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Introduction: There is a research gap in how mental health and cognition are associated with antiretroviral treatment (ART) adherence among people living with HIV (PLWH) in Kazakhstan. Methods: We randomly selected and enrolled 230 PLWH from the Almaty City AIDS Center registry (June−November 2019) into a cross‐sectional study. We examined associations between self‐reported ART adherence for the last 1 and 2 weeks; the Adherence Self‐Efficacy Scale (ASES) and symptoms of depression (Patient Health Questionnaire‐9 [PHQ‐9]), anxiety (Generalized Anxiety Disorder tool [GAD‐7]), post‐traumatic stress disorder (PTSD Checklist [PTSD]); cognitive function (PROMIS v2.0 Adult Cognitive Function 8a short form) and forgetfulness (Forgetfulness Assessment Inventory). We used cut points of ≥5 for at least mild and ≥10 for at least moderate symptom severity for PHQ‐9 and GAD‐7 and of ≥44 for PTSD. Logistic and linear regression analyses were used. Results: Participants' median age was 40.0 (IQR: 34−47) with 40.9% (n = 94) of females in the sample. Those who missed at least one pill for the last 2 weeks had higher odds of reporting at least mild depression (aOR = 3.34, 95% CI: 1.22–9.11, p < 0.05); mild anxiety (aOR = 3.27, 95% CI: 1.20–8.92, p < 0.05); and PTSD (aOR = 4.04, 95% CI: 1.15–14.21, p < 0.05) symptoms. Participants who missed at least one pill for the last week had higher odds of at least mild depression (aOR = 7.74, 95% CI: 1.31–45.7, p < 0.05), moderate anxiety (aOR = 21.33, 95% CI: 3.24–140.33, p < 0.005) and PTSD (aOR = 13.81, 95% CI: 2.36–80.84, p < 0.005) symptoms. Participants with better cognitive function had lower odds of non‐adherence over the last week (aOR = 0.88, 95% CI: 0.81–0.96, p < 0.005) and higher ASES scores (β = 0.26, 95% CI: 0.13–0.40, p < 0.005). Poor memory was associated with higher odds of non‐adherence over the last week (aOR = 4.64, 95% CI: 1.76–12.24, p < 0.005) and lower ASES score (β = −0.31, 95% CI: −0.45 to 0.16, p < 0.005). Those who had at least mild depression (β = −0.21, 95% CI: −0.35 to −0.07, p < 0.005); moderate anxiety (β = −0.21, 95% CI: −0.34 to −0.07, p < 0.005) and PTSD (β = −0.19, 95% CI: −0.33 to −0.05, p < 0.005) symptoms had lower ASES scores. Conclusions: Depression, anxiety and PTSD symptoms, poorer cognition, and forgetfulness were associated with poorer ART adherence and worse adherence self‐efficacy. It is crucial to assess and treat mental illness and provide support for PLWH with worsened cognition to enhance ART adherence. [ABSTRACT FROM AUTHOR]

Introduction: Kazakhstan has one of the fastest‐growing HIV epidemics in the world, with increasing rates among adolescents and young adults (AYA). Innovative strategies are needed to increase HIV testing uptake and decrease HIV stigma among AYA. Citizen science, defined as the active engagement of the general public in scientific research tasks, promotes and facilitates community engagement throughout the research process. This citizen science study used crowdsourcing to engage AYA in Kazakhstan to develop a digital intervention to reduce HIV stigma and promote HIV self‐testing. Our objectives in this paper are to describe the approach used, its feasibility and acceptability, and AYA motivations for and lessons learned collaborating on the study. Methods: From October 2021 to July 2022, in collaboration with a Community Collaborative Research Board and a Youth Advisory Board, we developed an open call requesting multimedia submissions to reduce HIV testing stigma. Eligible submissions were separated by age group (13−19 or 20−29 years) and judged by a panel composed of AYA (n = 23), healthcare professionals (n = 12), and representatives from the local government and non‐governmental organizations (n = 17). Each entry was reviewed by at least four judges and ranked on a 5‐point scale. The top 20 open call contestants were asked to submit self‐recordings sharing their motivation for and experience participating in the contest and lessons learned. Descriptive statistics were calculated for quantitative data. Qualitative data were coded using open coding. Results: We received 96 submissions from 77 youth across Kazakhstan. Roughly, three‐quarters (n = 75/96) of entries met judging eligibility criteria. Of the eligible entries, over half (n = 39/75) scored 3.5 or higher on a 5‐point scale (70.0%). The most frequent types of entries were video (n = 36/96, 37.5%), image (n = 28/96, 29.2%) and text (n = 24/96, 25.0%). AYA's primary motivations for collaborating on the study included a desire to improve society and help youth. The main challenges included creating content to address complex information using simple language, finding reliable information online and technological limitations. Conclusions: Crowdsourcing was feasible and highly acceptable among AYA in Kazakhstan. Citizen science approaches hold great promise for addressing the increasingly complex health and social challenges facing communities today. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. Keywords: structural interventions; sex workers; drug use; HIV prevention; clinical trials, 1 | INTRODUCTION Female sex workers (FSW) are a key population at high risk for HIV and other sexually transmitted infections (STIs). In low and middle-income countries, estimates put their [...]

BackgroundIn Central Asia, between 33% and 72% of cumulative HIV infections has been attributed to unsafe injection practices among people who inject drugs (PWID).MethodsWe reviewed the current status and trends of national efforts in Central Asian countries to control HIV among PWID, and also reviewed the key structural and health-systems-related challenges that facilitate drug-use-related HIV risk in Central Asia.ResultsThe spectrum and scale of HIV prevention services targeting PWID vary considerably among Central Asian countries. In all countries, the potential impact of these interventions is hindered by several key features: a restrictive legal environment, poor performance of service providers, widespread opposition to harm reduction, deficient human resources and funding mechanisms, poor services integration, insufficient community involvement, and other structural factors.ConclusionsScaling up HIV prevention interventions in Central Asia will demand greater attention to the structural, health-care-related and social factors that facilitate HIV risk and impede service utilization among PWID. Multi-level combination prevention interventions should be developed with a focus on the sexual partners and risk networks of PWID, aiming at early detection of HIV, timely enrollment in HIV care, and retention in HIV care.

HIV incidence and mortality are increasing in Eastern Europe and Central Asia and are concentrated in people who inject drugs. Maintenance with opioid agonist therapies (OAT) like methadone or buprenorphine is the best treatment for opioid use disorder and a key HIV-prevention strategy in the region. In Kazakhstan, the scale-up of methadone has been minimal since methadone's introduction in 2008 and has been supported through international charitable organizations. As the Republic of Kazakhstan is designated to assume financial and administrative oversight of OAT, legislative gains can ensure treatment continuity and scale-up. Here, we review legislative barriers to OAT scale-up in Kazakhstan using an implementation science lens. We review legislative, political, and cultural barriers that undermine the efficient distribution and allocation of medications and impose burdensome clinical and administrative demands on patients and clinicians. Legislative reform is required to support further OAT expansion. We therefore provide policy recommendations to overcome these barriers to increase access to this life-saving, life-prolonging, evidence-based medical treatment. Minimally, these include increased numbers of clinical sites and patients at these sites; re-engineering OAT delivery across the country and directly to patients; introducing newer formulations of OAT; and creating an open bidding process to procure treatment medications. [ABSTRACT FROM AUTHOR]

Purpose: This paper examines differences in attitudes, stigma, and discrimination towards people living with HIV (PLWH) in needle and syringe programs (NSPs) in Kazakhstan to help inform HIV care interventions in these settings. Method: We collected data on HIV/AIDS attitudes using a modified Health Policy Project Standardized Brief Questionnaire with two subscales: attitudes within the health facility environment in a facility caring for PLWH, and opinions about PLWH. Results: Outreach workers were significantly more likely than nurses to report health professionals disparaging PLWH, and having stigmatizing attitudes towards PLWH. Outreach workers LWH were significantly more likely to report HIV discrimination in the NSP, and male staff was significantly more likely to have negative opinions of PLWH. Conclusions: Assessing different staff attitudes of nurses versus outreach workers, male versus female staff, and HIV positive versus negative staff and conducting follow-up training may decrease stigma and improve attendance at harm reduction programs. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to summarize 15 years of intervention science in combination HIV prevention and microfinance among women engaged in sex work (WESW) in Central Asia, identifying gaps in our understanding and recommendations for future studies. We begin by describing the emergence of HIV/STI risk among WESW in the Central Asia region, specifically Mongolia and Kazakhstan, and bridge to the formative stages of our methodology as well as completed prevention intervention studies. We describe the development of combining HIV prevention with asset-based microfinance interventions, lessons learned, and contributions these studies make to HIV prevention, intervention science, and practice. We end by recommending next steps to move prevention science forward in this area and among this key population, which continues to be underserved in HIV prevention science worldwide. [ABSTRACT FROM AUTHOR]

Purpose: This paper reports a review of couple-based behavioral HIV interventions conducted by the Social Intervention Group (SIG); and addresses gaps, future directions, and implications for couple-based HIV interventions. Method: We performed a literature review for SIG research on intervention and prevention studies involving couples/partners. Results: We identified nine couple-based interventions. Outcomes included reduced sexual and substance use-related risk behaviors and improved use of anti-retroviral treatment. We conducted these studies in diverse venues, including needle/syringe exchange programs, primary care clinics, and criminal justice settings. Conclusions: The findings of this review provide strong evidence for the efficacy of couple-based HIV interventions in reducing sexual HIV risks and linkage to HIV and substance-use treatment. SIG has advanced couple-based HIV intervention research science by improving study design, intervention core components, conceptual models, and implementation strategies; which have informed scientific directions and transformed couple-based HIV prevention research. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]