Reducing Partner Violence Against Women who Exchange Sex and use Drugs through a Combination Microfinance and HIV Risk Reduction Intervention: A Cluster Randomized Trial.

Women who exchange sex and use drugs (WESUD) are at high risk for HIV infection and partner violence. The few tested interventions at the intersection of HIV and IPV show mixed results. This analysis examined the impact of a combination HIV risk reduction (HIVRR) and microfinance (MF) intervention on reported paying and intimate partner violence against WESUD in Kazakhstan. This cluster randomized controlled trial enrolled 354 women from 2015 to 2018 and randomized them to either a combination of HIVRR and MF intervention or HIVRR alone. Outcomes were assessed at four time points over 15 months. Logistic regression within a Bayesian approach assessed change in odds ratio (OR) of recent physical, psychological, or sexual violence perpetrated by current or past intimate partners; and paying partners/clients by study arm over time. Compared to the control arm, the combination intervention decreased the odds of participants experiencing physical violence from past intimate partners by 14% (OR = 0.861, p = 0.049). Women in the intervention group reported significantly lower rates of sexual violence from paying partners (HIVRR + MF - HIVRR: 25.9%; OR = 0.741, p = 0.019) at 12-month follow-up. No significant differences in rates from current intimate partners were found. A combination HIVRR and microfinance intervention may reduce gender-based violence from paying and intimate partners among WESUD above and beyond HIVRR interventions alone. Future research should examine how microfinance reduces partner violence and how to implement combination interventions in diverse settings.

RESUMEN: Las mujeres que intercambian sexo y consumen drogas (WESUD) tienen un alto riesgo de infección por VIH y violencia por parte de sus parejas. Las pocas intervenciones que se han probado en la intersección del VIH y la violencia de pareja muestran resultados mixtos. Este ensayo controlado aleatorio por grupos inscribió a 354 mujeres de 2015 a 2018 y las asignó al azar a una intervención combinada de HIVRR y MF o HIVRR sola. Los resultados se evaluaron en 4 puntos temporales durante 15 meses. La regresión logística dentro de un enfoque bayesiano evaluó el cambio en la violencia reciente perpetrada por las parejas que pagan y/o las parejas y ex-parejas (p.ej. esposos, novios) por brazo de estudio, a través del tiempo. En comparación con el grupo de control, la intervención combinada disminuyó las probabilidades de que los participantes sufrieran violencia física por parte de sus parejas íntimas anteriores en un 14% (OR = 0,861, p = 0,049). Las mujeres en el grupo de intervención informaron tasas significativamente más bajas de violencia sexual por parte de parejas que pagan (HIVRR + MF - HIVRR: 25,9%; OR = 0,741, p = 0,019) a los 12 meses de seguimiento. No se encontraron diferencias significativas en las tasas de parejas íntimas actuales. La combinación de HIVRR y microfinanzas puede ofrecer mayores reducciones en la violencia de las parejas que pagan y las ex-parejas en esta población.

Compounding vulnerabilities: victimization and discrimination is associated with COVID-19 disruptions to HIV-related care among gay, bisexual, and other men and transgender and nonbinary people who have sex with men in Kazakhstan.

Gay, bisexual, and other men and transgender and nonbinary people who have sex with men (MSM and TSM) are disproportionately impacted by the HIV epidemic in Kazakhstan. MSM and TSM in Kazakhstan also face high levels of discrimination and victimization, known barriers to engagement in HIV prevention and care. We examined data from surveys with 455 MSM and TSM collected May -- October 2020 to determine whether access to HIV testing and treatment was disproportionately limited among those exposed to victimization and discrimination during the early COVID-19 pandemic. Odds of reporting COVID-19 disruptions to HIV-related care access were significantly higher (OR: 1.96; 95% CI: 1.25-3.06; P = .003) among those who experienced recent sexual or gender-based victimization, and recent discrimination (OR: 2.93; 95% CI: 1.65-5.23; P < .001), compared to those who did not experience victimization or discrimination, respectively. Odds of reporting disruptions among those who experienced both victimization and discrimination were significantly higher (OR: 3.59; 95% CI: 1.88-6.86; P < .001) compared to those who experienced neither . Associations remained significant after adjustment for potentially confounding factors. Findings suggest the COVID-19 pandemic is compounding vulnerability among MSM and TSM in Kazakhstan - highlighting need for intervention efforts targeting the most marginalized groups.

Preferences for an HIV Self-Testing Program Among Women who Engage in sex Work and use Drugs in Kazakhstan, Central Asia.

Purpose: Women engaged in sex work (WESW) who use drugs face barriers to HIV testing. HIV self-testing (HST) may empower sex workers to learn their HIV status; however, it is not scaled up among WESW in Kazakhstan. This study aimed to explore barriers and facilitators to traditional HIV testing and HST among this population. Method: We conducted 30 in-depth interviews (IDIs) and four focus groups (FGs) with Kazakhstani WESW who use drugs. Pragmatic analysis was used to explore key themes from qualitative data. Results: Participants welcomed HST due to its potential to overcome logistical challenges by accessing HIV testing, as well as the stigma that WESW faces in traditional HIV testing. Participants desired emotional and social support for HST, and for linkage to HIV care and other services. Discussion: HST among women who exchange sex and use drugs can be successfully implemented to mitigate stigma and barriers to HIV testing.

Implementation of a Dyad-Based Intervention to Improve Antiretroviral Therapy Adherence Among HIV-Positive People Who Inject Drugs in Kazakhstan: A Randomized Trial.

Purpose: HIV-positive people who inject drugs (PWID) in Kazakhstan face many challenges to antiretroviral therapy (ART) adherence. Interventions that leverage social support from an intimate partner, family member, or friend may be effective in improving ART adherence among this population. The purpose of this paper is to describe the implementation process of a dyad-based intervention among HIV-positive PWID and their treatment support partners. Method: Sixty-six HIV-positive PWID and 66 of their treatment support partners will be enrolled in this pilot randomized controlled trial in Almaty, Kazakhstan, and randomized as dyads to receive an adapted version of the SMART Couples intervention or standard of care. Results: Several implementation strategies were used to facilitate intervention delivery, including remote delivery, training of staff, supervision, technical assistance, quality assurance, and collection of assessments through diverse sources. Discussion: This trial responds to a need for dyad-based ART adherence interventions adapted specifically for HIV-positive PWID.

'I never hoped for anything now I have other plans': The role of microfinance in HIV intervention for women who use drugs and engage in sex work in Kazakhstan.

Over the past decade, Kazakhstan has experienced increased cases of HIV, especially among women who engage in sex work and use drugs. Research has examined the efficacy of structural interventions to reduce HIV risk; however, few studies have examined the experiences of women participating in these interventions. This study aimed to understand the perceived impact that HIV risk reduction and savings-led microfinance components of the Nova study had on women's sexual and drug risk behaviors as well as their capacity for reducing income from sex work and finding alternative sources of income over time. The Nova study is a cluster-randomized controlled trial conducted from 2013 to 2018 in Kazakhstan. It examines the efficacy of a combination of HIV risk reduction and microfinance among women who engage in sex work and women who use drugs. Data were drawn from the qualitative component of this study; 56 interviews with 19 participants were conducted. Template analysis and a qualitative trajectory approach were used to understand women's perceptions of the impact that intervention had over time. Findings indicated that women perceived increased knowledge and skills related to condom use, safe sex practice, and drug use reduction. Women who received the microfinance component described perceived gains on budget management, capacity to plan for their future, and motivation to find alternative sources of income. Giving women the opportunity to express narrative experiences over time regarding the impact of this structural intervention may inform needed cultural adaptations of the intervention components and nuances of the environment in which the intervention is offered.

HIV Stigma, Homophobia, Sexual and Gender Minority Community Connectedness and HIV Testing Among Gay, Bisexual, and Other Men and Transgender People Who Have Sex with Men in Kazakhstan.

Although HIV incidence is rising among gay, bisexual, and other men (MSM) and transgender people who have sex with men (TSM) in Kazakhstan, whether stigmatizing attitudes and connectedness are associated with HIV testing in this region is not known. We analyzed data from one-time interviews with 304 adult MSM and TSM conducted 2018-2019 in three cities in Kazakhstan. Logistic regression determined whether HIV stigma, internalized homophobia, sexual and gender minority (SGM) connectedness predicted HIV testing (within the lifetime, past year, and past 6 months) before and after adjustment for sociodemographic characteristics. 80% of participants reported ever receiving an HIV test. Gay-identified participants reported less HIV stigma and internalized homophobia as well as greater connectedness relative to those with bisexual or other identities. In adjusted models, those who had ever tested reported lower HIV stigma (aOR 0.83, 95% CI 0.76-0.91, P < .001) and higher connectedness (aOR 1.17, 95% CI 1.06-1.29, P = .003) than those who had not; those who had ever tested reported lower internalized homophobia in the unadjusted model only (OR 0.95, 95% CI 0.91-0.99, P = .01). Similar differences and trends were found in models examining testing in the past year and past 6 months. Addressing stigmatizing attitudes and connectedness may improve uptake of HIV testing among MSM and TSM in Kazakhstan.

RESUMEN: Aunque la incidencia del VIH está aumentando entre homosexuales, bisexuales y otros hombres (HSH) y entre personas transgénero que tienen sexo con hombres (TSM) en Kazajistán, se desconoce si las actitudes estigmatizantes y la conexión están asociadas con las pruebas del VIH en esta región. Analizamos datos de entrevistas únicas con 304 HSH adultos y TSM realizadas en 2018-2019 en tres ciudades de Kazajistán. La regresión logística determinó si el estigma del VIH, la homofobia internalizada, la conexión de las minorías sexuales y de género (SGM) predijeron la prueba del VIH (durante la vida, el año pasado y los últimos 6 meses) antes y después del ajuste por características sociodemográficas. El 80% de los participantes informaron haber recibido alguna vez una prueba de VIH. Los participantes identificados como homosexuales informaron menos estigma del VIH y homofobia internalizada, así como una mayor conexión en relación con aquellos con identidades bisexuales u otras. En modelos ajustados, aquellos que alguna vez se habían hecho la prueba informaron un menor estigma del VIH (ORa 0,83, IC del 95% 0,76-0,91, P <0,001) y una mayor conectividad (OR 1,17, IC del 95% 1,06-1,29, P = 0,003) que aquellos quien no lo había hecho; aquellos que alguna vez habían realizado la prueba informaron una menor homofobia internalizada solo en el modelo no ajustado (OR 0,95; IC del 95%: 0,91-0,99; p = 0,01). Se encontraron diferencias y tendencias similares en modelos que examinaron las pruebas en el último año y los últimos 6 meses. Abordar las actitudes estigmatizantes y la conexión pueden mejorar la aceptación de las pruebas del VIH entre los HSH y TSM en Kazajistán.

If You Build It, Will They Use It? Preferences for Antiretroviral Therapy (ART) Adherence Monitoring Among People Who Inject Drugs (PWID) in Kazakhstan.

Adherence to antiretroviral therapy (ART) is an important predictor of long-term treatment success and is associated with optimal individual and public health outcomes. Novel technologies, such as electronic monitoring devices (EMDs) or pharmacokinetic testing, provide more objective measures of ART adherence than traditional measures of adherence (e.g., self-report) and may facilitate improved adherence through the provision of patient feedback. This study examines preferences for ART adherence monitoring among people who inject drugs (PWID) in Kazakhstan. In-depth interviews were conducted with 20 HIV-positive PWID, 18 of their intimate partners, and 7 AIDS Center healthcare providers in Almaty, Kazakhstan. Results indicated that patients varied in their preferences of which strategies would be most effective and acceptable to use in monitoring their adherence. Overall, patients were highly enthusiastic about the potential use of pharmacokinetic testing. Many participants supported the use of EMDs, though some were concerned about having their adherence tracked. Other participants thought reminders through text messaging or smart phone applications would be helpful, though several had concerns about confidentiality and others worried about technological difficulties operating a smart phone. Future studies should evaluate the feasibility and impact of providing quantitative drug levels as feedback for ART adherence using biomarkers of longer-term ART exposure, (i.e., hair sampling or dried blood spot testing).

Project Nova: A Combination HIV Prevention and Microfinance Intervention for Women Who Engage in Sex Work and Use Drugs in Kazakhstan.

Innovative combination HIV-prevention and microfinance interventions are needed to address the high incidence of HIV and other STIs among women who use drugs. Project Nova is a cluster-randomized, controlled trial for drug-using female sex workers in two cities in Kazakhstan. The intervention was adapted from prior interventions for women at high risk for HIV and tailored to meet the needs of female sex workers who use injection or noninjection drugs. We describe the development and implementation of the Nova intervention and detail its components: HIV-risk reduction, financial-literacy training, vocational training, and a matched-savings program. We discuss session-attendance rates, barriers to engagement, challenges that arose during the sessions, and the solutions implemented. Our findings show that it is feasible to implement a combination HIV-prevention and microfinance intervention with highly vulnerable women such as these, and to address implementation challenges successfully.

Correction to: How Do Risk Environment Factors Influence Perpetration of Partner Violence among Male Migrant and Non-migrant Market Workers in Central Asia?

The surname of coauthor Lynn Michalopoulos was misspelled (as "Michalopolous") in this originally published. The original article has been corrected.

How Do Risk Environment Factors Influence Perpetration of Partner Violence among Male Migrant and Non-migrant Market Workers in Central Asia?

Intimate partner violence (IPV) has emerged as a serious public health issue in migrant communities in Central Asia and globally. To date, however, research on risk factors associated with male perpetration of IPV among migrants remains scant. This study aims to examine risk environment theory-driven factors associated with male perpetration of IPV in the prior 6 months. We recruited, enrolled, and surveyed a respondent-driven sample of 1342 male market workers in Almaty, Kazakhstan, that included 562 (42%) non-migrants defined as Kazakhstan citizens who reside in Almaty; 502 (37%) external migrants from Kyrgyzstan, Tajikistan, or Uzbekistan; and 278 (21%) internal migrants from other areas of Kazakhstan. We conducted multivariate logistic regressions to estimate the effects of physical, economic, and political risk environment factors on IPV perpetration by migration status after controlling for potentially confounding socio-demographic and psychosocial variables. A total of 170 participants (12.7%) reported ever perpetrating physical or sexual IPV and 6.7% perpetrated such IPV in the prior 6 months. Multiple logistic regression results suggest that the risk environment factors of poor living conditions, exposure to political violence, and deportation experiences are associated with IPV perpetration among external and internal migrants, but not among non-migrants. Food insecurity is associated with IPV perpetration among external migrants and non-migrants, but not among internal migrants. Homelessness and arrests by police are associated with IPV perpetration among internal migrants, but not among external migrants or non-migrants. These findings underscore the need to consider the unique combination of risk environment factors that contribute to male IPV perpetration in the design of programs and policies to address IPV perpetration among external and internal migrant and non-migrant men in Central Asia.

Traumatic Events and HIV Sexual Risk Behaviors Among Migrant and Non-Migrant Male Market Workers in Central Asia.

We examined potentially traumatic events (PTEs) and the relationship between PTEs and HIV risk behaviors among male market workers in Kazakhstan, comparing Kazakhstani to external migrants. Using respondent-driven sampling, participants were 1342 male marketplace workers in Almaty, Kazakhstan. Univariate, bivariate, and logistic regressions were conducted. We found high prevalence of PTEs among participants, and significant differences between PTEs and HIV risk by migrant status. Kazakhstanis reporting 1-2 or three-or-more traumatic events were more likely to report engaging in sex trading, compared to Kazakhstanis who reported no PTEs (OR = 3.65, CI 1.20-11.11, p = 0.022; OR = 8.17, 95% CI 2.66-25.09, p = 0.000, respectively). Kazakhstanis who reported three-or-more PTEs were more likely to report unprotected sex (OR = 2.17, CI 2.17-3.89, p = 0.009). Results did not support this relationship among external migrants. Findings underscore the need for attention on services that address trauma and HIV risk among this population and more research to understand differences by migrant status.

Sexual Risks and Policing among Male Migrant and Non-migrant Market Vendors in Central Asia.

The following study examined associations between sexual risk behaviors and policing among external migrant, internal migrant, and non-migrant male market workers in Almaty, Kazakhstan. Negative binomial regression and logistic regressions examined associations between sexual risk behaviors and policing (questioning by market officials and migration police, and arrest) for 1342 external, internal, and non-migrant workers recruited using respondent-driven sampling (RDS). Incidence rate ratios (IRR) and adjusted odds ratios (OR) were stratified by migration status. External migrants were more likely than non-migrants to experience questioning by market officials (IRR = 2.07, p<0.01), migration police (IRR = 3.60, p<0.001), and arrest (OR = 5.32, p<0.001). When stratified by migration status, being under the influence of drugs or alcohol (IRR = 3.04, p<0.01) and sex with men (IRR = 2.71, p<0.05) were associated with being questioned or harassed by market police among external migrants. External migrant who reported having more than one sex partner while traveling were also more likely to report being arrested than external migrants (OR = 3.92, p<0.05). Meeting HIV prevention needs of labor migrants demands acknowledging the role of policing and allocating sufficient resources to support the implementation of HIV prevention programs in these settings.

What Prevents Central Asian Migrant Workers from Accessing HIV Testing? Implications for Increasing HIV Testing Uptake in Kazakhstan.

Several barriers prevent key populations, such as migrant workers, from accessing HIV testing. Using data from a cross-sectional study among Central Asian migrant workers (n = 623) in Kazakhstan, we examined factors associated with HIV testing. Overall, 48% of participants had ever received an HIV test. Having temporary registration (AOR 1.69; (95% CI [1.12-2.56]), having an employment contract (AOR 2.59; (95% CI [1.58-4.23]), being able to afford health care services (AOR 3.61; (95% CI [1.86-7.03]) having a medical check-up in the past 12 months (AOR 1.85; 95% CI [1.18-2.89]), and having a regular doctor (AOR 2.37; 95% CI [1.20-4.70]) were associated with having an HIV test. HIV testing uptake among migrants in Kazakhstan falls far short of UNAIDS 90-90-90 goals. Intervention strategies to increase HIV testing among this population may include initiatives that focus on improving outreach to undocumented migrants, making health care services more affordable, and linking migrants to health care.

Depression Among People Who Inject Drugs and Their Intimate Partners in Kazakhstan.

This paper examines individual, social, and structural factors associated with depression among 728 people who inject drugs (PWID) and their intimate partners in Kazakhstan, with separate multivariate models by gender. Depression scores were higher on average among participants of both genders who recently experienced sexual intimate partner violence, food insecurity, and who had lower levels of self-rated health. Among females, higher depression scores were associated with experiencing childhood sexual abuse, lower levels of social support, and not having children. Findings highlight a need to incorporate gender differences and factors associated with depression in designing mental health services for PWID in Kazakhstan.

Scaling Up HIV Self-Testing and Linkage to Care Among Women Who Exchange Sex and/or Use Drugs in Kazakhstan.

HIV testing is the point of entry for linkage to treatment and prevention and is critically important to ending the HIV epidemic. HIV self-testing (HST) is an acceptable, user-controlled tool that can address testing barriers, which is especially important for populations who need to test frequently, like women who exchange or trade sex for money or other needed resources (WES) and women who use drugs. HST is feasible and acceptable among WES, but research among WES who also use drugs is limited, particularly in places like Kazakhstan, where HIV rates remain high and where scale-up of HST and pre-exposure prophylaxis (PrEP) is in process. To develop effective programming, there is a need to develop tailored services for WES and/or use drugs that address key barriers. We discuss opportunities to increase HST and linkage to services among WES and/or use drugs in Kazakhstan, with a focus on stigma reduction.

Earlier Sexual Debut and Anti-Gay Victimization Among Men Who Have Sex With Men (MSM) in Kazakhstan.

Limited research has examined predictors of anti-gay victimization among men who have sex with men (MSM), despite anti-gay violence continuing to be a global problem. We conducted a secondary analysis of data from structured interviews with 600 MSM adults to examine anti-gay victimization and earlier sexual debut among MSM in Kazakhstan. Multiple linear regression was used to test for associations between earlier sexual debut-categorized as age of sexual onset between 13 and 15 years of age and prior to 13 years old, with ages 16 and older as the reference group-and recent and lifetime anti-gay victimization. Adjusted logistic regression models were used to assess earlier sexual debut and specific types of victimization. The majority of MSM reported lifetime (89%) or recent (68%) experiences of anti-gay victimization. Earlier sexual debut prior to 13 years of age was significantly associated with greater number of types of lifetime and recent reports of anti-gay victimization. Among specific types of anti-gay victimization, earlier sexual debut was associated with higher odds of experiencing verbal, physical, and sexual violence. Anti-gay violence in Kazakhstan is a significant and prevalent public health issue. Future research and clinical interventions addressing anti-gay victimization among MSM populations should consider the lifetime and current implications of consensual and non-consensual childhood and adolescent sexual experiences.

Earlier Sexual Debut and Exchange Sex among Men Who Have Sex with Men (MSM) in Kazakhstan.

Limited research has examined prevalence rates and associations related to exchange sex behaviors among gay, bisexual, and other men who have sex with men (MSM) in Kazakhstan. This study aimed to examine associations between earlier sexual debuts and lifetime exchange sex behaviors among Kazakhstani MSM. Using data from a National Institute on Drug Abuse-funded Human Immunodeficiency Virus (HIV) prevention trial, we conducted a secondary analysis of self-reported data from 766 adult cisgender MSM in Kazakhstan, who completed structured screening interviews. Earlier sexual debuts were measured as age of sexual onset prior to 16 years old with ages 16 and older as the reference group. Logistic regression models were used to estimate associations between earlier sexual debuts and lifetime reports of buying or selling sex for resources, with covariance adjustment for sociodemographic characteristics. The study findings indicated that, among our sample of MSM in Kazakhstan, 23% had sold sex, and 26% had bought sex in their lifetime. Kazakhstani MSM who reported an earlier sexual debut had significantly higher odds of ever selling or buying sex in their lifetime. Future research should examine how consensual and non-consensual sexual activities during childhood and adolescence relate to exchange sex behaviors and risk among MSM.

"Protected Means Armed": Perspectives on Pre-Exposure Prophylaxis (PrEP) Among Women Who Engage in Sex Work and Use Drugs in Kazakhstan.

Pre-exposure prophylaxis (PrEP) for HIV prevention has recently become available in Kazakhstan, but women engaged in sex work who use drugs (WESW-UD) could benefit from tailored approaches to support uptake and adherence. To better understand how best to support WESW-UD at each stage of the PrEP continuum (awareness, acceptability, uptake, and adherence), we analyzed data from 30 in-depth interviews and four focus groups with 48 WESW-UD from two cities in Kazakhstan. We conducted thematic analysis to characterize perceptions, barriers, and motivators within each step of the PrEP continuum. Participants reported low awareness, but high interest in PrEP. Motivating factors included optimizing health and increased confidence. Participants expressed many preferences and concerns regarding PrEP modality and delivery. Participants also described how organizational mistrust and social support can prevent or facilitate PrEP uptake or adherence. Kazakhstan's scale-up of PrEP should consider the needs and preferences of WESW-UD to ensure equitable access.

Association of gender-based violence with sexual and drug-related HIV risk among female sex workers who use drugs in Kazakhstan.

BACKGROUND: Little is known about the prevalence of intimate partner violence (IPV) or client violence, and associated HIV risk among women who engage in sex work (WESW) and use drugs in Kazakhstan, despite a growing HIV epidemic. METHODS: Women who reported engaging in sex work and using illicit drugs were recruited from Almaty and Temirtau, Kazakhstan between 2015 and 2017. A cross-sectional analysis was conducted to determine prevalence and correlates of physical and sexual violence perpetrated by intimate partners and clients. Associations between each type of violence with sexual and drug-related HIV risk behaviors were assessed with negative-binomial and logistic regression models, respectively. RESULTS: Of the 400 women, 45% and 28% reported recent IPV and client violence, respectively. IPV and client violence was associated with a greater number of sex work clients [IPV: adjusted incidence rate ratio (aIRR)physical: 1.86, 1.28-2.71; aIRRsexual: 2.28, 1.56-3.35]; [client violence: aIRRphysical: 2.20, 1.44-3.42; aIRRsexual: 2.54, 1.72-3.83], and client violence was associated with greater frequency of condomless sex with clients [aIRRphysical: 2.33, 1.41-4.03; aIRRsexual: 2.16, 1.35-3.56]. Violence was not associated with injection drug use, despite exchanging sex for drugs being associated with higher odds of violence. CONCLUSION: HIV prevention programs for WESW in Kazakhstan should consider multi-sectoral approaches that address economic hardship and relationship-based components, in addition to violence reduction.

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

INTRODUCTION: The coronavirus disease (COVID-19) pandemic and resulting lockdowns have disrupted health care service delivery globally. This includes disruptions in harm reduction and HIV service delivery for people who inject drugs (PWID), a population at high risk for not only COVID-19 but also poor HIV and drug-treatment access. However, little is known about these issues in Kazakhstan. We examined harm reduction provider experiences with delivering services and regulatory changes during the COVID-19 pandemic. METHODS: We conducted in-depth interviews with 24 nurses, social workers, and doctors serving both HIV-positive and HIV-negative PWID at 13 needle and syringe programs (NSPs) and 4 AIDS Centers (HIV treatments centers) in Kazakhstan from May to August 2020. Participants were asked how the COVID-19 pandemic had impacted their PWID clients' risks, their organizational environment, and the services offered to PWID over the prior 3-6 months. Thematic content analysis was used to elicit findings. FINDINGS: The COVID-19 pandemic considerably impacted NSP and AIDS Center operations. Participants perceived high risks of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection for themselves and their clients, as well as pandemic-related increases in substance use and HIV risks for clients. Organizations instituted several policy and regulatory changes to adapt to the pandemic, most notably tasking NSPs with delivering HIV medications; these changes necessitated new roles and responsibilities for many providers. Despite this stressful changing environment and increased service demands, participants still shared examples of persistence and resilience as they worked to meet client needs during these challenging times. DISCUSSION: NSPs in Kazakhstan are well-positioned to reach key populations with crucial information and flexible services during the COVID-19 pandemic. However, they need recognition as essential organizations and additional equipment and staff support to protect staff and clients, maintain pandemic-related regulatory changes, and address additional challenges such as overdose prevention among clients.