Scaling Up HIV Self-Testing and Linkage to Care Among Women Who Exchange Sex and/or Use Drugs in Kazakhstan.

HIV testing is the point of entry for linkage to treatment and prevention and is critically important to ending the HIV epidemic. HIV self-testing (HST) is an acceptable, user-controlled tool that can address testing barriers, which is especially important for populations who need to test frequently, like women who exchange or trade sex for money or other needed resources (WES) and women who use drugs. HST is feasible and acceptable among WES, but research among WES who also use drugs is limited, particularly in places like Kazakhstan, where HIV rates remain high and where scale-up of HST and pre-exposure prophylaxis (PrEP) is in process. To develop effective programming, there is a need to develop tailored services for WES and/or use drugs that address key barriers. We discuss opportunities to increase HST and linkage to services among WES and/or use drugs in Kazakhstan, with a focus on stigma reduction.

"Protected Means Armed": Perspectives on Pre-Exposure Prophylaxis (PrEP) Among Women Who Engage in Sex Work and Use Drugs in Kazakhstan.

Pre-exposure prophylaxis (PrEP) for HIV prevention has recently become available in Kazakhstan, but women engaged in sex work who use drugs (WESW-UD) could benefit from tailored approaches to support uptake and adherence. To better understand how best to support WESW-UD at each stage of the PrEP continuum (awareness, acceptability, uptake, and adherence), we analyzed data from 30 in-depth interviews and four focus groups with 48 WESW-UD from two cities in Kazakhstan. We conducted thematic analysis to characterize perceptions, barriers, and motivators within each step of the PrEP continuum. Participants reported low awareness, but high interest in PrEP. Motivating factors included optimizing health and increased confidence. Participants expressed many preferences and concerns regarding PrEP modality and delivery. Participants also described how organizational mistrust and social support can prevent or facilitate PrEP uptake or adherence. Kazakhstan's scale-up of PrEP should consider the needs and preferences of WESW-UD to ensure equitable access.

Implementation of a Dyad-Based Intervention to Improve Antiretroviral Therapy Adherence Among HIV-Positive People Who Inject Drugs in Kazakhstan: A Randomized Trial.

Purpose: HIV-positive people who inject drugs (PWID) in Kazakhstan face many challenges to antiretroviral therapy (ART) adherence. Interventions that leverage social support from an intimate partner, family member, or friend may be effective in improving ART adherence among this population. The purpose of this paper is to describe the implementation process of a dyad-based intervention among HIV-positive PWID and their treatment support partners. Method: Sixty-six HIV-positive PWID and 66 of their treatment support partners will be enrolled in this pilot randomized controlled trial in Almaty, Kazakhstan, and randomized as dyads to receive an adapted version of the SMART Couples intervention or standard of care. Results: Several implementation strategies were used to facilitate intervention delivery, including remote delivery, training of staff, supervision, technical assistance, quality assurance, and collection of assessments through diverse sources. Discussion: This trial responds to a need for dyad-based ART adherence interventions adapted specifically for HIV-positive PWID.

Reducing Partner Violence Against Women who Exchange Sex and use Drugs through a Combination Microfinance and HIV Risk Reduction Intervention: A Cluster Randomized Trial.

Women who exchange sex and use drugs (WESUD) are at high risk for HIV infection and partner violence. The few tested interventions at the intersection of HIV and IPV show mixed results. This analysis examined the impact of a combination HIV risk reduction (HIVRR) and microfinance (MF) intervention on reported paying and intimate partner violence against WESUD in Kazakhstan. This cluster randomized controlled trial enrolled 354 women from 2015 to 2018 and randomized them to either a combination of HIVRR and MF intervention or HIVRR alone. Outcomes were assessed at four time points over 15 months. Logistic regression within a Bayesian approach assessed change in odds ratio (OR) of recent physical, psychological, or sexual violence perpetrated by current or past intimate partners; and paying partners/clients by study arm over time. Compared to the control arm, the combination intervention decreased the odds of participants experiencing physical violence from past intimate partners by 14% (OR = 0.861, p = 0.049). Women in the intervention group reported significantly lower rates of sexual violence from paying partners (HIVRR + MF - HIVRR: 25.9%; OR = 0.741, p = 0.019) at 12-month follow-up. No significant differences in rates from current intimate partners were found. A combination HIVRR and microfinance intervention may reduce gender-based violence from paying and intimate partners among WESUD above and beyond HIVRR interventions alone. Future research should examine how microfinance reduces partner violence and how to implement combination interventions in diverse settings.

RESUMEN: Las mujeres que intercambian sexo y consumen drogas (WESUD) tienen un alto riesgo de infección por VIH y violencia por parte de sus parejas. Las pocas intervenciones que se han probado en la intersección del VIH y la violencia de pareja muestran resultados mixtos. Este ensayo controlado aleatorio por grupos inscribió a 354 mujeres de 2015 a 2018 y las asignó al azar a una intervención combinada de HIVRR y MF o HIVRR sola. Los resultados se evaluaron en 4 puntos temporales durante 15 meses. La regresión logística dentro de un enfoque bayesiano evaluó el cambio en la violencia reciente perpetrada por las parejas que pagan y/o las parejas y ex-parejas (p.ej. esposos, novios) por brazo de estudio, a través del tiempo. En comparación con el grupo de control, la intervención combinada disminuyó las probabilidades de que los participantes sufrieran violencia física por parte de sus parejas íntimas anteriores en un 14% (OR = 0,861, p = 0,049). Las mujeres en el grupo de intervención informaron tasas significativamente más bajas de violencia sexual por parte de parejas que pagan (HIVRR + MF - HIVRR: 25,9%; OR = 0,741, p = 0,019) a los 12 meses de seguimiento. No se encontraron diferencias significativas en las tasas de parejas íntimas actuales. La combinación de HIVRR y microfinanzas puede ofrecer mayores reducciones en la violencia de las parejas que pagan y las ex-parejas en esta población.

Earlier Sexual Debut and Anti-Gay Victimization Among Men Who Have Sex With Men (MSM) in Kazakhstan.

Limited research has examined predictors of anti-gay victimization among men who have sex with men (MSM), despite anti-gay violence continuing to be a global problem. We conducted a secondary analysis of data from structured interviews with 600 MSM adults to examine anti-gay victimization and earlier sexual debut among MSM in Kazakhstan. Multiple linear regression was used to test for associations between earlier sexual debut-categorized as age of sexual onset between 13 and 15 years of age and prior to 13 years old, with ages 16 and older as the reference group-and recent and lifetime anti-gay victimization. Adjusted logistic regression models were used to assess earlier sexual debut and specific types of victimization. The majority of MSM reported lifetime (89%) or recent (68%) experiences of anti-gay victimization. Earlier sexual debut prior to 13 years of age was significantly associated with greater number of types of lifetime and recent reports of anti-gay victimization. Among specific types of anti-gay victimization, earlier sexual debut was associated with higher odds of experiencing verbal, physical, and sexual violence. Anti-gay violence in Kazakhstan is a significant and prevalent public health issue. Future research and clinical interventions addressing anti-gay victimization among MSM populations should consider the lifetime and current implications of consensual and non-consensual childhood and adolescent sexual experiences.

Association of gender-based violence with sexual and drug-related HIV risk among female sex workers who use drugs in Kazakhstan.

BACKGROUND: Little is known about the prevalence of intimate partner violence (IPV) or client violence, and associated HIV risk among women who engage in sex work (WESW) and use drugs in Kazakhstan, despite a growing HIV epidemic. METHODS: Women who reported engaging in sex work and using illicit drugs were recruited from Almaty and Temirtau, Kazakhstan between 2015 and 2017. A cross-sectional analysis was conducted to determine prevalence and correlates of physical and sexual violence perpetrated by intimate partners and clients. Associations between each type of violence with sexual and drug-related HIV risk behaviors were assessed with negative-binomial and logistic regression models, respectively. RESULTS: Of the 400 women, 45% and 28% reported recent IPV and client violence, respectively. IPV and client violence was associated with a greater number of sex work clients [IPV: adjusted incidence rate ratio (aIRR)physical: 1.86, 1.28-2.71; aIRRsexual: 2.28, 1.56-3.35]; [client violence: aIRRphysical: 2.20, 1.44-3.42; aIRRsexual: 2.54, 1.72-3.83], and client violence was associated with greater frequency of condomless sex with clients [aIRRphysical: 2.33, 1.41-4.03; aIRRsexual: 2.16, 1.35-3.56]. Violence was not associated with injection drug use, despite exchanging sex for drugs being associated with higher odds of violence. CONCLUSION: HIV prevention programs for WESW in Kazakhstan should consider multi-sectoral approaches that address economic hardship and relationship-based components, in addition to violence reduction.

Compounding vulnerabilities: victimization and discrimination is associated with COVID-19 disruptions to HIV-related care among gay, bisexual, and other men and transgender and nonbinary people who have sex with men in Kazakhstan.

Gay, bisexual, and other men and transgender and nonbinary people who have sex with men (MSM and TSM) are disproportionately impacted by the HIV epidemic in Kazakhstan. MSM and TSM in Kazakhstan also face high levels of discrimination and victimization, known barriers to engagement in HIV prevention and care. We examined data from surveys with 455 MSM and TSM collected May -- October 2020 to determine whether access to HIV testing and treatment was disproportionately limited among those exposed to victimization and discrimination during the early COVID-19 pandemic. Odds of reporting COVID-19 disruptions to HIV-related care access were significantly higher (OR: 1.96; 95% CI: 1.25-3.06; P = .003) among those who experienced recent sexual or gender-based victimization, and recent discrimination (OR: 2.93; 95% CI: 1.65-5.23; P < .001), compared to those who did not experience victimization or discrimination, respectively. Odds of reporting disruptions among those who experienced both victimization and discrimination were significantly higher (OR: 3.59; 95% CI: 1.88-6.86; P < .001) compared to those who experienced neither . Associations remained significant after adjustment for potentially confounding factors. Findings suggest the COVID-19 pandemic is compounding vulnerability among MSM and TSM in Kazakhstan - highlighting need for intervention efforts targeting the most marginalized groups.

Earlier Sexual Debut and Exchange Sex among Men Who Have Sex with Men (MSM) in Kazakhstan.

Limited research has examined prevalence rates and associations related to exchange sex behaviors among gay, bisexual, and other men who have sex with men (MSM) in Kazakhstan. This study aimed to examine associations between earlier sexual debuts and lifetime exchange sex behaviors among Kazakhstani MSM. Using data from a National Institute on Drug Abuse-funded Human Immunodeficiency Virus (HIV) prevention trial, we conducted a secondary analysis of self-reported data from 766 adult cisgender MSM in Kazakhstan, who completed structured screening interviews. Earlier sexual debuts were measured as age of sexual onset prior to 16 years old with ages 16 and older as the reference group. Logistic regression models were used to estimate associations between earlier sexual debuts and lifetime reports of buying or selling sex for resources, with covariance adjustment for sociodemographic characteristics. The study findings indicated that, among our sample of MSM in Kazakhstan, 23% had sold sex, and 26% had bought sex in their lifetime. Kazakhstani MSM who reported an earlier sexual debut had significantly higher odds of ever selling or buying sex in their lifetime. Future research should examine how consensual and non-consensual sexual activities during childhood and adolescence relate to exchange sex behaviors and risk among MSM.

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.

Polydrug Use, Sexual Risk, and HIV Testing Among Cisgender Gay, Bisexual, and Other Men and Transgender and Nonbinary Individuals Who Have Sex With Men in Kazakhstan.

This study examined substance use and sexual risk correlates of HIV testing among cisgender gay, bisexual, and other men (MSM) and transgender and nonbinary individuals (TSM) who have sex with men in Kazakhstan. We analyzed baseline data from an HIV prevention trial collected prior to intervention deployment (N = 304). Multivariable logistic regression analyses revealed that lifetime HIV testing was positively associated with poly-drug use (AOR = 4.4, 95% CI [2.0, 9.9]) and negatively with sexual risk (AOR = 0.4, 95% CI [0.2, 1.0]). Similarly, recent HIV testing was positively associated with polydrug use (AOR = 2.7, 95% CI [1.4, 5.2]) and negatively with sexual risk (AOR = 0.5, 95% CI [0.3, 0.9]). Current HIV testing was negatively associated with sexual risk (AOR = 0.6, 95% CI [0.3. 0.9]). Findings support the value of integrating drug treatment with HIV testing among MSM and TSM in Kazakhstan.

Social and structural determinants of health associated with police violence victimization: A latent class analysis of female sex workers who use drugs in Kazakhstan.

INTRODUCTION: Punitive legal environments remain a challenge to HIV prevention efforts in Central Asia, and female sex workers who use drugs are vulnerable to police violence. Little is known about the heterogeneity of police violence against female sex workers who use drugs and factors associated with HIV risk in Central Asia, despite the growing HIV epidemic. METHODS: We recruited a community-based sample of 255 female sex workers who use drugs in Almaty, Kazakhstan between February 2015 and May 2017. We used latent class analysis to differentiate women into distinct classes of police violence victimization, and multinomial logistic regression to identify individual-level health outcomes, HIV risk behaviors, and social and structural factors within the risk environment associated with class membership. RESULTS: A three-class model emerged: Low Victimization (51%), Discrimination and Extortion (15%), and Poly-Victimization (34%). Relative to Low Victimization, factors associated with Poly-Victimization included being positive for HIV and/or sexually-transmitted infections (STI) (aOR: 1.78 (95% CI: 1.01, 3.14)), prior tuberculosis diagnosis (2.73 (1.15, 6.50)), injection drug use (IDU) (2.00 (1.12, 3.58)), greater number of unsafe IDU behaviors (1.21 (1.08, 1.35)), homelessness (1.92 (1.06, 3.48)), greater drug use (1.22 (1.07, 1.39)) and sex work stigma (1.23 (1.06, 1.43)), greater number of sex work clients (2.40 (1.33, 4.31)), working for a boss/pimp (2.74 (1.16, 6.50)), client violence (2.99 (1.65, 5.42)), economic incentives for condomless sex (2.77 (1.42, 5.41)), accessing needle/syringe exchange programs (3.47 (1.42, 8.50)), recent arrest (2.99 (1.36, 6.55)) and detention (2.93 (1.62, 5.30)), and negative police perceptions (8.28 (4.20, 16.3)). Compared to Low Violence, Discrimination and Extortion was associated with lower odds of experiencing intimate partner violence (aOR= 0.26 (0.12, 0.59)), but no other significant associations with the risk environment upon adjusting for socio-demographic characteristics. CONCLUSION: Police violence against female sex workers who use drugs is pervasive in Kazakhstan. Patterns of police violence vary, with greater HIV susceptibility associated with a higher probability of experiencing multiple forms of police violence. Police sensitization workshops that integrate policing and harm reduction, and drug policy reforms that decriminalize drug use may help mitigate the HIV epidemic in Kazakhstan.

HIV Care Continuum Services for People Who Inject Drugs in Kazakhstan During COVID-19: A Qualitative Study of Service Provider Perspectives.

INTRODUCTION: The coronavirus disease (COVID-19) pandemic and resulting lockdowns have disrupted health care service delivery globally. This includes disruptions in harm reduction and HIV service delivery for people who inject drugs (PWID), a population at high risk for not only COVID-19 but also poor HIV and drug-treatment access. However, little is known about these issues in Kazakhstan. We examined harm reduction provider experiences with delivering services and regulatory changes during the COVID-19 pandemic. METHODS: We conducted in-depth interviews with 24 nurses, social workers, and doctors serving both HIV-positive and HIV-negative PWID at 13 needle and syringe programs (NSPs) and 4 AIDS Centers (HIV treatments centers) in Kazakhstan from May to August 2020. Participants were asked how the COVID-19 pandemic had impacted their PWID clients' risks, their organizational environment, and the services offered to PWID over the prior 3-6 months. Thematic content analysis was used to elicit findings. FINDINGS: The COVID-19 pandemic considerably impacted NSP and AIDS Center operations. Participants perceived high risks of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection for themselves and their clients, as well as pandemic-related increases in substance use and HIV risks for clients. Organizations instituted several policy and regulatory changes to adapt to the pandemic, most notably tasking NSPs with delivering HIV medications; these changes necessitated new roles and responsibilities for many providers. Despite this stressful changing environment and increased service demands, participants still shared examples of persistence and resilience as they worked to meet client needs during these challenging times. DISCUSSION: NSPs in Kazakhstan are well-positioned to reach key populations with crucial information and flexible services during the COVID-19 pandemic. However, they need recognition as essential organizations and additional equipment and staff support to protect staff and clients, maintain pandemic-related regulatory changes, and address additional challenges such as overdose prevention among clients.

An observational prospective cohort study of naloxone use at witnessed overdoses, Kazakhstan, Kyrgyzstan, Tajikistan, Ukraine.

Objective: To determine whether participation in the United Nations Office on Drugs and Crime (UNODC) and the World Health Organization's (WHO) Stop Overdose Safely (S-O-S) take-home naloxone training project in Kazakhstan, Kyrgyzstan, Tajikistan and Ukraine resulted in naloxone use at witnessed opioid overdoses. Methods: An observational prospective cohort study was performed by recruiting participants in the implementation of the S-O-S project, which was developed as part of the broader S-O-S initiative. Training included instruction on overdose responses and naloxone use. Study participants were followed for 6 months after completing training. The primary study outcome was participants' naloxone use at witnessed overdoses, reported at follow-up. Findings: Between 400 and 417 S-O-S project participants were recruited in each country. Overall, 84% (1388/1646) of participants were interviewed at 6-month follow-up. The percentage who reported witnessing an overdose between baseline and follow-up was 20% (71/356) in Tajikistan, 33% (113/349) in Kyrgyzstan, 37% (125/342) in Ukraine and 50% (170/341) in Kazakhstan. The percentage who reported using naloxone at their most recently witnessed overdose was 82% (103/125) in Ukraine, 89% (152/170) in Kazakhstan, 89% (101/113) in Kyrgyzstan and 100% (71/71) in Tajikistan. Conclusion: Implementation of the UNODC-WHO S-O-S training project in four low- to middle-income countries resulted in the reported use of take-home naloxone at around 90% of witnessed opioid overdoses. The percentage varied between countries but was generally higher than found in previous studies. Take-home naloxone is particularly important in countries where emergency medical responses to opioid overdoses may be limited.

More than saving lives: Qualitative findings of the UNODC/WHO Stop Overdose Safely (S-O-S) project.

BACKGROUND: The Stop Overdose Safely (S-O-S) initiative-developed in compliance with WHO guidelines-aims to prevent opioid overdose deaths. Under the umbrella of this initiative a multi-country project was implemented in Kazakhstan, Kyrgyzstan, Tajikistan, and Ukraine, that involved overdose recognition and response training, including the provision of take-home naloxone (THN). More than 14,000 potential overdose witnesses were trained and more than 16,000 THN kits were distributed across the participating countries. This paper reports on the qualitative component of an evaluation aiming to understand the views and experiences of S-O-S project participants. METHODS: Data were drawn from focus group discussions with 257 project participants from across all four countries, including people who use and inject drugs, and others likely to witness an opioid overdose. Data were analysed thematically. RESULTS: Findings revealed how past experiences of trauma and loss related to overdose death were common, as was appreciation and gratitude for the opportunity to participate in the S-O-S training. Participants described how they shared knowledge and skills with others. Empowerment and destigmatising narratives featured prominently, and highlighted how for people who use drugs, feeling valued and cared about-not only by families and friends, but by health care providers, and sometimes police-was a positive outcome of their participation. Nevertheless, findings also revealed how real experiences of fear regarding police intervention was a barrier to carrying naloxone and intervening when faced with an overdose situation. CONCLUSION: Our analysis found that the S-O-S project produced positive outcomes that go well beyond saving lives. Despite identifying barriers to THN uptake, our findings support a growing body of evidence that broad access to THN as part of a continuum of care can enhance the health and wellbeing of people who use drugs and their communities, in low- to middle-income countries.

'I never hoped for anything now I have other plans': The role of microfinance in HIV intervention for women who use drugs and engage in sex work in Kazakhstan.

Over the past decade, Kazakhstan has experienced increased cases of HIV, especially among women who engage in sex work and use drugs. Research has examined the efficacy of structural interventions to reduce HIV risk; however, few studies have examined the experiences of women participating in these interventions. This study aimed to understand the perceived impact that HIV risk reduction and savings-led microfinance components of the Nova study had on women's sexual and drug risk behaviors as well as their capacity for reducing income from sex work and finding alternative sources of income over time. The Nova study is a cluster-randomized controlled trial conducted from 2013 to 2018 in Kazakhstan. It examines the efficacy of a combination of HIV risk reduction and microfinance among women who engage in sex work and women who use drugs. Data were drawn from the qualitative component of this study; 56 interviews with 19 participants were conducted. Template analysis and a qualitative trajectory approach were used to understand women's perceptions of the impact that intervention had over time. Findings indicated that women perceived increased knowledge and skills related to condom use, safe sex practice, and drug use reduction. Women who received the microfinance component described perceived gains on budget management, capacity to plan for their future, and motivation to find alternative sources of income. Giving women the opportunity to express narrative experiences over time regarding the impact of this structural intervention may inform needed cultural adaptations of the intervention components and nuances of the environment in which the intervention is offered.

Costs and impact on HIV transmission of a switch from a criminalisation to a public health approach to injecting drug use in eastern Europe and central Asia: a modelling analysis.

BACKGROUND: HIV incidence is increasing in eastern Europe and central Asia, primarily driven by injecting drug use. Coverage of antiretroviral therapy (ART) and opioid agonist therapy are suboptimal, with many people who inject drugs (PWID) being incarcerated. We aimed to assess whether use of monies saved as a result of decriminalisation of drug use or possession to scale up ART and opioid agonist therapy could control HIV transmission among PWID in eastern Europe and central Asia. METHODS: A dynamic HIV transmission model among PWID incorporating incarceration, ART, and opioid agonist therapy was calibrated to Belarus, Kazakhstan, Kyrgyzstan, and St Petersburg (Russia). Country-specific costs for opioid agonist therapy, ART, and incarceration were collated or estimated. Compared with baseline, the model prospectively projected the life-years gained, incremental costs (2018 euros), and infections prevented over 2020-40 for three scenarios. The decriminalisation scenario removed incarceration resulting from drug use or possession for personal use, reducing incarceration among PWID by 24·8% in Belarus, Kazakhstan, and Kyrgyzstan and 46·4% in St Petersburg; the public health approach scenario used savings from decriminalisation to scale up ART and opioid agonist therapy; and the full scale-up scenario included the decriminalisation scenario plus investment of additional resources to scale up ART to the UNAIDS 90-90-90 target of 81% coverage and opioid agonist therapy to the WHO target of 40% coverage. The incremental cost-effectiveness ratios per life-year gained for each scenario were calculated and compared with country-specific gross domestic product per-capita willingness-to-pay thresholds. Costs and life-years gained were discounted 3% annually. FINDINGS: Current levels of incarceration, opioid agonist therapy, and ART were estimated to cost from €198 million (95% credibility interval 173-224) in Kyrgyzstan to €4129 million (3897-4358) in Kazakhstan over 2020-40; 74·8-95·8% of these total costs were incarceration costs. Decriminalisation resulted in cost savings (€38-773 million due to reduced prison costs; 16·9-26·1% reduction in overall costs) but modest life-years gained (745-1694). The public health approach was cost saving, allowing each setting to reach 81% ART coverage and 29·7-41·8% coverage of opioid agonist therapy, resulting in 17 768-148 464 life-years gained and 58·9-83·7% of infections prevented. Results were similar for the full scale-up scenario. INTERPRETATION: Cost savings from decriminalisation of drug use could greatly reduce HIV transmission through increased coverage of opioid agonist therapy and ART among PWID in eastern Europe and central Asia. FUNDING: Alliance for Public Health, US National Institute of Allergy and Infectious Diseases and National Institute for Drug Abuse, and Economist Intelligence Unit.

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.

HIV Stigma, Homophobia, Sexual and Gender Minority Community Connectedness and HIV Testing Among Gay, Bisexual, and Other Men and Transgender People Who Have Sex with Men in Kazakhstan.

Although HIV incidence is rising among gay, bisexual, and other men (MSM) and transgender people who have sex with men (TSM) in Kazakhstan, whether stigmatizing attitudes and connectedness are associated with HIV testing in this region is not known. We analyzed data from one-time interviews with 304 adult MSM and TSM conducted 2018-2019 in three cities in Kazakhstan. Logistic regression determined whether HIV stigma, internalized homophobia, sexual and gender minority (SGM) connectedness predicted HIV testing (within the lifetime, past year, and past 6 months) before and after adjustment for sociodemographic characteristics. 80% of participants reported ever receiving an HIV test. Gay-identified participants reported less HIV stigma and internalized homophobia as well as greater connectedness relative to those with bisexual or other identities. In adjusted models, those who had ever tested reported lower HIV stigma (aOR 0.83, 95% CI 0.76-0.91, P < .001) and higher connectedness (aOR 1.17, 95% CI 1.06-1.29, P = .003) than those who had not; those who had ever tested reported lower internalized homophobia in the unadjusted model only (OR 0.95, 95% CI 0.91-0.99, P = .01). Similar differences and trends were found in models examining testing in the past year and past 6 months. Addressing stigmatizing attitudes and connectedness may improve uptake of HIV testing among MSM and TSM in Kazakhstan.

RESUMEN: Aunque la incidencia del VIH está aumentando entre homosexuales, bisexuales y otros hombres (HSH) y entre personas transgénero que tienen sexo con hombres (TSM) en Kazajistán, se desconoce si las actitudes estigmatizantes y la conexión están asociadas con las pruebas del VIH en esta región. Analizamos datos de entrevistas únicas con 304 HSH adultos y TSM realizadas en 2018-2019 en tres ciudades de Kazajistán. La regresión logística determinó si el estigma del VIH, la homofobia internalizada, la conexión de las minorías sexuales y de género (SGM) predijeron la prueba del VIH (durante la vida, el año pasado y los últimos 6 meses) antes y después del ajuste por características sociodemográficas. El 80% de los participantes informaron haber recibido alguna vez una prueba de VIH. Los participantes identificados como homosexuales informaron menos estigma del VIH y homofobia internalizada, así como una mayor conexión en relación con aquellos con identidades bisexuales u otras. En modelos ajustados, aquellos que alguna vez se habían hecho la prueba informaron un menor estigma del VIH (ORa 0,83, IC del 95% 0,76-0,91, P <0,001) y una mayor conectividad (OR 1,17, IC del 95% 1,06-1,29, P = 0,003) que aquellos quien no lo había hecho; aquellos que alguna vez habían realizado la prueba informaron una menor homofobia internalizada solo en el modelo no ajustado (OR 0,95; IC del 95%: 0,91-0,99; p = 0,01). Se encontraron diferencias y tendencias similares en modelos que examinaron las pruebas en el último año y los últimos 6 meses. Abordar las actitudes estigmatizantes y la conexión pueden mejorar la aceptación de las pruebas del VIH entre los HSH y TSM en Kazajistán.