Exploration of the multi-level barriers to scaling up methadone for HIV prevention among people who inject drugs in Kazakhstan.

Introduction: Kazakhstan's HIV epidemic is concentrated among key populations like people who inject drugs (PWID), with a prevalence of at least 7.6 %. Opioid agonist therapies like methadone are the most effective treatment for opioid use disorder and HIV prevention in PWID. Despite methadone being free in Kazakhstan since 2008, coverage has remained at <0.5 % of those in need. This study explored barriers and solutions for methadone scaleup.

Methods: Using the Exploration-Preparation-Implementation-Sustainment framework, the research team explored barriers to methadone scaleup at the client, clinic, community, and policy levels. The study used nominal group technique (NGT) to assess PWID clients on methadone (N = 30, mean age 45.9, 73 % male) and not on methadone (N = 31, mean age 45.8, 74 % male), along with narcologists (N = 13, mean age 42.3, 46 % male) and community health workers (CHWs, N = 6, mean age 45.7, 17 % male) in four cities in Kazakhstan. In-depth interviews were conducted with methadone clinic directors (N = 4) and policymakers (N = 4). NGT, a mixed-methods focus group, produced rank-ordered lists that researchers analyzed across groups. Researchers conducted interviews in Russian, coded them thematically, and aligned barriers within the socioecological model to prioritize implementation opportunities.

Results: For clients, the top barriers to methadone scaleup were concerns about methadone safety (i.e., the belief that methadone was more harmful than heroin) (24 %), restrictive eligibility and program entry/retention requirements (18 %), and limited accessibility (18 %), although these barriers differed by those on and not on methadone. Narcologists and CHWs identified lack of accurate information about methadone as the largest barrier (35 %), with restrictive eligibility (21 %) and accessibility (11 %) also important. CHWs also noted a lack of alternative medications to methadone. For solutions, clients prioritized more flexible dosing of medications while clinicians prioritized easing treatment entry and engagement requirements.

Conclusions: Clients and clinicians viewed the program differently, underscoring the need to better understand the customer so that clinicians can improve implementation. Process improvements can address most barriers by easing demands on patients during entry and retention and by educating clients and community stakeholders about methadone. System changes are also necessary to reform governmental registration and methadone administration policies and to expand clinical sites nationwide.