Medication-Assisted Treatment in Kazakhstan, Kyrgyzstan and Tajikistan

The project assists governments and communities to more effectively meet the needs of vulnerable populations, with the aim of increasing utilization of health services and improving health outcomes. The Quality Health Care Project is part of USAID's third objective of investing in people as part of the US Strategic Framework for Foreign Assistance. Medication-Assisted Treatment (MAT) is an effective means of combating the combined threats posed by HIV and opioid dependence. The World Health Organization (WHO) has endorsed MAT and recommended that at least 40% of opioid-dependent Injecting Drug Users (IDUs) should receive MAT using methadone or buprenorphine. In the Central Asian region, HIV infection is reaching endemic levels, mostly attributable to the injection of illicit opioids and more recently an upsurge in sexual transmission among partners of IDUs. The consultant team visited Tajikistan, Kyrgyzstan, and Kazakhstan to visit MAT sites and participate in dialogues with clinicians, NGOs, and international aid partner representatives. Kyrgyzstan introduced MAT in 2002 and now has 20 treatment centers in various settings, including penitentiary facilities. Kazakhstan and Tajikistan introduced MAT later, each having only two or three pilot sites currently providing such treatment. The longer experience in Kyrgyzstan was reflected in a greater number of treatment sites, greater numbers of patients, and greater decentralization with clinics also situated in family medicine centers. MAT in Tajikistan and Kazakhstan appeared to have a more rigid and centralized approach, perhaps related to being at an earlier stage of evolution. The number of people receiving MAT is inadequate by any standard in all three countries. Kazakhstan, for example, has only around 120 patients receiving methadone among its estimated 100,000-160,000 IDU population. An urgent need exists in the countries for a massive scale-up of MAT availability and clinics need to examine their service-delivery models. The MAT programs have tenuous political support and their "pilot-program" status remains indefinite at this stage. Funding is met almost entirely from donor assistance, with little financial commitment from national governments. Considerable pressure to curtail MAT has been brought to bear by Russia, some members of the medical profession, and other parts of the society. The consultants identified four major areas of recommendations, common among the countries to a greater or lesser degree. These recommendations include overcoming barriers to the expansion of MAT clinics, deregulating MAT delivery systems, ensuring existing pilot MAT sites are "low threshold," and maximizing client retention to achieve MAT goals. In Kyrgyzstan, the clinics seemed to have the most welcoming environment in the region, with effective linkage to a comprehensive needle-and-syringe program. MAT in Tajikistan and Kazakhstan appeared to have a more rigid and centralized approach, perhaps related to being at an earlier stage of evolution. The consultants recommended that the countries should seek to achieve a balance between a public health approach, which would maximize IDU population coverage, and a clinical approach, which would ensure individual patients had access to high-quality holistic care.