Stalled scale-up of opioid agonist therapies for HIV prevention in Kazakhstan: history, policy, and recommendations for change

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

Role and Importance of the Damu Enterprise Development Fund and International Investment Funds in Implementing Project and Leasing Financing Programs in Kazakhstan

This article considers the loan indicators in the Republic of Kazakhstan and defines promising areas for the development of project and leasing financing of alternative investment instruments in infrastructure projects. The results of the research demonstrate that on the financial market of the Republic of Kazakhstan the volume of bank credit falls and the availability of capital decreases, which stipulates the attraction of alternative sources of financing for infrastructure projects. Prospective mechanisms of investing in projects of this kind include projects and leasing financing. It is noted that currently, the Republic of Kazakhstan is successfully cooperating with international financial companies and multilateral development banks to attract financial resources to implement investment projects. In spite of the existing leasing development potential, this mechanism for financing infrastructure projects is not entirely used. Stimulation of demand for leasing programs by corporate clients, the development of subsidy programs or guarantees to suppliers to purchase equipment, the reduction of the cost of funding, the development and implementation of project financing programs on the basis of syndication of loans are singled out as promising directions for the further development of project and leasing financing mechanisms

Bioprinting of a Cell-Laden Conductive Hydrogel Composite.

Bioprinting has gained significant attention for creating biomimetic tissue constructs with potential to be used in biomedical applications such as drug screening or regenerative medicine. Ideally, biomaterials used for three-dimensional (3D) bioprinting should match the mechanical, hydrostatic, bioelectric, and physicochemical properties of the native tissues. However, many materials with these tissue-like properties are not compatible with printing techniques without modifying their compositions. In addition, integration of cell-laden biomaterials with bioprinting methodologies that preserve their physicochemical properties remains a challenge. In this work, a biocompatible conductive hydrogel composed of gelatin methacryloyl (GelMA) and poly(3,4-ethylenedioxythiophene):poly(styrenesulfonate) (PEDOT:PSS) was synthesized and bioprinted to form complex, 3D cell-laden structures. The biofabricated conductive hydrogels were formed by an initial cross-linking step of the PEDOT:PSS with bivalent calcium ions and a secondary photopolymerization step with visible light to cross-link the GelMA component. These modifications enabled tuning the mechanical properties of the hydrogels, with Young's moduli ranging from ∼40-150 kPa, as well as tunable conductivity by varying the concentration of PEDOT:PSS. In addition, the hydrogels degraded in vivo with no substantial inflammatory responses as demonstrated by haematoxylin and eosin (H&E) and immunofluorescent staining of subcutaneously implanted samples in Wistar rats. The parameters for forming a slurry of microgel particles to support 3D bioprinting of the engineered cell-laden hydrogel were optimized to form constructs with improved resolution. High cytocompatibility and cell spreading were demonstrated in both wet-spinning and 3D bioprinting of cell-laden hydrogels with the new conductive hydrogel-based bioink and printing methodology. The synergy of an advanced fabrication method and conductive hydrogel presented here is promising for engineering complex conductive and cell-laden structures

The Silk Road Health Project: How Mobility and Migration Status Influence HIV Risks among Male Migrant Workers in Central Asia

Objectives We examined whether mobility, migrant status, and risk environments are associated with sexually transmitted infections (STIs) and HIV risk behaviors (e.g. sex trading, multiple partners, and unprotected sex). Methods We used Respondent Driven Sampling (RDS) to recruit external male migrant market vendors from Kyrgyzstan, Uzbekistan, and Tajikistan as well internal migrant and non-migrant market vendors from Kazakhstan. We conducted multivariate logistic regressions to examine the effects of mobility combined with the interaction between mobility and migration status on STIs and sexual risk behaviors, when controlling for risk environment characteristics. Results Mobility was associated with increased risk for biologically-confirmed STIs, sex trading, and unprotected sex among non-migrants, but not among internal or external migrants. Condom use rates were low among all three groups, particularly external migrants. Risk environment factors of low-income status, debt, homelessness, and limited access to medical care were associated with unprotected sex among external migrants. Conclusion Study findings underscore the role mobility and risk environments play in shaping HIV/STI risks. They highlight the need to consider mobility in the context of migration status and other risk environment factors in developing effective prevention strategies for this population

CREATION OF AN INNOVATIVE ROBOT WITH A GRIPPER FOR MOVING PLANT MICROSHOOTS FROM THE IN VITRO TRANSPORT TANK TO THE WORKING TANK WITH SOIL GROUND AT THE STAGE OF THEIR ADAPTATION IN SOIL GROUND DURING MICROCLONAL REPRODUCTION

The industrial development of cities is the main cause of the destruction and degradation of natural resources around the world. Urbanization negatively affects the species composition of plants, the atmosphere and soil cover of areas of populated areas of large cities of the World. Tree plantations are the main mechanism for stabilizing the ecological situation in large cities and arid territories of the countries of the World. In this regard, in order to obtain a large number of genetically identical plants using their micropropagation, it is necessary to automate the main stages of this technological process. The result of the study is the creation of an adaptive phalanx gripper of a robotic complex for automating the technological process of handling operations. That will have a positive effect on solving the urgent problem of planting greenery in large cities and areas of arid territories not only in the Republic of Kazakhstan, but also in other countries of the World and represents a fundamentally new approach to solving the environmental problems of the Earth. The article substantiates various options for structural-kinematic schemes of the robot gripper, taking into account the stochastic conditions of its interaction with the overloaded object. Mathematical methods have been created for the selection and justification of the geometric, structural-kinematic and dynamic parameters of grippers for overloading plant microshoots and their computer 3D models. Software has been developed for modeling the functioning of a remotely controlled physical prototype of a mobile robot with an adaptive gripper for reloading microshoots from a transport tank to a cargo tank

The Financial Lives and Capabilities of Women Engaged in Sex Work: Can Paradoxical Autonomy Inform Intervention Strategies?

INTRODUCTION- Despite growing attention to structural approaches to HIV prevention, including economic empowerment interventions for key populations, few studies examine the financial lives of women engaged in sex work (WESW) and even fewer examine the financial lives of those who also use drugs. The purpose of this paper is to examine the financial status, sex work involvement, and individual and structural vulnerabilities of women involved in sex work and drug use in Kazakhstan. METHODS- We used baseline data from Project Nova, a cluster-randomized controlled trial that tested the efficacy of a combined HIV risk reduction and microfinance intervention for WESW in two cities in Kazakhstan. We collected data on income, savings, debt, sex work, drug use, homelessness, food insecurity, HIV status, attitudes towards safety, and financial knowledge from 400 participants through computer-assisted self-interview techniques. Descriptive statistics were utilized to describe and characterize the sample and aforementioned measures. RESULTS- Findings illustrate the paradoxical nature of sex work, wherein women may achieve economic independence despite the great adversities they encounter in their daily lives and work. The majority of women (65%) in this study reported being the highest income earner in the household, caring for up to 3 dependents, and demonstrated entrepreneurial characteristics and aspirations for the future. However, many were still living below the poverty line (72.5%), as well as experiencing high levels of homelessness (58%) and food insecurity (89.5%). CONCLUSION- Study findings underscore the need for better understanding of the existing capabilities of WESW and those who use drugs, including financial autonomy and community supports, that may guide the design of programs that most effectively promote women’s economic well-being and ensure that it is not at the expense of wellness and safety. Designing such programs requires incorporating a social justice lens into social work and public health interventions, including HIV prevention, and attention to the human rights of the most marginalized and highest risk populations, including WESW and those who use drugs

Association of gender-based violence with sexual and drug-related HIV risk among female sex workers who use drugs in Kazakhstan

Background: Little is known about the prevalence of intimate partner violence (IPV) or client violence, and associated HIV risk among women who engage in sex work (WESW) and use drugs in Kazakhstan, despite a growing HIV epidemic. Methods: Women who reported engaging in sex work and using illicit drugs were recruited from Almaty and Temirtau, Kazakhstan between 2015 and 2017. A cross-sectional analysis was conducted to determine prevalence and correlates of physical and sexual violence perpetrated by intimate partners and clients. Associations between each type of violence with sexual and drug-related HIV risk behaviors were assessed with negative-binomial and logistic regression models, respectively. Results: Of the 400 women, 45% and 28% reported recent IPV and client violence, respectively. IPV and client violence was associated with a greater number of sex work clients [IPV: adjusted incidence rate ratio (aIRR)physical: 1.86, 1.28–2.71; aIRRsexual: 2.28, 1.56–3.35]; [client violence: aIRRphysical: 2.20, 1.44–3.42; aIRRsexual: 2.54, 1.72–3.83], and client violence was associated with greater frequency of condomless sex with clients [aIRRphysical: 2.33, 1.41–4.03; aIRRsexual: 2.16, 1.35–3.56]. Violence was not associated with injection drug use, despite exchanging sex for drugs being associated with higher odds of violence. Conclusion: HIV prevention programs for WESW in Kazakhstan should consider multi-sectoral approaches that address economic hardship and relationship-based components, in addition to violence reduction

Association of Violence Against Female Sex Workers Who Use Drugs With Nonfatal Drug Overdose in Kazakhstan

Importance: Female sex workers (FSWs) who use drugs face increased risk of intimate partner violence (IPV) and nonpartner violence (NPV). The association between violence and drug overdose is unknown. Objective: To examine the association between IPV, NPV, and nonfatal drug overdose among FSWs who use drugs in Kazakhstan. Design, Setting, and Participants: This cross-sectional study included 400 adult FSWs in Kazakhstan who reported illicit drug use in the past year, exchanged sex for money or drugs, and reported having unprotected sex in the past 90 days. Baseline data were collected from February 2015 to May 2017 from Project Nova, an HIV prevention study among FSWs who use drugs in Kazakhstan. Data analysis was conducted from April 2019 to March 2020. Exposures: Lifetime and recent (past 90 day) experiences of physical, sexual, and psychological IPV and NPV using the Revised Conflict Tactics Scale. Subtypes of violence were identified using exploratory factor analysis. Main Outcomes and Measures: Lifetime and recent incidence of nonfatal overdose; sociodemographic characteristics as well as lifetime and recent sex work and drug use behaviors were also collected. Results: The 400 participants had a mean (SD) age of 34.1 (8.4) years. Most experienced food insecurity (358 [89.5%]) and homelessness (232 [58.0%]) in the past 90 days; one-third (130 [32.5%]) reported a history of incarceration. Most (359 [89.7%]) experienced some form of violence; 150 (37.5%) reported a lifetime nonfatal overdose, of whom 27 (18.0%) reported nonfatal overdose in the past 90 days. Lifetime severe physical violence (adjusted odds ratio [aOR], 1.27; 95% CI, 1.02-1.59; P = .03), engagement in sex work for more than 10 years (aOR, 2.54; 95% CI, 1.50-4.28; P < .001), and a history of incarceration (aOR, 4.34; 95% CI, 2.58-7.32; P < .001) were associated with greater odds of nonfatal overdose. Engaging in sex work for more than 10 years (aOR, 3.97; 95% CI, 1.36-11.61; P = .01) and a history of incarceration (aOR, 3.63; 95% CI, 1.39-9.48; P = .008) were associated with greater odds of recent nonfatal overdose. Conclusions and Relevance: In this study, violence against FSWs who use drugs in Kazakhstan was associated with increased odds of nonfatal overdose. Harm reduction programs for women should consider including services to address gender-based violence and the needs of women after incarceration

Project Nova: A Combination HIV Prevention and Microfinance Intervention for Women Who Engage in Sex Work and Use Drugs in Kazakhstan

Innovative combination HIV-prevention and microfinance interventions are needed to address the high incidence of HIV and other STIs among women who use drugs. Project Nova is a cluster-randomized, controlled trial for drug-using female sex workers in two cities in Kazakhstan. The intervention was adapted from prior interventions for women at high risk for HIV and tailored to meet the needs of female sex workers who use injection or noninjection drugs. We describe the development and implementation of the Nova intervention and detail its components: HIV-risk reduction, financial-literacy training, vocational training, and a matched-savings program. We discuss session-attendance rates, barriers to engagement, challenges that arose during the sessions, and the solutions implemented. Our findings show that it is feasible to implement a combination HIV-prevention and microfinance intervention with highly vulnerable women such as these, and to address implementation challenges successfully

A cluster-randomized controlled trial of a combination HIV risk reduction and microfinance intervention for female sex workers who use drugs in Kazakhstan

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