1. Implementation of the Substitution Maintenance Therapy in the framework of the Programme “Overcoming HIV/AIDS Epidemics in Ukraine” Stakeholders meeting Kyiv, 14 February 2006 Sergiy Dvoryak, MD, PhD Ukrainian Institute on Public Health Policy

2. Previous projects’ outcomes February-December 2005 (1) The Expert commission has been formed, which implemented assessment of legislative base and have produced recommendations on improvement. Order of the Ministry of Healthcare № 161 have been issued to allow organization of buprenorphine pilot projects with attached schedule of drug administration. A strategy for procurement, administration, transporting and distribution of the drug has been developed. A joint survey with the Ministry of Healthcare and WHO was conducted to assess the readiness of the regions for the SMT.

3. Previous projects’ outcomes February-December 2005 (2) 1. Development of the multidisciplinary team concept. 2. Search of partners in the narcological institutions. 3. Selection of models for SMT implementation: narcological insitution based, AIDS Center based, municipal clinic based, or NGO Rehab Centers. 4. Staff training for the SMT projects. Development of the training programmes. Six trainings conducted, seven MDT formed. 5. Preparation and printing of the 3 manuals on SMT for doctors, social workers and counselors, and patients. 6. Translation and printing of the manual on cognitive behavioral therapy model for clients and staff.

4. Previous projects’ outcomes February-December 2005 (3) 1.Monitoring visits and evaluation of regional projects’ activities in Donetsk, Simferopol, Odesa, Mykolaiv, Dnipropetrivsk and Kyiv (18 visits) 2.Web-based resource center on SMT created, allowing to inform on current state of the projects and provide help to MDT in the regions 3.Monitoring and evaluation plan developed in cooperation with WHO. 4.Work underway on the development of SMT scale-up plan for Ukraine.

5. Ednok procurement Drug administration schedule outlined by the order of the Ministry of Healthcare Documents to support purchase of the drug as humanitarian aid prepared Respective licenses on procurement and sale acquired («Ліки України») Procurement monitoring and control mechanism developed (“Соціотерапія”) Protocol for drug administration control in the narcological institutions developed Ednok distribution control forms developed

6. SMT Project in the framework of the Programme “Overcoming HIV/AIDS Epidemics in Ukraine“, as at 01.26.2006 Kyiv (AIDS Centre) Kyiv (Socioth erapy) DonetskKherson Dnipropetr ovsk OdesaSimferopolMykolaivTOTAL SMT commencement date 16.11.2005 10.10.20 05 7.10.200515.05.200507.11.200527.10.200514.10.20051.11.2005 Number of clients183130222323232723197 male / female15 / 321 / 1027 / 616 / 620 / 321 / 220 / 718 / 5 Average age / average drug use experience 34/16,5 yr28 / 9 yr 30 / 12 yr32 / 8 yr36/13 yr32 /12,5 yr37/17 yr40/18 yr HIV+ clients181620812232723147 Hepatitis В or С7246161140068 Tuberculosis0101043052 Clients on HAART173424101205752 Clients in prep for HAART 1050013152357 Average dosage14 mg10 mg12 mg3-4 mg8 mg10 mg5 mg8 mg min/max dosage8 / 16 mg 12 /13 mg 4 / 22 mg0,8 / 7,2 mg2 / 12 mg4 / 12 mg2 / 8 mg2 / 10 mg 0,8/22 Number of clients that terminated the programme 0420752525

7. Programme “Overcoming HIV/AIDS Epidemics in Ukraine“ 2006 TOTAL% Number of clients 197100 male / female 157/4080/20 Average age / average drug use experience 31/12,5 HIV+ clients 14775 Hepatitis В or С 6131 Clients on HAART 5226 Clients in prep for HAART 5729 Average dosage, mg ~10 min/max dosage, mg 0,8/22 Number of clients that terminated the programme 2512,7

8. Scaling up the SMT in Ukraine in accordance with the Programme «Overcoming HIV/AIDS Epidemics in Ukraine» (2006) (1) Ongoing collaboration with MoH and corresponding healthcare institutions aimed at the further development of functional networking in the framework of SMT infrastructure (narcological institutions+AIDS Centers+NGO+family doctors+WHO Technical Assistance ) Development of a database of scientific, methodical, regulatory materials on SMT; maintenance of the web-based resource center and its usage for interactive communication among experts and project staff and to facilitate the access to information on SMT

9. Scaling up the SMT in Ukraine in accordance with the Programme «Overcoming HIV/AIDS Epidemics in Ukraine» (2006) (2) Systematic consulting and assistance to MDT Conducting Monitoring and Evaluation of SMT projects Development and dissemination of a licensed study course on pscycho-social support of SMT clients and a study course on SMT for family doctors Fostering access to SMT of HIV-negative IDUs

10. Primary tasks Complete and acquire approval for national SMT development plan in Ukraine; Work out a cooperation mechanism with appropriate governmental agencies through NCC on HIV/AIDS in order to mobilize political element of SMT development in the country; Enlarge the number of SMT clients through diversification of Ukrainian buprenorphine market (finding another manufacturer); Launch methadone pilot projects; With the assistance of MoH create the mechanism of drug purchasing at own costs; Together with WHO initiate the Monitoring and Evaluation Project.

11. Main obstacles The poor cooperation between narcological institutions and AIDS Centers The little interest of local healthcare institutions in SMT implementation The insufficient professional level of NGOs, that cooperate with narcological institutions Obsolete drug circulation control system and disinclination to change it in order to adapt SMT Lack of purchasing mechanism at personal expense, through charity organizations, local and national budget expense. Stigma associated with HIV/AIDS and drug abuse.

12. CONCLUSIONS First steps of SMT implementation in Ukraine show: SMT is an effective treatment method Existing infrastructure allows for further development and scale-up There is an acute necessity for legislation change regarding drug substance administration More efforts needed to lower the cost of treatment. Methadone is an alternative, that will broaden the access to SMT treatment Advocacy should be continued as political opposition to SMT programmes remains stiff.