Abstract
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 aims to examine associations between earlier sexual debut and lifetime exchange sex behaviors among Kazakhstani MSM. Using data from a NIDA-funded 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 debut was 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 debut and lifetime reports of buying or selling sex for resources, with covariance adjustment for sociodemographic characteristics. Study findings indicate 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 activity during childhood and adolescence relate to exchange sex behaviors and risk among MSM.
Keywords: MSM, sex initiation, exchange sex, Kazakhstan, men
Introduction
As rates of HIV transmission have accelerated in Kazakhstan over the past ten years, gay, bisexual, and other men who have sex with men (MSM) in Kazakhstan have experienced a disproportionate burden of the HIV epidemic, including a seven-fold increase in HIV prevalence (ECOM, 2018; UNAIDS, 2020). Despite this context of increased risk, two known dimensions of sexual experience that predict the acquisition of HIV among MSM globally—earlier age of first sexual activity (i.e., earlier sexual debut) and exchange sex behaviors (Nelson et al., 2016; Outlaw et al., 2011)—have not yet been examined among Kazakhstani MSM.
During adolescence, many young people begin to form romantic relationships and initiate partnered sexual activity (Lindberg et al., 2021). Although various types of sexual behaviors are prevalent across the lifespan, children and early adolescents (i.e. ages 12 and younger) rarely engage in oral-genital, vaginal, or anal sex with peers (Felzen Johnson, 2002; Haugaard, 1996; Hornor, 2004); when such sexual behaviors are reported within this age group, they are associated with adverse childhood events, particularly child sexual abuse (Felzen Johnson, 2002; Haugaard, 1996; Hornor, 2004). In other contexts, earlier sexual activity during childhood and early adolescence is associated with exchange sex and other HIV-risk behaviors. Among adolescent boys in Sweden, earlier sexual debut before fourteen years old was associated with an increased risk of sexual abuse as well as exchange sex (Kastbom et al., 2015).
Earlier sexual debut among MSM has been associated with illicit use of substances as well as risky sexual behaviors, including exchange sex and unprotected sex (Cheung et al., 2014; Outlaw et al., 2011). In a U.S. study of young men who have sex with men (YMSM) living with HIV, YMSM with an earlier sexual debut were significantly more likely to use marijuana, experience emotional problems related to substance use, have a history of suicide attempts, and engage in exchange sex compared to YMSM with an older debut (Outlaw et al., 2011). Among MSM at risk of HIV transmission in China, earlier anal sexarche (anal sexual debut) was associated with recreational drug use as well as risky sexual behaviors, including unprotected sex, having multiple male sexual partners, and exchanging sex for money (Cheung et al., 2014).
In Kazakhstan, exchange sex among women has been the predominant focus of HIV prevention research with limited attention to sexually diverse men (Berry et al., 2012; Davis et al., 2017; El-Bassel et al., 2020; Mergenova et al., 2019). Over the past several years, constellations of higher risk behaviors have been associated with exchange sex among women in Kazakhstan (Davis et al., 2017; El-Bassel et al., 2020). Women in Kazakhstan who reported engaging in both exchange sex and drug use were at increased risk of intimate partner and non-partner violence as well as nonfatal overdose (El-Bassel et al., 2020). HIV-positive women in Kazakhstan who have exchanged sex were more likely to report housing insecurity, intimate partner violence, risky sexual behavior, and injection drug use compared to HIV-positive women who did not exchange sex (Davis et al., 2017). Additional research about exchange sex behaviors among MSM in Kazakhstan may strengthen interventions aimed at reducing HIV risk. In one study examining exchange sex among MSM in Kazakhstan, unprotected anal intercourse with male partners was associated with sexually transmitted infection (STI) symptoms, exchange sex, and non-injection drug use (Berry et al., 2012).
To our knowledge, the present study is the first to examine associations between earlier sexual debut and lifetime exchange sex behaviors among MSM in Kazakhstan. The age of majority in Kazakhstan is 16 years old and will be used as a primary age-cut off for earlier sexual debut (UNPF, 2018). Earlier sexual debut will be examined within the context of a lifetime history of buying or selling sex in exchange for resources. Given the findings in other contexts, we hypothesize that Kazakhstani MSM reporting a sexual debut before sixteen years of age will be more likely to report buying and selling sex in exchange for resources.
Method
This is a secondary analysis of data that were obtained during the conduct of a NIDA-funded clinical trial of a behavioral intervention that sought to increase the engagement of MSM who use substances in Kazakhstan in the HIV care continuum (e.g., learning one’s HIV status via HIV testing, receiving HIV medical care for those living with HIV, and achieving viral suppression for those who have started antiretroviral therapy) (see Paine et al., 2021). Briefly, the parent study was a clinical trial designed to test a behavioral intervention for MSM across three geographically disparate cities in Kazakhstan: Almaty, Nur-Sultan (formerly Astana), and Shymkent. The clinical trial commenced in 2018, and the data presented in this report utilized self-reported data collected during structured screening interviews conducted in Russian or Kazakh with MSM in Almaty, Nur-Sultan, and Shymkent that were completed between September 2018 and September 2021 (N= 766). All study procedures were approved by the Institutional Review Board (IRB) at Columbia University (Protocol # IRB - AAAQ7251) and the Local Ethical Committee at Al-Farabi Kazakh National University (Protocol # IRB - A052).
Participants
For this study, the sample consisted of individuals who completed a screening interview (conducted to determine eligibility of the parent study) and met the following additional eligibility criteria: ≥18 years old, assigned male at birth, and reported having had consensual sex with a man. Exclusion criteria included insufficient English, Russian, or Kazakh comprehension or cognitive ability to provide informed consent in those languages. The original target sample size for the parent study was 1,000. The COVID-19 pandemic resulted in a pause and modification of study activities that cut about one-third of the recruitment time. The proportionally reduced sample size was estimated to still achieve 80% power for the parent study to detect a clinically significant change in HIV testing rates (the first step in the HIV care continuum). For this secondary analysis, the sample involves the 766 screened individuals who met the aforementioned inclusion and exclusion criteria.
Measures
Earlier Sexual Debut
Sexual debut was measured using a single continuous question about age of first sexual activity. The measure was divided into three categories to assess earlier sexual debut. The following are justifications for sexual debut categorization. Sexual debut at 16 years or older was used as a reference category in all final models because 16 years old is age of majority in Kazakhstan as well the average age of sexual debut in our MSM sample (UNPF, 2018). The two earlier sexual debut categories included sexual debut occurring at ages 12 and younger and between 13–15 years old. Earlier sexual debut was divided into two categories to assess possible differences between earlier sexual activity that occurred during childhood through late childhood/early adolescence (i.e., ages 1–12) versus earlier sexual activity during adolescence but prior to the average age of sexual debut in our sample (i.e. ages 13–15) (Kellogg, 2010; Wurtele & Kenny, 2011).
Exchange Sex
Participants were asked several questions about exchange sex behaviors in their lifetime. Exchange sex is defined as a dynamic where partners exchange sex for resources (i.e., money, drugs, shelter, or some other resource). MSM were asked if they have ever exchanged sex (yes or no) separately as a seller or buyer. Participants were also asked at what age they first sold sex; this variable was collapsed into three categories by median age of first selling sex (never exchanged sex; under 21 years of age; and ages 21 and older). Age at which the participant first bought sex was not collected as a survey question.
Covariates
Categorical population characteristics that were included in bivariate and multivariable models were city (Almaty, Nur-Sultan, Shymkent); marital status (single, married, no longer with spouse, or ‘other’); highest educational attainment level (9th grade or less, high school or vocational, bachelor’s degree or more, or ‘other’); employment (full-time, part-time, unemployed, or ‘other’), housing insecurity (ever homeless or without a regular place to sleep in the past 6 months); self-reported HIV-status (HIV-positive, HIV-negative, unknown); self-reported sexual orientation (gay/bisexual/other or heterosexual); binge drinking (ever in the past 90 days); and any illicit use of substances (ever in the past 90 days). Continuous population characteristics included current age and income. Income was measured as a self-reported estimated monthly income over the past six months in Kazakhstani Tenge (KZT). Income was used for population descriptives and income log squared was used in all models.
Data Analysis
Frequencies of categorical population characteristics and exchange sex variables were used for descriptive analysis (see Table 1 and 2). Chi-square tests were used for bivariate analyses to assess associations between earlier sexual debut and exchange sex (see Table 3). Chi-square tests were also used to assess differences between population characteristics by exchange sex categories. Three adjusted multivariable models were used to examine associations between earlier sexual debut as a predictor of ever selling or buying sex and age of onset for selling sex. A logit link was used since the outcome variable (engaging in exchange sex) was binary. Statistical assumptions were met by examining tolerance measures to avoid multicollinearity (all values were well above .10), and the categorization of the key independent variable (age of sexual debut) obviated any potential impact of extreme outliers.
Table 1.
Categorical population characteristics of the sample of MSM in Kazakhstan, 2018–2021 (N=766)
| Population Characteristic | n(%) |
|---|---|
| City | |
| Almaty | 303(39.6%) |
| Nur-Sultan | 263(34.3%) |
| Shymkent | 200(26.1%) |
| Marital Status | |
| Single | 604(78.9%) |
| Married | 51(6.7%) |
| No Longer with Spouse | 62(8.1%) |
| Other | 49(6.4%) |
| Highest Educational Attainment Level | |
| Other | 28(3.7%) |
| 9th Grade or Less | 48(6.3%) |
| High School or Vocational | 319(41.6%) |
| Bachelor’s Degree or More | 371(48.4%) |
| Employment | |
| Full-Time | 409(53.4%) |
| Part-Time | 153(20.0%) |
| Unemployed | 87(11.4%) |
| Other | 117(15.3%) |
| Housing Insecurity in the Past 6 Months | |
| Yes | 75(9.8%) |
| No | 691(90.2%) |
| Self-Reported HIV Status | |
| HIV-Positive | 51(6.7%) |
| HIV-Negative | 440(57.7%) |
| Unknown | 275(35.9%) |
| Self-Reported Sexual Orientation | |
| Gay, Bisexual, or Other | 740(96.6%) |
| Heterosexual | 26(3.4%) |
| Binge-Drinking [Past 90 Days] | |
| Yes | 444(58.0%) |
| No | 322(42.2%) |
| Any Illicit Substance Use [Past 90 Days] | |
| Yes | 206(26.9%) |
| No | 560(73.1%) |
| Sexual Debuta | |
| Ages Less Than 13 | 61(8.0%) |
| Ages 13–15 | 182(23.8%) |
| Ages 16 and older | 522(68.1%) |
Note. The percentage (%) of population characteristics within this table represents the total sample of MSM participants.
One participant response was coded as missing for sexual debut.
Table 2.
Exchange sex among MSM in Kazakhstan, 2018–2021 (N=766)
| Exchange Sex | n(%) |
|---|---|
| Ever Exchanged Sex (Seller) | |
| Yes | 179(23.4%) |
| No | 587(76.6%) |
| Ever Exchanged Sex (Buyer) | |
| Yes | 199(26.0%) |
| No | 567(74.0%) |
| Age First Exchanged Sex (Seller)a | |
| Never | 587(76.6%) |
| Under 21 Years of Age | 104(13.6%) |
| Ages 21 and Older | 73(9.5%) |
Note. The present table represents the percentage (%) of exchange sex variables reported within the total sample of MSM.
Two participant responses were coded as missing for age first sold sex.
Table 3.
Earlier sexual debut and exchange sex among MSM in Kazakhstan, 2018–2021 (N=766)
| Exchange Sex (Seller) | Exchange Sex (Buyer) | Age First Exchanged Sex (Seller) | |||
|---|---|---|---|---|---|
|
|
|||||
| Exchange Sex Characteristics | Ever | Ever | Never | Under 21 Years of Age | Ages 21 and Older |
|
| |||||
| n(%) | n(%) | n(%) | |||
| Sexual debut less than 13 years old | 26(42.6%) | 21(34.4%) | 35(57.4%) | 16(26.2%) | 10(16.4%) |
| Sexual debut 13–15 years old | 54(29.7%) | 63(34.6%) | 128(70.3%) | 30(16.5%) | 24(13.2%) |
| Sexual debut 16 years or older | 99(19.0%) | 115(22.0%) | 423(81.3%) | 27(5.2%) | 70(13.5%) |
Note. The present table represents the percentage (%) of participants within a sexual debut category who engaged in exchange sex behavior.
Results
Population Characteristics
Demographic characteristics of our MSM respondents are displayed in Table 1. Most participants were single (79%), college-educated (42%), and an average age of 28 years old. The majority of our sample lived in Almaty (40%), worked full-time (53%), housing secure (90%), and had an average monthly income of approximately 180,000 KZT (about 460 USD) over the past six months. Almost all of our participants identified as gay, bisexual, or a sexual orientation other than heterosexual (97%), and over half self-reported being HIV-negative (58%). Most of the men in our sample had recently binge drank (58%) but had not illicitly used any type of substance recently (73%). Over two-thirds (68%) of respondents were ages 16 years or older during their sexual debut.
Exchange Sex
The following subsections describe significant bivariate associations found between categorical demographic variables and exchange sex behaviors.
Ever Sold Sex
Participants who reported ever selling sex reported greater rates of living in Shymkent, having attained an education of 9th grade or less, housing insecure, binge drank in the past 90 days, and having had illicitly used any drugs in the past 90 days.
Ever Bought Sex
Respondents who reported ever having bought sex had higher rates of no longer being with their spouse, being unemployed, identifying as heterosexual, and having illicitly used any substances in the past 90 days.
Age First Sold Sex
In our sample, MSM who first sold sex under 21 years of age had higher frequencies of having attained an ‘other’ type education, an ‘other’ type of employment, experiencing housing insecurity, having binge drank in the past 90 days, and having used any type of illicit substance in the past 90 days.
Associations Between Earlier Sexual Debut and Exchange Sex
Table 3 presents crosstabulation results between earlier sexual debut and exchange sex outcomes. Earlier sexual debut differed by lifetime exchange sex behavior (see Table 3). MSM with a sexual debut less than 13 years old and between 13–15 years old had higher rates of ever selling and buying sex compared to those with a later age of sexual debut. MSM who reported a sexual debut less than 13 years old reported the highest rates of earlier age onset of selling sex (before 21 years of age) compared to older sexual debut age groups.
All three adjusted multivariable models found significant associations between earlier sexual debut and exchange sex (see Table 4). MSM with an earlier sexual debut prior to 13 years old had approximately 3 times higher odds of ever selling sex and 2 times higher odds of ever buying sex (aOR=2.99, 95%CI: 1.65–5.41; aOR= 2.13, 95%CI: 1.15–3.94). MSM with an earlier sexual debut between 13 to 15 years old had 1.6 times higher odds of ever selling sex and 1.6 times higher odds of ever buying sex (aOR=1.62, 95%CI: 1.07–2.46; aOR= 1.56, 95%CI: 1.05–2.34). In our final model, MSM with a sexual debut before 13 years old and between 13–15 years old had, respectively, 6.9 and 3.5 times higher odds of selling sex at an earlier initial age (aOR= 6.91, 95%CI: 3.21–14.90; aOR= 3.54, 95%CI: 1.95–6.43) compared to MSM with a later sexual debut.
Table 4.
Associations between earlier sexual debut and exchange sex among MSM in Kazakhstan, 2018–2021
| Sexual Debut | Exchange Sex (Seller) | Exchange Sex (Buyer) | Age First Exchanged Sex (Seller) | |
|---|---|---|---|---|
|
| ||||
| Ever | Ever | Less Than 21 Years Old | Ages 21 Years and Older | |
|
| ||||
| a0R (95% CI) | a0R (95% CI) | a0R (95% CI) | ||
| Sexual Debut: Less Than 13 Years Old |
2.99***(1.65–5.41) | 2.13*(1.15–3.94) | 6.91***(3.21–14.90) | 1.62(0.74–3.56) |
| Sexual Debut: 13–15 Years Old |
1.62*(1.07–2.46) | 1.56*(1.05–2.34) | 3.54***(1.95–6.43) | 0.99(0.58–1.69) |
|
|
||||
| Age | 1.00(0.97–1.03) | 1.03*(1.00–1.05) | 0.97(0.93–1.10) | 1.01(0.98–1.05) |
| Income log2(𝑛) | 1.00(0.94–1.07) | 1.08(0.98–1.19) | 1.00(0.91–1.10) | 1.00(0.92–1.10) |
| City | ||||
| Nur-Sultan | 0.62*(0.39–0.97) | 1.29(0.84–1.98) | 0.74(0.38–1.42) | 0.54*(0.31–0.95) |
| Shymkent | 0.97(0.62–1.54) | 1.35(0.85–2.14) | 1.21(0.62–2.35) | 0.84(0.47–1.46) |
| Marital Status | ||||
| Single | 2.03(0.84–4.93) | 0.46*(0.24–0.88) | 1.76(0.47–6.58) | 2.19(0.72–6.63) |
| No Longer with Spouse | 2.03(0.70–5.86) | 1.22(0.54–2.72) | 2.42(0.50–11.81) | 1.91(0.52–7.06) |
| Other | 2.33(0.78–6.99) | 0.35*(0.14–0.90) | 0.64(0.09–4.59) | 3.78*(1.03–13.83) |
| Highest Educational Attainment Level | ||||
| High School or Vocational | 0.68(0.33–1.39) | 0.91(0.43–1.92) | 1.17(0.42–3.27) | 0.55(0.23–1.32) |
| Bachelor’s Degree or More | 0.62(0.29–1.29) | 1.24(0.58–2.66) | 0.66(0.22–1.93) | 0.66(0.27–1.63) |
| Other | 0.86(0.28–2.62) | 1.27(0.36–4.47) | 1.70(0.41–7.05) | 0.43(0.08–2.38) |
| Employment | ||||
| Full-Time | 0.58(0.33–1.01) | 0.73(0.42–1.29) | 1.07(0.42–2.71) | 0.40**(0.21–0.76) |
| Part-Time | 0.59(0.31–1.10) | 0.78(0.42–1.48) | 0.77(0.27–2.17) | 0.50(0.25–1.03) |
| Other | 0.53(0.26–1.07) | 0.25***(0.11–0.57) | 1.31(0.46–3.79) | 0.27**(0.12–0.67) |
| Housing Insecurity in the Past 6 Months | ||||
| Yes | 2.90***(1.71–4.91) | 1.37(0.77–2.43) | 3.59***(1.76–7.32) | 2.36**(1.23–4.51) |
| Self-Reported HIV Status | ||||
| HIV-Positive | 1.04(0.50–2.19) | 0.44(0.19–1.03) | 0.71(0.21–2.41) | 1.27(0.55–2.91) |
| Unknown | 1.08(0.73–1.60) | 1.26(0.86–1.84) | 1.14(0.64–2.02) | 1.05(0.64–1.70) |
| Self-Reported Sexual Orientation | ||||
| Gay, Bisexual, or Other | 1.26(0.46–3.46) | 0.40*(0.17–0.92) | 1.51(0.32–7.25) | 1.15(0.35–3.80) |
| Binge-Drinking (Past 90 Days) | ||||
| Yes | 1.69**(1.14–2.50) | 1.12(0.77–1.62) | 1.73(0.96–3.11) | 1.74*(1.07–2.82) |
| Any Illicit Substance Use (Past 90 Days) | ||||
| Yes | 2.21***(1.50–3.26) | 2.12***(1.44–3.11) | 2.12**(1.21–3.71) | 2.30***(1.44–3.68) |
Note: The reference groups include: sexual debut 16 years and older; living in Almaty; married marital status; 9th grade or less education; unemployment; HIV-negative status; heterosexual sexual orientation; no binge-drinking in the past 90 days; and no illicit substance use in the past 90 days. CI: Confidence interval. P-values:
p≤0.05
p≤0.01.
p≤0.001.
We would like to note that in our final models sexual orientation is categorized as either heterosexual or a sexually diverse identity. While developmental work at the start of the study revealed that the practical context and culture in Kazakhstan is heavily homophobic to the extent that any non-heterosexual behavior/identity is the primary driver of stigma and other social dynamics (rather than specific identities/expressions within the constellation of non-heterosexual sexualities and behaviors), we reran multivariable models with sexual orientation having four categories–gay, bisexual, heterosexual, and other. All of the significant associations between sexual debut and outcome variables remained significant except for the <13 years old sexual debut and buying sex; since the sign of the association remained the same and p<.10 is suggestive, our overall conclusions remain unchanged and the failure to achieve p<.05 criterion level of significance is mostly likely due to a loss in statistical power.
Discussion
This is the first study to find associations between earlier sexual debut and exchange sex behaviors among MSM in Kazakhstan. Notably, the significant associations between sexual initiation during childhood (i.e. ages 12 and under) and exchange sex behaviors strongly suggests the presence of child sexual abuse and/or other forms of adverse childhood events. Previous research has shown that children who have experienced sexual abuse and other forms of neglect are at increased risk of engaging in exchange sex behaviors (Brown et al., 2015). Similarly, earlier sexual debut has been previously associated with both sexual abuse and exchange sex behaviors (Kastbom et al., 2015). The possible influence of adverse childhood events may be particularly salient for sexually diverse populations in Kazakhstan who report high rates of homophobic discrimination within their families and greater community (Amnesty International, 2017). Future research and clinical interventions aimed at examining exchange sex risk behaviors among MSM in Kazakhstan should include sexual histories that incorporate age and context of first sexual activity, including non-consensual or abusive sexual experiences during childhood.
The significant associations found between selling sex and population characteristics such as living in Shymkent, housing insecurity, lower educational attainment, and substance use suggests that exchange sex behaviors among Kazakhstani MSM may be a form of survival sex. Sexually diverse young people are at increased risk of family rejection due to homophobia, and as result experience disproportionate rates of homelessness (Castellanos, 2016). Additionally, sexually diverse youth who experience violence and/or parental substance use in the home may leave their family in order to remove themselves from abuse within the home (Ream & Forge, 2014). Homelessness can be traumatizing, and adapting to this environment may involve substance use and exchanging sex for resources (Castellanos, 2016; Ream & Forge, 2014). Similarly, obstacles and other stressors related to housing insecurity and substance use may also result in lower educational attainment. Additional research is needed to assess why selling sex among MSM is associated with specific city centers, such as Shymkent. Clinicians and other providers who work with Kazakhstani MSM who are at risk of HIV transmission and selling sex for resources, particularly in Shymkent, should consider the potential impact of trauma, homelessness, lack of access to education, and substance use.
There is no singular reason why some men exchange resources for sex, however, research examining men who buy sex from women suggests that some motivators include desire for emotional intimacy, sexual novelty, and/or sexual control (Sanders, 2013). This study found significant associations between buying sex and characteristics such as substance use, heterosexual identity, and no longer being with a spouse. It is possible that some MSM in Kazakhstan buy sex to attain a form of intimacy and/or control that is absent from their non-commercial sexual relationships with women or other men. Substance use and buying sex could be emotional coping mechanisms, or they may simply be a result of novelty seeking. Future research should examine the motivators, risk factors, and contexts of gay, bisexual, and other MSM who buy sex in Kazakhstan.
Limitations
The present study sample may not be representative of MSM populations in Kazakhstan. Our sexual debut survey question was relatively simple and only asked the participant’s age of first sexual activity. The study survey did not ask or differentiate between consensual and non-consensual sexual debut; the study’s Community Advisory Board dissuaded asking about child sexual abuse during instrument development. In our screening survey, we asked participants their age of onset for selling sex, but we did not replicate this question for buying sex. Our study is cross-sectional and cannot assert a temporal relationship between sexual debut and exchange sex. Finally, social desirability-bias may have influenced reporting of socially sensitive behaviors, such as exchange sex and sexual activity during childhood or adolescence.
Conclusion
Kazakhstani MSM reporting an earlier sexual debut had significantly higher odds of ever buying or selling sex in exchange for resources as well as selling sex at an earlier age. Kazakhstani MSM with a sexual debut prior to thirteen years of age were particularly likely to report exchange sex behaviors. Differentiating between consensual and non-consensual earlier sexual experiences is an important contextual detail for future research to consider. Additional research and clinical interventions are needed to better understand the context of exchange sex behaviors and pathways between consensual and non-consensual earlier sexual activity and exchange sex behaviors among MSM in Kazakhstan.
Acknowledgments
In addition to the co-authors, this work was only made possible by the research staff who showed tremendous dedication, skill, and sensitivity—Gassan Akhmedov, Karina Alipova, Farruh Aripov, Dilara Belkesheva, Daniyar Bekishev, Ferangiz Hazanova, Altynay Kambekova, Saltanat Kuskulova, Aitkul Nazarova, Syrim Omirbek, Olga Balabekova, Sultana Kali, Aidar Yelkeyev, Saida Yessenova, Valeria Davydova, and Aizhan Toleuova—and, most importantly, the time and trust given by the participants. The findings and conclusions in this report do not necessarily represent the views of NIDA, the Columbia University School of Social Work, or the Global Health Research Center of Central Asia.
Funding Details
The data for this study were funded by the National Institute on Drug Abuse (NIDA; https://www.drugabuse.gov/), grant # R01DA040513.
Footnotes
Declaration of Interest Statement
No competing financial interests exist.
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