Substance Use & Misuse

ISSN: 1082-6084 (Print) 1532-2491 (Online) Journal homepage: https://www.tandfonline.com/loi/isum20

Social Support is Key to Retention in Care during

Covid-19 Pandemic among Older People with HIV
and Substance Use Disorders in Ukraine

Julia Rozanova, Sheela Shenoi, Irina Zaviryukha, Oleksandr Zeziulin, Tetiana

Kiriazova, Katherine Rich, Elmira Mamedova & Volodymyr Yariy

To cite this article: Julia Rozanova, Sheela Shenoi, Irina Zaviryukha, Oleksandr Zeziulin,
Tetiana Kiriazova, Katherine Rich, Elmira Mamedova & Volodymyr Yariy (2020) Social Support
is Key to Retention in Care during Covid-19 Pandemic among Older People with HIV and
Substance Use Disorders in Ukraine, Substance Use & Misuse, 55:11, 1902-1904, DOI:
10.1080/10826084.2020.1791183

To link to this article: https://doi.org/10.1080/10826084.2020.1791183

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SUBSTANCE USE & MISUSE
2020, VOL. 55, NO. 11, 1902–1904
https://doi.org/10.1080/10826084.2020.1791183

NOTE

Social Support is Key to Retention in Care during Covid-19 Pandemic among

Older People with HIV and Substance Use Disorders in Ukraine
Julia Rozanovaa , Sheela Shenoia , Irina Zaviryukhab, Oleksandr Zeziulinb, Tetiana Kiriazovab,
Katherine Richc, Elmira Mamedovad, and Volodymyr Yariye
a
Department of Internal Medicine, Yale University, New Haven, Connecticut, USA; bUkrainian Institute on Public Health Policy (UIPHP), Kyiv,
Ukraine; cSchool of Medicine, Harvard University, Boston, Massachusetts, USA; dKyiv City AIDS Center, Kyiv, Ukraine; eKyiv City Addiction
Treatment Clinic “Sociotherapy”, Kyiv, Ukraine

ABSTRACT KEYWORDS
Background: Older people with human immunodeficiency virus - HIV (OPWH) defined as
50 years Social support; medication-
old account for a growing proportion of newly diagnosed infections in Ukraine (16% in 2018), but assisted treatment; older
the prevalence of substance use disorder among OPWH in Ukraine remains unknown. Ukraine adults with HIV; Covid-19
lockdown; low- and
responded to the Covid-19 pandemic with a comprehensive lockdown in late March 2020. middle-income settings
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 pharmaco-
logical 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 interven-
tions. The lessons learned may be relevant to other countries as well.

Introduction Previous research established the value of social support to

Of 4.2 million older people with human immunodeficiency
virus – HIV (OPWH) worldwide, defined as
50 years old,
80% reside in low- and middle-income settings (Autenrieth
et al., 2018) that experience unequal Covid-19 burdens on
healthcare. Ukraine is a low- and middle- income country
with increasing HIV incidence and mortality (UNAIDS,
2016). The HIV epidemic in Ukraine has been primarily
driven by injection drug use (IDU) (Booth et al., 2016;
Dumchev et al., 2017), with the transition to a generalized
epidemic mainly through sexual contact (Avert, 2018). In
2017, 25% of all new HIV infections in Ukraine were associ-
ated with IDU (UNAIDS, 2018b), with HIV prevalence
among people who inject drugs (PWID) estimated at 22.6%
(UNAIDS, 2018a). OPWH account for a growing proportion
of newly diagnosed infections in Ukraine (16% in 2018)
(Rozanova et al., 2018). but data on OPWH is sparse con-
cerning comorbidities including substance use disorder
(SUD). As OPWH get diagnosed with later-stage HIV (52%
with CD4 < 200 among older PWH vs. 35% among younger
PWH, p < 0.001) and multiple comorbidities, antiretroviral
therapy (ART) adherence is essential for preserving long term
positive outcomes (Group et al., 2015; Lifson et al., 2017).
improving HIV and addiction treatment adherence in persons
with SUD including OPWH across a variety of international
settings like the US (Edelman et al., 2014; Polcin & Korcha,
2017), Ukraine, Vietnam, and Indonesia (Lancaster et al.,
2019). However, a recent systematic review concluded that in
combination with medication-assisted therapies the utility of
social support (via psychosocial interventions) was not con-
sistent (Dugosh et al., 2016). Given the growing opioid prob-
lem in the United States (and elsewhere), expanding access to
medication-assisted therapy (MAT) with methadone, bupre-
norphine, or naltrexone by removing programmatic, adminis-
trative, and stigma-related barriers has been a key healthcare
goal (Volkow et al., 2014; Volkow & Wargo, 2018), social
support fading from priority focus.
We have researched lived experiences of OPWH in
Ukraine since 2018, exploring the growing cases of HIV
infection among older adults (Rozanova et al., 2019a), and
examining the meaning and implications of receiving an
HIV diagnosis in later life (Rozanova et al., 2019b). Focus
groups, we conducted in Kyiv in October-December 2019
with OPWH with SUD, and their HIV and addiction treat-
ment providers helped us appreciate the extent of OPWH’s
vulnerability (Rozanova et al., 2020). Older adults with HIV
especially with a history of SUD live with multiple physical

CONTACT Julia Rozanova julia.rozanova@yale.edu Yale AIDS Program, 135 College Street, Suite 323, New Haven, CT 06510, USA.
ß 2020 Taylor & Francis Group, LLC

and mental comorbidities,(Edelman et al., 2014) and may
frequently experience the stigma of HIV, substance use, and
social exclusion (Rozanova et al., 2019b). By their late forties
or early fifties, some PWID with HIV may die from these
conditions, while others switch to alcohol as their drug of
choice (legal and easier to obtain) (Shipunov, 2019), and a
minority initiate MAT as a respite from procuring street
drugs (as patients in Ukraine may receive MAT for free,
likewise to ART) or as a means of recovery (Rozanova
et al., 2017).
Materials and methods
Ukraine responded to the Covid-19 pandemic with a com-
prehensive lockdown in late March 2020. In May 2020 we
surveyed by phone 120 OPWH receiving HIV care in Kyiv,
including 50 (42%) patients diagnosed with SUD about how
Covid-19 pandemic impacts older patients and their ability
to continue HIV and/or addiction treatment. 47% of partici-
pants were women; participants’ age ranged from 55 to
81 years, 96% were prescribed ART, and 72% had comorbid-
ities other than HIV and SUD. We also performed phone
interviews with HIV and addiction treatment providers in
Kyiv both at the frontlines and senior executive levels.
How HIV and addiction treatment providers supported
OPWH during the lockdown
Our data demonstrated that while OPWH with SUD main-
tained HIV and SUD therapy throughout the lockdown,
there is great anxiety about the availability of treatment
services. Providers reported concerns about the stability of
clinical services given decreased billable patient volume, par-
ticularly among social workers, whose salaries are based on
a per-patient fee. Simultaneously the amount of non-billable
tasks to keep patients in care, increased (e.g., mailing ART
to OPWH unable to visit the clinic to obtain refills). Patient
and provider responses pointed to the importance of social
support that in recent years has become optional alongside
pharmacological treatment to SUD. Yet, Covid-19 lockdown
demonstrated how support by trusted clinicians providing
HIV and addiction treatment services enabled OPWH with
SUD to stay in care: they have developed a schedule of fre-
quent informal phone conversations with their clinicians
punctuated by infrequent visits to the clinics. However,
when lockdown restrictions are lifted OPWH with SUD will
need to visit clinics more frequently for checkups and
receiving methadone, but providers may not be able to
maintain support at the same level as the early pandemic.
But, this support is sorely needed. In our survey, a quarter
of OPWH with SUD reported having fewer than 2 people
including healthcare providers who can support them (with
29% of OPWH never disclosed their HIV status to anybody
other than treatment providers), and 61% of OPWH had no
treatment supporter. Thus, after the lockdown, OPWH with
SUD may feel more isolated and their risk of discontinuing
addiction treatment or relapsing to substance use may not
be sustained but increase.
SUBSTANCE USE & MISUSE 1903
Implications for HIV and SUD treatment in Ukraine
post-Covid-19
Examining experiences of OPWH with SUD and their HIV
and addiction treatment providers during lockdown pro-
vided four insights. While specific to the Ukrainian context,
they may have implications for addiction treatment pro-
viders and researchers of addictions in other countries, par-
ticularly in other low- and middle-income settings.
First, reviewing OPWH’s adherence to SUD treatment
during lockdown may paint an overly optimistic picture,
masking social costs of these results. Covid-19 lockdown
may disrupt MAT and ART among OPWH with SUD not
only while being in place, but also during the reopening.
After hefty doses of support by clinicians, reduction of sup-
port may lead to OPWH feeling even more isolated.
Second, definitions of billable (to the public insurance)
services prior to Covid-19 provided to OPWH by clinicians
have no provisions for intra- and extra-mural activities to
retain patients in care during pandemics and quarantines.
Thus, clinics and care providers risk being financially penal-
ized for efforts to support high-burden OPWH with SUD.
Current definitions create disincentives for HIV and addic-
tion treatment providers to take up OPWH patients in com-
parison to younger groups – which is true for many
countries outside of Ukraine, including the United States.
The definitions of what constitutes a billable service need to
be revised and extended considering the Covid-19 lockdown
experience to ensure OPWH with SUD get the support
they need.
Third, post-Covid-19 pharmacological approaches to
SUD treatment without social support are like vehicles with-
out gas. Availability of MAT post-Covid-19 may not be
sufficient to yield good patient outcomes particularly after
re-opening after Covid-19 when some of the patients who
were temporarily allowed to get take-home MAT, may be
required to return to sites more frequently or even daily.
Relationships involving MAT providers, OPWH, and their
social supports, can offer creative solutions.
Fourth, post-Covid-19 the social support needed by
OPWH patients with SUD will exceed support available
from their addiction and HIV providers. This is particularly
salient given that in many countries including the US and
the UK, many front-line clinicians like social workers had
their hours significantly cut, or made redundant as routine
patient care was suspended during the lockdown. This def-
icit may be mitigated by utilizing lay health workers, espe-
cially in low- and middle-income settings, through remote
Peer-based interventions to support OPWH with SUD to
continue HIV and addiction care. Given Covid-19’s toll on
OPWH with SUD, 21% of whom reported having suicidal
ideation and 55% had substantial depressive symptoms,
interventions must address mental health in this vulnerable
population. OPWH can become an extended network help-
ing one another leverage social and emotional costs of
Covid-19 and fostering social belonging.
In sum, the examination of Covid-19 lockdown experien-
ces in Ukraine demonstrated that alongside biomedical ther-
apy, social support is critical to avoiding treatment
1904 J. ROZANOVA ET AL.
interruption for OPWH with SUD. The research agenda for
these patients going forward must include (1) determining
the type of telehealth support that will be effective to retain
OPWH PWID, (2) provision of support by lay health work-
ers, and (3) the cost-effectiveness of such interventions.
Acknowledgements
We wish to thank Drs. Oleksandr Shipunov, Natalya Vykhtyk, Tetiana
Bodnaruk, Oleg Tandavkiy, and Natalya Knyazeva for sharing their
experiences of providing front-line care to OPWH with SUD during
Covid-19 lockdown. We wish to thank Yuliia Minster, Tetiana Orlova,
and Nataliia Radych for their assistance in conducting phone inter-
views with OPWH participants.
Declaration of interest
The authors report no conflict of interest.
Funding
This work was supported by the National Institutes of Health [grant
number K01DA047194-01 to J. Rozanova]; the Yale Women’s Faculty
Forum Award to J. Rozanova, the Yale Fund for Lesbian and Gay
Studies Award to J. Rozanova, and the Yale MacMillan International
and Area Studies Center Award to S. Shenoi and J. Rozanova.
ORCID
Julia Rozanova http://orcid.org/0000-0002-9971-6767
Sheela Shenoi http://orcid.org/0000-0001-7654-4344
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