Eastern Europe and Central Asia (EECA) have among the highest (5 of the top 10) incarceration rates worldwide, with staggering numbers of people who inject drugs (PWID), mostly with opioid use disorder (OUD: 82%) and HIV (PWH: 18%). The HIV epidemic in EECA is primarily concentrated in PWID, who account for 56% of new HIV infections with a high HIV prevalence among PWID (7.3-53.4%). The prisons and probation settings provide an opportunity for HIV prevention using opioid agonist therapies (OAT). The newly (past 5 years) formed probation system in these countries presents new opportunities and challenges for HIV prevention as probation does not have an international mandate to ensure human rights access to HIV prevention and treatment. This proposal builds on our existing implementation science network in several EECA countries. Specifically, first, MAT-LINK used SBIRT (screening, brief intervention, and referral to treatment) with trained researchers to pilot test a strategy to scale-up opioid agonist therapies. Second, many EECA countries have recently introduced probation, providing opportunities to ensure access to trans-institutionalized persons in probation to better align public health with public safety. Third, real-world implementation using existing infrastructure and staffing across more sites is now needed to expand OAT throughout prisons and probation. Fourth, we developed the first Project ECHO in EECA to guide OAT integration into primary care and psychiatric care into OAT settings. We have successfully used the EPIS (Explore, Prepare, Implement and Sustain) framework combined with the NIATx model of process improvement to scale-up OAT. Also using EPIS, we used Project ECHO to integrate OAT and HIV care into primary care clinics in Ukraine to teach specialized care to non-specialists, which we propose to use to teach prison doctors. NIATx is an evidence-informed facilitation strategy with documented successes in the adoption and scale-up of evidence-based practices (EBPs), like OAT. Using the EPIS framework and the NIATx approach we propose to: AIM 1: Scale-up OAT as HIV prevention in prisons and pre- trial detention in EECA and for individuals with OUD and link them to community treatment after release; and AIM 2: Scale-up OAT as HIV prevention in the newly formed probation system in EECA and for individuals with OUD and link them to OAT treatment as part of routine care to align public safety and public health. We will continue using our network to achieve these goals through collaboration with our partners in EECA. Significance is high due to the need to reduce HIV transmission in EECA where HIV, PWID and incarceration are syndemic, which is primarily concentrated in PWID and where OAT coverage is low. Innovation is high by using the NIATx model to scale-up OAT in prisons and probation, along with collaborative learning tools like Project ECHO to teach and maintain skills. Feasibility is high due to longstanding collaborations between these many collaborators and buy-in from CJS settings. Public health benefit is high due to addressing the interface of health and justice where many of the most vulnerable exist.

Project Narrative Prisons concentrate people who inject drugs and people living with HIV, especially in the Commonwealth of Independent States of the former Soviet Union, where the HIV epidemic and drug injectors and their sexual partners remains volatile. Introducing and expanding an evidence-based HIV prevention strategy like opioid substitution therapy within the prisons in a legal, political, and cultural context is fraught with barriers that involve the client, prison staff and the criminal justice infrastructure. Implementation science strategies are effective approaches to study and promote intervention effectiveness that simultaneously works to overcome barriers at each level.