In this Ukrainian cohort, spanning more than 10 years, just under one-fifth of women were current or past-IDUs. IDUs had higher prevalence of coinfections, advanced HIV disease and severe immunosuppression compared with other women. One in 10 IDUs did not access PMTCT prophylaxis, mainly because they were diagnosed too late. Adverse pregnancy outcomes, including PTD and LBW as well as MTCT, were more frequent in IDUs and IDU history was associated independently with a 30% increased MTCT risk.
IDUs are frequently socially marginalized and socio-economically deprived, and can be hard to reach with services, including HIV testing. Coverage of IDUs with HIV testing (in previous 12 months) is an estimated 30% in Ukraine [37
]. More IDUs here knew their HIV-positive status before pregnancy than non-IDUs (47% versus 28%), probably reflecting HIV testing within addiction services. However, among women with unknown HIV status at conception, IDUs were more likely to be diagnosed late. One in 10 IDUs were diagnosed intrapartum, with sdNVP the only potential option for PMTCT prophylaxis compared with 3% of other women, reflecting the fact that one in six received no ANC. In a study in St Petersburg, Russian Federation, two-thirds of women presenting in labour with unknown HIV status were IDUs, mostly without ANC [27
]; here the equivalent figure was 43%. IDU has been identified previously as a risk factor for non-receipt of PMTCT prophylaxis in western Europe [25
], but not consistently [38
In unadjusted analyses, IDU was associated with a twofold increased MTCT risk and IDUs contributed 31% of all vertical transmissions. The main mechanisms behind the elevated MTCT risk associated with IDUs were most probably their lower coverage with PMTCT interventions and higher rate of PTD. Infants of current IDUs were at greatest risk of MTCT, with a rate of 13.1%. Such infants were significantly more likely to be delivered preterm than other infants and had a nearly threefold increased probability of non-receipt of PMTCT prophylaxis, resulting in a nearly 2.5-times increased transmission risk versus never IDUs in unadjusted analyses. The finding that current IDUs were at greatest risk of MTCT underscores the need to strengthen harm reduction in Ukraine as a key component of the broad PMTCT strategy. IDUs remained associated significantly with a 30% increased MTCT risk in adjusted analysis; this might be explained by factors including poorer adherence to prophylaxis/treatment and higher rates of some coinfections, including HCV [39
], but we were unable to explore further due to limited data.
The trend of declining MTCT rates over time applied to IDUs as well as other women, with both groups having rates <4% by 2008–09. This is above the target for ‘virtual elimination’ of HIV among infants [44
], but is very encouraging and largely reflects the introduction of HAART for PMTCT. Challenges remain, however: although non-receipt of PMTCT prophylaxis declined significantly over time due to scaling-up of the PMTCT programme in Ukraine, IDUs still had a two- to threefold increased risk of non-receipt after adjustment for time-period and other confounding factors, including late HIV diagnosis and PTD.
NAS, which occurs in approximately 60% of all newborns exposed in utero
to opiates [45
], was identified in 62% of newborns of current IDUs. Although NAS is easy to treat with morphine drops, this treatment is not currently available in Ukraine. Of particular public health concern is that nearly a third of PTD here were contributed by IDUs, probably reflecting factors including no or limited ANC, poor nutrition, alcohol use and smoking, maternal infections, socio-economic factors and direct effect of illicit drugs [18
]. Smoking among IDUs was nearly universal (94%), and is associated with more intense NAS [48
]. Maternal drug use is associated with infant abandonment in eastern Europe [49
], and we reported recently that infants with NAS in our cohort were 10 times more likely to be abandoned than other infants [52
Problems faced by IDUs in accessing addiction, HIV, reproductive and other services [18
] reflect barriers to service access (including geographical or administrative barriers and chaotic and/or mobile life-styles), but may also arise from specific avoidance of services following prior negative/stigmatizing experiences [31
]. Our study population most probably faced a double stigma, due to their IDU and HIV status, which may have been compounded by their gender and pregnancy [56
]. The higher rate of pregnancy terminations and of unplanned pregnancy in IDUs compared with non-IDUs are consistent with inadequate access to services. Although the proportions of IDUs and non-IDUs receiving antenatal HAART were similar, IDUs had worse health status, and among women with treatment indications IDUs were significantly less likely to receive HAART. This inequity is consistent with other findings, demonstrating that IDUs are less likely to receive HAART or start HAART later than non-IDUs [42
A comprehensive package of care for IDUs should include HIV testing, treatment and care, tuberculosis (TB) and STI services and harm reduction, including needle/syringe exchange programmes (NSP) and opioid agonist maintenance treatment [58
]. For female IDUs, linkages between these services and reproductive health services, including pregnancy testing, contraception and PMTCT are very important [58
], but frequently weak. Provision of multi-disciplinary care is particularly challenging in Ukraine, where there remains a traditional vertical health system with few functional linkages between services. Coverage with NSP was initially low in Ukraine, with fewer than 10% of IDUs estimated to be reached by early 2003 [59
]; however, recent estimates indicate that 32% of IDUs were reached by preventive interventions in the previous 12 months in 2008 [27
Implementation of opioid agonist maintenance treatment for IDUs has also been slow, with methadone maintenance not available until mid-2008 [7
]; no women in our postnatal study received methadone (no data in the ECS). WHO guidelines include a strong recommendation for provision of such treatment to pregnant IDUs [58
], and the first pilot study of methadone maintenance in pregnant women will soon start in Ukraine. An additional benefit of a daily intake of methadone is the facilitation of close medical monitoring in pregnant drug addicts.
One of the most effective ways of preventing HIV infection in infants is to prevent their mothers from becoming infected in the first place. Recent models suggest that HIV prevalence in Odessa could be reduced by 41% over the next 5 years if there were a 60% reduction in unmet need for services, including NSP, opioid agonist maintenance treatment and antiretroviral therapy started promptly when indicated [60
]. The specific barriers that female IDUs face in accessing harm reduction services and the role these play in their increased risk of HIV acquisition require further investigation. Prevention of unintended pregnancies in HIV-infected women is another important approach to preventing infant infections. Nearly half the IDUs here had not planned their pregnancy, significantly more than other women, in a context of low levels of effective family planning use and identified considerable unmet need for contraception [30
This study is limited by its observational nature and the potential for confounding. Social desirability bias may have prevented some women from reporting IDU. Although our classification also used clinical observation and NAS, up to 40% of infants with fetal exposure to opiates do not develop NAS. We therefore cannot exclude the possibility that some IDUs may have been included in the non-IDU group, underscored by the 22% prevalence of HCV in the non-IDU group. Our study population lives in cities with the highest antenatal HIV prevalence in Ukraine, including Odessa, Kyiv and Mykolaiv [9
], and we estimate that approximately 30% of HIV-infected women delivering in Ukraine are included in our study (1166 of 3649 in 2008) [10
]. Our study excluded women terminating their pregnancy and stillbirths; such groups may include more IDUs than the study population.
Some important successes documented here include the increasing proportion of IDUs knowing their HIV status before pregnancy, the declining proportion receiving no PMTCT prophylaxis and substantially lower MTCT risk in recent years, regardless of IDU status. However, important challenges remain, such as provision of comprehensive care to female IDUs, including harm reduction, family planning and HIV treatment as well as provision of ANC and PMTCT, with an emphasis on improving timely access.