Date of Award

January 2024

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Frederick L. Altice

Second Advisor

Assel M. Terlikbayeva

Abstract

Background: In Eastern Europe and Central Asia, HIV incidence and mortality continue to increase, and this epidemic is concentrated among people who inject drugs (PWID). In Kazakhstan, the prevalence of HIV among PWID is higher than for any other key population. Opioid agonist therapies like methadone are the only evidence-based treatment for opioid use disorder and thus are crucial tools for HIV prevention. Though methadone has been provided for free in Kazakhstan since 2008, less than 1% of PWID currently access this service. An intervention to increase methadone scale-up is necessary, and the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework for implementation science emphasizes the need to begin with understanding context when planning any type of intervention.

Objective: As part of the Exploration stage of the EPIS framework, we investigated barriers and facilitators to methadone for opioid use disorder treatment at the system level (with policymakers), at the client level, and at the staff level.

Methods: We conducted nominal group technique (NGT) focus groups with PWID in four cities in Kazakhstan. Among the eight focus groups, four included people currently on methadone, while the other four included people who had never received methadone. Additionally, we conducted two focus groups with narcologists from all over the country, one focus group with community health workers, four in-depth interviews with methadone clinic directors, and four interviews with political figures shaping methadone policy in Kazakhstan. NGT produces rank-ordered lists, which were analyzed across groups. All research was conducted in Russian, and interviews were transcribed and coded using a grounded theory approach by Russian-speaking team members.

Results: Barriers existed at the state, program, clinician, and patient levels. A legislative review is provided in this thesis, as well as a detailed rank-ordered list of barriers to methadone uptake and quotes from in-depth interviews to contextualize findings.

Conclusions: Findings from this study identify many opportunities for potential methadone scale-up, which is required to control the HIV epidemic in Kazakhstan and throughout Central Asia.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 04/30/2025

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