SUMMARY OF FACT FINDING MISSION TO KYRGYZSTAN
Maitland J. "Aaron" Peak – Peak Options Consulting
For Soros Foundation – Open Society Institute,
International Harm Reduction Development Program
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The fact finding mission, which ran from August 9-19, 2000, did its work in Bishkek and Osh. The majority of the meetings and site visits were held in Bishkek.

How Illicit Drug Use Affects the Lives of People in Kyrgyzstan

Trafficked drugs travel into Kyrgyzstan from Tajikistan and out to neighboring countries. The number of drug users may be seven times those registered, 3,791. While the official number has dropped, all other signs show an increase, especially in injecting drug users. The government will only allocate funds based on the official number. The State Commission on Drug Control held a conference recently where a national strategic program of drug control was discussed. As a result, laws were established to address drug users’ needs for medical attention, education, employment, and higher living standards.

The current policy [probably the government’s but not clear how written] has these three elements: primary prevention to make all youth aware of the dangers of drugs and discourage them from its use or trafficking; drug treatment and rehabilitation, for which there is a low level of commitment at present; and harm reduction, since other treatment options for infectious diseases are lacking. Representation of the drug using community is included in all three sectors. At least 40% of what is needed in comprehensive harm reduction must be supported in order to have a "real" impact. (Ref. 11)

Once a representative body to coordinate efforts is established, work can advance in providing comprehensive harm reduction. A successful study tour to Krakow, sponsored by the Soros Foundation, changed the attitude of the law enforcement community to support any initiative that yields a healthy society. (Ref. 11)

To bring the government into the effort alongside the NGOs, seminars on preventing infectious diseases need to be offered to top-level authorities. Some official representatives are concerned that harm reduction contradicts Kyrgyzstan laws, which make possession of drugs, but not use of them, illegal. But most accept the necessity of implementation. Front-line police who sometimes still beat, arrest, and incarcerate drug users without provocation or proof of illegal activities, need to be constantly oriented, especially because of turn-over in the ranks. In many cases, police demand payment from the drug users or plant drugs on them. There is frightening sexual abuse of girls by police, as well. The Children’s Welfare Foundation is gathering such accounts with which to approach the Ministry of Internal Affairs. (Ref. 15)

Continual harassment by police officers, therefore, is the primary obstacle to needle exchange programs. As a result few IDUs participate in them and there is a high level of relapse. Many drug users fear the police will arrest them when they access the trust points even if they do not have drugs.

The second barrier to the programs is the lack of employment and methods to build marketable skills. Assistance was requested for a plan of action to address the issue. (Ref. 10)

The third barrier is the lack of information on and understanding of the medical consequences of drug use. While the National AIDS Center provides information on HIV, more information is needed on TB, hepatitis B and C, safer injecting, nutrition, primary health care, and overdose. (Ref. 10) Although it is required by law, some drug users refuse treatment for TB since continuing to have TB gives them the status of "invalid," eligible for a pension. As a consequence, many have drug-resistant TB and will inevitably die from it. Ninety percent of the patients who died from TB in the hospital were drug users or alcoholics.

In the hospitals, it is encouraged for patients to be treated as in-patients so that they can get full care of medications, food, and oversight. Much of the hospital staff, who are afraid to work at night since thieves and strangers lurk about with drugs, favor substitution drug therapy as it would make their jobs easier. (Ref. 7) At the Infectious Disease Hospital, drug users are not categorized as such and are given proper treatment like everyone else. (Ref. 8)

The fourth barrier to the harm reduction programs is the lack of primary health care. It is achievable and the staff are interested in it, but they have not received training or equipment. Overdose is a major problem. Overdose mortality rates in 1998 were 38% and mortality from drug related diseases was 14%. Overdose can occur from taking too much of the drug or by the potency of heroin, which is sometimes difficult to discern. (Refs. 5, 10) The equipment to deal with patients in a coma is old and inadequate. There is only one doctor in the country who has received credentials in toxicology. (Ref. 12) The majority of hospital patients are indigent and uninsured. In the hospital, 25-27% of patients are insured, while in the toxicology unit only 6-7% are insured. (Ref. 12)

The fifth barrier to the drug using community is the lack of affordable, appropriate, and sustainable drug treatment. Most users cannot afford the USD $200-300 for a ten day treatment. There are no rehabilitation programs or reintegration initiatives even though government officials and drug users alike would like it to be available. (Ref. 10) The extended periods patients were kept in dispensaries during Soviet times has shortened due to a lack of funds. There are some in-patient psychology/narcology departments. A reform initiative (MANAS) was developed by the Ministry of Health and funded by the World Bank, to reduce bed allotments for drug users. [sic] The number of beds in Bishkek’s narcology dispensary, for instance, went from 1000 in 1991 to 300 in 1999. Presently, the state budget for medication for the narcology centers is an inadequate USD $25,000 annually. (Ref. 3)

The sixth barrier to comprehensive harm reduction programs is the lack of supplies, such as needles, syringes, condoms, cotton, and alcohol. Workers are frustrated by diminishing supplies and increasing clients.

Children of drug users suffer. Many of the children of drug users who are incarcerated, whether justly or framed by the police, turn to drug use and prostitution for survival and do not attend school. Right now 850 children have parents in jail on drug use charges; 350 children are in jail themselves with the parents. (Ref. 10) A survey in 1998 of 1,600 children found that half were eligible for assistance from the Children’s Welfare Foundation, an NGO. Often these children are beaten by the police, who treat them as they do the parents, and sent to labor camps. Some girls turn to sex work to earn money. (Ref. 15)

The estimated 25,000 sex workers in Bishkek are in danger of infectious diseases, although 80% now use condoms, up from 13%. (Ref. 9) The Gender in Development initiative is a crucial response right now to the increase of women using drugs. Its purpose is to train women to create small businesses in lieu of participating in the drug trade.

In spite of barriers, HIV prevention is advancing and the quality of life has improved for drug users. Needle exchange was looked on unfavorably, especially by the International Committee of Drug Control, and thought to provoke the use of illicit drugs. But with the help of the director of the National AIDS Center and the general director of the State Commission of Drug Control, needle exchange has proceeded. (Ref. 11) Funds previously marked for the AIDS program and the Ministry of Health, however, have been diverted to the security forces for the border wars and to fight international terrorism. (Ref. 13)

Because of the Muslim culture in Osh, many families are afraid to approach hospitals for their son or daughter drug user and prefer to use a private doctor. There is no HIV testing and patients are not categorized as drug users. Many families try to deal with overdoses themselves and therefore bring the patient into the hospital too late. Most overdoses go to the narcology dispensary. Some are suicides. Harm reduction programs should include education on coping skills. (Ref. 17) A rehabilitation center is needed for proper treatment; but users need to want to stop. WHO estimates that 95% of detoxification patients relapse. (Ref. 19) Some parents who have difficulty with their children selling off the household goods even asked for the "golden dose" for their son or daughter. (Ref. 21) The success of overdose management depends on when the patient is admitted to the hospital. The Soros Foundation’s donation of USD $25,000 for equipment and literature has been very helpful and the hospital hopes that it will continue. (Ref. 22).

The laws against commercial sex workers, drug users, and HIV infected individuals are strict in Osh and so more needs to be done from the top-down. The strong laws will be enforced since the deputy director of Internal Affairs was formerly part of the KGB and many in that office still have the old Soviet mentality. (Ref. 23)

Illicit Drug Prevalence and Consumption

The drugs most widely available in Kyrgyzstan are cannabis and opium extracts, including heroin. The number of new drug users increased six times from 1991 to 2000. No records are provided to the government, which figured the number of drug users at 4,500. Drug use among youth under the age of 25 is estimated to have risen from 10% to 30%. Drug use among women has risen from 10% to 35%. There is no methodology to determine the exact number of drug users, but the best realistic estimate comes from multiplying the official number eight to ten times. Regardless, all professionals in the field agree that drug use has increased dramatically.

The cannabis that is cultivated over approximately 300,000 hectares has a 5% content level of THC, much higher than the usual 0.5% in other areas. The purity of heroin in Bishkek is high and the price is approximately 150-250 soms. (Refs. 3, 5)

Use of heroin among sex workers has risen to about 10%. The NGO "Tais Plus" that works with sex workers on HIV prevention distributes condoms but had difficulty distributing needles without encouraging discrimination between sex workers who inject drugs and those who do not. Users are now referred to existing harm reduction program sites instead. (Ref. 9) While women drug users make up 10% of the total, they represent 35% of those using the OSI harm reduction services. Of those women, 40 are sex workers, thus there is a good linkage with "Tais Plus." (Ref. 4) Medecins Sans Frontieres in Osh revealed that there are quite a few migrant sex workers who are young females with children.

Children’s Welfare Foundation conducted a survey of children and found some astonishing results. Sixty percent knew about injecting drugs; 57% said they know how to inject; 66% said they had tried drugs. (Ref. 15)

Alcohol and psychosis patients represent 80% of the intakes at the narcology dispensary, whereas drug users represent only 20%. There is a trend moving from alcohol to drug use, especially since drugs are cheaper, but alcoholism is still a problem and needs better techniques of monitoring. (Ref. 3)

After the demise of opium on the market, heroin became the drug of choice. Overdoses have been common when transferring from dosages of one to the other. Generally, the heroin that is sold is so pure that it does not need to be cooked, only dissolved with water. Sometimes Dimidrol is added to avoid vomiting and Diazepam is added to prolong the high. The average number of injections per day is three. To avoid being detected by the police, many inject into their groin, making the user more susceptible to infection. Veins are apt to collapse when using Dimidrol. Users who have no more proper veins inject under their tongue or resort to skin popping.

The central narcology dispensary for detoxification uses burprenorphine and morphine, but the government has refused to supply these drugs to other dispensaries in the country. Procuring licit drugs is complicated as it is done through two pharmaceutical companies that trade in imported medicines. Stocks of burprenorphine are depleted and consequently expensive, therefore few patients receive it. The first patients who are eligible for it are those who can pay for it. Other patients receive obsolete treatments, such as tranquilizers and vitamins. Non-medical avenues, such as Narcotics Anonymous, are tried by the NGOs. (Ref. 10)

The OSI needle exchange programs offer syringes made in India, which are preferred by users to those made in Russia. No company in Kyrgyzstan manufactures syringes or needles. As drug users switch to heroin from opium they request smaller syringes. (Ref. 4)

The town of Osh is a drug trafficking crossroad as it is close to the borders of Uzbekistan, Tajikistan, and Afghanistan. Afghani soldiers come over the border with their drugs when the cannabis harvest peaks, as well as with heroin. The Osh narcology dispensary registered 500 drug users, but the figure for the Oblast is assessed at 10 to 15 times higher, 85% of which are injecting. (Ref. 17) The situation of illicit drugs has changed dramatically, especially in the rural areas, from five years ago when there were no serious problems. A survey of the 100 patients released last year from the narcology dispensary in Osh showed that 50 were in prison, 20 had died, and 30 had left the oblast. The dispensary receives 100-120 admissions per year. Some drug users return to using the week they are released from treatment. (Ref. 19)

Infectious Diseases Associated with Drug Use

Of the 47 people identified as HIV infected, 37 have been foreigners. The most prevalent route of transmission was through injecting drug use. In spite of the low numbers, 400,000-800,000 HIV tests are provided each year. (Ref. 2)

Various programs have integrated HIV prevention into their activities. In addition to HIV prevention, the OSI needle exchange programs offer IDUs consultation on TB and hepatitis B and C. (Ref. 4) With WHO support, an anonymous testing center was opened for sex workers in Bishkek to test for HIV and STDs. Many more have used the facility than expected. (Ref. 9)

The health of children of drug users, alcoholics, and incarcerated parents is below average. They are registered and indirectly become criminals. If they get into trouble they are treated more severely than other children and put in detention centers. (Ref. 15)

In 1995, along with all other CIS countries, Kyrgyzstan’s president launched a national campaign to address TB. The rate of TB in Kyrgyzstan is high and the year 2000 data indicate that TB affects a wide segment of the population. Bishkek’s TB hospital treats 1,200-1,300 patients every year. Out of a sampling of 230 patients, 73 have been poly-drug users and 161 chronic alcoholics. Most TB drug using patients come from prison and have hepatitis, which was also contracted in prison. The prisons do have TB hospitals and in some cases the prisoners are released early to their home or village because of their deteriorating health. Many patients leave the hospital before their treatment is completed without the permission of the doctors. The doctors and nurses are unable to stop the flow of alcohol and drugs into the hospital and, in any case, it is preferable to violent withdrawal. (Ref. 7)

Hepatitis B and C has steadily increased in the 1990s, especially among drug users. This is true in Osh as well, where it is calculated that the route of infection is caused by injection (35-40%) and not through sexual contact. It is difficult to detect hepatitis B and C because test kits are not always available. Two cases of necrotizing fascialitis have occurred and many patients have abscesses. Free treatment rarely exists and all medication must be purchased by the patient. Soon a law will be passed to require prescriptions for many of the medications presently on the open market, including antibiotics. (Ref. 8)

The Osh Oblast center is the primary testing site for half of the Oblast for HIV, hepatitis B and C, and STDs. The ELISA method is used. Two cases of HIV have been detected in this center – one in 1998 and one in 1999. Both were drug users, one of whom came from prison. Both shared syringes and had sexual relationships for an extended period of time with local drug users. The number of HIV infected people is low but there is great concern about a pending epidemic. The Osh trust point only has the capacity to provide services to 200 out of the 5,000 drug users, which means that only 3-4% are being tested for HIV. UNDCP’s preliminary survey of HIV rates among IDUs in Osh show that 20% are infected. Some people who have tested positive have paid to have their tests changed to negative. The vast majority of tests are not voluntary and some do not even know they are being tested.

STDs are on the rise. Sixty percent of those with STDs are between the ages of 20 and 40 years. Eighty percent of the patients are unemployed. (Ref. 20) MSF/F has a center for STDs in Osh with medications provided by MSF/F. At present there are approximately 4,000 cases of gonorrhea per year and 2,000 cases of syphilis. Lack of compliance has caused resistant strains of STDs to appear, necessitating ever more expensive medications. Compliance in taking medications on schedule and for the full course is poor. No STDs in prison initiatives exist, but police are informed of current events and trends. The STD clinic generally does not get involved in drug treatment. (Ref. 23)

How Service Providers and International Aid Meet the Needs of the Drug Users

UNDP is working on HIV/AIDS within the framework given by the UNAIDS Theme Group and has discussed with the Minister of Health decentralizing finances and activities to the oblasts. The National AIDS Program should be evaluated, as should work at the oblast level, and it should be done by donor agencies, including the Soros Foundation.

At a meeting with a representative from UN Volunteers it was stated that UNVs are not yet active in HIV/AIDS but want to know more about the TAPAS Initiative which utilizes UNVs in promoting harm reduction. Support for an international UNV is about USD $40,000; for a national UNV USD $4,800; and for the field worker UNV, about USD $520 a year.

UNFPA does not work directly in the HIV or drug use fields, but it has worked with high risk families with a history of drug use, HIV infection, and issues surrounding family planning and reproductive health. Most of UNFPA’s work concerns, naturally, contraception analyses, building national capacity in family planning, working with professionals who provide primary health care, and producing IEC materials on reproductive health. Information will be distributed on drug use and HIV vulnerability will be sub-contracted to the National AIDS Center. (Ref. 14)

The National AIDS Program’s first project, in 1997, targeted safe sex in Bishkek with USD $850,000 from the UN. The second project targeted the entire country at a cost of USD $285,000. UNFPA has continued support for the National AIDS Program with USD $5,000, which is insufficient to continue to project. UNDP’s contributions likewise have decreased in the last few years. The rest of the international donor community, aside from the UN, has not supported the National AIDS Program, in spite of efforts to engage the international and national NGOs and volunteers. The Program’s priority is prevention of drug use and HIV and only secondarily needle exchange. (Ref. 13)

The Program’s multi-sectorial initiative, including the Ministries of Health, Labor and Social Services, Education, Internal Affairs, and Defense will produce and distribute IEC materials and focus on medical services. New strategic planning will focus on drug users, youth, and commercial sex workers. There is also an initiative on prisoners, refugees, and special groups of youth. Four NGOs have joined to work in these areas: Oasis, which works with MSM; Tais Plus, which was developed and is operated by commercial sex workers; Sanistas, a harm reduction group; and Parents Against Drugs.

The National AIDS Program produces a quarterly magazine on HIV-related activities and issues. A newsletter in English is sponsored by UNAIDS and UNESCO. This UN/government project has received the Jonathan Mann Award. (Ref. 2)

WHO, USAID, and CDC Atlanta sponsored a project for hepatitis testing in the Infectious Disease Hospital. (Ref. 8)

The labor market policy and employment projects of GTZ in Bishkek will come to a completion at the end of 2001. The government began collaboration with GTZ in 1991. One of the pilot projects, Reconstruction Industrial Enterprise, renovates derelict industrial buildings for the use of small medical-based work enterprises. Another pilot program, Employment Promotion Company, has been so successful that 11 have been opened in the country. (Ref. 6)

GTZ’s job club initiative was launched in 1997 in Takmak and Karabolta. Job clubs provide trainings and discussion groups for the unemployed and people who have had difficulty with lack of work in the transition period. Job placement is higher among members of the job clubs than in regular employment facilities. In an area of a large population of single mothers, in the Osh Oblast, a project specific to women has been set up. These women who are discriminated against are trained to operate their own businesses, many of which have been bakeries. Since one must present a passport and labor book to receive unemployment services, which is sometimes a tall order, training for the unemployed is offered. A mobile employment service initiated in 1997 and funded by GTZ is geared toward the country’s population of internal migrants. The service helps verify the residence of people and issue residency papers, as well as provide employment services. (Ref. 6)

The Narcology Center in Bishkek was created three years ago to bring together agencies and organizations concerned with drug addiction and its consequences. It has an in-patient component, a dispensary for detoxification, and a department for teenagers for drug use prevention issues. The government has not stepped in to help the Center’s lack of finances. The Center considers counseling an integral part of harm reduction and so defines harm reduction as skills + knowledge + means. (Ref. 3)

Drug users who have overdosed are admitted to the First Aid Hospital Toxicology Unit – the only one in the country. An increase in overdoses has made the working environment more difficult and increased mortality rates. (Ref. 12)

The NGO Sotsium, opened in Bishkek in 1998, is one of the most promising harm reduction initiatives. So far, 823 injecting drug users have requested Sotsium’s services, but over 200 users have been turned away because of lack of funds for an adequate supply of syringes and needles. Sotsium uses one room for what have turned out to be very successful meetings of AA, NA, ALATEEN, and ALANON. (Ref. 4) It has two full-time staff and an average of 20 paid volunteers, mostly drug users, who attend regular meetings. It opened a second site across town, the October District Trust Point, so that clients would have services closer to them. Meetings are also held in this location. (Ref. 16) The staff, drug users, and their spouses are all frustrated by police harassment, which they consider a barrier to their work, but the NGO does not have funds for a lawyer to address the corruption. Another barrier is the lack of appropriate IEC materials. The literature by the Center of Information and Enlightenment is medically based and needs to be re-developed, produced, and distributed. This need has been discussed many times but there is still a lack of funding. The NGO photocopies materials on HIV/AIDS. (Ref. 10)

The NGO Tais Plus, that aims to prevent HIV and STDs among commercial sex workers, has had many obstacles and setbacks but nevertheless covers 20 areas in Bishkek. It would like to start similar programs in Karabalt and Takmak. It works closely with the NGO that works with the gay community, Oasis. (Ref. 9)

The Children’s Welfare Foundation helps create a better environment for children of alcoholics, drug users, and incarcerated parents. It aims to prevent drug addiction, alcoholism, HIV/AIDS, STDs, and negative behavior in youth from seven to 18 years of age. The NGO currently helps 34 children and does not have the funds to help all 800 who have been identified for assistance. Its office space is becoming too small and the Foundation will have to look for new space, for which financial support is needed. The Foundation and Sotsium have initiated plans to open a temporary boarding school for children while parents are in treatment. The school will offer medical attention, counseling, training, and schooling. (Ref. 15)

The Soros Foundation has never funded the Ministry of Internal Affairs and it is unlikely to do so in the future. The Ministry’s mission is to arrest people for drug use, including clients of Soros’s needle exchange program. According to the Deputy Director, if the Soros Foundation launches a comprehensive harm reduction initiative – encompassing primary prevention, harm reduction, and drug treatment that includes detoxification, rehabilitation, and reintegration into society – the Ministry will cooperate with it fully. Other branches of the law enforcement community should also be included in harm reduction training. The Ministry is willing to help administrate post-rehabilitation training if funding is supplied by the Soros Foundation. (Ref. 18)

The only available drug treatment is the Osh oblast narcology dispensary. Rural areas have consultation rooms. The two toxicologists in Osh need up-dated training on overdose. (Ref. 22)

Risk of HIV infection is high since only 4% of Osh’s estimated drug users are reached by the Soros and UNDCP program. Funding for an initiative to reach at least 1,000 more IDUs should be granted. Other cities in the region need harm reduction programs, especially since drug users are mobile and can infect users in other areas. (Ref. 20)

There is a growing concern about the spread of STDs in the Osh oblast. Medecins Sans Frontieres/France operates the leading STD treatment center which also provides general information and special information for CSWs engaged in drug use. Another detoxification center in Osh, called Musada, is a rival and not spoken of much. MSF/F provides medication for their programs whereas UNDP does not. The MSF/F director feels that the UN is not doing enough to fight the spread of HIV and that their support is only just enough to make them look good and give them political clout. Regardless, one collaborative effort that is needed concerns the incineration of medical waste. UNDP, MSF/F, and Soros Foundation should support this initiative. (Ref. 23)

The Osh narcology dispensary has an in-patient division with 60 beds, and an out-patient department that follows up on those who have completed detoxification. The dispensary also has a consultation and prevention center for teenagers. Some attempts at AA and NA groups have not been successful. (Ref. 19) Because government funding for the dispensary is insufficient the NGO Parents Against Drugs has been located within the dispensary. The NGO’s needle exchange is off the premises, however, to maintain its independence from the government.

The Soros Foundation is the only organization in Osh working in HIV prevention for drug users even though other international agencies are there: MSF/F, SCF/UK, GTZ, OBSCE, ACCELS, UNESCO, and inter-Bilium. The view of the Soros Foundation focus is that it is too narrow and should be broadened to include education of the general public with assistance from the Ministries of Health and Internal Affairs. The funding that Soros Foundation provides means that coverage of its project is limited and drug users are being turned away.

Since there is no law prohibiting needle exchange the law enforcement community allows the program to continue. While they are neutral, it would help drug using clients if the top officials were actually in favor of harm reduction. If methadone treatment is initiated, however, the clients and volunteers will be arrested. (Ref. 17)

The Osh trust point, located in the First Aid Hospital, believes that drug users who come to the program are sick rather than criminals and should be left alone by the police. At one point 30 drug users were arrested, and after this scandal few drug users came to the program. The NGO appealed to UNDCP to help educate the police about the uselessness of incarcerating drug users. The situation improved considerably as a result.

Volunteers cover the city but not all drug users are willing to admit their use since there is still not a great amount of trust. The families of drug users, however, are eager for the NGO’s help. While doctors are obligated to promote abstinence, volunteers promote harm reduction instead. If users agree they can be sent to the narcology dispensary for treatment. It is said that 90% are willing to have treatment but have no money to pay for it. The volunteers are trained in primary health care and are able to treat abscesses and other infections, but they do not have the equipment or materials. Volunteers receive in-service training once a week on primary health care, overdose, and referral service management. The site doctor, however, provides most health services. (Ref. 21)

Observations and Recommendations

Fact finding mission: Due to a change in people accompanying the mission, Osh was chosen as the second site visit. Unfortunately, the mission coincided with the majority of the UN representatives’ annual home leave. The only meeting that could be scheduled was with UNFPA, which is not working in the HIV or drug use fields.

UN: The UN’s commitment seems as low as in the other two countries. However, the cohesiveness of the collaboration of the UN, international and national NGOs, and the government is conducive for moving forward with innovative programs in Bishkek. The drug using community was more involved and there seemed to be lower levels of prejudice than in the other two countries.

Primary care: It was clear from meetings with the State Commission of Drug Control, the Ministry of Internal Affairs, and the UNDCP Country Office that the harm reduction initiative needs to be expanded to include a wider range of services. They expressed willingness to collaborate with OSI if they included assistance in primary prevention, referral mechanisms, rehabilitation, and reintegration of drug users back into society.

Recommended: The Soros Foundation should consider addressing issues relating to a continuum of care and treatment for potential, current, and former drug users. For example, OSI program volunteers could accompany police when they talk to school children about prevention. The law enforcement community as well as the medical, NGO, and target communities have requested appropriate drug treatment, rehabilitation, and reintegration.

The Soros Foundation should be involved with or be represented at the government’s newly developing representative body to address supply, demand, and harm reduction initiatives and policies. Soros would add an active and credible voice.

UNDCP: The UNDCP regional office will soon fund an assessment of the current state of illicit drug use in Central Asia. There has been difficulty finding an appropriate partner for the initiative in Kyrgyzstan. As a result of this mission, however, UNDCP may collaborate with Sotsium. The assessment will document the accurate and current statistics of drug use in the country, which in turn would increase the funding for UNDCP and the Ministry of Health. UNDCP has contributed the most financial support for HIV and drug use within the whole UN system as well as among the non-UN agencies. UNDCP will implement an overall strategy on demand reduction in the coming year focusing on primary prevention in youth and redefining the drug treatment arena.

The Soros Foundation cannot, and should not, be the primary donor agency to provide a comprehensive approach to harm reduction. The ministries, donor agencies, and NGOs need to cooperate on a three-prong approach to harm reduction, including detoxification, rehabilitation, and reintegration.

Recommended: The Soros Foundation should initiate a working relationship with UNDCP and lend support for the possible involvement of Sotsium in UNDCP’s assessment of drug use in Kyrgyzstan. There should be a seminar on developing rehabilitation and reintegration as part of the drug treatment and harm reduction schemes.

Law enforcement: Across the board there has been agreement that something has to be done about the interference of the law enforcement community with volunteers, clients, and former drug users. The low, below survival rate salaries of the police and low status of drug users encourages the corruption and harassment. The ultimate solution, resolution of the country’s financial crisis, is far in the future. In the meantime some pragmatic steps can be taken to address the issues that affect the OSI programs.

Recommended: Support should be given for orientation seminars for the law enforcement community. The seminars should focus on comprehensive harm reduction strategies and highlight the importance of a continuum of care. This is a VERY sensitive issue and any approach has to be well thought out. Another option is to document all the cases of non-legal conflicts between the clients and law enforcement officers. This may demonstrate that the individuals committing the offenses are few. Some officers may enhance the program through referrals rather than arrests. Advice should be requested from the Soros Foundation’s legal division at the country office so that procedures are correctly undertaken.

Osh: Osh was somewhat different than Bishkek. First, it seemed incestuous, as the deputy director of the Ministry of Internal Affairs seems to be related to the chief of the narcology dispensary, who is also the director of the OSI harm reduction program. The head psychiatrist is married to the director and it is said that relatives are working on the program as volunteers. Second, there was little interaction with drug users in Osh. The approach in Osh seemed more autocratic and leaned towards abstinence-based objectives. The main agenda seemed to be to request support from the Soros Foundation for every aspect and initiative. Third, whereas the Bishkek program was more client driven, in Osh the program was more monetarily driven – spacing out the clients, even turning them away, so that in the end they reached the total number for which they had been funded.

The OSI program felt that there was a need to open a second site in Bishkek. The office lacks all infrastructure required to operate a productive and sustainable program.

Recommended: The Soros Foundation should allocate funds to supply the new Bishkek office with equipment, telephone, and supplies so that this much needed additional site can operate at full capacity.

National AIDS Program: It was unfortunate that more insight was not gathered on the reasons for the reduced support from the various UN agencies to the National AIDS Program, which tended to be very bureaucratic.

Recommended: There were repeated requests for the Soros Foundation’s support of the book "Health and Lifestyle" accompanied by workbooks and training for teachers.

TB: There is a continual interaction between drug users and the Tuberculosis Hospital because drug users are susceptible to TB infection and some enjoy retaining the "invalid" status of having TB.

Recommended: Support should be allocated to produce IEC materials on TB and the consequences of sustained TB infection. More collaborative initiatives should be undertaken by the OSI harm reduction staff and the narcologist, doctors, and nursing staff at the TB hospital to enhance knowledge and foster more interaction between the volunteers and drug users that are also TB patients at the hospital.

Disease studies: The Infectious Disease Hospital has been collaborating with the Center for Disease Control on viral hepatitis studies. CDC informally expressed interest in forming a relationship with the Soros Foundation for studies with drug users on the prevalence of hepatitis B and C.

Recommended: The Soros Foundation should establish a relationship with CDC and discuss collaborations on prevention strategies and developing appropriate IEC materials for drug users. A hospital staff member or narcologist should be a liaison between the OSI program and hospital so that an improved standard of treatment can be provided to the drug users.

Printed materials: The mission stopped at the Center for Information and Enlightenment to gather materials, most of which was technical and unsuitable to the drug using community, on different diseases. The National AIDS Program has an adequate but narrow selection of materials on HIV/AIDS. The OSI program has already started re-developing materials for drug users with their assistance, but it does not have enough.

Recommended: Materials from the Center for Information and Enlightenment should be used as a basis to develop appropriate IEC materials for distribution to drug users. Support should be allocated to develop, field test, produce, and distribute materials on primary health care, hepatitis B and C, vein care, nutrition, overdose management, and TB. Extra copies may need to be produced for distribution to agencies or medical houses in the rayons where drug use is most prevalent.

Supplies: Both the client driven program and the monetary driven program, described above, have their pros and cons, but both lack supplies. Hundreds of drug users have been turned away in Osh due to a lack of supplies and not wanting to over-extend the budget. It is difficult, however, to devise an accurate initial budget. Further, those programs that have offered primary health care have demonstrated that the trust between new clients and staff has been accomplished more rapidly when immediate needs of the drug users have been attended to before HIV has been discussed or syringes distributed.

Recommended: A formal primary health care component should be incorporated into the harm reduction program. It should include basic supplies, such as plasters, gauze, ointments, creams, medical utensils, gloves, disinfectants, rehydration solutions, antibiotics, and overdose medication. There should be quarterly trainings.

Toxicology Unit: Staff at the First Aid Hospital Toxicology Unit feel that the unit is not a high government priority. Only one doctor in Bishkek has credentials in the toxicology field. The main toxicology unit does not even have a computer or Internet so that the doctors can have access to up-to-date information.

Recommended: A computer with Internet access should be supplied to the toxicology unit. A seminar should be developed for all staff so that they can share experiences, briefings on current methodology, and orientation on harm reduction strategies and information. A session should be incorporated into the agenda to train harm reduction staff on patient survival before he or she is transferred to the toxicology unit or hospital. Basic equipment should be procured for the main toxicology unit to assist the survival of drug users and others.

Drug substitution: The chief of the narcology dispensary was open to piloting different approaches in drug user treatment. He was most interested in the drug substitution scheme even though methadone is controversial. The alternative drug burprenorphine has been used in South Asia successfully and is currently a detoxification medication at the dispensary. It has less of a stigma than methadone and might be easier to get approvals.

Recommended: Discussion should take place on a pilot project of burprenorphine drug substitution in the narcology center. Mechanisms should be explored to procure sufficient supplies directly from the manufacturers so that they are a reasonable price. One pharmaceutical company that supplies burprenorphine to harm reduction programs is also a sponsor of the 12^th IHRC in New Delhi.

Peer groups: Bishkek had the best models for AA, NA ALANON, and ALATEEN programs, most of which have been in operation for five years and have met with some success. Some of the individuals associated with the programs have a good amount of sobriety behind them. They extended their experiences to drug users by visiting Osh, but were limited as they had to pay their own way. These individuals would be a great help if they could travel to the sites and talk to drug users as well as local authorities. This would be beneficial for Tajikistan as well as Kyrgyzstan.

Recommended: A small amount of funding should be allocated so that some of the AA, NA ALANON, and ALATEEN members can assist in developing programs as well as interacting with drug users, alcoholics, and families that are interested in joining the programs.

Children: There is a need to address issues concerning children of drug users, alcoholics, and parents that are incarcerated on drug charges. The Children’s Welfare Foundation is dedicated and their work plan is thorough, but they need to secure funding for their activities.

Recommended: The Soros Foundation should assist in setting up meetings and introductions of the Children’s Welfare Foundation to donor agencies. It should also critique the Foundation’s funding proposal so that it is more presentable to the donor community. Its expertise could also be used to explore the possibility of incorporating rehabilitation and reintegration initiatives.

CSWs: Tais Plus is a valuable service to the 25,000 sex workers in Bishkek and the rest of the community. They were pragmatic enough to discontinue their needle exchange component as it was going to undermine their overall efforts. However, they still need harm reduction services.

Recommended: The OSI harm reduction program should include a position – staff or volunteer – to focus on drug users who are CSWs to ensure that this specific population is represented in the OSI program.

GTZ: Collaboration with GTZ is a good idea, even though it is not directly involved in working with the drug using community. New labor laws mean that drug users are included in the ranks of the unemployed. Some of GTZ’s techniques for gaining employment should be duplicated in the OSI harm reduction program to reduce the rate of relapse. GTZ is willing to lend its expertise to the OSI programs for such schemes as a mobile unit for documenting residency, procedures for acquiring official papers and passports, and getting lists of employment opportunities. The "job clubs" would be beneficial to the OSI programs. Other NGOs might wish to be included.

Recommended: Meetings should be scheduled with GTZ and the government to explore collaboration on a sustainable human development component for drug users. If this proves to be a viable working relationship then support from the Soros Foundation should be allocated to the schemes.

Waste: There is no facility at the local hospital in Osh to incinerate syringes or other medical waste that may be contaminated with infectious diseases. MSF/F, the Soros Foundation, and UNDP together could fund and install a medical waste incinerator.

Recommended: The Soros Foundation should move forward on this collaboration for a central medical waste incinerator, as one is urgently needed in the area.

Conclusion: The OSI programs and other initiatives in Bishkek were impressive, especially for the cohesiveness demonstrated among the different entities, from the drug using community to top officials. Bishkek is an example of perseverance to overcome obstacles to the harm reduction movement. With the inclusion of the above-mentioned suggestions and recommendations to the harm reduction movement and a study tour to several Asian countries, Bishkek could be a prime example of a "best practice" approach in the international arena.

References

1. Soros Foundation Kyrgyzstan: Medet Tulegenov, Deputy Executive Director.
2. National Project Manager on HIV/AIDS: Larisa Bashmakova.
3. Narcology center, Dr. Tynchiykbek Asanov, Director.
4. Sotsium: Dr. Batma Abybovna, Director.
5. UNDCP: Temur Aziz Ahmad, Chief Technical Advisor, and Nurlan Kenenbaev, National Project Coordinator.
6. German Technical Cooperation (GTZ): Janyl Kojomuratova, Local Adviser.
7. Tuberculosis Hospital: Dr. Kurmanbik Osuyevich, Director.
8. Infectious Disease Hospital: Dr. Alla Sarkina, Deputy Director.
9. Tais Plus: Group of commercial sex workers meeting.
10. Sotsium: Drug user group meeting.
11. Crime Police Illicit Drugs: Lt. Col. Almaz Garifullin, Director; Licit Drugs: Vira Jurchenco, Director; International Legal Department: Almaz Karabalaev, Director; Dr. Kairat Osmanaliev, Researcher – Law; and Kyrgyzstan University: Stanislav Grionev, Student.
12. First Aid Hospital – Toxicology Unit: Dr. Akylbek Usupbaev, Director of Hospital; Dr. Ibraimov Nurlan, Chief of Toxicology MoH Kyrgyzstan; Dr. S.S. Satiev, Head of Neuro Surgery; and Olga Deshpet, Head of Nursing Department.
13. National AIDS Program: Dr. Boris M. Shapira, Director.
14. UNFPA Country Office: Elmira Suyumbaeve, Coordinator Population and Development; Gulnara Kadyrkulova, Coordinator Reproductive Health.
15. Aitana Children Welfare Foundation: Three Foundation board members, two volunteers, and ten children.
16. Trust Point, October District: Volunteer, lawyer, police, and two IDUs.
17. Parents Against Drugs: Dr. Burchanov Mamaobyr, Director.
18. Ministry of Internal Affairs: Colonel Rasulberdy R. Raimberdiev, Deputy Director.
19. Narcology Dispensary: Dr. Burchanov Mamaobyr, Chief Narcologist for Osh.
20. Osh Oblast Center on AIDS Prevention: Tugelbay M. Mamaev, Chief Doctor.
21. Trust Point Needle Exchange Program: Burkhanova Rano, Psychotherapeutics and Narcologist; Akimbekova Nurilya, Nurse; and six volunteers.
22. Ministry of Health: Deputy Director.
23. Medecins Sans Frontieres/France: Dr. Yves Marchandy, Head of Mission and Medical Coordinator.

1. Elvira Muratalieva, Medical Coordinator, Soros Foundation, Bishkek.
2. Batma Abybovna Estebesova, Director of Sotsium NGO, Bishkek.
3. Tynchiykbek Asanov, Chief Narcologist of Ministry of Health (Pharmacist), Bishkek.
4. Kairat Osmanaliev, Research and Law Department, State Commission on Drug Control (PhD in law), Bishkek.
5. Glinenco Victor, Deputy Health Minister on Epidemiology, Bishkek.
6. Colonel Raslil Raimberdiev, Deputy Director of Internal Affairs, Osh.
7. Burkhanov Mamasobyr, Chief of Narcology Center and Director of Parents Against Drugs, NGO, Osh.

Note: While the Open Society Institute funded this mission, it did not have any input or verify the contents or findings of the mission. The author is solely responsible for the accuracy of this report.