This post is by Center Director Christine Lubinski, who is in Almaty, Kazakstan this week for a meeting of the HIV/TB core working group of the Stop TB Parternship.
We visited an NGO run by the International Federation of the Red Cross with an on-site HIV clinic. The small staff, consisting of two social workers, a coordinator, a lawyer and a psychologist, was joined by a number of clients of the group who welcomed the opportunity to tell us about the challenges they face in Kazakhstan. They also made it clear that this site provides a safe haven where they feel respected and supported and where the clinical staff also treat them well.
There are approximately 15,584 persons living with HIV infection in Kazakhstan, with about 1100 persons receiving HIV therapy. There are fewer than 130 on ART in Almaty, this city of 2 million people. Sixty-percent of HIV cases are among injection drug users.
The group provides services for 120 clients co-infected with HIV/TB and 500 injection drug users living with HIV infection. Many of the individuals receiving services here were formerly incarcerated, adding to the stigma and barriers they face to accessing services.
The challenges facing this population are numerous. One huge hurdle is a requirement that they report to the authorities every six months to register their “permanent residence.” No certificate of residency means no services, including medical care such as TB treatment, HIV treatment, or drug treatment. TB treatment is supposed to be free to all, notwithstanding residency status, but those without adequate paperwork are nevertheless denied care by many clinics. Many of the marginalized individuals living with HIV infection cannot establish permanent residency; they don’t have appropriate paper work for a variety of reasons. The lawyer spends a great deal of her time advocating for this group. When one member of our group asked what options individuals who cannot establish residency have, one of the clients replied: “Prison or the cemetery.”
Drug treatment is largely religious in nature , in other worlds controlled by Christian or Muslim groups, and it is frequently not free. There are very few 12-step programs and methadone is not available in this part of the country. Currently only 50 persons have access to substitution therapy nationally. Finally, a number of drug treatment centers refuse to admit persons with HIV infection. Advocating for HIV infected clients with these treatment programs is one of the activities of this client-centered NGOs.
Gainful employment can be virtually impossible for this population. Despite laws that prohibit such discrimination, it is commonplace for prospective employers to require job applicants to provide documentation from the office of the prosecutor showing that they have no criminal record, and documentation from a physician certifying their TB and their HIV status. Even though this practice is patently against the law, law enforcement authorities have no interest in taking action against these employers.
Tuberculosis, including MDR-TB, is a much bigger problem in Kazakhstan than HIV infection, although the numbers of individuals who are co-infected is growing. A visit to a TB clinic illustrated the very different approach to TB treatment in this region. Twenty percent of all cases of tuberculosis in Kazakhstan are drug resistant and the percentage of retreatment cases that are MDR is 45 percent. Generally speaking, tuberculosis is treated on an in-patient basis, requiring patients to spend very long periods of time in the hospital. The average length of stay is 103 days for drug-susceptible pulmonary TB. This is not likely to change soon, since budget allocations for TB are based on numbers of hospital beds occupied. However, there is a growing acknowledgement that this treatment of TB in congregate settings has real implications for infection control and for perpetuating high MDR-TB rates. One government representative noted that while laws specify inpatient treatment for tuberculosis, they do not specify length of stay, providing some opportunity to reduce inpatient stays under current regulations. Those with MDR can be hospitalized as long as two years.
All patients with TB are automatically tested for HIV infection. Persons with HIV infection without active tuberculosis are placed on isoniazid preventive therapy (IPT) for 6 months.