Background: Stigma related to both HIV and substance use (SU) affects HIV-positive people who use drugs (PWUD) in Ukraine. While integration of HIV and SU treatment improves access to care and care outcomes, its effect on internalized stigma is unknown. This study assessed HIV and SU stigma perceived by HIV-positive PWUD in addiction treatment, and associations of stigma with care integration in Ukraine.
Methods: We conducted a cross-sectional survey of HIV-positive PWUD, receiving opioid agonist treatment (OAT), in six regions of Ukraine, at 3 facilities providing addiction treatment only and 3 integrated facilities providing both SU and HIV care. Primary outcomes were total HIV and SU stigma scores measured with Berger Scale and Substance Abuse Stigma Scale, respectively. We assessed the facilities'' user-friendliness and accessibility, on-site support from non-governmental organizations (NGO), regular HIV care visits, receiving ART, receiving OAT, and presence of depressive symptoms as predictors of stigma in linear and logistic regression models.
Results: Study participants (n=191) had the following characteristics: 75% male; mean age 40; 59 % unemployed; mean time in OAT 34 months; and 73% receiving NGO services at OAT site. Levels of HIV stigma (mean 0.39 out of 1; 95% CI:0.36-0.41) and SU stigma (mean 0.41 out of 1; 95% CI:0.38-0.43) were similar. Receiving integrated services was not associated with total HIV stigma (AOR=1.08; 95% CI:0.59-1.98) or SU stigma scores (AOR=1.16; 95% CI:0.60-2.25). SU stigma was the only predictor of HIV stigma (AOR=2.59; 95% CI:1.41- 4.85). SU stigma was associated with high HIV stigma (AOR=3.01; 95% CI:1.58;5.91), depressive symptoms (AOR=2.00; 95% CI:1.01-3.97), and being unemployed (AOR=2.10; 95% CI:1.04-4.32). Receiving NGO services on-site was associated with lower SU stigma (AOR=0.27; 95% CI:0.12-0.59).
Conclusions: In our study, integrated treatment was not associated with a significant decrease in substance use or HIV stigma. Findings indicate that targeted interventions are necessary at integrated and non-integrated care facilities to address both forms of stigma affecting HIV-positive PWUD. Reinforcing protective factors such as NGO support at addiction care facilities, including assistance with employment, might help mitigate the highly persistent stigma related to substance use and its potential interaction with HIV stigma in Ukraine.

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