HIV Care Continuum Services for People Who Inject Drugs in Kazakhstan During COVID-19: A Qualitative Study of Service Provider Perspectives

COVID-19 Information and Risk Perceptions

Participants received general information about COVID-19 from a variety of sources, both official and unofficial, including the Ministry of Health, AIDS Center management, colleagues, internet, television, and social media. While some participants felt that they had sufficient information, several discussed obstacles to staying adequately informed, including a lack of information, too much information, a rapidly changing epidemiological situation, isolation from colleagues/sources of information, and concerns about the trustworthiness of information.

I think that no one has the most adequate information… no one can definitively say what the situation is now… I watch [TV channel], also, Internet, WhatsApp groups. But the TV is no longer truthful. That's the way [it is]. —Nurse, NSP, Almaty

Now, since we have a lot of sources of information, it's just some type of informational intoxication. You try, of course, to choose information only from trusted sources. —Doctor, AIDS Center, Temirtau

Participants often mentioned that misinformation about COVID-19 was a widespread and concerning issue, and some indicated that their NSP clients believed rumors about COVID-19. The main content of the misinformation appeared to be the idea that COVID-19 was not real and/or was a manufactured bioweapon.

Unfortunately, there is no such information on how COVID-19 affects PWID and PLHIV. —Doctor, AIDS center, Shymkent

This response represented the views of many providers, who noted a lack of official information regarding COVID-19 risks among these vulnerable client groups. Despite this, several expressed their beliefs that their PWID clients, particularly those living with HIV, were at increased risk for SARS-CoV-2 infection. Many stated that their HIV-positive clients had increased biological susceptibility to the virus due to their immunocompromised state.

Others noted that PWID have comorbidities that may worsen disease outcomes.

All PWID who use drugs have weak immunity. Moreover, everyone has concomitant diseases. Therefore, they are at risk. —Nurse, AIDS Center-based NSP, Shymkent

You understand that HIV infection is associated with immunity, naturally, such people are more at risk of getting coronavirus, therefore, of course, the important point is that people living with HIV receive [ART] without interruption. —Doctor, AIDS Center, Temirtau

Participants expressed mixed views on their clients' protective measures from COVID-19. Some described great cautions taken by clients to avoid infection. However, many others were critical of clients for not observing distancing or mask wearing. Some believed PWID lacked self-control when under the influence of drugs, increasing their risk of SARS-CoV-2 infection.

When they inject, they do not control their actions. —Nurse, NSP, Karaganda

The clients don't always come in wearing masks. Many of our clients just don't care, and they don't think about the personal protective equipment. —Director, NGO, Shymkent

Others noted that economic insecurity put their PWID clients at higher risk for both SARS-CoV-2 infection and negative COVID-19 outcomes, as they were unable to purchase masks, register for health care without state-issued identification documents (which many PWID struggle to maintain amidst socioeconomic instability), or afford medications.

Naturally, they are more vulnerable. They are unable to buy masks, they cannot buy sanitizers. If they get sick, many of them are not able to buy basic medicines… Without [identification] documents, as you know, they are not attached to the clinic, to the medical institutions. And as a result, they may not even receive basic medical care. —Nurse, NSP, Temirtau

Participants described a range of protective measures for staff and visitors, including staff rotations, limiting clients inside and in waiting areas, contact tracing, temperature checks, and disinfecting (air filters, disinfectant wipes) in between clients. Some participants received enough personal protective equipment (PPE) from their employers to distribute masks among clients; others reported having to purchase PPE for themselves.

We all worked in turn, one person at a time, … because the situation worsened; orders were received from management to separate the team as much as possible. —Doctor, AIDS Center, Temirtau

But the pandemic also affects the schedule… We clean everywhere, all day, and wipe our hands constantly. We are very serious about it. This affects the schedule; more attention is separated for this. —Nurse, NSP, Karaganda

Participants acknowledged that these protective measures added to their workload, changed the atmosphere of the NSPs, and discouraged PWID client visits. One participant noted that PWID clients were uncomfortable with providing their names for COVID-19-related contact tracing when they visited the polyclinic where the NSP is located. Others noted that PWID, who usually visit in groups, were less comfortable coming individually.

They register their last names, first names… they write everything, and our PWID do not want to be advertised… Before…when there was no epidemic, I could let them through the back door and provide services and then let them go, but now I cannot do this. —Nurse, NSP, Karaganda

They come in separately… they used to go there [together]… they liked to communicate, but now [if] a person is coming, they ask him to get syringes, condoms. —Nurse, NSP, Karaganda

In addition to implementing these new protective measures in the workplace, NSP staff also described providing COVID-19 information to clients. Participants disseminated information through outreach workers, hung informational posters, and made themselves available to PWID with questions by phone and in person. One participant mentioned that it was difficult to keep PWID informed who didn't have access to smartphones and that their NSP was undertaking efforts to overcome this barrier through printed media.

They even call [about COVID-19] and ask: “Is it dangerous? How? What about it?" It feels like they have me, well, like, the main source of information. —Nurse, NSP, Karaganda

We are trying to get that information to our clients, but unfortunately, not everyone has a smartphone. They all use simple phones and so it is very difficult to provide the information in an electronic format. But we are trying to print them out in our office to hang up. Our whole office has COVID-19 informational posters hung up. —Director, NGO, Shymkent

Client Overdose and HIV Risks

Participants recognized that COVID-19 itself was only one risk facing their clients. Local and national response measures to the pandemic impacted their clients economically, as well as in terms of drug use and HIV. A few reported clients resorting to stealing, selling property, and extortion to obtain money to live or buy drugs.

Participants expressed diverse views regarding the impact of the pandemic on injection drug use and overdose risk. Many said they were unaware of this issue or emphasized that their primary role and responsibility was related to HIV risk reduction.

The main thing is to stop the spread of HIV infection and hepatitis B, C… I don't talk to PWID about overdoses. —Doctor, AIDS Center, Shymkent

While some respondents believed that access to drugs was more difficult in the pandemic, others maintained that their clients were finding ways to access drugs regardless. Participants stated that supply chain issues encouraged PWID to switch drugs (particularly from opioids to stimulants), mix drugs, or use alcohol. Several recognized the increased risk of overdose that came with polysubstance use or use of unfamiliar drugs.

[Overdose] is definitely increasing. Their bodies are already adjusted to the opium, but then they start to mix new drugs and then overdoses start occurring. —Social worker, NSP, Shymkent

Others noted additional factors contributing to overdose risk or death from overdose, including increased substance use due to the mental health impacts of isolation, use in isolation without responders available in case of overdose, and resources like ambulances being occupied with COVID-19 and unable to respond to overdoses.

You won't go anywhere; you won't talk to anyone. You are at home all the time within 4 walls. Maybe someone is oppressed by such an atmosphere, and a person could start using more often … it could lead to more frequent overdoses. —Doctor, AIDS Center, Temirtau

Because the ambulance is actually very busy right now… even if he got through, he must wait … it sometimes takes several hours. —Doctor, AIDS Center, Temirtau

Some participants in Almaty mentioned that their clients had previously accessed naloxone for overdose prevention through a United Nations Office of Drugs and Crime-World Health Organization project that had ended the year prior;²⁷ however, none described ongoing efforts to distribute naloxone among PWID. Naloxone distribution is insufficient and underprioritized in Kazakhstan, limited to first responders and donor-funded projects such as this.

Finally, a few participants expressed the belief that the pandemic provided an opportunity for PWID to reflect upon their drug use behaviors and possibly change them.

This period of self-isolation, all this situation, let us rethink life… I don't know how they changed their behavior or not, but many were given time to change themselves. —Doctor, AIDS Center, Temirtau

Participants also noted clients' increased risks of HIV acquisition during this period, particularly if they quarantined together.

If they gathered in one room all together, then this year there may be many [HIV] positive people… after all, they are injecting each other. —Nurse, NSP, Almaty

One participant described how public transit restrictions (Figure) and resulting police control of movement through the city could make PWID reluctant to seek risk reduction services.

[Police] could stop any citizen, not just PWID, and explain the limitations. Because the movement limitations meant you could only go to the pharmacy and to buy groceries. So, of course, with PWID, this affects whether they receive clean syringes. —Doctor, AIDS Center, Almaty

Changes in Harm Reduction and HIV Service Delivery and Regulations

NSP staff described a substantial shift in how harm reduction services were delivered in response to national and regional lockdowns, directives from parent organizations (polyclinics, AIDS Centers, and NGOs) as well as local transportation limitations and movement restriction zones. At the most extreme, services were suspended entirely; other times, staff were directed to work remotely. In addition, there were individual cases when an organization or a portion of its staff would quarantine due to SARS-CoV-2 exposure. Many NSP staff viewed this as a period of stagnation.

Participants noted a few cases of the pandemic resulting in the delay of planned services and opportunities. Notably, in Shymkent, a participant described how plans for methadone maintenance treatment (the only form of MOUD approved for use in Kazakhstan) had been postponed as everyone turned their attention to the pandemic.

[Methadone maintenance treatment] is … postponed in connection to the pandemic. We haven't had therapy since then, because of quarantine…. the [SARS-CoV-2] infection flare-up increased, so we are concentrating on that. These programs are on freeze. —Director, NGO, Shymkent

Many participants mentioned that workers at NSPs (including outreach workers and nurses) were asked to take leave from work due to COVID-19-related closures and quarantines.

Many large [medical] centers were quarantined, so everything was suspended, and the office room was closed. Some were sent on non-paid leave, others were sent on vacation, to be honest, I can't tell you exactly whether people came to the clinic. —Nurse, NSP, Almaty

Participants described the impossibility of remote work for nurses and outreach workers. Several described arranging individual meetings with clients despite officially working remotely.

If I work in the “remote office” how will they exchange syringes? They will have panic. When I go on vacation, I come 2 or 3 times a week, hand out syringes to them. They cannot be left without attention. —Nurse, NSP, Karaganda

Participants employed by the AIDS Center reported fewer disruptions in HIV care services in their facilities. Many attributed this to the fact that their organizations, unlike NSPs, were considered “medical” facilities and therefore were permitted to continue operations as essential services.

NSPs and AIDS Centers implemented new policies and procedures to facilitate operations during the pandemic. Many of these entailed additional or shifting responsibilities for staff. Participants described several instances of staff reallocations. In Temirtau, AIDS Center doctors were reallocated to COVID-19-dedicated hospitals, and nurses took over their responsibilities in the AIDS Center. In both Karaganda and Shymkent, outreach work at polyclinic-based NSPs were shifted to NGOs to allow polyclinics to focus their energies on COVID-19 cases.

We no longer provide outreach services… [NGO] provides them with syringes and condoms. We only test for HIV, a rapid test and take blood samples from them. —Nurse, NSP, Karaganda

By some participants' accounts, the COVID-19 pandemic provided the opportunity to overcome preexisting regulations related to secondary exchange of materials and longer-term provision and home delivery for antiretroviral therapy (ART).

Previously, we gave individual syringes and condoms to [PWID] who came, and now we agree that they pass them on to each other. —Nurse, NSP, Karaganda

We might give [ART] for a long period of time … so that people aren't risking their health on public transportation to get all the way to the AIDS Center. —Doctor, AIDS Center, Almaty

However, the most notable policy regulation that was overcome occurred in Karaganda, where polyclinic-based NSPs were charged with distributing ART (previously only available at the dispensary department at the AIDS Center itself). Two NSP nurses described their experience with providing medications to their PWID-PLHIV clients.

[The AIDS Center] brought medicines to NSPs for those who live far away. We still have transportation there… It's easier for [clients] to get there. —Nurse, NSP, Karaganda

I distributed a lot of medicines to my patients, that is, we had a connection with our treatment department. They said that it was necessary to give this to patients who were running out of medicine. —Nurse, NSP, Karaganda

When asked whether this service could be provided beyond the end of the pandemic, the 2 nurses expressed doubts.

I don't know. I cannot answer that. We could, of course, distribute medicines, but they probably had better come there to the AIDS Center, talk to a doctor, tell them what side effects they have, if they can increase or decrease the dose. We can transfer, of course, distribute and transfer these ART medicines, right? It will probably be more convenient for them to come there, take a [viral load test], and talk to a doctor. It will probably be more effective for them. —Nurse, NSP, Karaganda

Of course, it can, because the NSP is in [neighborhood], it is more convenient… But it won't be possible all the time… [the doctor] must find out about his condition. —Nurse, NSP, Karaganda

NSP nurses in Karaganda and doctors (elsewhere) described increased responsibility for home delivery of ART for clients, given that their medical licenses permitted them to move around the city and through travel checkpoints.

Since I had a certificate that I could move, I went to distant places myself, brought them medicine. I had a shortened working day and then I took all this and called up that I would come and go deliver medicines. —Nurse, NSP, Karaganda

We had clients who, during the restrictive measures, remained outside the checkpoints. The delivery of [ART] to checkpoints was organized for such patients, where they received drugs and signed for their receipt. At the time of the ban on movement in the city, patients who ran out of [ART], they contacted their doctors. They left the coordinates with their location; the doctors organized the delivery of ART for them. —Doctor, AIDS Center, Shymkent

Providers had mixed experiences and opinions on telemedicine, which in these interviews was defined as the remote delivery of services by either phone or internet. Particularly among AIDS Center providers, telemedicine was noted as an opportunity for interprofessional communication and learning, rather than direct communication with clients. Participants expressed the view that telemedicine was particularly difficult to use with PWID, given both their lack of access and familiarity with technology.

Not all clients have … smartphones with video cameras. There are some clients, especially problem clients, who have low adherence, they generally do not have access to telemedicine, purchase specialized mobile devices, and pay for Internet services. —Doctor, AIDS Center, Shymkent

Many noted that telemedicine was a useful tool but cannot cover all service provision. Some noted that it was effective for continuing to monitor clients but not for making changes to their medication regime, or anything that required a visual diagnosis.

It's kind of just consultations for our clients, over the phone, online… Kind of like a hotline… It's possible that the client doesn't receive information on a service that they would really like to receive. —Doctor, AIDS Center, Almaty

Impacts on Service Providers

Participants frequently discussed their own risk of developing COVID-19 as well as actual cases of illness among providers. Several highlighted factors that increased their risk of SARS-CoV-2 infection, including a lack of PPE.

More than half of the clinic [staff] got infected. Many are on sick leave, and they come to the office. Even many are not allowed, thermal imagers do not work… This is also scary. Now everybody lives in fear. —Nurse, NSP, Karaganda

Our partners have been under a lot of stress the past 3–4 months, because of the deficit of personal protective equipment. Not because there weren't any, but because our partners sometimes needed to buy it themselves… The situation in Shymkent right now is stressful. Unfortunately, a flare-up of infections increased. —Director, NGO, Shymkent

Furthermore, the previously described changes in policies and procedures represented a substantial shift from the regular responsibilities of harm reduction and HIV service provision. Several participants explained that, in conjunction with the pandemic overall, these new responsibilities entailed providers working long/nontraditional hours, under increased stress and at high risk.

At all times, the nurses and doctor are on call with our patients and outreach workers. They are working in the evening, and even at night. …[Staff] take the situation seriously and feel the weight of it everywhere. Of course, this psychological and physical weight increased. —Nurse, NSP, Karaganda

Participants also expressed financial concerns related to role reassignment and lack of official support for those who may become ill with COVID-19 through their continued work during this time.

They have very good bonuses during the COVID-19 pandemic… I now work under an agreement with the provisional center. And after I finish this work, I will return to my hospital, where I'll do the same work, and even more. And the salary will be as small as it was; it worries me very much. —Nurse, NSP, Shymkent

I got sick with pneumonia… We were treated on our own wallet, not at any hospital, but we went and bought medicine on our own. So, our partners aren't the only people at risk, but their families are too. The low pay cannot always cover the needs of our partners' families. We are working in these stressful conditions. —Director, NGO, Shymkent

Despite the fear of infection, actual cases of COVID-19, and increased responsibilities, participants exhibited resilience, adaptability, stoicism, and dedication to continuing to serve clients.

Maybe, sometimes [nurses] were busy doing other tasks. But whenever a client came in, they would make time for them. So, these medical workers were still dedicated to preventative care, and they were in the medical organizations from morning to night. —Doctor, AIDS Center, Almaty

Our nurses, they showed their knowledge, they really showed it… They all showed their qualifications. They were able to work without doctors. They consulted when they had difficulties, but… they knew that we were very involved in difficult situations… —Doctor, AIDS Center, Temirtau

Finally, nurses at NSPs described how outreach workers served as a key bridge between their organization and their clients during the pandemic.

In clinics, we only accept people with an urgent problem. Our clients are brought in by outreach workers. They call us in advance. I meet them at the clinic… —Nurse, NSP, Almaty

More people started to connect with the outreach workers over the phone. And of course, the outreach workers are on the phone more, so that they can negotiate to allow the patients to come in. —Nurse, NSP, Karaganda