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