1. Integrated services for people who use drugs in vertical health care systems: challenges and solutions Kostyantyn Dumchev, MD, MPH July 19, 2016 21 st International AIDS Conference, Durban, South Africa

2. Disproportionate access of PWID to ART Newly registered cases by mode of transmission Patients on ART by drug use status

3. Insufficient financing of health care Stigma in the society and health system Understaffing of health facilities Health care system is not quality/ performance oriented Inconvenient working hours, discoordination with other services Bad experiences with health care (low satisfaction) Decreased probability of follow-up visit Poor treatment adherence Low treatment effectiveness Limited access to effective treatment of Drug Dependence Need to attend multiple facilities to receive all needed services Vertical nature of the health system (separate HIV, TB, Substance Abuse services) Spread of HIV, Hepatitis, TB High disease burden Bad quality of life Chaotic lifestyle of IDUs Barriers to service utilization for PWID in Ukraine (2009 assessment results)

4. Barriers to service provision (continued) 2014-15 assessment results Inconvenient location, need to travel long ways to obtain services in multiple facilities Inefficient patient flow though facilities Lack of cross-discipline training in providers Low health awareness among PWID Conclusion: Majority of the barriers are caused by the vertical structure of health care system, typical for post- Soviet countries

5. ‘Vertical’ healthcare system Public Health Tertiary Secondary Primary TBSTIHIVSubst. abuse + also, in Ukraine patients are bound to facilities serving their registered place of residence

6. Response 1: Evolution of integrated care for PWID in Ukraine 80+ sites, 4000+ patients Still funded by external donors Present Integrated care projects (funded by GF, CHAI, PEPFAR) pilot various mode of service delivery 12 sites >800 patients 2008-2010 MAT programs implement additional services 2005 Harm reduction projects provide referrals to various clinical facilities 2000+

7. Integrated care projects in Ukraine Piloting “integrated care” for drug users by posting multidisciplinary teams at different vertical service facilities Photo: Theo Smart

8. Aims of integrated care Increased effectiveness of specific interventions through improved access and coverage Increased adherence to treatment Increased treatment effectiveness and cost- effectiveness

9. Principles of integrated care 1.Appropriate location for the site and main services 2.A basic package of essential services 3.A multidisciplinary team model linked through individual patient case management 4.Efforts to build trust with patients, and a collaborative approach to their healthcare 5.Inclusion of harm reduction principles* across care 6.Cooperation between governmental and nongovernmental sectors Source: “Implementation of integrated services for persons with substance dependence in health care facilities” - 2011

10. Case-management – an intervention reducing barriers mostly from the client side Case-management Integration Integration – a process reducing barriers from the provider side Both are working to make a service closer to the client

11. Integrated care models Multidisciplinary patient management: Patient is managed by a multidisciplinary team, or cross-disciplinary provider Co-location: Provision of related services in one location Referral: Structured referral to the services that are not available on-site (formal agreement with facilities, appointment confirmation, accompanying, result tracking) MATTBHIVSTI MAT, HIV, TB HIV TB MAT

12. Components of IC package Diagnostics and treatment of mental disorders, of DRUG DEPENDENCE in the first place, including MAT Diagnostics, treatment, and prevention of HIV/AIDS Diagnostics, treatment, and prevention of VIRAL HEPATITIS В and C Diagnostics, treatment, and prevention of TB Diagnostics, treatment, and prevention of STIs Reproductive health services Diagnostics and treatment of OTHER commonly occurring diseases IDU HARM REDUCTION Socio-psychological SUPPORT, including psychological and legal counseling, assistance in employment, and social reintegration

13. Further challenges in vertical healthcare (2009 assessment results) Existing legislature and health care structure limit the possibilities for integration of health and social services, but, at the same time, the existing and feasible mechanisms are not widely known and utilized. […] Скрининг и лечение ТБ, обследование на СД4, консультации специалистов, снижение вреда…

14. Response 2: integrated care manual “Implementation of integrated services for persons with substance dependence in health care facilities” Goal: Systematize all possible approaches and options to service implementation within the existing health care system and legislature Answering the “HOW?” question Describe stepped algorithms for service implementation: Service Components (e.g. for ART: 1.physician 2.drugs 3.lab…) (options) Steps (options)

15. Effectiveness: results of a cross-sectional study Bachireddy C, Soule MC, Izenberg JM, Dvoryak S, Dumchev K, Altice FL. Integration of health services improves multiple healthcare outcomes among HIV- infected people who inject drugs in Ukraine. Drug and alcohol dependence. 2014;134:106-14.

16. Further challenges in vertical healthcare (2009 assessment results) Existing legislature and health care structure limit the possibilities for integration of health and social services, but, at the same time, the existing and feasible mechanisms are not widely known and utilized. But even more serious barrier is the lack of motivation in health administrators and personnel, mostly caused by non-result-based financing in healthcare.

17. Insufficient financing of health care Stigma in the society and health system Understaffin g of health facilities Health care system is not quality/ performance oriented Inconvenient working hours, discoordination with other services Bad experiences with health care (low satisfaction) Decreased probability of follow-up visit Poor treatment adherence Low treatment effectiveness Limited access to effective treatment of Drug Dependence Need to attend multiple facilities to receive all needed services Vertical nature of the health system (separate HIV, TB, Substance Abuse services) Spread of HIV, Hepatitis, TB High disease burden Bad quality of life Chaotic lifestyle of IDUs If the fundamental barriers are not addressed BY HEALTHCARE REFORM, the progress in IC scale-up will remain limited

18. Thank you for attention!