Assessment on the Medication Assisted Therapy program in the Kyrgyz Republic
In September 2010, ICAP at Columbia University received funding from the US Centers for Disease Control and Prevention (CDC), under the President’s Emergency Plan for AIDS Relief (PEPFAR), to work with the Ministries of Health (MOH) and other governmental and non-government partners to strengthen HIV care, treatment and prevention services in Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan (the SUPPORT Project).1 The Assessment of medication assisted therapy (MAT) projects in the Kyrgyz Republic is an integral part of the SUPPORT Project’s work plan and results of this assessment will be used for provision of technical support to improve MAT.
The purpose of this assessment was to collect information on the scale and quality of the existing MAT services for people who inject drugs (PWID) in the Kyrgyz Republic, and to identify any gaps in such services. The assessment results will be presented to the MOH and other stakeholders in order to plan, coordinate and implement interventions to improve opioid drug dependence treatment, particularly MAT, in the Kyrgyz Republic. The information will also be used by ICAP to guide the development of strategies and activities aimed at advancing HIV prevention services in the region. The protocol and data collection tools were developed jointly by ICAP teams in New York and Almaty. Prior to their use in the field, the teams consulted stakeholders and made revisions based on their feedback. The assessment included a mixture of qualitative and quantitative research methods, including interviews with MAT patients, PWID, MAT staff, key stakeholders and healthcare service users, as well as medical record reviews. A review of prior assessments conducted by other agencies was also performed.
Key findings of the Assessment include:
1. The MAT program (locally more frequently referred to as opiate substitution therapy, or OST), funded under Global Fund for AIDS Tuberculosis and Malaria (GFATM) grants for the Kyrgyz Republic, clearly demonstrates the feasibility and efficacy of prescription of methadone to treat opioid dependence.
2. The legislation of the Kyrgyz Republic is favorable for the introduction of MAT as a standard of care for treatment of opioid dependence and HIV prevention among people who inject drugs.
3. Outcomes of the MAT project in Kyrgyzstan include reduction in non-prescribed (illicit) opioid use, criminal activities, and HIV-risk behavior. MAT also helped to improve patients’ perception of their health.
4. Enrollment in the program is associated with significant reductions in patients’ spending on non-prescribed psychoactive substances, resulting in reductions of social harms caused by criminal activities associated with the need to find money for the drugs.
5. Methadone-based MAT may be provided in the Kyrgyz Republic at a very low cost: in 2012, the cost of a daily dose of methadone was only USD 0.28 per patient.
6. The MAT sites outside of the capital experience a great lack of technical guidance. Insufficient attention is paid to the training of nurses – in a number of MAT sites the nurses did not have any formal MAT training.
7. The current monitoring and evaluation system for MAT in the Kyrgyz Republic has a number of deficiencies, including those related to the collection and analysis of data from the MAT sites, and does not afford proper evaluation of the quality of the services provided, patients’ satisfaction with the program, and MAT’s impact on their sexual,
drug use, and criminal behaviors.
8. The existing infrastructure of organizations providing MAT and their material capacity hinder the quality provision of MAT and require improvement.
9. Despite a significant reduction in injecting non-prescribed substances in comparison with the period before MAT, some patients continue injecting psychoactive substances (PAS), mostly Dimedrol (Diphenylhydramine).
10. Collaboration with other healthcare and social services that target drug users is poor. For example, there is a lack of cooperation with needle exchange programs, even when they are located next door to the MAT sites.
11. A system for social adaptation and employment of MAT patients is lacking.
12. PWID and patients report that the interference of law enforcement services precludes their participation in MAT.
Based on the findings of the Assessment, the following recommendations are provided for improving the treatment of opioid dependence, specifically MAT, in Kyrgyz Republic:
1. Further expand the MAT program, improving access to the therapy in remote areas of the country, where there is a need for such therapy. Special attention should be paid to the expansion of MAT in penitentiary institutions.
2. Improve the provision of technical assistance to the MAT sites through selection, training, and involvement of specialists in addiction psychiatry and narcology from medical institutions to serve as technical advisors.
3. Continue infrastructural improvement of the narcology centers, ensuring the provision of a full range of services in a confidential environment. Equip MAT sites with automated dispensers to improve the quality of services and prevent the diversion of methadone for illegal purposes.
4. Improve monitoring and evaluation procedures for MAT, ensuring the collection and analysis of data related not only to program implementation, but also related to MAT patient outcomes.
5. Increase the participation of non-governmental organizations and MAT patients in promotion of MAT to PWID and their families. The expertise and experience of NGOs must also be used in the provision of psychosocial support to MAT patients and their families.
6. Enhance interactions between MAT sites and HIV and tuberculosis harm reduction and treatment programs. Identify ways to provide comprehensive care for MAT patients with HIV and tuberculosis as a “one stop shop” model.
7. Develop a mechanism to ensure that MAT patients get free screening for viral hepatitis in accordance with Ministry of Health guidelines.
8. Scale-up comprehensiveness of MAT including improvements in provision of counseling to patients, people who inject drugs (PWID) and their relatives; development of peer-support groups and increase interaction between medical and social services for PWID.
9. Improve activities aimed at building enabling environment for operation of MAT programs, reduction of stigma and discrimination by medical personnel and legal assistance to MAT patients.
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