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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.

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.

Purpose: Women engaged in sex work (WESW) who use drugs face barriers to HIV testing. HIV self-testing (HST) may empower sex workers to learn their HIV status; however, it is not scaled up among WESW in Kazakhstan. This study aimed to explore barriers and facilitators to traditional HIV testing and HST among this population., Method: We conducted 30 in-depth interviews (IDIs) and four focus groups (FGs) with Kazakhstani WESW who use drugs. Pragmatic analysis was used to explore key themes from qualitative data., Results: Participants welcomed HST due to its potential to overcome logistical challenges by accessing HIV testing, as well as the stigma that WESW faces in traditional HIV testing. Participants desired emotional and social support for HST, and for linkage to HIV care and other services., Discussion: HST among women who exchange sex and use drugs can be successfully implemented to mitigate stigma and barriers to HIV testing., Competing Interests: Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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.

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., (© McCrimmon et al.)

Background: Ambulatory based treatment of tuberculosis has been recently introduced in Kazakhstan. We sought to assess the attitudes of the general population, TB patients and their household members towards ambulatory TB treatment and identify how knowledge of TB is associated with these attitudes., Methods: New pulmonary TB cases and their household and community controls were recruited from three regions of Kazakhstan in 2012-2014. 1083 participants completed audio computer-assisted self interviews to assess their knowledge of TB and attitudes towards ambulatory care. Mixed effects logistic regression models were used to identify factors associated with attitudes toward ambulatory TB treatment., Results: The proportion of people who considered ambulatory TB treatment as appropriate was very low (24.9%). Positive attitudes towards ambulatory TB treatment were significantly associated with region of residence, higher level of education, family support and experience with TB. The association between sufficient tuberculosis knowledge and favorable attitude toward ambulatory treatment was stronger among community controls compared to TB patients and their family members., Conclusions: This study provides insight into attitudes toward ambulatory TB treatment among different groups and the specific influence of TB knowledge on these attitudes. Our findings can inform the process of integration of new TB treatment strategies and the development of appropriate education and advocacy programs in the general population.

Background: People who inject drugs (PWID) in Kazakhstan face many barriers to HIV testing as well as to accessing HIV care, to retention in HIV care, and to initiating and adhering to anti-retroviral treatment (ART). Needle and syringe programs (NSPs) are an opportune setting for integrated interventions to link PWID to HIV care., Methods: This Hybrid Type II study employs a stepped-wedge design to evaluate both effectiveness and implementation outcomes of Bridge, an intervention to identify, test, and link HIV-positive PWID to HIV care. The study is conducted at 24 NSPs in three different regions of Kazakhstan, to assess outcomes on the individual, organizational, and policy levels., Discussion: This trial responds to an identified need for new models of HIV service delivery for PWID through harm reduction settings., Trial Registration: NCT02796027 on June 10, 2016.

Background: High levels of stigma towards people who inject drugs (PWID) and people living with HIV (PLWH) exist in Kazakhstan, yet little is known about the role of stigma in harm reduction service settings. In this paper, we use a mixed method design to explore and describe the actionable drivers and facilitators of stigma among harm reduction service providers. Additionally, we describe the manifestations of stigma among PWID who are living with HIV (PWID/LWH), and the impact that stigma has on harm reduction and healthcare service utilization., Methods: Eight focus groups with 57 PWID/LWH were convened between March 2016 and July 2016 to describe manifestations of stigma from the perspective of syringe exchange program (SEP) clients. Additionally, we surveyed 80 nurses, social workers, outreach workers, and providers of HIV care at SEPs between January 2017 and July 2017 to assess stigmatizing attitudes among staff within the SEP environment. Joint displays were used to integrate quantitative and qualitative data., Results: The actionable drivers of stigma identified in this study include negative opinions and moral judgements towards PWID/LWH. Facilitators identified included stigmatization as a social norm within the service provision environment, a lack of awareness of anti-discrimination policies, and lack of enforcement of anti-discrimination policies. Qualitative findings highlight manifestations of stigma in which PWID/LWH experienced denial of services, perceived negative attitudes, and avoidance from service provision staff. PWID/LWH also described segregation in healthcare settings, the use of unnecessary precautions by providers, and unauthorized disclosure of HIV status., Conclusions: This paper highlights the urgent need to address stigma in the harm reduction and HIV service settings in Kazakhstan. These findings have implications for informing an actionable model for stigma reduction for providers who deliver services to PWID/LWH in Kazakhstan. Drivers, facilitators, and manifestations of stigma are multifaceted and addressing them will require a multilevel approach., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: HIV-infected people who inject drugs (PWID) are particularly vulnerable to suboptimal ART adherence. The fastest-growing HIV epidemics globally are driven by injection drug use, but only a small percentage of HIV-positive PWID have achieved viral suppression. Virally suppressed individuals have better HIV-related health outcomes and effectively no risk of transmitting HIV to others. Hence, ART adherence is important for both HIV treatment and HIV prevention. There is a paucity of data on barriers and facilitators of ART adherence among PWID in low and middle income countries, which is problematic given the growing HIV epidemics among PWID in these countries., Methods: Using the Theory of Triadic Influence, this paper examines individual, interpersonal, and structural barriers and facilitators of ART adherence among HIV-positive PWID in four cities in Kazakhstan. Eight focus groups were conducted (two in each city) with a total of 57 participants. Data were coded and analyzed by three researchers., Results: We found a number of barriers and facilitators to ART adherence among PWID at the individual, interpersonal, and structural levels. Individual barriers to ART adherence include misperceptions about ART, forgetfulness due to the effects of illicit drug use, and medication side effects. Interpersonal facilitators of ART adherence include social support and good relationships with healthcare providers. Structural barriers include poverty, legal challenges, disruptions in the ART supply, and stigma and discrimination., Conclusion: The paper highlights important factors related to ART adherence for HIV-positive PWID and identifies potential strategies for intervention efforts, including couple-based interventions, electronic reminders, linkage to drug treatment services, and patient navigation. Effectively enhancing adherence to ART among PWID will likely require multi-level approaches and strategies. Further research should be conducted on potential methods and interventions for improving ART adherence among this vulnerable population., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Sputum smear-positive tuberculosis (TB) patients have a high risk of transmission and are of great epidemiological and infection control significance. Little is known about the smear-positive populations in high TB burden regions, such as Kazakhstan. The objective of this study is to characterize the smear-positive population in Kazakhstan and identify associated modifiable risk factors., Methods: Data on incident TB cases' (identified between April 2012 and March 2014) socio-demographic, risk behavior, and comorbidity characteristics were collected in four regions of Kazakhstan through structured survey and medical record review. We used multivariable logistic regression to determine factors associated with smear positivity., Results: Of the total sample, 193 (34.3%) of the 562 study participants tested smear-positive. In the final adjusted multivariable logistic regression model, sex (adjusted odds ratio (aOR) = 2.0, 95% CI:1.3-3.1, p < 0.01), incarceration (aOR = 3.6, 95% CI:1.2-11.1, p = 0.03), alcohol dependence (aOR = 2.6, 95% CI:1.2-5.7, p = 0.02), diabetes (aOR = 5.0, 95% CI:2.4-10.7, p < 0.01), and physician access (aOR = 2.7, 95% CI:1.3-5.5p < 0.01) were associated with smear-positivity., Conclusions: Incarceration, alcohol dependence, diabetes, and physician access are associated with smear positivity among incident TB cases in Kazakhstan. To stem the TB epidemic, screening, treatment and prevention policies should address these factors.

Introduction: Vitamin D receptor (VDR) plays an important role in activating the immune response against various infectious agents. It is known that the active metabolite of ligand receptor Vitamin D (1,25 - dihydroxyvitamin D) is encoded by VDR and helps mononuclear phagocytes to suppress the intracellular growth of M. tuberculosis . The VDR gene harbors approximately 200 polymorphisms, some of which are linked to differences in receptor Vitamin D uptake and therefore can be considered as candidate disease risk variants. The relation between VDR gene polymorphisms and susceptibility to TB has been studied in different populations. There is not a great deal of information regarding the association of these SNPs with TB risk in the Kazakh population. The four most commonly investigated VDR polymorphisms in association with different diseases, including susceptibility to tuberculosis, are located in exon 2 (rs2228570 or FokI), intron 8 (rs1544410 or BsmI and rs7975232 or ApaI), and exon 9 (rs731236 or TaqI). The aim of our study was to determine whether these four VDR gene single nucleotide polymorphisms were associated with TB and whether they were a risk for the development of TB in the Kazakh Population in Almaty city and Almaty area., Methods: This study was a hospital-based case-control analysis of 283 individuals (99 TB patients and 184 healthy controls). Genotyping was performed by Taqman SNP allelic discrimination using commercial TaqMan SNP Genotyping assays. Statistical analysis was conducted using SPSS Version 19.0 software., Results: Genotype frequencies for the Kazakh population are close to world (HapMap) data on Asian populations. FokI and ApaI polymorphisms genotypes tend to be associated with TB risk under the co-dominant model [OR=1.18; 95%CI: (0.68, 2.07), p=0.15] for FokI and [OR=1.33; 95%CI: (0.61, 2.91), p=0.6] for ApaI. No significant association between the disease and TaqI, BsmI genotypes was observed., Conclusions: In summary, we explored potential associations between SNPs in the VDR (FokI, ApaI) gene and susceptibility to tuberculosis in the Kazakh Population, which requires further detailed analysis with a larger sample size and greater geographic diversity including other regions of Kazakhstan.

Introduction: Rates of tuberculosis in Central Asia are extremely high, and even more alarming are the very high rates of multidrug-resistant tuberculosis (MDR-TB) in Kazakhstan, Uzbekistan, Tajikistan and Kyrgyzstan. In addition, rates of HIV infection related to injection drug use seems to be rising as well, thus creating conditions for a potentially devastating co-epidemic of TB/HIV and MDR-TB/HIV which would have terrible consequences for public health in these countries., Current Status: In many countries of Central Asia, diagnosis of tuberculosis still rests on clinical grounds or simple technologies such as chest radiograph and sputum smear examination. Modern molecular techniques such as GenExpert are being introduced in Kazakhstan and Uzbekistan, and perhaps soon in Kyrgyzstan. Treatment of TB is still often centered around prolonged inpatient stay at TB hospitals. Only a minority of patients with HIV infection are receiving ART, and TB and HIV services are not well integrated. Needle exchange programs are becoming increasingly available, but opioid substitution therapy is rarely used in Central Asia. TB, drug treatment and HIV services are generally not well-integrated., Conclusions: To combat this developing storm, integration of TB services, HIV care, and substance abuse treatment programs is needed urgently to allow efficient and effective diagnosis and treatment of these conditions in a coordinated manner., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)