Central Asia (CA) has one of the world?s fastest growing HIV epidemics, increasing 30% since 2010. By 2017, key populations and their sex partners made up 95% of new HIV infections, including 9% among female sex workers (FSW), 39% among people who inject drugs (PWID), and 28% among clients/sex partners of sex workers/other key populations. In Kazakhstan, a major CA regional economy, there was a 106% increase in new HIV infections from 2010 to 2017. FSW who also inject drugs (FSWID) are at significantly increased risk of HIV infection, but are less likely to engage in HIV testing and receive care. HIV testing is the key point of entry to HIV care and ART, and, for HIV-negative individuals, to PrEP/PEP. In Kazakhstan, barriers to HIV testing for FSWID, include stigma, inconvenience, and health care provider bias against women who are FSW and/or drug users. Although HST is recommended by the WHO, very limited research on FSW and PWID exists. Reviews of interventions to increase testing suggest that HST can increase consistent or frequent testing, but that linkage to care rates can be lower with HST. Importantly, no studies have been conducted in CA or, to our knowledge, among FSWID, a vital population to target given their elevated risk for HIV, low uptake of HIV testing, and experiences of dual stigma. The primary goal of this study is to assess acceptability, feasibility, preliminary efficacy and cost of a peer-based HIV self-testing intervention to increase consistent HIV testing and linkage to care or prevention among women who exchange sex and inject drugs in Kazakhstan using the R34 mechanism. In Phase 1, we will conduct in-depth interviews and focus groups with 40 FSWID to identify responses to HST components from efficacious HST and linkage to care interventions with FSW. In Phase 2, we will engage design thinking approaches and intervention adaptation to optimize fidelity and fit of existing components and develop novel components reflecting our theoretical approaches; we will component test (N=20) and pre-pilot components (N=20). In Phase 3, we will randomize 90 HIV-uninfected FSWID to either the adapted experimental condition (4 sessions) or a time- and attention-controlled standard HIV test-counseling condition and follow for 18 months for impacts on consistent HIV testing, HST and linkage to care/prevention. The RCT will be conducted in partnership with Amelia, a non-profit, FSW advocacy organization, and KSCDID, which leads national HIV treatment/prevention strategy. Results will fill key gaps in the knowledge base around optimal HST implementation among FSWID in CA, through analysis of an innovative intervention with an explicit focus on stigma reduction and peer support with substance using populations. Results will have relevance for HST and linkage programming in other CA countries, as well as the 120 countries that have HIV epidemics where FSW and PWID play important roles, including the United States.
This study responds to the identified need in HIV research for rigorous development and testing of HIV case finding and linkage to care interventions, leveraging self-testing technology and addressing stigma as a barrier, among women at high risk for HIV related to sex work and injecting drug use. The findings from this study will have important HIV prevention and public health implications for Central Asia and other countries where the HIV epidemic is growing, where sex exchange and injection drug use are key epidemic drivers. Lessons learned from this study can guide similar research in the U.S. among this group of vulnerable women.
