Abstract
Background
Pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, yet uptake among people who use drugs (PWUD) remains low. In Kazakhstan, PrEP is delivered through centralized AIDS Centers, which may limit equitable access. This study examined health system and implementation barriers to PrEP uptake among PWUD.
Methods
We conducted 11 nominal group technique (NGT) focus groups (N = 108; 57 PWUD, 51 providers) across Kazakhstan. Participants generated and ranked barriers and facilitators to PrEP uptake (PWUD=171 votes; providers=150). Quantitative rankings were integrated with thematic analysis.
Results
Barriers reflected systemic gaps in service delivery. The most prominent barriers were lack of information (23%), stigma, fear of registration and lack of anonymity (23%), and regulatory constraints and bureaucracy (20%). Stakeholder perspectives diverged: PWUD prioritized stigma and anonymity (30%) and concerns about side effects (19%), while providers emphasized lack of awareness (31%) and patient engagement (19%). Logistical barriers such as time and distance (10%) further limited access. Facilitators highlighted feasible system adaptations, including community-based outreach and education (31%), co-location of services (19%), and improved staffing and funding (17%). Across groups, low-threshold and anonymous access was critical.
Conclusions
PrEP availability alone does not ensure access for PWUD. Centralized, facility-based delivery models are misaligned with the needs of marginalized populations. Decentralized, integrated, and low-threshold approaches—particularly through outreach and addiction services—are essential to improve equitable access. These findings provide actionable insights for health system adaptation in Kazakhstan and similar settings.
Key messages
• PrEP is effective for HIV prevention, but uptake among PWUD remains low globally.
• Multi-stakeholder evidence shows that system design—particularly stigma, bureaucracy, and lack of integration—limits access, highlighting the need for decentralized, low-threshold delivery models.