Drug use, trafficking and the HIV epidemic in Central Asia
Kasia Malinowska-Sempruch
Director, International Harm Reduction Development Program
Open Society Institute

Introduction

Central Asia is in danger of an explosive HIV crisis. As we have seen in other parts of the world, HIV follows the same route as drug trafficking, and Central Asia is a critical drug trafficking route. Central Asia must immediately tend to its emerging HIV problem by re-examining its drug policies and practices. To dogmatically marginalize people who are at risk of HIV transmission, which most of the policies do, is counterproductive and leads to limiting our knowledge about infection rates and encourages HIV to spread faster.

The Central Asian problem has been noticed at the high level of the United Nations Secretary-General. The report for the Special session of the General Assembly on HIV/AIDS, just issued on February 16, says that "recent data from some [Central Asian] countries suggest that the spread of HIV has begun to spread among injecting drug users."

The governments of Central Asia cannot afford the epidemic of drug use that already exists today. They certainly cannot afford the HIV epidemic that is sure to follow tomorrow. The only productive, humanitarian response available is the pragmatic one of meeting drug users where they are, not where we wish them to be. We must assist them to minimize the harms from drug use and prevent infectious diseases.

Lessons from Asia

Asia, which had an estimated 7.2 million cumulative HIV infections in 2000, is the world leader in HIV infections after Africa (The information on Asia in this section comes from Chris Beyrer, "Accelerating and Disseminating Across Asia." [The Washington Quarterly, Winter 2001, Vol. 24, No. 1, p. 211]). In Asia, HIV spread first among injecting drug users, next throughout the sex trade, and finally into the wider population of sexually active adults and their infants. Now it is spreading quickly across Asia and mostly among people under the age of 25. We can safely predict that without any intervention the progression of HIV in Asia will be replicated in Kazakhstan, Kyrgyzstan, Tajikistan, Uzbekistan, Azerbaijan, and Turkmenistan.

There is ample evidence that drug trafficking, injecting drug use, and HIV infection are woven closely together and that HIV follows drug trafficking routes. The most infected provinces of China, for instance, are on the heroin trafficking routes from southeastern Asia. According to the 1999 International Narcotics Strategy Control Report from the U.S. State Department, Afghanistan is now ahead of Burma in opium production and heroin exports. This has obvious, grave consequences for Central Asia and in particular Tajikistan, which shares a 1,350 km border with Afghanistan. Central Asia itself produces enough drugs to meet the annual use in the U.S., Europe, and Central Asia (Vincent McClean, Director, United Nations, with information from the United Nations Office of Drug Control and Crime Prevention).

The problem of having a narcotics industry deeply embedded in the economy and a growing population of drug users makes the Central Asian countries Kyrgyzstan and Tajikistan as susceptible to the drug and HIV crisis as a country like Pakistan (which has one of the highest drug addiction rate in the world.) Every day press reports of drug seizures come out of Central Asia.

Asia did not predict the HIV crisis it has now or manage it well once it started. To spare itself the same AIDS drama, Central Asian countries have a responsibility to learn the lessons. To avoid the loss of millions of lives they need to adopt honest, pragmatic approaches -- and quickly.

Poverty

The country fact-finding reports on Kazakhstan, Kyrgyzstan, and Tajikistan commissioned by IHRD in 2000 produced important findings, some of which I will describe below.

Poverty is fueling the drug trade in Central Asia. As incomes have all but disappeared from farming and agriculture, more people go into the drug trade. Even law enforcement has become involved in the drug trade to supplement their low income. The Tajik Prosecutor-General admitted as much in early February. Women who have joined the drug trade are often motivated by a desperate attempt to support their children when the father’s income is lost to addiction or unemployment. The reports found that 30 percent of the population in Tajikistan is dependent on the illicit drug business.

Poverty has also encouraged an increase in drug use. While exact numbers are impossible to figure, professionals in the field agree that drug use has increased dramatically. The reports found 135,000 users in Tajikistan and perhaps 200,000 in Kazakhstan. A recent rapid situation assessment in Kazakhstan suggests that 30% of commercial sex workers are using drugs. In Kyrgyzstan the use of heroin among sex workers has risen to 10%, according to the reports.

Poverty makes the method of drug use more risky. People are switching from vodka to heroin, which is cheaper, and heroin users are starting to switch from smoking or snorting to injection, because it is more efficient. In Tajikistan, 70% of drugs taken are smoked or snorted while 30% are injected. For HIV prevention, it would be good to maintain this ratio. As law enforcement cracks down and heroin becomes less available and more expensive, however, people will shift to injection.

Impoverished social services mean that addiction treatment is so scarce it can be considered unavailable. While the government in Tajikistan, for instance, acknowledges the need for rehabilitation and psychological services, it only advocates detoxification. Addiction does not respond to one model of drug treatment, however. It is essential to provide a variety of models to increase the chances of success. Replacement therapy is also very important because it can reach those who are not ready to commit to abstinence and it reduces the crime associated with drug use as well as the harms associated with sharing needles.

The medical care system under former Soviet Union was probably the most wasteful in the world, having one of the highest number of hospital beds and hospital stays in the world. But efforts to make this system more efficient by cutting the number of beds for drug treatment in Kyrgyzstan, for instance, is wrong-headed since drug use, along with STIs and TB, is the most explosive problem in the country. Further, TB is most prevalent among drug users.

Culture of Fear

Essential to preventing HIV and other infectious diseases is timely treatment. The period from the onset of infection to before treatment is when the diseases are most readily spread to the greater community, in the case of TB, and other drug users and sexual partners, in the cases of HIV and hepatitis C. A culture of fear, however, is inhibiting people from seeking treatment.

Drug users fear that the police will arrest them as they enter needle exchange programs, even if they do not have any drugs on them. This fear is not irrational. It actually happened in Osh, when 30 clients of the outreach program were arrested. The more people are marginalized, the more they are likely to stay away from service providers or hospitals during a time when meaningful intervention is possible.

The Kazakhstan report says: "Harm reduction is difficult in a country in which drug users still remember that under Soviet leadership their names were taken by health professionals and given to public security officials to record. Many drug users and commercial sex workers, therefore, are unwilling to go to government medical services"

Not only is individual health compromised by this culture of fear, but it also prevents an accurate assessment of the extent of the drug problem.

Progress

We have seen one small positive step in Kazakhstan, where the Timertau City Council has started revisions of the criminal code to ensure that the law

enforcement community focuses on supply reduction rather than arresting drug users. The country’s Interior Minister Bolat Iskakov said in early February that drug users "should be treated rather than imprisoned" and that treatment centers should be expanded.

IRHD organized and paid for a study tour of Kazak and Kyrgyz police from cities with HR projects to go to Krakow to meet with the local police officers, as well as service providers for drug users. It was a useful meeting is shows how police can continue to do its job without interfering with service provision.

The poor economic situation in Central Asia means that all drug use and HIV initiatives must for the time being be supported by the international donor community. This support will be meaningless, however, unless the national and local governments take ownership. IHRD will encourage this process with more policy initiatives over the next year.

Recommendations

To minimize the spread of HIV and infectious diseases in Central Asia, IHRD makes the following recommendations:

• Governments must re-examine their drug policies to be less punitive of drug users and more supportive of treatment.
• A consortium of government and nongovernmental, national and international bodies, must develop alternative sources of income for people who turn to drug trafficking as means for assuring basic economic survival.
• The ministries of health must make a variety of drug treatments and rehabilitation available, including replacement therapy.
• Drug users must be encouraged to seek help and not be turned away by law enforcement.
• Services have to be open and non-judgmental.
• All parties must continue the long process of educating all of the drug stakeholders, including the police, medical workers, and policy makers

Email this article
Posted March 1, 2001 © Eurasianet
http://www.eurasianet.org

	The Central Eurasia Project aims, through its website, meetings, papers, and grants, to foster a more informed debate about the social, political and economic developments of the Caucasus and Central Asia. It is a program of the Open Society Institute-New York. The Open Society Institute-New York is a private operating and grantmaking foundation that promotes the development of open societies around the world by supporting educational, social, and legal reform, and by encouraging alternative approaches to complex and controversial issues. The views expressed in this publication do not necessarily represent the position of the Open Society Institute and are the sole responsibility of the author or authors.