HIV among drug users in Kazakhstan

1. Dr. Nabila El-Bassel Columbia University http://www.ghrcca.columbia.edu HIV among drug users in Kazakhstan

2. Central Asia Russia China Afghanistan Map: GoogleEarth

3. The presentation will cover… • HIV epidemic in Central Asia focusing on Kazakhstan • Forces that drive the HIV epidemic in Kazakhstan • What needs to be done to curb the HIV epidemic among drug users in Kazakhstan • Project Renaissance: A couples-based model of HIV prevention

4. HIV prevalence (%) in adults (15-49) in Eastern Europe and Central Asia, 2007 1.6 million HIV: 150,000 in ‘07 2.16 UNAIDS, 2008

5. Global prevalence of IDU in 2008 0.25%-1.0%IDU Mathers, et al, Lancet

6. HIV and IDUs

7. HIV prevalence among IDU in 2008 5%-20%HIV among IDU Mathers, et al, Lancet

8. Kazakhstan Russia Kazakhstan • Population:15.3 million • Territory:2.7 million km • 9th largest countryon earth China Afghanistan Map: GoogleEarth

9. Estimated adult HIV prevalenceKazakhstan (1990-2007) > 0.1% Rate more than doubled 2002-2007 0.05% UNAIDS/WHO, 2008

10. Number of people living with HIVKazakhstan (1990-2007) 12,000 Number of HIV+ people tripled from 2001-2007 UNAIDS/WHO, 2008

11. Number of new HIV cases (1987-2007) Republican AIDS Center, 2008

12. Trends in antiretroviral therapy (ART) coverage (2004-2007) • Nearly 50% of those on ART are drug users (205) • National ART adherence rate is 50-70%, however rates are lower among drug users (Republican AIDS Center) 41% 31% 25% 0% 2004 2005 2006 2007 UNAIDS, 2008

13. Forces that drive the HIV epidemic in Kazakhstan

14. Forces that drive the HIV epidemic in Kazakhstan • Widespread availability of drugs, drug trafficking as a major industry within and through the country • Limited access and barriers to drug and HIV prevention and treatment • Criminalization of drug use and drug risk

15. Opium production in Afghanistan (1998-2008) UNODC, 2008

16. Opium poppy cultivation in Afghanistan (1997 – 2008) + 17% - 20.7% UNODC, 2008

17. Major Drug Trafficking Routes Russia Almaty China Afghanistan UNODC, 2008 Map: GoogleEarth

18. Heroin trafficking in Kazakhstan (2006) • Estimated 100-120 tons of drugs were trafficked in Kazakhstan in 2006 • Estimated 10-12 tons remained in the country Division of Combating International Drug Trafficking of the National Security in Kazakhstan in 2007

19. Barriers to HIV prevention for drug users

20. Barriers to HIV prevention for drug users • Few Needle Exchange Programs (NEP) • 146 NEP programs in Kazakhstan • 29% of IDUs in Kazakhstan attend NEPs • Most NEPs housed in medical facilities where IDUs do not feel welcome

21. Barriers to HIV prevention for drug users • IDUs do not access NEP programs for fear of police harassment • NEPs have difficulty obtaining regular supply of syringes. No formal protocol for syringe collections • Limited access to HIV prevention services such as condom distribution

22. Death overdose among drug users in Kazakhstan In an Almaty hospital, serving approximately 300,000 people 2007: 1,311 overdose calls with 81 deaths 2008: 1,032 overdose calls with 77 deaths Naloxone, an overdose prevention and treatment drug, although officially registered in Kazakhstan is only administered by medical professional is not available for IDUs to purchase in pharmacies or through harm reduction programs

23. Limited access to drug treatment • Limited drug treatment and harm reduction options (no drug rehabilitation, one substitution therapy program) • Most common drug treatment is detoxification • Very limited access to evidence-based drug treatment models/strategies

24. Criminalization of drug use • Drug users are subject to arrest, compulsory detoxification and imprisonment • Drug users are required to register • Fear of registration prevents access to drug treatment and HIV services • Harsh penalties for possession of insignificant amounts of drugs

25. What needs to be done to curb the HIV epidemic

26. What needs to be done to curb the HIV epidemic • Eliminate: - Registration of drug users • Punitive approaches by the police against drug users • Scale up effective HIV prevention models for drug users • Implement couple-based interventions to reach sex partners of drug users

27. Why Couple-Based Prevention? • HIV has already bridged from IDUs to their female regular sexual partners • Studies conducted among IDUs in Central Asia have found that: • The majority are under age of 30 and sexually active • Between 20% to 40 % reported having multiple concurrent sex partners • Between 50% to 70% percent have exchanged sex for money or drugs • Rates of condom use with regular or casual partners in Central Asia remain very low • IDUs frequently share syringes with their sexual partners

28. Project Renaissance: A model for HIV prevention

29. Project Renaissance • We adapted an effective couple-based HIV intervention: Project Connect • Project Connect has been tested in the US by the Social Intervention Group (SIG)

30. Couple-based HIV prevention conducted in the US

31. Connect I:Funded by NIMH, completed 2001 HIV efficacy trial tested with 217 couples Intervention delivered to the women alone or the couple One-third drug users Intervention consisted of six sessions Intervention was effective in: Improving communication skills about safety Improving the promotion of protected sexual acts and reducing unprotected acts

32. EBAN:Multi-site project, funded by NIMH, completed 2008 HIV efficacy trial tested with 535 serodiscordant African American couples Intervention consisted of 8 sessions: 4 sessions delivered to a couple and 4 sessions with a group of 6-8 couples Intervention was effective in: Improving promotion of protected intercourse acts and reducing unprotected intercourse acts

33. Connect II:Funded by NIDA, completed 2009 HIV efficacy trial tested with 280 HIV-negative drug involved couples Intervention consisted of 7 sessions delivered one-on-one to the couple Intervention was effective in: Improving promotion of protected intercourse acts

34. What we have learned from couple-based intervention • Allows a more realistic appraisal of the couple’s risks for HIV transmission • Addresses the context of gender and power in the relationship and how they are related to HIV risk among couples • Provides a supportive environment that enables intimate partners to feel safe disclosing highly personal information (extra-dyadic relationships, STIs, sharing needles) and to learn effective couple communication and negotiation of condom use together

35. Project Renaissance: A Pilot HIV Prevention Study • 1. Adapt and test the feasibility and preliminary outcomes of a 4-session, couple-based HIV prevention intervention on increasing condom use and reducing unsafe injection behaviors • 2. To inform a larger scale Stage II study 

36. Study Site: Shu, Kazakhstan Shu • Strategically located near Kazakhstan’s border with Kyrgyzstan and a major entry point for the drug trade • 34,000 population and, among adults, an estimated 3,000 are IDUs Shu • Unemployment rate is very high • No access to drug treatment for IDUs, no NGOs • One primary care clinic and one Needle Exchange Program Map: GoogleEarth

37. Project Renaissance • Informed by qualitative research: in-depth interviews with 20 IDU couples and a focus group with 10 IDU couples • Informed by feedback from a Community Collaborative Board (CCB) that consisted of the Deputy Mayor of Shu, representatives from the primary care clinic, the district attorney’s office, and the police department as well as community leaders • The role of the CCB was to provide feedback on the study protocols including DSMP and IRB procedures

38. Focus Group Findings • Couples expressed enthusiasm about participating in the research • Level of knowledge about HIV and, in particular, STIs was extremely low • Lack of information on how to clean syringes

39. Focus Group Findings • Both male and female IDUs indicated that they would feel more comfortable discussing sensitive sexual issues in same gender groups before talking with their partners • Preferred that a female facilitator conduct the sessions • Participants requested protection from the police when they come to the sessions - apprise the police about their visit to the NEP

40. Qualitative Research Findings • No access to bleach to disinfect syringes • Use of bleach is discouraged by the NEP • Needles are sold to pharmacies to obtain pain killers for withdrawal • Sharing syringes with main sex partner and their network is common

41. Qualitative Research Findings • No access to drug treatment, health or mental health services • Death from overdose is high among IDUs • Condom use with regular partner is low

42. Recruitment • Participants were recruited from the waiting room of the NEP by giving them a flyer about the study • If a potential participant agreed to participate, s/he signed a consent form and took part in a screening interview in a private office • Participant was given a letter to invite partner and/or gave permission to mail the letter to the partner

43. Eligibility & Exclusion Criteria • Screened participants and their partners for eligibility criteria: • Both partners over age 18 • Both partners identify each other as main sexual partner • Both partners report having had unprotected sex with each other at least once in the past 30 days • At least one partner reports injecting drugs in the past 30 days • Either partner reported that the couple was planning a pregnancy within the next 18 months • Either partner was not fluent in Russian

44. Study Design - Pilot Phase 4-session HIV Risk Reduction Intervention (20) Visit 1 Screen (n=120 participants) Visit 3 Randomization (n=40 couples) Visit 7 3-Month Follow-up (n=38 couples) 4-session Wellness Promotion Intervention (20) Visit 2 Eligible Baseline STI (n=40 couples)

45. Methods • Participants received non-monetary compensation (food coupons) for attending intervention and assessment sessions • Attendance for both interventions was above 90%

46. Intervention Components • To increase a couple’s: • Motivation to stay healthy as a couple and increase perceived vulnerability for HIV as a couple • Shared responsibility for protecting each other • Awareness of gender roles and expectations related to safer sex practices, use disinfected syringes • Speaker-listener skills, safer sex communication, problem-solving skills , increase support for safe sex from peers and friends • Male and female condom use • Correct use of cleaning needles, syringes and works; identify barriers to using disinfected syringes

47. Socio-Demographics

48. Socio-Demographics

49. Drug Risk Behavior • All participants (100%) injected drugs in past 30 days (both members of couple are IDUs) • Participants reported sharing syringes with an average of 3.6 (SD=2) different people in the past 30 days

50. Sexual Behavior • Participants reported on average of 10 (SD=4.7) unprotected acts of vaginal sex in the past 30 days • 21% participants reported having sex with outside partner • 59% tested positive for HCV • 10% tested positive for syphilis • No participants tested positive for HIV