Exploring multi-level barriers and human-centered solutions to expand methadone for HIV prevention among people who inject drugs in Kyrgyzstan.

backgroundOpioid agonist therapy, including methadone, is an evidence-based practice for treating opioid use disorder and preventing HIV. Yet in Kyrgyzstan, methadone coverage among people who inject drugs (PWID) remains suboptimal despite decades of availability. A human-centered design lens and implementation science frameworks guided exploration of multi-level barriers and potential strategies to increase opioid agonist therapy uptake.

methodsIn June-July 2023, a pre-implementation study was conducted in three high-burden regions (Bishkek, Chuy, Osh), following the exploration phase of the Exploration-Preparation-Implementation-Sustain framework. We used nominal group technique to conduct six focus groups stratified by methadone use (clients vs. non-clients) with 52 PWID. Participants generated and rank-ordered barriers to methadone scale-up. Analyses applied the Socio-Ecological Model, and identified barriers were mapped to discrete and blended implementation strategies via the Expert Recommendations for Implementing Change framework.

resultsParticipants identified 25 distinct barriers across individual, interpersonal, clinic, community, and policy levels. The four highest-ranked barriers were: (1) fear of consequences from narcological registration (e.g., driver's license revocation, employment discrimination); (2) perceived poor quality or diluted methadone, especially among clients who associated symptoms of withdrawal with low-dose variability; (3) structural inconveniences in methadone programs, such as rigid dosing schedules and lack of geographic access; and (4) insufficient medical, psychosocial, and socioeconomic support services at clinics. Stigma permeated across socioecological model levels-participants described judgment from family, community members, peers, and healthcare providers. Participants not on methadone commonly endorsed misinformation about methadone's side effects (e.g., harmful consequences, dental decay). Region-specific variations were pronounced: for example, registration concerns predominated in Osh, while program inconvenience was more salient in Chuy. Participants proposed client-driven solutions, including eliminating narcology registration, expanding take-home dosing, enhancing transparency in dosing practices, offering additional support services, and promoting success stories from current clients. Proposed solutions aligned with Expert Recommendations for Implementing Change strategies, including altering incentive structures, conducting educational outreach, revising professional roles, and facilitating client-centered care redesign.

conclusionsApplying human-centered design within implementation science frameworks identified context-specific barriers and actionable strategies. Addressing these client-prioritized challenges may be essential to improving methadone retention and could contribute to reducing HIV risk among PWID in Kyrgyzstan.