Dr. Nabila El-Bassel
Columbia University
http://www.ghrcca.columbia.edu
HIV among drug
users in Kazakhstan
Central Asia
Russia
China
Afghanistan
Map: GoogleEarth
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
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
Global prevalence of IDU in 2008
0.25%-1.0%
IDU
Mathers, et al, Lancet
HIV and IDUs
HIV prevalence among IDU in 2008
5%-20%
HIV among IDU
Mathers, et al, Lancet
Kazakhstan
Russia
Kazakhstan
Population:
15.3 million
Territory:
2.7 million km
9th largest country
on earth
China
Afghanistan
Map: GoogleEarth
Estimated adult HIV prevalence
Kazakhstan (1990-2007)
Adult HIV prevalence (%)
0.2
> 0.1%
0.15
Rate more than doubled
2002-2007
0.1
0.05%
0.05
Year
UNAIDS/WHO, 2008
20
07
20
06
20
05
20
04
20
03
20
02
20
01
20
00
19
99
19
98
19
97
19
96
19
95
19
94
19
93
19
92
19
91
19
90
0
Number of people living with HIV
Kazakhstan (1990-2007)
15,000
12,000
People living with HIV
12,500
Number of HIV+ people
tripled from 2001-2007
10,000
7,500
5,000
2,500
Year
UNAIDS/WHO, 2008
20
07
20
06
20
05
20
04
20
03
20
02
20
01
20
00
19
99
19
98
19
97
19
96
19
95
19
94
19
93
19
92
19
91
19
90
0
Number of new HIV cases (1987-2007)
2000
1800
1600
1400
1200
1000
800
600
400
200
0
1979
1754
1175
437
4 3 4 4 2 1 6 2 5 48
964
746
699
735
299
347
185
1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007
Republican AIDS Center, 2008
Trends in antiretroviral therapy (ART)
coverage (2004-2007)
• National ART adherence
rate is 50-70%, however
rates are lower among
drug users
(Republican AIDS Center)
UNAIDS, 2008
50
% of adult coverage
• Nearly 50% of those on
ART are drug users (205)
41%
40
31%
30
25%
20
10
0%
0
2004
2005
2006
Year
2007
Forces that drive the HIV
epidemic in Kazakhstan
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
Opium production in Afghanistan
(1998-2008)
UNODC, 2008
Year
Percentage of
production in
Afghanistan (%)
Opium production
in Afghanistan
(metric tons)
1998
62%
2,693
1999
79%
4,565
2000
70%
3,276
2001
12%
185
2002
76%
3,400
2003
76%
3,600
2004
87%
4,200
2005
89%
4,100
2006
92%
6,100
2007
93%
8,200
2008
93%
7,700
Opium poppy cultivation in Afghanistan
(1997 – 2008)
250,000
+ 17%
Hectare
200,000
150,000
100,000
- 20.7%
50,000
0
1997
1998
1999
2000
2001
2002
2003
Year
UNODC, 2008
2004
2005
2006
2007
2008
Major Drug Trafficking Routes
Russia
Almaty
China
Afghanistan
UNODC, 2008
Map: GoogleEarth
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
Barriers to HIV
prevention for drug users
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
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
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
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
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
What needs to be done to
curb the HIV epidemic
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
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
Project Renaissance:
A model for HIV prevention
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)
Couple-based HIV prevention
conducted in the US
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
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
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
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
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
Study Site: Shu, Kazakhstan
Shu
• Strategically located near Kazakhstan’s
border with Kyrgyzstan and a major
entry point for the drug trade
Shu
• 34,000 population and, among adults,
an estimated 3,000 are IDUs
• 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
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
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
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
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
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
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
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
Study Design - Pilot Phase
4-session HIV
Risk Reduction
Intervention
(20)
Visit 1
Screen
(n=120
participants)
Visit 2
Eligible
Baseline
STI
(n=40 couples)
Visit 3
Randomization
(n=40 couples)
4-session
Wellness
Promotion
Intervention
(20)
Visit 7
3-Month
Follow-up
(n=38 couples)
Methods
• Participants received non-monetary
compensation (food coupons) for attending
intervention and assessment sessions
• Attendance for both interventions was
above 90%
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, problemsolving 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
Socio-Demographics
Background
Category/ Statistics
N (%)
Age
Mean (SD)
31.5 (8.2)
Year of education
Mean (SD)
9.2 (3.3)
Kazakh
19 (24%)
Russian
40 (50%)
Other
21 (26%)
Employed full-time
2 (3%)
Employed part-time
6 (8%)
Get stipend
1 (1%)
Temporary work
49 (62%)
Other source of income
21 (27%)
Nationality
Employment
Socio-Demographics
Background/ relationship
N (%)
Married
36 (45%)
Length of relationship (years)
4.0 (4.6)
Have children?
41 (51%)
Study partner is the parent of
child
33 (41%)
Currently lives together with
study partner
80 (100%)
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
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
Data Analysis
• Ordinal least square (OLS) regression
• Random-effects estimates to handle the within
group independency in which the unit of analysis
was the individual who was a member of a couple
• The adjusted model included age, education,
gender and baseline measures of outcome
variables as covariates
Primary HIV Risk Outcomes
Proportion of Protected Sex Acts (%)
40
Effect size (se):
32
30
Unadjusted =
23 (8)**
Adjusted =
19 (8)**
% 20
9
10
3
0
1
Baseline
HIV Risk Reduction
3-months
Wellness Promotion
Proportion of Injection Acts in Which
Needles or Syringes were Shared
90
81
Effect size (se):
80
70
76
73
% 60
Unadjusted =
-1 (0.5)*
Adjusted =
-1 (0.5)**
50
40
33
30
Baseline
HIV Risk Reduction
3-months
Wellness Promotion
Number of Injection Acts in Which
Syringes were Shared
40
36
35
Effect size (se):
Unadjusted =
-30 (5)**
30
26
#
Adjusted =
-33 (5)**
25
21
20
19
15
Baseline
HIV Risk Reduction
3-months
Wellness Promotion
Number of Unprotected Sex Acts
15
Effect size (se):
11
Unadjusted =
-17 (4)**
10
9
#
4
5
3
0
Baseline
HIV Risk Rediction
3-months
Wellness Promotion
Adjusted =
-12 (4)**
Number of Different People with Whom
Participant Shared Needles
5
Effect size (se):
4
4
3.6
#
3
3.4
3.1
2
Baseline
HIV Risk Reduction
3-months
Wellness Promotion
Unadjusted =
-0.5 (0.2)**
Adjusted =
-0.4 (0.2)**
Secondary Outcomes
HIV / AIDS Knowledge
10
9
8
Effect size (se):
Unadjusted =
6 (0.4)**
6
Adjusted =
7 (0.4)**
4
4
3
3
2
Baseline
HIV Risk Reduction
3-months
Wellness Promotion
Condom Negotiation Self-Efficacy
14
13
12
10
9
Effect size (se):
Unadjusted =
5 (1)**
Adjusted =
5 (1)**
8
7
6
6
4
Baseline
HIV Risk Reduction
3-months
Wellness Promotion
Conclusion
• Feasible to conduct couple-based HIV prevention
with IDUs
• Preliminary effects show that participants in the
HIV intervention reduce drug and sexual risks
compared to the control group at 3 month follow-up
• No adverse events were reported by staff,
providing preliminary evidence that the study
procedures are safe
Challenges
• Addressing multiple problems associated with
injection drug use
– i.e., Hepatitis C, STIs, tuberculosis, unemployment,
extreme poverty, access to treatment
• Engaging and maintaining trust of IDUs who fear
police and feel stigmatized
• Accessing bleach
• Lack of overdose management and lack of Naloxone
Project Renaissance is needed in low
resource countries like Kazakhstan for
IDUs and their regular sex partners
Project Renaissance
R01: NIDA
• Renaissance study being conducted in a community space
at the School of Public Health in Almaty
• 400 couples, with at least one member an IDU
• Recruited as a couple from Almaty
• Two arms:
– 6 sessions of HIV risk reduction
– 6 sessions of health promotion
• Overdose prevention and management in both arms
– Naloxone voucher and access to bleach
Project Renaissance - Almaty
GHRCCA
office
Overdose Prevention Components
• Raising awareness of risks for overdose
• Identifying personal risks or triggers for overdose
and coming up with a plan to reduce risks and
avoid triggers
• Identifying early signs of an overdose
• Review myths and facts about overdose
• Introduce Naloxone
Overdose Prevention Components
• Provide vouchers to all participants for a Naloxone
Kit that contains two ampules of Naloxone, 2
syringes, gauze, alcohol wipes and instructions
• Distribute kits to participants with vouchers
and review instructions with participants
• Participant may request additional kits after they
complete a Naloxone debriefing questionnaire
Project Renaissance: Progress update
• Since May 2009, 75 couples were randomized
• Prevalence rates of HIV at 20%
• Have observed high rates of attendance for both conditions,
100% retention rate for three months follow-up
• Participants have reported high satisfaction with both
interventions, they particularly like the focus on overdose
prevention
• We have lost 2 potential participants to overdose before they
were able to complete the baseline assessment
Status of HIV prevention with couples
• Bringing IDUs and their female regular partners together in HIV
prevention interventions in Central Asia can be an effective
strategy to reduce both sexual and drug risk behavior and lower
HIV transmission
• Science of couples-based HIV intervention is still in the early
stages of development in the US and abroad
• Efficacy of couples-based HIV prevention interventions comes
mainly from voluntary counseling and HIV testing (VCT) studies
conducted abroad
• HIV prevention with drug-involved couples is limited
• Interventions include minimal contents of HIV drug risk reduction
(clean syringes, needles, and other drug equipment)
IDU Driven Epidemics
WHO, UNAIDS, UNODC
Comprehensive approach for IDUs. Package of services includes:
•
•
•
•
•
•
•
•
Needle and syringe programs (NSP)
Opioid Substitution Therapy (OST)
Voluntary HIV Counseling and Testing (VCT)
Anti-Retroviral Therapy (ART)
Sexually Transmitted Infections (STI) prevention
Condom programming for IDUs and partners
Targeted Information, Education and Communication
Hepatitis diagnosis, treatment (Hepatitis A, B and C) and vaccination
(Hepatitis A and B)
• Tuberculosis (TB) prevention, diagnosis and treatment
Our Team in Central Asia