Lower Intersecting HIV-related Stigmas to Facilitate Treatment as Prevention (LIFT)

Overview

The purpose of this study is to reduce HIV transmission risk among people who inject drugs (PWID) through a multilevel intervention known as LIFT. LIFT intervenes to build intragroup PWID support at the community-level to reduce overall drug use and stigma. LIFT also increases efficacy in navigating HIV services in the presence of structural stigma. Additionally, LIFT intervenes on abstinence-based drug use stigma at the health facility-level to improve clinic policy and staff interactions with clients. This is an implementation study to adapt and pilot a stigma reduction intervention with persons who inject drugs (PWID) in Kyrgyzstan. The intervention includes peer-led group sessions focused on stigma reduction and providing support to increase HIV prevention efficacy. The aim will be to adapt, refine, and pilot the intervention among PWID and methadone maintenance treatment (MMT) clinic staff. Participants will be randomized to the intervention or control arms.

Kyrgyzstan is located within a region-Eastern Europe and Central Asia (EECA)-experiencing the world's most rapidly expanding HIV epidemic. Furthermore, this regional HIV epidemic is predominantly concentrated among persons who inject drugs (PWID). PWID face unique challenges engaging in the HIV care continuum. Intersecting stigmas related to HIV, drug use, and drug treatment (i.e., methadone maintenance therapy) uniquely amplify HIV risk in this population and impede engagement in effective HIV prevention services such as needle and syringe exchange programs, methadone maintenance therapy, and HIV antiretroviral therapy (among PWID with HIV) and Pre-exposure prophylaxis (PrEP; among PWID without HIV). Kyrgyzstan and the EECA are battling a growing HIV epidemic among PWID not seen in other regions. UNAIDS 2022 report states the EECA has one of the fastest growing HIV epidemics in the world, with a 48% increase in new infections since 2010. HIV prevalence among PWID in Kyrgyzstan is high (14.3% PWID vs. 0.2% general population), and HIV incidence is rapidly increasing among sex partners among whom the proportion of new infections increased from 63.0% in 2017 to 86.7% in 2022. Underreporting of stigmatized injection, and same-sex behaviors may partially explain this increase in HIV incidence attributed to sexual transmission. Female sex partners of PWID who reported no injection risk and HIV-negative partners had an HIV prevalence of 4.4% but an HCV prevalence of 13.0%, indicating a high probability of injection-related transmission risk. As a regional HIV service implementation leader, Kyrgyzstan's approach can inform future EECA HIV responses. Of the 16 UNAIDS-monitored EECA nations, SSP and MMT coverage is low in most, and MMT is illegal in three. MMT was the only form of opioid use disorder medication in seven EECA nations, including Kyrgyzstan although now buprenorphine is also offered as of August 2025. The historic roots of EECA addiction treatment stem from the punitive abstinence-focused legacy of the Soviet-era Narcology system, and MMT is more often seen as an effective HIV prevention tool than an effective drug use treatment given the emergence of MMT in the region via HIV service donor funding. Kyrgyzstan is one of the few EECA nations to provide free evidence-based HIV services nationally (HIV testing, SSP, MMT, antiretroviral therapy \[ART\], PrEP). Yet, the full HIV prevention power of these services remains untapped. The 2021 national surveillance data report 848 of \~25,000 PWID in Kyrgyzstan are using MMT, and 56% had consistent sterile syringe access. This is concerning as HIV testing is significantly tied to the recent use of these services. Few PWID (8.4%) are estimated to have received PrEP since 2020. Multilevel strategies to reduce stigma and improve uptake of evidence-based prevention services (e.g., MMT, PrEP) to lower HIV incidence among PWID in this region are needed. Similarly, the U.S. can learn how to increase HIV-related service use among PWID through interventions like LIFT, designed to reduce multilevel intersectional stigma.