: A national sample (N = 204) of ART-prescribing physicians in Ukraine were surveyed between August and November 2019. Participants underwent a series of randomized, hypothetical HIV clinical scenarios and decided whether to initiate or defer (or withhold) ART. Scenarios varied based on 5 distinct CD4 counts (CD4: 17, 176, 305, 470, or 520 cells/mL) and 10 different PWH key populations. Z scores and McNemar's test for paired samples were used to assess differences between key populations and CD4 count. Feeling thermometers were used to assess stigma-related measures toward key populations among physicians., Results: Physicians were highly experienced (mean = 19 years) HIV treaters, female (80.4%), and trained in infectious diseases (76.5%). Patients who drink alcohol (range: 21.6%-23.5%) or use (PWUD range: 16.7%-20.1%) or inject (PWID range: 15.5%-20.1%) drugs were most likely to have ART deferred, even at AIDS-defining CD4 counts. PWID maintained on methadone, however, were significantly (p<0.001) less likely to have ART deferred compared with those who were not (range: 7.8%-12.7%) on methadone. Men who have sex with men (range: 5.4%-10.8%), transgender women (range: 4.9%-11.3%), sex workers (range: 3.9%-10.3%),and having an HIV-uninfected sex partner (range: 3.9%-9.3%) had the lowest likelihood of ART deferral. Increasing levels of stigma (i.e., feeling thermometers) towards a key population was correlated with ART deferral (i.e., discrimination)., Conclusions: Despite international and Ukrainian guidelines recommending ART prescription for all PWH, irrespective of risk or CD4 count, ART deferral by experienced HIV experts remains high in certain key populations, especially in PWH and substance use disorders. Strategies that initiate ART immediately after diagnosis (i.e., rapid start antiretroviral therapy), independent of risk group, should be prioritized to truly mitigate the current epidemic., Competing Interests: Research reported in this publication were supported by the following grants: Fund for Lesbian and Gay Studies (FLAGS) award (Ottesen) and National Institute of Health (Award numbers: R01 DA043125, R01 DA029910, R01 DA033679, and U01 DA045384) (Altice). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors have no conflicts of interest to declare that are relevant to the content of this article., (Copyright: © 2024 Ottesen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The overlapping COVID-19 crisis and the war starting in 2022 threaten front-line healthcare workers' mental health, well-being and job retention in Ukraine. This paper provides a synopsis of a panel discussion held by the Global Mental Health Humanitarian Coalition in May 2022 and expert consultations with clinicians between December 2022 and February 2023 on these challenges. The crises created new problems and exacerbated many pre-existing difficulties. We found that healthcare workers had needed to mobilise previously untapped strengths, including portable emergency medical documents and bespoke local psychosocial support services, amid the costs and pressures of ongoing healthcare reforms., Competing Interests: None., (© The Author(s) 2024.)

Background: In resource-limited settings, HIV-related services are often targeted to younger key populations, although increasing reports have found that adults ≥50 years now account for among the highest increase in new HIV diagnosis. We assessed the proportion of new HIV infections among older adults (≥50 years) and compared their sociodemographics, risk behaviors, and HIV-related outcomes to newly diagnosed younger adults (<50 years)., Methods: This retrospective analysis included all new HIV diagnosis from 2016 to 2019 at the University of Malaya Medical Centre, Malaysia. Trends of HIV diagnosis was assessed using join point regression analysis, and characteristics between the older and younger adults were compared using χ 2 test or Mann-Whitney U test. Kaplan-Meier analysis and log-rank test were used to compare the survival probability in both age groups., Results: From a total of 594 new HIV diagnosis between 2016 and 2019, 11.5% (N = 68) were among older adults with an annual percent increase of 5.50%. Older adults were more likely ethnic Indians ( P < 0.001), acquired HIV through heterosexual contact ( P = 0.001), had late presentation to care ( P = 0.003), and multimorbidity ( P < 0.001). Immunological responses after 12 months on antiretroviral therapy were comparable in both the groups. Older adults had a higher probability of death compared with younger adults (adjusted hazard ratio 1.81, 95% confidence interval: 1.02 to 3.23, P = 0.043) after adjusting for sex, mode of HIV transmission, late presentation to care, antiretroviral therapy initiation, and multimorbidity., Conclusion: Older adults diagnosed with HIV were associated with late care presentation and increased mortality. There is an urgent need to enhance uptake of HIV testing and linkage to care among older individuals in our setting., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The war in Ukraine has posed significant challenges to the healthcare system. This paper draws upon expert consultations, held between December 2022 and February 2023, focused on HIV/AIDS, addiction, and mental health service delivery during the first year of this war, and following the Global Mental Health Humanitarian Coalition panel discussion in May 2022. Objectives: This commentary presents the experiences of frontline healthcare workers in Ukraine, challenges, and local adaptations to meet the increased mental health needs of healthcare providers. We aimed to document the adaptations made in the addiction healthcare system and to acknowledge the changes in vulnerabilities and lessons learned. Results: Burnout among healthcare providers delivering addiction, HIV/AIDS and mental health services became more visible after the second half of 2022. Challenges included increased workload, contextual threats, lack of job relocation strategies, and money-follow-the-patient policies. Recommendations: The lessons from the first year of war in Ukraine hold significant generalizability to other contexts. These include enabling bottom-up approaches to tailoring services and allowing healthcare providers to respond to the dynamics of war in an effective and active manner. Other recommendations include departmental-specific resources and strategies, particularly as vulnerable groups and challenges are unstable in humanitarian contexts. Conclusions: Globally and in Ukraine, healthcare workers need more than applause. Along with monetary incentives, other strategies to prevent burnout, ensure sustainable capacity building, job relocation opportunities, and bespoke adaptations are imperative to protect healthcare providers' wellbeing and overall public health.

Background: People with HIV in the United States are aging, with risk for negative health outcomes from social isolation. PositiveLinks is a mobile health (mHealth) intervention that includes an anonymous Community Message Board (CMB) for peer-to-peer conversations. We investigated differences in CMB usage and social support between younger (<50 years) and older (≥50) members., Methods: We assessed the relationship between age groups and app use using chi-square tests. CMB posts were analyzed qualitatively to categorize forms of social support. To have a visual understanding of this relationship, we created a network diagram to display interactions among PL members., Results: Among 87 participants, 31 (42.5%) were in the older age group. Older members launched the app more often at 6 months (445.5 vs. 240.5 mean launches per participant, p  ≤ 0.001) and 12 months (712.3 vs. 292.6 launches, p  ≤ 0.001) compared with younger members. Older members also demonstrated more CMB posts at 6 months (47.4 vs. 7.6 mean posts per participant, p  = 0.02) and 12 months (77.5 vs. 10.6 posts, p  = 0.04). Of 1861 CMB posts, 7% sought support and 72% provided support. In addition, the network visualization showed that four participants, who were in the older age group, had more post generation than others and most of their posts provided support., Conclusions: Older PL members demonstrated significantly more app use than younger members, including CMB posts for social support. This durable app engagement indicates that mHealth can enable social connection among people living with chronic disease across the lifespan., Competing Interests: R.D. provides consulting services to WHT, Inc., an mHealth company. None of the other authors have any financial or nonfinancial interests to disclose., (© Tabor E. Flickinger et al., 2022; Published by Mary Ann Liebert, Inc.)

Ukraine imposed a COVID-19 lockdown in March 2020. From April to June 2020, we surveyed 123 older people with HIV (OPWH) by phone to assess their mental health, engagement in HIV and other healthcare, and substance use using standardised scales. Variables of key interest were symptoms of depression and symptoms of anxiety. Univariate and multivariable Firth logistic regression models were built to assess factors associated with: (1) symptoms of depression, and (2) symptoms of anxiety. Findings indicated high suicidal ideation (10.6%); 45.5% met the screening criteria for moderate to severe depression; and 35.0% met the criteria for generalised anxiety disorder (GAD). Independent correlates of having moderate to severe depression included being female (AOR: 2.83, 95%CI = 1.19-7.05), having concerns about potential barriers to HIV treatment (AOR: 8.90, 95%CI = 1.31-104.94), and active drug use (AOR: 34.53, 95%CI = 3.02-4885.85). Being female (AOR: 5.30, 95%CI = 2.16-14.30) and having concerns about potential barriers to HIV treatment (AOR: 5.33, 95%CI = 1.22-28.45) were independently correlated with GAD, and over half (58.5%) were willing to provide peer support to other OPWH. These results highlight the impact of the COVID-19 restrictions in Ukraine on mental health for OPWH and support the need to screen for psychiatric and substance use disorders, potentially using telehealth strategies.

Background: Efficient and linguistically appropriate instruments are needed to assess response to addiction treatment, including severity of addiction/mental health status. This is critical for Russian-speaking persons in Eastern Europe and Central Asia (EECA) where Medications for Opioid Use Disorder (MOUD) remain underscaled to address expanding and intertwined opioid, HIV, HCV and tuberculosis epidemics. We developed and conducted a pilot validation of a Russian version of the 24-item Behavior and Symptom Identification Scale (BASIS-24), an addiction/mental health severity instrument with six subscales, previously validated in English., Methods: Using the Mapi approach, we reviewed, translated, and back-translated the content to Russian, pilot-tested the Russian-version (BASIS-24-R) among new MOUD patients in Ukraine (N = 283). For a subset of patients (n = 44), test-rest was performed 48 h after admission to reassess reliability of BASIS-24-R. Exploratory principal component analysis (PCA) assessed underlying structure of BASIS-24-R., Results: Cronbach alpha coefficients for overall BASIS-24-R and 5 subscales exceeded 0.65; coefficient for Relationship subscale was 0.42. The Pearson correlation coefficients for overall score and all subscales on the BASIS-24-R exceeded 0.8. Each item loaded onto factors that corresponded with English BASIS-24 subscales ≥ 0.4 in PCA., Conclusion: Initial version of BASIS-24-R appears statistically valid in Russian. Use of the BASIS-24-R has potential to guide MOUD treatment delivery in the EECA region and help to align addiction treatment with HIV prevention goals in a region where HIV is concentrated in people who inject opioids and where healthcare professionals have not traditionally perceived MOUD as effective treatment, particularly for those with mental health co-morbidities., (© 2022. The Author(s).)

HIV incidence continues to increase in Eastern Europe and Central Asia (EECA), in large part due to non-sterile injection drug use, especially within prisons. Therefore, medication-assisted therapy with opioid agonists is an evidence-based HIV-prevention strategy. The Kyrgyz Republic offers methadone within its prison system, but uptake remains low. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a framework for identifying people who would potentially benefit from methadone, intervening to identify OUD as a problem and methadone as a potential solution, and providing referral to methadone treatment. Using an SBIRT framework, we screened for OUD in Kyrgyz prisons among people who were within six months of returning to the community (n = 1118). We enrolled 125 people with OUD in this study, 102 of whom were not already engaged in methadone treatment. We conducted a pre-release survey followed by a brief intervention (BI) to address barriers to methadone engagement. Follow-up surveys immediately after the intervention and at 1 month, 3 months, and 6 months after prison release assessed methadone attitudes and uptake. In-depth qualitative interviews with 12 participants explored factors influencing methadone utilization during and after incarceration. Nearly all participants indicated favorable attitudes toward methadone both before and after intervention in surveys; however, interest in initiating methadone treatment remained very low both before and after the BI. Qualitative findings identified five factors that negatively influence methadone uptake, despite expressed positive attitudes toward methadone: (1) interpersonal relationships, (2) interactions with the criminal justice system, (3) logistical concerns, (4) criminal subculture, and (5) health-related concerns., Competing Interests: The authors have declared that no competing interests exist.

In this study, using the "click-chemistry" azide-alkyne cycloaddition reaction, two new types of polymers, namely, water-soluble amine-functional and water-insoluble pyridine-functional hyperbranched 1,2,3-triazoleorganoethoxysiloxane polymers, capable of stabilizing ultra-small silver nanoparticles and efficient for chemical surface modification were synthesized and characterized by 1 H-NMR, 13 C-NMR, 29 Si-NMR and FT-IR spectroscopy, MALDI and GPC. Coordinatively active hetero-organic polymers with a flexible branched polyethoxysiloxane backbone bearing chelating 1,2,3-triazolyl-dimethylamine and -pyridine conjugated functional groups were exploited towards coordination with Ag+ metal ions, and formation and stabilization of narrowly dispersed silver nanoparticles (Ag-NPs) obtained in the process of radiation induced metal ion reduction. The influence of the chemically assisted radiation process on the Ag-NP size and size distribution was investigated. Hyperbranched polyorganoethoxysiloxanes loaded with Ag-NPs were covalently cross-linked on a Stöber silica surface, demonstrating the efficiency of the developed hetero-organic functional polymers in the preparation of functional nanocomposite coatings for various applications (heterogeneous catalytic systems, antibacterial materials, nanoparticle-based optical sensing devices, etc. ). The nanocomposites were investigated and characterized by TEM-EDS, DLS, UV-Vis spectroscopy and 29 Si MAS NMR spectroscopy.

Background: HIV incidence in Eastern Europe and Central Asia (EECA) continues to increase, primarily among people who inject drugs (PWID) and people in prisons. In Kyrgyzstan, an estimated 35% of people in prison are PWID, and 10% have been diagnosed with HIV. In 2008, Kyrgyzstan became the first country in EECA to provide free and voluntary methadone in prisons. We examine the impact of this national program on methadone within prison as well as linkage to and retention in treatment upon release to the community., Methods: Administrative data from a national methadone registry with de-identified information were assessed retrospectively. We examined the delivery of methadone services, including the duration of treatment both within prison and after release, for all prisoners who were prescribed methadone in Kyrgyz prisons from 2008 to 2018. Reasons for discontinuing methadone, HIV status and methadone dose are also analyzed., Results: Between 2008 and 2018, nine of Kyrgyzstan's 16 prisons offered methadone, and 982 incarcerated people initiated methadone within prison. Prisoners prescribed methadone were mostly male (96.2%), in their mid-30s (mean=34.9 years), and had been incarcerated for a relatively long time (mean = 44.1 months); their mean treatment duration in prison was 12.5 months, and 31.6% had HIV. A subsample (N = 645; 65.7%) of these were released to the community. Of these 645 people, 356 (55.2%) were not taking methadone at the time of release, 128 (19.8%) were on methadone and continued it after release, and the remainder (N=161, 25.0%) were on methadone at the time of release, but subsequently discontinued it, most within the first 7 days after release. Among those continuing methadone, 14.8% (N=19) remained on treatment ≥ 12 months. Independent correlates of linkage to methadone after release included positive HIV status (adjusted hazard ratio (aHR)=1.55; p = 0.033), receipt of methadone before their incarceration (aHR=2.01; p = 0.039), and receipt of methadone at the time of release (aHR = 20.81; p<0.001)., Conclusion: This is the first evaluation of within-prison methadone treatment in EECA. Uptake of methadone within prison and retention in treatment after release were both low. Continuous maintenance of treatment throughout incarceration is an opportunity to optimize HIV prevention and link patients to methadone post-release., Competing Interests: Declarations of Interest The authors of this study have no conflicts of interest to declare., (Copyright © 2021. Published by Elsevier B.V.)

Tajikistani migrants who work in Russia and acquire HIV seldom receive HIV treatment while in Russia. Barriers to engagement in the HIV care cascade were identified from in-depth, semi-structured interviews with purposefully sampled Tajikistani migrants (n = 34) with HIV who had returned from Russia. Data were analyzed using thematic analysis, drawing from Putnam's theory of social capital, showing how bridging and bonding social capital relate to poor engagement in HIV care. We identified three barriers to Tajikistani migrants' movement through the HIV care cascade: (1) Russia's migration ban on people with HIV interrupts social capital accumulation and prevents access to HIV treatment within Russia; (2) mistrust of authority figures, including healthcare providers, leads to avoiding treatment and harm-reduction services upon their return to Tajikistan; and (3) because of pervasive discrimination, Tajikistani migrants form weak social ties while in Russia, which exacerbates risk, including with Russian citizens, and deters engagement with HIV care. Deploying a treatment as prevention strategy and abolishing Russia's ban on people with HIV would improve both individual and public health., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Low- and middle-income countries are home to 80% of older people with HIV (OPWH). Ukrainian OPWH experience higher mortality and decreased antiretroviral therapy (ART) initiation than younger patients, but there is little data examining OPWH's perspectives around new diagnosis and impact on care. In this study, we examined accounts of 30 newly diagnosed OPWH in Ukraine, exploring challenges faced in the peri-diagnosis period. Themes emerged representing the longitudinal coping process: OPWH (1) viewed themselves as low risk before diagnosis; (2) experienced HIV diagnosis as a traumatic event challenging their self-image; (3) used disclosure to seek support among a small circle of family, friends, or health care providers; (4) avoided disclosure to outsiders including primary care providers for fears of stigma and breaches in confidentiality; (5) viewed age as an asset; and (6) used HIV diagnosis as starting point for growth. These findings highlight the need for age-specific programming to increase HIV knowledge and coping, increase screening, and improve long-term planning.

Introduction: The Eastern Europe and Central Asian (EECA) region has the highest increase in HIV incidence and mortality globally, with suboptimal HIV treatment and prevention. All EECA countries (except Russia) are low and middle-income (LMIC). While LMIC are home to 80% of all older people living with HIV (OPWH), defined as ≥50 years, extant literature observed that newly diagnosed OPWH represent the lowest proportion in EECA relative to all other global regions. We examined HIV diagnoses in OPWH in Ukraine, a country emblematic of the EECA region., Methods: We analysed incident HIV diagnoses from 2015-2018 and mortality trends from 2016-2018 for three age groups: 1) 15-24 years; 2) 25-49 years; and 3) ≥50 years. AIDS was defined as CD4<200cells/mL. Mortality was defined as deaths per 1000 patients newly diagnosed with HIV within the same calendar year. Mortality rates were calculated for 2016, 2017, and 2018, compared to age-matched general population rates, and all-cause standardized mortality ratios (SMRs) were calculated., Results: From 2015-2018, the proportion of OPWH annually diagnosed with HIV increased from 11.2% to 14.9% (p<0.01). At the time of diagnosis, OPWH were also significantly (p<0.01) more likely to have AIDS (43.8%) than those aged 25-49 years (29.5%) and 15-24 years (13.3%). Newly diagnosed OPWH had the same-year mortality ranging from 3 to 8 times higher than age-matched groups in the Ukrainian general population., Conclusions: These findings suggest a reassessment of HIV testing, prevention and treatment strategies in Ukraine is needed to bring OPWH into focus. OPWH are more likely to present with late-stage HIV and have higher mortality rates. Re-designing testing practices is especially crucial since OPWH are absent from targeted testing programs and are increasingly diagnosed as they present with AIDS-defining symptoms. New strategies for linkage and treatment programs should reflect the distinct needs of this target population., Competing Interests: The authors have declared that no competing interests exist. SS’s spouse worked for Merck pharmaceuticals 1997-2007 and retains company stock in his retirement account. There is no conflict of interest, but it is included in the interest of full disclosure.

Background: The Kyrgyz Republic (Kyrgyzstan) is one of few countries in Eastern Europe and Central Asia to provide methadone within its prisons, but uptake of this program has been suboptimal, in part because methadone uptake may have personal or social risks and consequences. Decision aids are evidence-based strategies that are designed to inform the patient's choice by objectively providing information that incorporates patient preferences., Methods: We conducted qualitative interviews in Kyrgyz and Russian with currently and formerly incarcerated people (n = 36) in Kyrgyzstan from October 2016 to September 2018. Interviews explored factors influencing methadone utilization in prisons. Transcripts were coded by five researchers using content analysis. A secondary thematic analysis was conducted to determine factors specific to initiation or continuation of methadone treatment in prisons., Results: We identified six interrelated themes affecting an individual's decision to initiate or continue methadone treatment: 1) informal prison governance (incarcerated people governing themselves); 2) informal prison economy; 3) perceived and objective benefits of methadone treatment; 4) perceived and objective side effects of methadone treatment; 5) distrust of formal prison administration (medical and correctional staff); and 6) desire for a "cure" from addiction., Conclusion: Respondents' perceptions about benefits, side effects, and addiction as a curable disease are not consistent with the available evidence. An evidence-based, informed decision-making aid would need to address the six themes identified here, of which several are specific to the Kyrgyz prison context. Unlike decision aids elsewhere, the unique aspects of incarceration itself alongside the informal governance system strongly present within Kyrgyz prisons will need to be incorporated into decisional processes to promote HIV prevention and treatment in a region with high rates of HIV transmission and mortality., Competing Interests: Declarations of Interest The authors declare that they have no competing interests. They do not have any direct or indirect connections with the alcohol, gambling, tobacco, or pharmaceutical industries., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background and Aims: Ukraine's HIV epidemic remains concentrated among opioid-dependent people who inject drugs (PWID) where opioid agonist therapies (OAT) like methadone (MMT) and buprenorphine (BMT) maintenance treatments are the most cost-effective HIV prevention strategies, but remain under-scaled. This study aimed to measure the association between dose and type of OAT prescribed and treatment retention., Design: Observational longitudinal cohort study., Participants and Setting: Patients (n = 15 290) prescribed OAT throughout Ukraine from 2004 through 2016., Measurements: Data were analyzed using time-event strategies to estimate cumulative treatment retention, defined as time to OAT discontinuation. Cumulative retention proportions at 1, 12 and 36 months were assessed for outcomes. Cox regression with log-rank likelihood assessed independent predictors of treatment discontinuation., Findings: The proportion prescribed high (MMT: > 85 mg; BMT: ≥ 16 mg), medium (MMT: > 40-85 mg; BMT: > 6-15 mg) and low (MMT: ≤ 40 mg; BMT: ≤ 6 mg) dosages was 25, 43 and 32%, respectively. Retention was significantly higher for BMT than MMT both at 12 (89 versus 75%) and 36 months (80 versus 56%). Although dosing levels for BMT did not influence retention, increasing dosages for MMT were significantly associated with higher retention rates at 1 (90, 96, 99%), 12 (59, 78, 91%) and 36 (34, 59, 79%) months, respectively. Independent predictors associated with 12-month OAT discontinuation were medium [adjusted hazard ratio (aHR) = 2.23; 95% confidence limit (CL) = 1.95-2.54] and low (aHR = 4.96; 95% CL = 4.37-5.63) OAT dosage relative to high dosage, male sex (aHR = 1.27; 95% CL = 1.14-1.41), MMT relative to BMT prescription (aHR = 1.57; 95% CL = 1.32-1.87) and receiving OAT in general (aHR = 1.22; 95% CL = 1.02-1.46) or tuberculosis (aHR = 1.43; 95% CL = 1.10-1.85) hospitals, relative to specialty addiction treatment and AIDS center settings. Lower dosages contributed more to dropout especially at 1 month (aHR 3.12; 95% CL = 2.21-4.41 and aHR 7.71; 95% CL = 5.51-10.79 for medium and low dosages, respectively). Younger age was significantly associated with OAT discontinuation only at 36 months (aHR = 1.08; 95% CI = 1.02-1.15)., Conclusions: Higher dosages of opioid agonist therapies, especially for methadone maintenance treatment patients, appear to be associated with higher levels of treatment retention in Ukraine., (© 2020 Society for the Study of Addiction.)

Background: Older people with human immunodeficiency virus - HIV (OPWH) defined as ≥50 years old account for a growing proportion of newly diagnosed infections in Ukraine (16% in 2018), but the prevalence of substance use disorder among OPWH in Ukraine remains unknown. Ukraine responded to the Covid-19 pandemic with a comprehensive lockdown in late March 2020. Objectives: We conducted a phone survey among 123 OPWH with substance use disorders (SUD) in Kyiv in May 2020 to learn if these older adults may continue HIV and SUD therapy while coping with the Covid-19 pandemic. Results: Data from the survey demonstrated that while OPWH with SUD maintained HIV and SUD therapy throughout Covid-19 lockdown, social support is critical to avoiding treatment interruption for OPWH with SUD. Conclusions/Importance: During reopening, reduction of support may lead to OPWH feeling even more isolated. Post-Covid-19 pharmacological approaches to SUD treatment without social support are like vehicles without gas. The research agenda for OPWH patients with SUD going forward must include determining the type of telehealth support that will be optimally effective to retain OPWH including people who inject drugs (PWID), provision of support by lay health workers, and cost-effectiveness of such interventions. The lessons learned may be relevant to other countries as well.

Background: Opioid agonist therapies (OAT) in Ukraine were first introduced in 2004 not as addiction treatment, but for HIV prevention. Numerous obstacles have thwarted OAT scale-up, including individual constraints and structural barriers., Methods: A cross-sectional survey of 1613 opioid dependent people who inject drugs (PWID) were recruited in 2014-2015 using stratified sampling in Kyiv, Odesa, Mykolayiv, Dnipro and Lviv. Analysis was restricted to a subset of 811 PWID who never received OAT. Barriers to OAT were assessed based on reasons why study participants were reluctant to enroll into OAT. A Rasch model from the Item Response Theory was applied to 24 potential barriers, used to score their severity and estimate a latent composite measure for each person's willingness and ability to participate in OAT., Results: The Rasch model confirmed the cumulative nature of barriers with concerns over treatment efficacy, safety and tolerability being more prevalent than barriers related to logistical constraints, opportunity costs and social stigma. If barriers related to treatment perception and logistics were eliminated, the average barrier number would decrease from 10 to 2.2. Participants were more likely to have a higher resistance to OAT entry if they experienced fewer overdoses, did not attain higher education, were not previously incarcerated and if their peers did not have a higher level of resistance to OAT., Conclusions: Understanding the interdependence of various barriers and attitudes toward OAT can improve the rate of OAT expansion and ameliorate entry into substance abuse treatment programs in Ukraine., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Facing competing demands with limited resources following release from prison, people who inject drugs (PWID) may neglect health needs, with grave implications including relapse, overdose, and non-continuous care. We examined the relative importance of health-related tasks after release compared to tasks of everyday life among a total sample of 577 drug users incarcerated in Ukraine, Azerbaijan, and Kyrgyzstan. A proxy measure of whether participants identified a task as applicable (easy or hard) versus not applicable was used to determine the importance of each task. Correlates of the importance of health-related reentry tasks were analyzed using logistic regression, with a parsimonious model being derived using Bayesian lasso method. Despite all participants having substance use disorders and high prevalence of comorbidities, participants in all three countries prioritized finding a source of income, reconnecting with family, and staying out of prison over receiving treatment for substance use disorders, general health conditions, and initiating methadone treatment. Participants with poorer general health were more likely to prioritize treatment for substance use disorders. While prior drug injection and opioid agonist treatment (OAT) correlated with any interest in methadone in all countries, only in Ukraine did a small number of participants prioritize getting methadone as the most important post-release task. While community-based OAT is available in all three countries and prison-based OAT only in Kyrgyzstan, Kyrgyz prisoners were less likely to choose help staying off drugs and getting methadone. Overall, prisoners consider methadone treatment inapplicable to their pre-release planning. Future studies that involve patient decision-making and scale-up of OAT within prison settings are needed to better improve individual and public health.

Objective: To provide a follow up of a 1976 study of the impact of captivity on U.S. Air Force (USAF) POWs and USAF Controls matched for time in Southeast Asia, military rank and aircraft crew position., Method: Qualitative study of replies to open ended questions of positive and negative changes due to their captivity/combat experiences made by participants (POWs and Controls) who replied in both 1976 and in 2003., Results: Both groups acknowledged positive and negative effects of the experiences in 1976. In 1976 and 2003 the POWs mainly reported negative effects on career and family domains but positive effects of individual development and growth. Controls reported mild negative effects on family in 1976, and benefits to their careers and sense of self in both 1976 and 2003., Conclusion: Captivity during the Vietnam War for USAF included two types of extreme duress which were the incarceration itself; and the repatriation experience which entailed re-assimilation despite loss of occupation and disrupted families. Despite these obstacles, POWs exhibited substantial resilience in achieving self-growth and how they regarded themselves psychologically in comparison to their matched control fellow aviators who while also suffering a lesser separation from family, tended to prosper in their careers and were proud of their accomplishments. Long term separation from work, family and friends and the inability to return to their families and careers with the effectiveness demanded by their ambition were a more devastating ongoing consequence of their captivity than the immediate suffering of their imprisonment.

Methadone maintenance therapy (MMT) treats opioid use disorder among people who inject drugs (PWID). To understand why PWID may voluntarily discontinue MMT, we analyzed data from 25 focus groups conducted in five Ukrainian cities from February to April 2013 with 199 participants who were currently, previously, or never on MMT. Using constant comparison method, we uncovered three themes explaining why PWID transition off MMT: (a) purposeful resistance to rigid social control associated with how MMT is delivered and to power asymmetries in provider-patient relationships, (b) self-management of a PWID's "wounded identity" that is common in socially stigmatized and physically sick persons-MMT serves as a reminder of their illness, and (c) the quest for a "normal life" uninterrupted by daily MMT site visits, harassment, and time inefficiencies, resources, and social capital. Focusing on holistic principles of recovery would improve addiction treatment and HIV prevention in Ukraine and globally.

Background: Kyrgyzstan, where HIV is concentrated in prisons and driven by injection drug use, provides a prison-based methadone maintenance therapy program as well as abstinence-oriented therapeutic community based on the 12-step model called the "Clean Zone." We aimed to qualitatively assess how prisoners navigate between these treatment options to understand the persistence of the Clean Zone despite a lack of evidence to support its effectiveness in treating opioid use disorders., Methods: We conducted an analysis of policy documents and over 60 h of participant observation in February 2016, which included focus groups with a convenience sample of 20 therapeutic community staff members, 110 prisoners across three male and one female prisons, and qualitative interviews with two former Clean Zone participants. Field notes containing verbatim quotes from participants were analyzed through iterative reading and discussion to understand how participants generally perceive the program, barriers to entry and retention, and implications for future treatment within prisons., Results: Our analyses discerned three themes: pride in the mission of the Clean Zone, idealism regarding addiction treatment outcomes against all odds, and the demonization of methadone., Conclusion: Despite low enrollment and lack of an evidence base, the therapeutic community is buttressed by the strong support of the prison administration and its clients as an "ordered" alternative to what is seen as chaotic life outside of the Clean Zone. The lack of services for Clean Zone patients after release likely contributes to high rates of relapse to drug use. The Clean Zone would benefit from integration of stabilized methadone patients combined with a post-release program.

In this study, we use data from a survey conducted in Ukraine among 196 HIV-infected people who inject drugs, to explore attitudes toward drug addiction and methadone maintenance therapy (MMT), and intentions to change drug use during incarceration and after release from prison. Two groups were recruited: Group 1 (n = 99) was currently incarcerated and Group 2 (n = 97) had been recently released from prison. This paper's key finding is that MMT treatment and addiction recovery were predominantly viewed as mutually exclusive processes. Group comparisons showed that participants in Group 1 (pre-release) exhibited higher optimism about changing their drug use, were less likely to endorse methadone, and reported higher intention to recover from their addiction. Group 2 participants (post-release), however, reported higher rates of HIV stigma. Structural equation modeling revealed that in both groups, optimism about recovery and awareness of addiction mediated the effect of drug addiction severity on intentions to recover from their addiction.

This study explored the journey of American armed forces personnel from their decision to join the service, through their service in an active military conflict and how these factors may be associated with potential resistance for mental healthcare. The data came from qualitative interviews with 46 OIF/OEF/OND active-duty military, reservists, and discharged veterans of the average age of 25 years, who presented for a new episode of mental health treatment to a large Veterans Affairs Hospital (VAH) in Northeastern United States in 2011-2012. Qualitative analysis of veterans' perceptions revealed several major themes describing how a mental health diagnosis would negatively impact both their sense of identity and pragmatic career-building goals: enlisting as a career-building avenue, 'noble superhero' identity, escaping from hardship, and mental illness as a career-killer. Findings suggest that factors making young veterans resist mental healthcare may be reduced by partnering VAH psychiatrists with career counselors, and by enhancing military leadership's awareness and understanding about how to support soldiers with emotional and mental health needs, with a goal to eliminating stigma.

The media shape both what people consider significant and how people think about key issues. This paper explored the cultural beliefs and stereotypes that underlie media portrayals of nursing homes. The analysis of texts of 157 articles about nursing homes published from 1999 to 2008 on the front pages of four major-market American newspapers ( The New York Times, Chicago Tribune, Los Angeles Times and The Washington Post ) was conducted using a qualitative approach inspired by comparative narrative and critical discourse analysis. Results suggest two major themes, each with several narrative components: (a) managing disposable lives (bodies outliving bank accounts; making frailty affordable; and the economics of triage); and (b) retaining purchasing power as successful ageing (consumption as a sign of market participation, spending money as an indicator of autonomy; and financial planning as preparation for future decline). Thus, the results indicate that nursing home residency in-and-of-itself is not a marker of unsuccessful ageing. This, instead, depends, in part, on the extent of choice available as a result of the level of financial solvency. This study shines light on the betwixt and between zone that distinguishes the Third and Fourth Ages; that is, independence versus dependence in old age. If individuals in a nursing home retain control over the management of their lives through the maintenance of financial independence, even if physically frail, association of nursing home residence with the Fourth Age may be ameliorated., Competing Interests: None of the authors has any conflict of interest pertaining to this paper, the study it describes, or any information, person or organisations it refers to.

Background: This paper examines how family and social relations facilitate and inhibit adherence to antiretroviraltherapy (ART) for people living with HIV (PLH) who have underlying substance use disorders and are transitioningto the community post-incarceration., Methods: Combining the methods of inductive close reading and constantcomparison, we analyzed the data from 30 semi-structured interviews of PLH who had recently transitioned to thecommunity within the previous 90 days., Results: Three central themes were anticipated as important socialrelationships post-release: self-reported family, friends and clinicians. Among these, four sub-themes (social isolation, 'double jeopardy', search for belonging, and trust and respect) emerged, highlighting how they impacted ART adherence. Post-release, participants returned to resource-poor communities where they experienced socialisolation. ART adherence was enabled by having a purpose in life, which correlated with having robust family support structures. Many former prisoners felt that a chasm between them and their families existed, both because of HIV stigma and their addiction problems. In this context, relationships with untrustworthy friends from their druguse networks led to relapse of drug use and risky behaviors, jeopardizing participants' ART adherence and persistence. To avoid the double jeopardy, defined as seeking friends for support but who were also the ones who contributed to drug relapse, participants searched for new social anchors, which often included their healthcare providers who represented trusted and respected persons in their life., Conclusions: While some former prisonersperceived doctors as uncaring and their relationships asymmetrical, positive relationships with these providers,when respect and trust was mutual, reinforced the participants' sense of belonging to what they called 'the world that don't do drugs' and motivated them to adhere to ART.

Loneliness and depression are serious mental health concerns across the spectrum of residential care, from nursing homes to assisted and retirement living. Psychosocial care provided to residents to address these concerns is typically based on a long-standing tradition of 'light' social events, such as games, trips, and social gatherings, planned and implemented by staff. Although these activities provide enjoyment for some, loneliness and depression persist and the lack of resident input perpetuates the stereotype of residents as passive recipients of care. Residents continue to report lack of meaning in their lives, limited opportunities for contribution and frustration with paternalistic communication with staff. Those living with dementia face additional discrimination resulting in a range of unmet needs including lack of autonomy and belonging-both of which are linked with interpersonal violence. Research suggests, however, that programs fostering engagement and peer support provide opportunities for residents to be socially productive and to develop a valued social identity. The purpose of this paper is to offer a re-conceptualization of current practices. We argue that residents represent a largely untapped resource in our attempts to advance the quality of psychosocial care. We propose overturning practices that focus on entertainment and distraction by introducing a new approach that centers on resident contributions and peer support. We offer a model-Resident Engagement and Peer Support (REAP)-for designing interventions that advance residents' social identity, enhance reciprocal relationships and increase social productivity. This model has the potential to revolutionize current psychosocial practice by moving from resident care to resident engagement., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To conduct a qualitative study of older American veterans' subjective perceptions of factors that contribute to successful physical, emotional, and cognitive aging., Methods: A nationally representative sample of 2,025 veterans aged 60 or older (range: 60-96; 96.9% male, 39.4% combat veterans) participated in the National Health and Resilience in Veterans Study. Using qualitative analysis software, the authors coded responses to three open-ended questions, inductively developed categories, aggregated similar categories into factors, and grouped factors into broader themes., Results: A total of 53, 56, and 61 categories of responses was identified in response to questions about successful physical, cognitive, and emotional aging, respectively, with 10 aggregate factors linking these categories. The most prominent theme overall was "What you do," which received 2,295, 2,210, and 1,247 mentions for each of these domains of successful aging, with health behaviors the most common factor for both successful physical and cognitive aging and social engagement the most common for successful emotional aging. The theme "Who you are" was the second-most common factor (discerned from 376, 247, and 943 total mentions, respectively), with the factors that comprise this theme-personality and explanatory style, moral compass, and emotional dispositions-more commonly endorsed for successful emotional aging. External factors such as healthcare were least commonly endorsed across all domains., Conclusion: Older U.S. Veterans emphasize health behaviors, social engagement, and dispositional characteristics as key determinants of successful aging. Prevention and treatment initiatives that target these potentially modifiable factors may help promote successful aging in this growing segment of the population., (Copyright © 2015 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Advertisements as well as contemporary literature and films often depict older adults as sexually undesirable and unattractive, which reinforces the stereotype that they are nonsexual. However, the evolving discourses of successful aging emphasize that active engagement in life is a key element of healthy aging and as such, have been influencing the ways that older adults' sexuality is represented. This paper explores how popular newspapers and magazines in Canada construct and portray later life sexuality within the context of online dating. We retrieved 144 newspaper and magazine articles about later life online dating that were published between 2009 and 2011. Our thematic and discursive analyses of the articles generated six themes. Of 144 articles, 13% idealized sexuality (sexual attractiveness and optimal sexual engagement) for older adults. The articles portrayed sexual interests and functioning as declining in later life (19%) more often than sustaining (15%). Approximately 15% of the articles suggested that older adults should explore new techniques to boost sexual pleasure, thereby medicalizing and ameliorating sexual decline. In addition, the articles challenged the stereotype of older adults as non-sexual and claimed that sexual engagement in later life was valuable as it contributed to successful aging. We address the paradox in the articles' positive portrayals of older adults' sexuality and the tensions that arise between the two distinct ideals of sexuality that they advance., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Context: Although observers have long highlighted the relationship of public distrust, government regulation, and media depictions of nursing-home scandals, no study has systematically analyzed the way in which nursing homes have been portrayed in the national media. This study examines how nursing homes were depicted in four leading national newspapers-the New York Times, Washington Post, Chicago Tribune, and Los Angeles Times-from 1999 to 2008., Methods: We used keyword searches of the LexisNexis database to identify 1,704 articles pertaining to nursing homes. We then analyzed the content of each article and assessed its tone, themes, prominence, and central actor. We used basic frequencies and descriptive statistics to examine the articles' content, both cross-sectionally and over time., Findings: Approximately one-third of the articles were published in 1999/2000, and a comparatively high percentage (12.4%) appeared in 2005. Most were news stories (89.8%), and about one-quarter were on the front page of the newspaper or section. Most focused on government (42.3%) or industry (39.2%) interests, with very few on residents/family (13.3%) and community (5.3%) concerns. Most were negative (45.1%) or neutral (37.0%) in tone, and very few were positive (9.6%) or mixed (8.3%). Common themes were quality (57.0%), financing (33.4%), and negligence/fraud (28.1%). Both tone and themes varied across newspapers and years., Conclusions: Overall, our findings highlight the longitudinal variation in the four widely read newspapers' framing of nursing-home coverage, regarding not only tone but also shifts in media attention from one aspect of this complex policy area to another. The predominantly negative media reports contribute to the poor public opinion of nursing homes and, in turn, of the people who live and work in them. These reports also place nursing homes at a competitive disadvantage and may pose challenges to health delivery reform, including care integration across settings., (© 2012 Milbank Memorial Fund.)

Although some studies have confirmed positive associations between social engagement and well-being in later life, this study aimed to understand why some seniors cannot be engaged. The authors analyzed the lived experiences of 89 seniors in three rural communities in Canada, from semi-structured interviews and using the constant comparison method. Five factors make choices for social engagement in later life unequal among older adults who differ by gender, class, age, and health status. Profound engagement in care work, compulsory altruism, personal resources, objectively perceived and subjectively available engagement opportunities, and ageist barriers around paid work constrain choices for seniors who lack privilege in the context of a market economy, particularly for low-income older women. To avoid stigmatizing vulnerable older persons, societal barriers to meaningful activities must be addressed - for example, through provision of income security or by reversing inter- and intragenerational ageism in access to the labor market.

In this article, we examine how seniors are portrayed in the Globe and Mail. Thirty articles published in 2004 were selected and thematically analysed. Seniors were discussed in six different contexts, including family, work/retirement, community networks, scientific studies of population, social and health care policy, and social attitudes to aging. Issues pertaining to seniors were captured in three themes. The theme diversity of seniors made visible seniors of different genders, ages, health statuses, abilities, and needs. The successful aging theme provided positive examples of aging well but marginalized seniors who did not meet these expectations, thereby fostering intra-generational ageism. The apocalyptic demography / inter-generational conflict theme underscored the importance of society's support system for the elderly but raised the issue of inter-generational inequality, of presenting the elderly as a burden on younger persons in families and on society at large. Critical analyses suggested that both negative and positive newspaper portrayals of seniors might be ageist.