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Summary Background Opioid agonist treatment (OAT) reduces many of the harms associated with opioid dependence. We use mathematical modelling to comprehensively evaluate the overall health benefits of OAT in people who inject drugs in Perry County (KY, USA), Kyiv (Ukraine), and Tehran (Iran). Methods We developed a dynamic model of HIV and hepatitis C virus (HCV) transmission, incarceration, and mortality through overdose, injury, suicide, disease-related and other causes. The model was calibrated to site-specific data using Bayesian methods. We evaluated preventable drug-related deaths (deaths due to HIV, HCV, overdose, suicide, or injury) averted over 2020–40 for four scenarios, added incrementally, compared with a scenario without OAT: existing OAT coverage (setting-dependent; community 4–11%; prison 0–40%); scaling up community OAT to 40% coverage; increasing average OAT duration from 4–14 months to 2 years; and scaling up prison-based OAT. Outcomes Drug-related harms contributed differentially to mortality across settings: overdose contributed 27–47% (range of median projections) of preventable drug-related deaths over 2020–40, suicide 6–17%, injury 3–17%, HIV 0–59%, and HCV 2–18%. Existing OAT coverage in Tehran (31%) could have a substantial effect, averting 13% of preventable drug-related deaths, but will have negligible effect (averting Interpretation OAT can substantially reduce drug-related harms, particularly in settings with HIV epidemics in people who inject drugs. Maximising these effects requires research and investment into achieving higher coverage and provision and longer retention of OAT in prisons and the community. Funding UK National Institute for Health Research, US National Institute on Drug Abuse.

Ukraine is one of the countries in Europe most affected by HIV. The escalation of open war on the European continent has affected HIV care in Ukraine in an unprecedented way. Treating physicians in Europe have little experience on how to handle HIV-specific care under these circumstances. A framework is urgently needed that both defines and sets out strategies to handle the specific challenges for emergency support for people living with HIV, both those staying in Ukraine and those becoming displaced. The optimal allocation of the few available medical resources, primarily antiretroviral therapy, is necessary to best prevent individual morbidity and achieve population transmission control. Professional HIV networks play a central role to create, optimise, and execute support strategies. Through a rapid literature review we identified the key strategies needed to create a support framework, adapted to Ukraine's HIV epidemiology. We produce a unified support framework aiming to reduce the inevitable impact on Ukraine's HIV care cascade now, and when rebuilding it after the war.

BackgroundDue to practical challenges associated with genetic sequencing in low resource environments, the burden of hepatitis C virus (HCV) in forcibly displaced people is understudied. We examined the use of field-applicable HCV sequencing methods and phylogenetic analysis to determine HCV transmission dynamics in internally displaced people who inject drugs (IDPWID) due to war in eastern Ukraine.MethodsIn this cross-sectional study, we used modified respondent-driven sampling to recruit IDPWID who have settled in Odessa, Ukraine. We generated partial and near full length genome (NFLG) HCV sequences using Oxford Nanopore MinION in a simulated field environment. Maximum likelihood and Bayesian methods were used to establish phylodynamic relationships.FindingsBetween June and September 2020, we collected epidemiological data and whole blood samples from 164 IDPWID. Rapid testing identified an HIV, anti-HCV, and HIV/HCV co-infection prevalence of 39%, 67.7%, and 31.1%, respectively. We generated 57 partial or NFLG HCV sequences and identified eight transmission clusters, of which at least two originated within a year and a half post-migration. Unstable housing post-migration was associated with more reports of injection drug use in the past 30 days (p=0.048).InterpretationLocal generation of viral sequencing data and phylogenetic analysis in rapidly changing low-resource environments, such as those faced by forcibly displaced people, can inform timely adaptation of prevention and treatment.FundingOxford University John Fell Fund, ISS Wellcome Trust, Branco Weiss Fellowship.

Introduction: Alliance for Public Health, the International Charitable Foundation, coordinates HIV prevention in Non-Governmental Organizations (NGO) working with people who inject drugs (PWID) in Ukraine. We aimed to describe the performance of the differential model of linking PWID to HIV care and treatment (Community Initiated Treatment Intervention – CITI). Methodology: A retrospective cohort study using routine program data was conducted among 8,927 PWID who were tested positive for the first time during January 2016 – June 2017. Study outcomes were enrollment into CITI and initiating antiretroviral treatment (ART). Factors associated with outcomes were estimated by logistic regressions with random effects. Results: Among the study participants, 54% enrolled into CITI and 23% initiated ART. CITI enrolment was associated with being married (adjusted odds ratio (AOR) = 1.17; 95%: 1.02-1.34); less than weekly compared to daily (AOR = 1.31; 95%: 1.13-1.52); less than 5 years of drug use compared to > 14 years (AOR = 1.73; 95%: 1.40-2.13), and having no criminal records (AOR = 1.30; 95%: 1.12-1.50). Factors of non-ART initiation were male gender (AOR = 1.33; 95%: 1.16-1.53); being single (AOR = 1.48; 95%: 1.21-1.82); drug use duration > 14 years compared to < 5 years (AOR = 1.38; 95%: 1.03-1.85), unemployment (AOR = 1.45; 95%: 1.15-1.83) and history of incarceration (AOR = 1.21; 95%: 1.003-1.45). Conclusion: Mobilizing the NGO community and PWID to engage in outreach HIV testing activity and harm reduction for key populations has succeeded in opening the gateway to prevention, care and ART for thousands of PWID in Ukraine.

Introduction: People Who Inject Drugs (PWID) should be offered HIV-testing and harm reduction services. We assessed the effectiveness of including PWID and their peers in HIV-testing by comparing for a period before (2013-2014) and after their introduction (2015-2017), the a) numbers HIV tested b) number enrolled in harm reduction and c) frequency of HIV-testing. Methodology: An analysis of programme data involved PWID aged ≥ 14 years (1st January 2013-31st December 2017) in Ukraine. Between 2013-2014, HIV-testing (VCT) was done by trained health workers. From 2015, this was Directly Assisted HIV Self-testing (DAST) done by social workers and peers. Optimized HIV case finding (OCF) was introduced (in 2016) as an overlapping strategy with DAST. Results: A total of 844,837 HIV tests were done with 23,427 (2.8%) HIV-positive results. With VCT, there were 164,417 HIV tests compared to 639,685 after engagement of PWID and their peers (>3-fold increase). The highest HIV positive yield (20%) was when OCF was included. With increasing HIV-testing caseload, a progressive decrease in enrollment in harm reduction was seen (85% in 2014 to 47% in 2017, X2 for trend P < 0.001). OCF resulted in enrollment into harm reduction of 2722 HIV-positives, which was 35% higher than through DAST alone (7,5%). HIV re-testing almost doubled with DAST. Conclusion: Active engagement of PWID and their peers in HIV-testing increased uptake of HIV-testing. Including OCF has a synergistic effect in HIV-positive yield. Strategies are urgently needed to ensure that individuals who are HIV tested are enrolled in harm reduction.

A growing body of evidence suggests that network-based interventions to reduce HIV transmission and/or improve HIV-related health outcomes have an important place in public health efforts to move towards 90–90–90 goals. However, the social processes involved in network-based recruitment may pose a risk to participants of increasing HIV-related stigma if network recruitment causes HIV status to be assumed, inferred, or disclosed. On the other hand, the social processes involved in network-based recruitment to HIV testing may also encourage HIV-related social support. Yet despite the relevance of these processes to both network-based interventions and to other more common interventions (e.g., partner services), there is a dearth of literature that directly examines them among participants of such interventions. Furthermore, both HIV-related stigma and social support may influence participants’ willingness and ability to recruit their network members to the study. This paper examines (1) the extent to which stigma and support were experienced by participants in the Transmission Reduction Intervention Project (TRIP), a risk network-tracing intervention aimed at locating recently HIV-infected and/or undiagnosed HIV-infected people and linking them to care in Athens, Greece; Odessa, Ukraine; and Chicago, Illinois; and (2) whether stigma and support predicted participant engagement in the intervention. Overall, experiences of stigma were infrequent and experiences of support frequent, with significant variation between study sites. Experiences and perceptions of HIV-related stigma did not change significantly between baseline and six-month follow-up for the full TRIP sample, and significantly decreased during the course of the study at the Chicago site. Experiences of HIV-related support significantly increased among recently-HIV-infected participants at all sites, and among all participants at the Odessa site. Both stigma and support were found to predict participants’ recruitment of network members to the study at the Athens site, and to predict participants’ interviewer-rated enthusiasm for naming and recruiting their network members at both the Athens and Odessa sites. These findings suggest that network-based interventions like TRIP which aim to reduce HIV transmission likely do not increase stigma-related risks to participants, and may even encourage increased social support among network members. However, the present study is limited by its associational design and by some variation in implementation by study site. Future research should directly assess contextual differences to improve understanding of the implications of site-level variation in stigma and support for the implementation of network-based interventions, given the finding that these constructs predict participants’ recruitment of network members and engagement in the intervention, and thereby could limit network-based interventions’ abilities to reach those most in need of HIV testing and care.

Author(s): Vasylyeva, Tetyana I; Smyrnov, Pavlo; Strathdee, Steffanie; Friedman, Samuel R | Abstract: IntroductionIn light of the COVID-19 pandemic, considerable effort is going into identifying and protecting those at risk. Criminalization, stigmatization and the psychological, physical, behavioural and economic consequences of substance use make people who inject drugs (PWID) extremely vulnerable to many infectious diseases. While relationships between drug use and blood-borne and sexually transmitted infections are well studied, less attention has been paid to other infectious disease outbreaks among PWID.DiscussionCOVID-19 is likely to disproportionally affect PWID due to a high prevalence of comorbidities that make the disease more severe, unsanitary and overcrowded living conditions, stigmatization, common incarceration, homelessness and difficulties in adhering to quarantine, social distancing or self-isolation mandates. The COVID-19 pandemic also jeopardizes essential for PWID services, such as needle exchange or substitution therapy programmes, which can be affected both in a short- and a long-term perspective. Importantly, there is substantial evidence of other infectious disease outbreaks in PWID that were associated with factors that enable COVID-19 transmission, such as poor hygiene, overcrowded living conditions and communal ways of using drugs.ConclusionsThe COVID-19 crisis might increase risks of homelessnes, overdoses and unsafe injecting and sexual practices for PWID. In order to address existing inequalities, consultations with PWID advocacy groups are vital when designing inclusive health response to the COVID-19 pandemic.

Introduction People who inject drugs (PWID) remain at high risk of HIV in many countries. The HIV prevention cascades have been proposed to replicate the success of the treatment cascades and reinvigorate the prevention programmes through improved monitoring, planning and delivery. We adapted the cascade framework to the PWID context in Ukraine, assessed gaps and analysed factors associated with achieving “access” and “effective use” outcomes. Methods Self‐reported data on the use of prevention services and risk behaviours from the 2017 integrated bio‐behavioural survey among PWID in Ukraine were used to construct cascades for needle/syringe and condom programmes (NSP and CP). Socio‐demographic and behavioural variables were evaluated as potential correlates of cascade outcomes. Results The NSP cascade analysis included 7815 HIV‐negative PWID. Motivation to use clean syringes was not assessed and assumed at 100%. Access to clean syringes through NSP in the past 12 months was reported by 2789 participants (35.7%). Effective use of syringes (no sharing in the past 30 days) was reported by 7405 participants (94.8%). NSP access was higher among women, individuals older than 44, and mixed drug users; while effective use was reported more frequently by men and opioid users, with no difference by age. The CP cascade analysis included 6606 (85%) of the HIV‐negative PWID who had sex in the past three months. Of those, 2282 (34.5%) received condoms, and 1708 (25.9%) reported consistent use with all partners in the past three months. Older PWID and mixed‐drug users accessed condoms more frequently; whereas younger subgroups and opioid users used them more consistently. Conclusions Overall, the cascade framework was useful to describe the status of HIV prevention among PWID in Ukraine and to identify areas for improvement in the programming and evaluation of HIV prevention. Access to needle/syringe and condom programmes was substantially below the recommended levels. Effective use of clean syringes was reported by a vast majority of PWID, although likely affected by self‐report bias; whereas consistent condom use was infrequent. Socio‐demographic and behavioural variables showed significant associations in NSP and CP cascade analyses, with little consistency between the access and effective use outcomes.

ObjectivesUkraine has one of the largest HIV epidemics in Europe, with high prevalence among female sex workers (FSWs). We aimed to identify factors associated with HIV testing and receipt of the test result in the last 12 months, HIV prevalence and self-reported positive status among FSWs in Ukraine.MethodsWe used data from an Integrated Bio-Behavioural Survey among FSWs conducted in 2013–2014. The survey methodology combined three sampling strategies: time and location sampling, respondent-driven sampling and key informant recruitment. We used multivariable regression to identify factors associated with self-reported HIV testing in the last 12 months, HIV prevalence and self-reported positive status among FSWs living with HIV. Explored factors included: age, age at first sex, age at entry into sex work, education, marital status, employment status beside sex work, condom use with last paying or non-paying sexual partner, drug or alcohol consumption and sex work venue.ResultsRecent HIV testing was low overall with only 63.2% of FSWs reported having tested and received their test result in the last 12 months prior to the survey. HIV prevalence was 7.1% overall, but only 45.0% of FSWs living with HIV were aware of their HIV status. Testing in the last 12 months with receipt of test result was less common among FSWs who used drugs ever in life (adjusted OR (AOR) 0.7, 95% CI 0.6 to 0.9), women soliciting clients indoors (AOR 0.8, 95% CI 0.7 to 0.9) and those not using a condom with last paying sexual partner (AOR 0.3, 95% CI 0.2 to 0.5). HIV positivity was associated with history of ever using drugs (AOR 2.3, 95% CI 1.4 to 3.6) and soliciting clients outdoors (AOR 1.5, 95% CI 1.1 to 2.0). Women working indoors were less aware of their positive status (AOR 0.1, 95% CI 0.1 to 0.9).ConclusionHIV prevalence is high among FSWs in Ukraine, and testing and knowledge of one’s status remain insufficient. HIV testing programmes need to expand with strategies to reach specific subgroups of FSWs.

Summary Background People who inject drugs (PWID) experience a high prevalence of incarceration and might be at high risk of HIV and hepatitis C virus (HCV) infection during or after incarceration. We aimed to assess whether incarceration history elevates HIV or HCV acquisition risk among PWID. Methods In this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO databases for studies in any language published from Jan 1, 2000 until June 13, 2017 assessing HIV or HCV incidence among PWID. We included studies that measured HIV or HCV incidence among community-recruited PWID. We included only studies reporting original results and excluded studies that evaluated incident infections by self-report. We contacted authors of cohort studies that met the inclusion or exclusion criteria, but that did not report on the outcomes of interest, to request data. We extracted and pooled data from the included studies using random-effects meta-analyses to quantify the associations between recent (past 3, 6, or 12 months or since last follow-up) or past incarceration and HIV or HCV acquisition (primary infection or reinfection) risk among PWID. We assessed the risk of bias of included studies using the Newcastle-Ottawa Scale. Between-study heterogeneity was evaluated using the I 2 statistic and the P-value for heterogeneity. Findings We included published results from 20 studies and unpublished results from 21 studies. These studies originated from Australasia, western and eastern Europe, North and Latin America, and east and southeast Asia. Recent incarceration was associated with an 81% (relative risk [RR] 1·81, 95% CI 1·40–2·34) increase in HIV acquisition risk, with moderate heterogeneity between studies ( I 2 =63·5%; p=0·001), and a 62% (RR 1·62, 95% CI 1·28–2·05) increase in HCV acquisition risk, also with moderate heterogeneity between studies ( I 2 =57·3%; p=0·002). Past incarceration was associated with a 25% increase in HIV (RR 1·25, 95% CI 0·94–1·65) and a 21% increase in HCV (1·21, 1·02–1·43) acquisition risk. Interpretation Incarceration is associated with substantial short-term increases in HIV and HCV acquisition risk among PWID and could be a significant driver of HCV and HIV transmission among PWID. These findings support the need for developing novel interventions to minimise the risk of HCV and HIV acquisition, including addressing structural risks associated with drug laws and excessive incarceration of PWID. Funding Engineering and Physical Sciences Research Council, National Institute for Health Research, National Institutes of Health.

Background We studied the association between sex in exchange for money, drugs or goods and HIV for women who inject drugs (WWID) in Ukraine, as previous data on this association from the post-USSR region are contradictory. Methods Data come from the Integrated Bio-Behavioral Survey of Ukrainian people who inject drugs collected in 2011 using respondent-driven sampling. Participants were interviewed and tested with rapid HIV tests. Results The sample included 2465 WWID (24% HIV positive); 214 (8.7%) of which reported having had exchange sex during the last 90 days. Crude analysis showed no association between exchange sex and HIV (OR = 0.644; 95% CI 0.385–1.077). No confounders were found to alter this result in a multivariable analysis. Further modeling showed that exchange sex modifies association between HIV and alcohol use: no association between HIV and daily alcohol use was found for those women who exchanged sex (OR = 1.699, 95% CI 0.737–3.956); while not engaging in sex work and daily using alcohol reduced odds to be HIV infected (OR = 0.586, 95% CI 0.389–0.885). Conclusions Exchange sex may have less impact on the HIV status of WWID who are exposed to injecting risks. The finding that daily alcohol use appears protective against HIV among WWID who do not exchange sex requires more research.

Introduction Ukraine has one of the largest HIV epidemics in Europe that was historically driven by people who inject drugs (PWID). The epidemic showed signs of stabilisation since 2012, but the recent war in the East of the country might be reinforcing the virus spread. We have studied HIV flow within Ukraine in recent years and explored factors that might explain it. Methods We used HIV subtype-A pol nucleotide sequences sampled in 2012–2015 from 427 patients of 24 regional AIDS Centres along with 40 publicly available reference sequences sampled between 1986–2010. We used phylogeographic analysis in BEAST to reconstruct viral spread among different geographic regions of Ukraine. We further used data from an Integrated Bio-Behavioural survey of PWID conducted in Ukraine in 2013. We built logistic regression model to test for an association between the virus flow and the reported risky sexual and injecting behaviours of PWID, the number of internally displaced persons, and HIV prevalence per region. Results Infections in the Centre, East, and Crimea were 3.9, 3.6, and 3.3 times, respectively, more likely to originate from Donetsk (the biggest city in the occupied East), suggesting that the epidemic is spreading westwards. Additionally, multivariable regression analyses showed that regions with a higher proportion of PWID practicing risky sexual behaviours were more likely to both be a source of infection to other regions and a recipient of infection from them. No such association was found for risky injecting behaviours. Conclusion We show that in recent years HIV has been spreading westwards in Ukraine at a higher than expected rate. This may be a consequence of the war that has led to over a million people migrating from the East to other regions of Ukraine. Risky sexual practices that involve PWID may be facilitating this spread. The estimated patterns of HIV-1 migration within Ukraine suggest that an effective prevention response should involve PWID, their sexual partners, and internally displaced people.

Past research suggests that as many as 50% of onward human immunodeficiency virus (HIV) transmissions occur during acute and recent HIV infection. It is clearly important to develop interventions which focus on this highly infectious stage of HIV infection to prevent further transmission in the risk networks of acutely and recently infected individuals. Project Protect tries to find recently and acutely infected individuals and prevents HIV transmission in their risk networks. Participants are recruited by community health outreach workers at community-based HIV testing sites and drug users’ community venues, by coupon referrals and through referrals from AIDS clinics. When a network with acute/recent infection is identified, network members are interviewed about their risky behaviors, network information is collected, and blood is drawn for HIV testing. Participants are also educated and given prevention materials (condoms, syringes, educational materials); HIV-infected participants are referred to AIDS clinics and are assisted with access to care. Community alerts about elevated risk of HIV transmission are distributed within the risk networks of recently infected. Overall, 342 people were recruited to the project and screened for acute/recent HIV infection. Only six index cases of recent infection (2.3% of all people screened) were found through primary screening at voluntary counseling and testing (VCT) sites, but six cases of recent infection were found through contact tracing of these recently infected participants (7% of network members who came to the interview). Combining screening at VCT sites and contact tracing the number of recently infected people we located as compared to VCT screening alone. No adverse events were encountered. These first results provide evidence for the theory behind the intervention, i.e., in the risk networks of recently infected people there are other people with recent HIV infection and they can be successfully located without increasing stigma for project participants.

Economic and political instability and related "big events" are widespread throughout the globe. Although they sometimes lead to epidemic HIV outbreaks, sometimes they do not-and we do not understand why. Current behavioural theories do not adequately address these processes, and thus cannot provide optimal guidance for effective intervention. Based in part on a critique of our prior "pathways" model of big events, we suggest that cultural-historical activity theory (CHAT) may provide a useful framework for HIV research in this area. Using CHAT concepts, we also suggest a number of areas in which new measures should be developed to make such research possible.

Despite global reductions in HIV incidence and mortality, the 15 UNAIDS-designated countries of Eastern Europe and Central Asia (EECA) that gained independence from the Soviet Union in 1991 constitute the only region where both continue to rise. HIV transmission in EECA is fuelled primarily by injection of opioids, with harsh criminalisation of drug use that has resulted in extraordinarily high levels of incarceration. Consequently, people who inject drugs, including those with HIV, hepatitis C virus, and tuberculosis, are concentrated within prisons. Evidence-based primary and secondary prevention of HIV using opioid agonist therapies such as methadone and buprenorphine is available in prisons in only a handful of EECA countries (methadone or buprenorphine in five countries and needle and syringe programmes in three countries), with none of them meeting recommended coverage levels. Similarly, antiretroviral therapy coverage, especially among people who inject drugs, is markedly under-scaled. Russia completely bans opioid agonist therapies and does not support needle and syringe programmes-with neither available in prisons-despite the country's high incarceration rate and having the largest burden of people with HIV who inject drugs in the region. Mathematical modelling for Ukraine suggests that high levels of incarceration in EECA countries facilitate HIV transmission among people who inject drugs, with 28-55% of all new HIV infections over the next 15 years predicted to be attributable to heightened HIV transmission risk among currently or previously incarcerated people who inject drugs. Scaling up of opioid agonist therapies within prisons and maintaining treatment after release would yield the greatest HIV transmission reduction in people who inject drugs. Additional analyses also suggest that at least 6% of all incident tuberculosis cases, and 75% of incident tuberculosis cases in people who inject drugs are due to incarceration. Interventions that reduce incarceration itself and effectively intervene with prisoners to screen, diagnose, and treat addiction and HIV, hepatitis C virus, and tuberculosis are urgently needed to stem the multiple overlapping epidemics concentrated in prisons.

a b s t r a c t Background: A peer-driven intervention (PDI) for injecting drug users (IDUs) was implemented in five Ukrainian city-sites to test-pilot its effectiveness in rejuvenating harm reduction (HR) projects that had become moribund. A PDI relies on drug users in a unique way to educate their peers in the community and recruit them for HIV prevention services. The goal of the PDI was to recruit in six month 500 IDUs who had never been respondents before to each of the five HR projects, especially stimulant- and women-injectors, and IDUs < 25 years of age. Method: We standardized the PDI's structure and operations across all five sites. All five PDIs were started in May 2007 using a carefully selected handful of "seed" IDU-recruiters who were trained to educate three peers who had never received HR services. We also accessed the database of all five projects and analysed the new respondents they recruited six-months prior to the start-up of the PDIs with the new recruits generated by the PDIs. Results: Whilst the HR projects in the five city-sites recruited 72 new respondents on average during the six months prior to the PDIs' start-up, the PDIs recruited 455 new respondents on average in each city during their six months of operation, indicating that the PDI was 6.3 times more powerful as a recruitment mechanism. Compared to traditional outreach the PDIs resulted in significant increases in the recruitment of women- and young-injectors, and IDUs who injected a more diverse variety of drugs. Conclusion: The PDI can have a rejuvenating effect when added to HR projects that had become stagnate over time, resulting in an increase in the number and diversity of new IDU-respondents. © 2012 Elsevier B.V. All rights reserved.

Setting: One hundred and forty non-governmental organisations implementing human immunodeficiency virus (HIV) prevention programmes among clients, including people who inject drugs, prisoners, female sex workers, men who have sex with men and street children in Ukraine, 2010–2011. Objective: Among enrolled clients, to assess factors associated with HIV testing, HIV retesting within a year of initial testing and HIV seroconversion. Design: Retrospective cohort study involving record reviews. Results: Of 192 487 clients, 42 109 (22%) underwent an initial HIV test (22% were positive). Among HIV-negative clients at baseline, 10 858 (27%) were retested within a year: 317 (3%) of these were HIV-positive. HIV testing and retesting rates were lower among prisoners (0.3%) and others (street children and partners of those in risk groups, 6%), and those who did not receive counselling or services such as condom and needle distribution. Individuals who were not counselled were more likely to seroconvert. Conclusions: In this large cohort of high-risk groups from Eastern Europe, HIV testing was low and HIV sero-conversion was high. This is of public health concern, bringing into question the overall quality of counselling and how well it is tailored to the specific needs of various risk groups. Qualitative studies to understand the reasons for non-testing are urgently required for designing client-specific interventions.

Conventional harm reduction (HR) projects overlook IDUs’ capabilities in offering them services but no active roles to play in preventing HIV. In contrast, “peer-driven interventions” (PDIs) offer IDUs rewards to educate and recruit peers for services. All IDU-recruits receive the opportunity to play both roles.

A peer-driven intervention (PDI) for female sex workers (FSWs) was implemented in harm reduction projects in two Ukrainian cities. The goal was to recruit and interview 500 FSWs in 6 months who had never received services before, and to measure how well FSW-recruiters educated FSWs in a body of fresh HIV prevention information. Recruiters were rewarded by earning tickets to win special prizes in a weekly lottery.