A Design Approach to Community-Level HIV Drug Access in Central Asia

Sarah Johnson
November 2, 2020
Social Justice
Global Health

This summer I worked with Gobee on a project to introduce community-based HIV drug access – ART and PrEP – in Kyrgyzstan and Tajikistan among two key populations (KP)—people who inject drugs (PWID) and men who have sex with men (MSM) as part of the Meeting Targets and Maintaining Epidemic Control (EpiC) project. According to PrEPWatch, only 78 countries currently have PrEP programs, and only 40 of those have more than 1,000 current PrEP enrollees. There are currently no PrEP programs in Central Asia.

We were tasked with using a human-centered design (HCD) approach to assess current community understanding of PrEP, as well as to better understand client preferences for ART services to inform future community-based ART models. Through secondary research and extensive interviews with community service organizations (CSOs) currently working with KPs in these countries, we found that KPs currently face many challenges accessing existing ART services, and that development of any new ART or PrEP programs must consider these challenges from the outset and and throughout in order to effectively slow the spread of HIV.

Two key challenges faced by KPs in both Kyrgyzstan and Tajikistan are criminalization and housing. Many PWID initiated drug use while in prison.While laws do not strictly prohibit drug use or positive HIV status, adjacent laws such as prohibition of drug possession or criminalization of spreading HIV infection (described by the United Nation Office of Drugs and Crime and the HIV Justice Network) may contribute to high recidivism rates and interaction with law enforcement among these groups. This often coincides with the common challenge among clients of homelessness. Meeting basic needs such as housing is essential to allow PWID to reliably access and continue HIV services, particularly with ART adherence, since a regular medication schedule is incredibly difficult when a client does not have stable housing.

Another common challenge is accessing services through the Republican AIDS Center. Currently, by law CSOs can only perform initial HIV testing and must bring clients to the nearest Republican AIDS Center facility for confirmatory testing and ART. This step is commonly a large barrier, since the client is required to register with the Republican AIDS Center in order to receive these services, and many KPs do not have ID, or are averse to the idea of registering. While CSOs work very hard to help clients navigate this process, we found that a majority of KP clients would still prefer to receive ART from CSOs directly rather than from health providers.

Among the reasons cited for clients’ aversion to seeing health providers is stigmatization. PWID, MSM, and people living with HIV (PLHIV) more generally, are highly stigmatized in these regions, and while many CSOs work regularly with health providers, police, and other groups to improve their interactions with KPs, clients still commonly experience discrimination from these groups as well as the general population as a whole.

There is certainly interest in community-based ART and PrEP delivery in both Kyrgyzstan and Tajikistan, but any such program must be developed from the start with input and guidance from the KPs to address the challenges to access that KPs face.