Sustainability of opioid agonist therapy programmes in Belarus, the Republic of Moldova, Tajikistan and Ukraine in the context of transition from Global Fund support during 2020-2023

Abstract Background Most national programmes of opioid agonist therapy (OAT) in Eastern Europe and Central Asia are at a critical juncture for building their sustainability due to decreasing support from the Global Fund and other international HIV funders. Therefore, it is timely to identify the status, trends, opportunities and risk factors of OAT preparedness in the face of donor transition. Methods The study assessed the OAT sustainability progress in 4 countries: Belarus, the Republic of Moldova, Tajikistan and Ukraine. The national assessments were conducted in 2020 and repeated during 2022–2023. In total, 363 sources were reviewed and used, 83 interviews with key informants and 13 focus groups were conducted with clients, using a joint methodology and a defined Framework with three dimensions: ‘Policy & Governance’; ‘Finance & Resources’; and, ‘Services’. Results All four countries have made improvements to increase OAT sustainability, though it varied. In 2022, Ukraine had a substantial degree of sustainability, followed by Belarus and Moldova with a moderate degree, while Tajikistan’s sustainability was at moderate-to-high risk. No country achieved a high degree of OAT sustainability in any of the three dimensions measured. However, a high degree of sustainability was reported for at least one indicator in Belarus, Moldova and Ukraine: ‘Medicines’; ‘Financial resources’; ‘Evidence and information systems’; ‘Service Accessibility’; or, ‘Service integration & quality’. On average, the greatest improvement between 2020 and 2022 was seen for ‘Availability & coverage’; ‘Financial resources’; ‘Service quality & integration’; and, ‘Service accessibility’. The highest risks across the countries, notably in Belarus and Tajikistan, were recorded for the indicator, ‘Availability and coverage’. Of concern is that the least progress, or even a decline, was found in ‘Human resources’ within the sustainability indicator. Conclusions OAT sustainability in 4 analysed countries remains at risk, although those countries are at a different point of donor transition. OAT resilience and ability to scale up depend upon multiple factors. Political will and continued funding are two of them, as demonstrated by Ukraine’s progress despite challenges posed by Russia’s full-scale invasion in 2022. The results show that both financial and programmatic areas are at risk and stagnating progress requires collective efforts.