Social Network Strategy improves access to HIV testing and harm reduction programs for PWID and their partners in Kazakhstan.

INTRODUCTION: The region of Eastern Europe and Сentral Asia has a growing HIV epidemic. Kazakhstan is a country in Central Asia with an estimated 33,000 people living with HIV. The new HIV infections have increased by 29% since 2010. Evidence suggests that HIV testing strategies focused on social networks are effective methods to identify more people with undiagnosed HIV. We conducted a study to describe the optimized HIV case finding (OCF) intervention for people who inject drugs (PWID) and their partners in Kazakhstan. METHODOLOGY: The OCF is based on recruitment of the extended risk social networks of HIV-positive PWID, using a two-step recruitment algorithm. RESULTS: There were 5,983 PWIDs and their partners tested for HIV, of those 149 (2.5%) received HIV-positive test results and the majority 145 (97%) were newly identified HIV-positive. The characteristics which had a statistically significant positive association with HIV-positive test results included: age group 15-19 (OR 4.12, 95% CI 1.44-11.7); age group 20-24 (OR 1.97, 95% CI 1.03-3.8); age group 50+ (OR 2.45, 95% CI 1.48-4.1); male sex (OR 1.78; 95% CI 1.2-2.6), participants who have previously received harm reduction services (OR 1.48; 95% CI 1.0-2.2); partners from "other groups" (OR 2.31, 95% CI 1.3-4.2). CONCLUSIONS: Low-threshold HIV testing and harm reduction services, like OCF using directly assisted self-testing and social network strategies are essential in reaching key populations with HIV prevention, increasing access to HIV testing and care.

Effectiveness of an Intervention to Improve HIV Service Delivery for People Who Inject Drugs in Kazakhstan: A Cluster Trial.

Importance: The increasing HIV incidence rates and suboptimal rates of testing, engagement, and retention in care for people who inject drugs (PWID) in Kazakhstan underscore the need for effective HIV care continuum interventions for PWID. Objective: To determine the effectiveness of the Bridge HIV care continuum intervention implemented in needle and syringe programs (NSPs) in Kazakhstan. Design, Setting, and Participants: This stepped-wedge cluster trial was conducted from February 2017 to May 2020, with implementation beginning sequentially across 3 cities (Almaty, Karaganda-Temirtau, and Shymkent) in August 2017, January 2018, and May 2019. Intervention effect sizes were estimated via population-averaged models, and hypothesis testing relied on a permutation testing approach. The primary unit of analysis was an NSP. Data analysis was performed from October 2020 to April 2022. Interventions: The intervention addresses the full HIV care continuum: identification, testing, referral to services, and linkage to HIV care. The 3 intervention components were (1) a social network strategy, a peer-driven recruitment approach for HIV testing; (2) HIV counseling, rapid testing, and referral following international and national guidelines and protocols; and (3) enhanced antiretroviral treatment and access to services. Main Outcomes and Measures: The primary outcomes were the effectiveness of implementing Bridge's enhanced service integration approach in increasing the number of PWID served at NSPs, increasing the number of PWID who are tested for HIV in NSPs, and improving linking HIV-positive PWID with HIV care. Secondary outcomes included numbers of clients registered for HIV care, initiation of antiretroviral therapy, and viral suppression. Results: Twenty-four NSPs (8 in each city) served a total of 1225 PWID (369 in Almaty, 618 in Karaganda-Temirtau, and 238 in Shymkent) at the preimplementation study step; 1015 clients (82.9%) were male, and the mean (SD) age was 36.7 (7.1) years. Compared with preimplementation study steps, during Bridge intervention implementation steps, NSPs experienced a significant increase in the number of PWID clients registered (incidence rate ratio, 2.37; 95% CI, 1.48-3.78) and the number of PWID who received rapid HIV tests (incidence rate ratio, 3.98; 95% CI, 2.30-6.90). No significant increase in referral to HIV care was observed. The study also found significant support for secondary outcomes of antiretroviral therapy initiation and the number of clients who achieved viral suppression. Conclusions and Relevance: In this stepped-wedge cluster trial, the findings suggest that implementation of the Bridge intervention was associated with significant improvement in several steps in the continuum of HIV care for PWID in Kazakhstan. Trial Registration: ClinicalTrials.gov Identifier: NCT02796027.

A cluster-randomized controlled trial of a combination HIV risk reduction and microfinance intervention for female sex workers who use drugs in Kazakhstan.

INTRODUCTION: Female sex workers (FSW) who use drugs are a key population at risk of HIV in Kazakhstan, and face multiple structural barriers to HIV prevention. More research is needed on the role of structural interventions such as microfinance (MF) in reducing HIV risk. This paper describes the results of a cluster-randomized controlled trial to test the efficacy of a combination HIVRR + MF intervention in reducing biologically confirmed STIs and HIV risk behaviours. METHODS: This study took place from May 2015 to October 2018 in two cities in Kazakhstan. We screened 763 participants for eligibility and enrolled 354 FSW who use drugs. Participants were randomized in cohorts to receive either a four-session HIVRR intervention, or that same intervention plus 30 additional sessions of financial literacy training, vocational training and asset-building through a matched-savings programme. Repeated behavioural and biological assessments were conducted at baseline, 3-, 6- and 12-months post-intervention. Biological and behavioural primary outcomes included HIV/STI incidence, sexual risk behaviours and drug use risk behaviours, evaluated over the 12-month period. RESULTS: Over the 12-month follow-up period, few differences in study outcomes were noted between arms. There was only one newly-detected HIV case, and study arms did not significantly differ on any STI incidence. At post-intervention assessments compared to baseline, both HIVRR and HIVRR + MF participants significantly reduced sexual and drug use risk behaviours, and showed improvements in financial outcomes, condom use attitudes and self-efficacy, social support, and access to medical care. In addition, HIVRR + MF participants showed a 72% greater reduction in the number of unprotected sex acts with paying partners at the six-month assessment (IRR = IRR = 0.28, 95% CI = 0.08, 0.92), and a 10% greater reduction in the proportion of income from sex work at the three-month assessment (b = -0.10, 95% CI = -0.17, -0.02) than HIVRR participants did. HIVRR + MF participants also showed significantly improved performance on financial self-efficacy compared to HIVRR over the 12-month follow-up period. CONCLUSIONS: Compared to a combination HIVRR + MF intervention, a robust HIVRR intervention alone may be sufficient to reduce sexual and drug risk behaviours among FSW who use drugs. There may be structural limitations to the promise of microfinance for HIV risk reduction among this population.

Factors associated with being on antiretroviral treatment among people living with HIV in Almaty, Kazakhstan.

Like other countries in the region of Eastern Europe and Central Asia, Kazakhstan has seen an increase in the number of new HIV cases in recent years. HIV treatment coverage among people living with HIV (PLHIV) in Kazakhstan is suboptimal; however, the country has committed to reaching the 90-90-90 goals for HIV diagnosis and treatment. Kazakhstan has recently committed to the "test and treat" approach, and provides antiretroviral treatment (ART) to all PLHIV. Using registry data from the City AIDS Center, we used logistic regression models to assess the factors associated with uptake of ART and its correlates among 2687 adult PLHIV in Almaty, Kazakhstan. 67.8% were on treatment. PLHIV are more likely to be on ART if diagnosed in the later clinical stages [aOR = 2.45, 95% CI (1.85, 3.25)], diagnosed after the country's change in treatment approach [aOR = 1.97, 95% CI (1.42, 2.72)], and acquired HIV via sexual transmission vs. injection drug use [aOR = 1.72, 95%CI (1.25, 2.35)]. Our findings highlight which subpopulations are most in need of interventions to promote ART in Kazakhstan, and also serve as an example for other countries in Central Asia for thinking about what factors are important to consider in improving HIV treatment coverage.

The survival rate of tuberculosis patients in HIV-treated cohort of 2008-2018 in Almaty, Kazakhstan.

INTRODUCTION: HIV/TB comorbidity is responsible for 1.6 million deaths worldwide. HIV/TB control and patients' survival are still among priorities of the national HIV and TB programs. We aimed to evaluate the HIV/TB survival in connection with TB treatment outcomes and factors influencing life duration of the cohort 2008-2018 in Almaty, Kazakhstan. METHODOLOGY: This retrospective cohort study extracted data for all HIV and pulmonary TB adults coinfected during 2008-2018 in Almaty from national registries to apply descriptive, Kaplan-Meier estimation, and Cox proportional hazards regression model. Survival function for the TB treatment outcomes and factors predicting the probability of survival were tested and described. RESULTS: The cohort population (n = 521) mean age was 37.4 years with 405 (77.7%) males and 210 (40.3%) marrieds. More than one TB treatment had 181 (34.7%) patients, 291 (55.9%) were smear-positive (SS+), and 423 (81.2%) were on antiretroviral therapy with mean CD4 count 254.22cells/µL. Probability to live longer was higher (128 versus 37 months, p = 0.003; 95% confidence interval (CI) 71.65, 184.35) for those who succeeded in TB treatment compared to "lost to follow-up" and "failed" treatment outcomes. Adjusted Cox regression model death hazard showed association with missing ART treatment (HR: 1.699, 95%CI 1.164, 2.481, p = 0.006) and having CD4 count < 499 (HR 2.398, 95%CI 1.191, 4.830, p < 0.014). CONCLUSION: TB treatment outcomes, ART treatment, and the CD4 count of HIV/TB coinfected population substantially influence their life duration. The medical decision- and policy-makers should take this into consideration when implementing targeted improvements in the national HIV and TB programs.

Antiretroviral therapy among patients with HIV in Almaty, Kazakhstan: the implication for HIV-associated tuberculosis control.

INTRODUCTION: Antiretroviral therapy (ART) is an effective preventive strategy against tuberculosis (TB) in people living with HIV (PLWH). In Kazakhstan, according to the revised HIV treatment guideline (2017), ART should be initiated immediately after HIV diagnosis established, regardless of CD4+ count. AIM: To evaluate the impact of early initiation of ART on TB infection in PLWH registered in the Center of Prevention and Control of AIDS, Almaty, Kazakhstan, between 2008 and 2018. METHODOLOGY: A retrospective cohort study was conducted using the data of 4,053 patients from electronic HIV case management system (2008-2018) (EHCMS). RESULTS: The study revealed low rates (12.6%) of rapid ART (≤ 1 month after HIV diagnosis). Patients in the rapid ART initiation group were less likely to develop TB compared with those who started treatment >1 month after the HIV detection (odds ratio 1.6; 95% confidence interval [1.1, 2.2]; p = 0.00799). Interestingly, the risk for developing TB among patients receiving ART ≥ 1 month after HIV diagnosis was significantly higher compared with those not taking any treatment. The latter was explained by several confounding not addressed during the analysis, since ART was prescribed to patients with primarily deeper immunodeficiency, while the patients not receiving ART were less immunocompromised. CONCLUSION: Despite the recently changed HIV treatment guideline in Kazakhstan, ART is still initiated based on the disease severity. In 2018, the initiation of ART during the first month after HIV diagnosis increased by 50%. However, it is necessary to reduce the time to initiation of ART for all patients.