“Drug users are marginalized and disconnected from the medical system, with abstinence proclaimed as the only worthy goal of drug treatment,” says Alex Khachatrian, a Russia-based program assistant for the Joint United Nations Programme on HIV/AIDS (UNAIDS).
Yet several studies over the past 15 years have shown that transmission rates among injecting drug users (IDU) plummet when they have easy, consistent access to clean needles, which lessens the need to share needles that might be contaminated with HIV. Although there is evidence that needle exchange programs can reduce HIV infection rates, the lack of widespread adoption of these programs stands as a startling reminder that factors other than hard data affect healthcare resource allocation.
Khachatrian believes that many Russian drug-treatment and HIV specialists are not convinced of the viability of needle exchange because of concerns it might lead to increased drug use. A widely publicized study from Vancouver, released in 1997, seemed to give credence to their concerns: nearly 10 years after that city’s first needle exchange program was initiated, both the total number of IDU and the percentage of those infected with HIV had increased.
However, the results from that study and a similar one from Montreal that was released at the same time are for the most part anomalies — especially compared with more recent studies. Data and logic beg the question: If evidence-based medical practices are the gold standard in most healthcare circles today, why don’t health authorities and the politicians who fund them follow the facts that have shown these programs to be effective?
As with many thorny issues associated with AIDS, answers are often found after an analysis of cultural values. In most cultures, drug use is an arguably more taboo subject than sex. Drug users often face social opprobrium and scorn unrivalled among groups most at risk for HIV infection. Consequently, efforts collectively known as ‘harm reduction’ that establish needle exchange projects and other HIV prevention and treatment strategies for drug users continue to face substantial political, social, and financial obstacles in most countries.
Not surprisingly, the battle over harm reduction has been especially heated in countries or regions with higher-than-average levels of drug use. This is especially true in Eastern Europe and the former Soviet Union, currently home to some of the world’s fastest rising HIV rates, and one of the few regions in the world where the majority of HIV infections to date are attributable to injecting drug use.
Drug use has exploded in the region since the mid-1990s, especially among young people. In particular, youths coming of age in Russia, Ukraine, and Central Asia continue to be disproportionately affected by the difficult post-Soviet economic and political transitions. Adolescents and teenagers are often easily tempted by drugs, which are reasonably cheap and readily obtainable because the region is located on the main heroin shipment route from Afghanistan to Western Europe.
Russia and Ukraine are experiencing the most severe drug-use epidemics in the region: recent estimates from UNAIDS and the Russian Federal AIDS Center indicate that there are at least 4 million active drug users in Russia and perhaps 1 million in Ukraine. The HIV epidemic in those two countries has followed closely on the heels of the surge in drug use. Official data for Russia, for example, indicate that some 250 000 people are now infected with HIV, compared with just 11 000 in 1999. Government officials and independent observers agree, however, that the true number of infections is at least four times official estimates — and about 80% of those infections have occurred among IDU
This dire situation was not wholly unexpected. Because the HIV epidemic gathered steam in this region later than in others, there were plenty of clear warning signs in the 1990s that mirrored conditions seen previously in other countries.
One of the first organizations to recognize the impending crisis was the International Harm Reduction Development program (IHRD), which is part of the Open Society Institute (OSI), a foundation created by billionaire financier George Soros. Although governments have generally welcomed OSI’s programs in areas such as public health, education, arts and culture, and the media, controversy dogs some of its funding areas. When IHRD helped establish the first harm reduction program in Russia in 1996, government officials were suspicious and often uncooperative — although authorities did not shut it down.
Now, 7 years later, IHRD directly supports about 50 harm reduction programs in Russia and an additional 150 or so in other countries in the region, from Poland to Uzbekistan. As the HIV epidemic has progressed, other international nongovernmental organizations (NGOs) such as Medecins Sans Frontieres (Doctors Without Borders) have begun funding harm reduction programs, often jointly with IHRD.
The expansion of projects does not mean that harm reduction is widely accepted, however. Even as some health ministries and regional health agencies have allocated funds for harm reduction, authorities at all levels remain divided over both its public health effectiveness and social appropriateness.
“[Stigmatization] translates into a lack of political will to deal with health and other issues affecting illicit drug users,” says Dave Burrows, a long-time consultant on harm reduction issues in Russia and the Ukraine, who is based in Sydney, Australia. Burrows says the outcome is a “lack of money to address these issues; lack of advocacy by health professionals for health budgets directed toward drug users; [and] repressive policies that jail drug users.”
Existing United Nations drug control treaties require signatory countries to implement policies aimed at reducing demand for illicit drugs, and many governments seek to comply by harassing, intimidating, and incarcerating drug users. Russia cited the treaties as a main reason to tighten its drug laws in 1998, just as the HIV and drug use epidemics were taking hold. Tougher anti-drug laws were also implemented around that time in other countries in the region, including Poland (1997), the Czech Republic (1998), and Hungary (1999). In those three countries, for example, the new laws mandated harsher criminal penalties for drug possession.
Without a corresponding increase in pragmatic drug treatment programs, such laws have had the effect of forcing drug users underground, advocates say, thereby limiting their access to services such as needle exchange that protect their health. The inevitable result is the increased spread of HIV and other blood-borne diseases such as hepatitis C.
Few observers believe that decreasing stigma against drug users anywhere in the World will be anything but a long, complicated process. But advocates have been heartened by a gradual recognition among international organizations that harm reduction is a viable, necessary strategy to control HIV transmission.
In many former Soviet bloc countries, HIV prevention and treatment funds distributed by the World Bank and the new Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) are now earmarked specifically for harm reduction programs. Advocates are hopeful that harm reduction capacity will eventually expand to cover at least 60% of IDU in a target region, the level at which World Bank analysts estimate will significantly reduce HIV transmission.
Coverage of IDU currently doesn’t exceed 20% in most countries of the region, according to Sergey Kostin of the Odessa Charity Fund, a harm reduction program in Ukraine. Additional funding might also make a big difference in countries that have taken measures to reduce stigma, such as the Czech Republic, Kyrgyzstan, Lithuania, and Romania, according to Konstantin Lezhentsev, an IHRD program officer based in Budapest, Hungary.
“Virtually the entire health system in each country has to be retrained to think of IDU as worthy members of society, as well as be schooled in the basics of HIV prevention, treatment, care, and support,” says Dave Burrows.
Advocacy, education, and training are perhaps even more important than funding in some countries, Burrows contends. For instance, money is only one part of the problem in Russia, where the government has so far been reluctant to apply for GFATM funds.
Russian President Vladimir Putin, who remains widely popular, has been largely silent on HIV. But providing a glimmer of hope, Vadim Pokrovsky, the head of the Russian Federal AIDS Center, directly addressed stigma against drug users when recently releasing data about the epidemic in his country.
“A group of our comrades assert that… most of those infected are drug addicts,” Pokrovsky said in a speech on May 21, 2003. “As such, they will die anyway, and there is nothing terrible about the virus spreading among them, why show concern for them? The drug addicts are also brothers and sisters of others and they are people who have the right to live.”