Collaborating with ukrainian NGOS: through researching and training to develop effective, evidense-based HIV prevention programs for drug users

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COLLABORATING WITH UKRAINIAN NGOS: THROUGH RESEARCHING AND TRAINING TO DEVELOP EFFECTIVE, EVIDENCE-BASED HIV PREVENTION PROGRAMS FOR DRUG USERS

Jill Owczarzak, Department of Health,

Sarah Phillips, Department of Anthropology,

Olga Filippova, Department of Sociology

Annotation

prevention program behavior policy

This article describes an ongoing study that will enable local HIV prevention service providers in Ukraine to develop novel, context-specific HIV prevention programs to include evidence-based strategies that seek to change risk behavior, do not require broad policy changes, and that address the multiple HIV risks drug users face. Eight NGOs were trained in common factors of effective interventions and then developed their own HIV prevention programs. The article presents preliminary study data to discuss how this unique approach to HIV prevention development can enhance providers' capacity to more effectively meet the prevention needs of populations at risk for HIV through context-specific program development.

Keywords: HIV-prevention, social epidemic, evidence-based approach to prevention, risk behavior, inject drag users.

Аннотация

По различным оценкам Украина относится к странам с высоким уровнем ВИЧ-инфицирования. Около 36% новых случаев ВИЧ-инфекции связано с употреблением инъекционных наркотиков. Неправительственные организации, работающие в Украине в сфере снижения риска ВИЧ- инфицирования, обладают небольшим опытом по созданию и внедрению эффективных, научно обоснованных программ по снижению поведенческих рисков, способных сократить эпидемию ВИЧ среди населения, употребляющего инъекционные наркотики. В статье представлено описание исследования (а также некоторые результаты осуществления его первой фазы), проводимого в Украине в 2012-2016 годах, которое позволит местным провайдерам услуг по профилактике ВИЧ разработать новые ВИЧ-профилактические программы, учитывающие социокультурный контекст и предлагающие научно обоснованные стратегии, направленные на изменение рискованного поведения населения. Данное исследование сочетает в себе качественные и количественные методы изучения модели разработки и внедрения ВИЧ- профилактического вмешательства, которое распространяет общие факторы эффективного снижения рискованного поведения и позволяет провайдерам услуг разрабатывать программы, которые отражают социокультурную специфику и организационные контексты.

Изначально было отобрано восемь НПО, работающих в различных регионах Украины с самыми высокими показателями ВИЧ и наркопотребления. Данные НПО отражают ключевые критерии организационного контекста (например, размер агентства, целевая группа населения, опыт работы в области ВИЧ-профилактики). Все они прошли обучение относительно общих факторов принятия эффективных мер по снижению рискованного поведения, а затем разработали собственные программы по профилактике ВИЧ. В ходе документирования процесса разработки программ по проведению вмешательства нами использовались качественные методы исследования, в частности, интервью и наблюдения. В статье представлены предварительные данные первой фазы исследования, позволяющие обсудить, как этот уникальный подход к развитию профилактики ВИЧ может повысить способность провайдеров более эффективно удовлетворять потребности в ВИЧ-профилактике среди групп риска путем развития программ, учитывающих конкретный социокультурный и организационный контекст.

Ключевые слова: ВИЧ-профилактика, социальная эпидемия, научно обоснованный подход в профилактике, рискованное поведение, потребители инъекционных наркотиков.

Анотація

За різними оцінками Україна відноситься до країн з високим рівнем ВІЛ-інфікування. Близько 36% нових випадків ВІЛ-інфекц'їпов'язано зі вживанням ін'єкційних наркотиків. Неурядові організацї, що працюють в Україні у сфері зниження ризику ВІЛ-інфікування, мають невеликий досвід щодо створення і впровадження ефективних, науково обгрунтованих програм зі зниження поведінкових ризиків, які здатні скоротити епідемію ВІЛ серед населення, що вживає ін'єкційні наркотики. У статті представлено опис дослідження (а також деякі результати здійснення його першої фази), що проводиться в Україні в 2012-2016 роках, яке дозволить місцевим провайдерам послуг з профілактики ВІЛ розробити нові ВІЛ-профілактичні програми, що враховують соціокультурний контекст і пропонують науково обґрунтовані стратегії, спрямовані на зміну ризикованої поведінки населення. Дане дослідження поєднує в собі якісні та кількісні методи вивчення моделі розробки та впровадження ВІЛ-профілактичного втручання, яке поширює загальні фактори ефективного зниження ризикованої поведінки і дозволяє провайдерам послуг розробляти програми, які відображають соціокультурну специфіку та організаційні контексти.

Спочатку було відібрано вісім НУО, що працюють у різних регіонах України, які мають найвищі показники ВІЛ та вживання наркотичних препаратів. Дані НПО відображають ключові критерії організаційного контексту (наприклад, розмір агентства, цільова група населення, досвід роботи в галузі ВІЛ-профілактики). Всі вони пройшли навчання стосовно загальних чинників ефективних заходів щодо зниження ризикованої поведінки, а потім розробили власні програми з профілактики ВІЛ. В ході документування процесу розробки програм з проведення втручання нами використовувалися якісні методи дослідження, зокрема, інтерв'ю та спостереження. У статті представлені попередні дані першої фази дослідження, що дозволяють обговорити, як цей унікальний підхід до розвитку ВІЛ-профілактики може підвищити здатність провайдерів більш ефективно задовольняти потреби в ВІЛ-профілактиці серед груп ризику шляхом розвитку програм, які враховують конкретний соціокультурний та організаційний контекст.

Ключові слова: ВІЧ-профілакитика, соціальна епідемія, науково обґрунтований підхід у профілактиці, ризикована поведінка, користувачі ін'єкційних наркотиків

The main text

General context. Ukraine has one of the most severe HIV epidemics in Eastern Europe, with an estimated 1.6% of the adult population living with the virus. Annual HIV diagnoses have more than doubled each year since 2001. Injection drug use accounts for 36% of new HIV cases, and the majority of HIV infection occurs among people who inject drugs (PWID) and their sex partners [1; 2]. Recent collaborative efforts between international, governmental, and nongovernmental agencies have been made to expand access to substitution therapies and needle/syringe exchange programs in Ukraine. However, systematic and legislative barriers remain for these IDU- specific programs. In addition, while provision of sterile injection equipment is important, and has been shown to reduce new HIV infections among IDUs, such programs alone do not address sexual HIV risk among drug users. Therefore, current HIV prevention efforts among Ukrainian IDUs need to be expanded to include evidence-based strategies that seek to change risk behavior, do not require broad policy changes or political support, and that address the multiple HIV risks drug users face.

Efforts to encourage service providers to deliver evidence-based interventions (EBIs) have focused on implementation with fidelity to “core elements,” or integral components specific to each intervention thought to be responsible for its effectiveness. While over 150 unique interventions have been identified as evidence-based, including 9 that target drug users, in practice they incorporate common factors of effective interventions: cognitive, affective, and behavioral skill-building; tailored, behavior-specific content; and addressing environmental barriers to behavior change.

The unique drug use practices among PWID in Ukraine and their associated HIV risks require tailored, context-specific prevention interventions. Current evidence-based interventions (EBIs) for drug users do not specifically incorporate information about these unique injection drug use risks and would require significant tailoring to increase their relevance for Ukrainian PWID.

Project description, main goals and research methods. In Ukraine nongovernmental organizations (NGOs) are the primary providers of HIV prevention services for PWID [3]. The MICT study, a 4-year NIDA- funded project¹, seeks to promote the use of evidence-based HIV prevention strategies among Ukrainian NGOs working with drug users [4].

This project seeks to understand how to best promote the use of these evidence-based HIV prevention strategies among Ukrainian NGOs working with drug users. This study combines qualitative and quantitative methods to explore a model of HIV prevention science dissemination and intervention development that 1)

Support for this project comes from the United States' National Institutes of Drug Abuse (R01DA033644).

promotes the dissemination of common factors of effective behavioral risk reduction interventions (rather than intervention-specific core elements); and 2) enables service providers to develop HIV prevention interventions that reflect their specific organizational contexts.

We do so via a unique collaborative-creative approach that takes into account the limits of pre-packaged interventions, barriers to adoption and implementation of EBIs, the politics of public health policy transfer, and the research to practice gap in EBI implementation. Specifically, we recognize the following challenges commonly encountered in EBI implementation in settings such as Ukraine:

- low capacity of NGOs to implement resource-intensive, theoretically informed interventions [5; 6];

- service providers rarely implement EBIs with fidelity, despite significant investment of financial, human, and material resources into dissemination efforts;

- insistence on “core elements” is problematic (those integral components of the intervention thought to be responsible for its effectiveness and that must be retained in order for HIV risk reduction to occur) and in practice there is low fidelity to “core elements'" of EBIs;

- from a dissemination and implementation perspective, core elements are often purely theoretical and not easily translatable to practice; do not capture critical aspects of the intervention; and lack specificity to guide service providers in program delivery.

More broadly, the project is also designed to surmount some of the limits of the current model of delivering pre-packaged HIV prevention programs. Commonly, pre-packaged programs are given to agencies, and the staff is trained to deliver them and get financial support to implement them. Frequently, however, as the epidemic shifts and prevention needs and donor priorities change, these programs are no longer supported. The MIST study is designed to address this problem by offering HIV service agencies tools so that they can be adaptive to these changes and develop more say and power in determining priorities and directions in HIV prevention in their own contexts.

In line with this focus, following Mary Jane Rotheram-Borus et al. [7], our study privileges the importance of common factors in EBIs for HIV prevention, which cut across theoretical models of behavior change. Common factors are broader constructs that support behavior change and are incorporated into a variety of EBIs. Generally, effective evidence-based prevention strategies are based on the idea that behavior change requires opportunities and practice, and that change occurs over time. Successful HIV prevention interventions include a framework to understand the HIV risk behavior and change; cognitive, affective, and behavioral skill-building; fostering sustainable social support; tailored, behavior-specific content; and addressing environmental barriers to behavior change. Factors common to effective behavioral interventions can be categorized into three domains: implementation, content, and pedagogy.

Research methods. Our study combines qualitative and quantitative methods to explore the extent to which NGOs in Ukraine can develop an HIV prevention intervention based on common factors of effective behavioral interventions, and that reflect their own clients' drug-use related HIV risks. We will also measure whether these agency-developed interventions reduce participants' drug use and sexual HIV risk behaviors.

We recruited eight HIV prevention organizations that work with people who inject drugs from regions with the highest HIV prevalence rates, specifically the eastern and southern regions and the central region. We purposely recruited NGOs to reflect real-world variability in terms of agency history, size, mission and context. The participating agencies receive funds and feedback support over four years for program development, implementation, evaluation, and modification. Data collection is occurring in 4 phases (Baseline, Intervention Development, Intervention Implementation, Effectiveness). In this paper we present some results of the completed phases--the Baseline and Intervention Development phases,

Phase 1 (Baseline) and Phase 2 (Intervention Development). To assess agency characteristics that potentially affect intervention implementation, NGO directors completed a provider questionnaire that assesses organizational capacity and other aspects of implementation context. Then, during summer 2013 we traveled to agencies to conduct in-depth interviews with agency staff to assess non-quantifiable aspects of implementation context and gain additional perspectives on the agency and HIV prevention among Ukrainian NGOs, including experiences implementing evidence-based interventions. Interviews also focused on the history of the NGO; current and future agency goals and scope of HIV prevention activities; and the interviewee's personal history of involvement in HIV prevention activities.

In a multi-day face-to-face workshop we taught staff from the eight NGOs common factors of EBIs. Subsequently each agency developed its own HIV prevention intervention for use with a specific IDU target group identified by them. We have been documenting the process of intervention development at each agency. Following training we conducted regular interviews with NGO staff involved in intervention development. These interviews focused on decision-making processes, such as how intervention design was determined; capacitybuilding activities the agency has conducted to prepare for implementation; development of procedures and relationships to facilitate intervention implementation; and barriers to program development. Early this year we collected each agency's intervention manual and utilized a checklist to document whether an agency's intervention includes an identifiable target population, clear objectives, and common factors of successful interventions. Agencies are now preparing to pilot their interventions.

All of these HIV service agencies target people who inject drugs, but their client bases are quite diverse (e.g. some focus on commercial sex workers; others work a lot with drug manufacturers and sellers; some NGOs target women specifically or have special women-focused programs) and they work in different environments (e.g. local politics towards IDUs, CSWs, NGOs, etc. varies; uneven social and medical programs; differing drug scenes). Buy-in from the participating agencies has been high: agency staff sees research as important and have been eager to try EBIs. It is clear that providers in these contexts really want programs that might better serve “resistant” clients, and that give them the tools to design the types of programs that are often implemented through them when they participate in other types of research or pilot programs.

In developing their interventions, the agencies worked on their own to define what they saw as the key challenges that contribute to their clients' behavior-related HIV risks. Each agency identified a unique target group for their intervention. Some of them tried to incorporate more structural or contextual elements of HIV vulnerability into their programs, such as teaching clients how to negotiate risk and achieve risk reduction in a particular buying/selling market structure, and incorporating issues of legislation and law enforcement into the programs. The interventions for commercial sex workers addressed problems of violence against women, for example. The agencies' interventions focus on specific behavioral determinants, teach problem solving skills, incorporate goal-setting strategies, and provide tools for participants to incorporate behavior change into daily lives and social relationships. A few challenges to intervention development include the following: a) interventions prepared by academics tend to include complicated theoretical concepts, and rely on lectures and discussions instead of activities; b) interventions are at times based on the priorities of specific individuals, rather than a reflection of the collective knowledge and experience of the organization more broadly.

Significance of the project. This study proposes a model of intervention development that provides NGO staff with the tools to develop their own evidence-based prevention programs by teaching them `common factors' of successful HIV prevention programs. We recognize that this approach is limited because it does not fundamentally address some of the more structural factors that contribute to HIV risk and disparities [8]. Agency staff recognizes this as well and some seek to address structural determinants as part of their interventions. Overall, we believe the MIST study can potentially increase the capacity of HIV prevention NGOs to conduct theory-based, multi-session risk reduction interventions. If this study demonstrates the feasibility of disseminating the common factors of effective behavior change interventions to frontline service providers, we anticipate several opportunities to broaden its impact. First, it could lead to the creation of training modules that emphasize skill-building and organizational capacity around behavioral risk reduction strategies more generally, rather than similar trainings based on specific interventions that must be significantly modified for new contexts. Second, this proposed model of intervention development could shift the ways in which local HIV prevention service providers are trained. By providing local experts with the tools of prevention intervention development based on principles of effective behavioral risk reductions, this model addresses the shortcomings of current dissemination methods and draws on the knowledge and experience of frontline service providers as a key resource in fighting the HIV epidemic.

References

1. Booth R.E., Lehman W., Dvoryak S., Brewster J.T., Sinitsyna L. Interventions with injection drug users in Ukraine // Addiction - 2009 - 104, P.1864-1873.

2. Ukraine Ministry of Health. Ukraine: Ukraine: National Report on Monitoring Progress towards the UNGASS Declaration of Commitment on HIV/AIDS. Kyiv 2010.

3. Mercer M.A., Liskin L. The role of non-governmental organizations in the global response to AIDS // AIDS Care - 1991 - 3(2), P.265-270.

4. Owczarzak J., Filippova O., Phillips S.D. A novel, bottom up approach to promote evidence-based HIV prevention for people who inject drugs in Ukraine: Protocol for the Mist (`Bridge') HIV prevention exchange project // Implementation Science - 2014, 9(18), P. 9-18.

5. Owczarzak J.T., Dickson-Gomez J.Providers' perceptions of and receptivity toward evidence-based HIV prevention interventions // AIDS Education and Prevention - 2011 - 23(2), P.105117.

6. Owczarzak J.T, Dickson-Gomez J.. Provider perspectives on evidence-based HIV prevention interventions: barriers and facilitators to implementation // AIDS Patient Care and STDs - 2011 - 25(3), P.171-179.

7. Rotheram-Borus M.J., Swendeman D., Flannery D., Rice E., Adamson D.M., Ingram B. Common factors in effective HIV prevention programs // AIDS Behavior - 2009 - 13(3), P. 399-408.

8. Owczarzak J. Defining HIV Risk and Determining Responsibility in Postsocialist Poland. // Medical Anthropology Quarterly. 2009 - 23(4):417-435.

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