Building Expanded Responses to HIV/AIDS and Injecting Drug Use in Central Asia
Henning Mikkelsen
Programme Development Officer, UNAIDS Secretariat

HIV/AIDS is the most formidable development challenge of our time. Kofi Annan, UN Secretary General, 16 February 2001

Introduction

The growing recognition of AIDS as a global emergency has recently led to mobilization around HIV/AIDS at the highest political levels and in an unprecedented scale: The UN Security Council as well as the US government have identified AIDS as a threat of to global stability and security. The G8 leaders have committed themselves to the target of reducing the number of HIV/AIDS-infected young people by 25% by 2010. In follow up of the UN Millennium Summit in September last year in New York, a UN General Assembly Special Session on AIDS is being organized for June next year.

It has taken 20 years and more than 50 millions infected people to get this far! In December 2000, the UNAIDS secretariat and WHO reported that by the end of 2000, 36.1 million men, women and children around the world were living with HIV or AIDS and 21.8 million had died from the disease. The same year saw an estimated 5.3 million new infections globally and 3 million deaths, the highest annual total of AIDS deaths ever. The spread of HIV has brought about a global epidemic far more extensive than was predicted even a decade ago.

The countries of the former USSR present some of the most dramatic trends in the worldwide AIDS epidemic. Fuelled by injecting drug use, the epidemic unfolds against a complicated backdrop of economic crisis, rapid social change, increased poverty and unemployment, growing prostitution and changes in sexual norms. Previously characterized by very low prevalence rates, the region now faces an extremely steep increase in the number of new infections, up from 420,000 at end-1999 to at least 700,000 one year later. In 2000 alone, more new infections were registered in the Russian Federation than in all previous years combined. Of the region’s 250,000 new infections, most occurred among men, the majority of them injecting drug users.

HIV/AIDS in the Central Asian Republics

The Central Asian Republics have until recently been little affected by the HIV/AIDS epidemic. By end 1999, estimated 3,500 persons were living with HIV/AIDS in Kazakhstan and in the other four republics – Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan – estimated less than 100 persons were living with HIV/AIDS. The very rapid spread of HIV in other parts of the former Soviet Union, and an outbreak with more than 200 reported cases in Uzbekistan, clearly demonstrate that the relatively low HIV prevalence does not give room for complacency. The Central Asian republics may well be on the verge of a major public health and socio-economic development disaster, in terms of large scale epidemics of HIV/AIDS.

The Central Asian republics, close to main production areas of opium in Afghanistan, minor opium producers themselves, and main corridors for drug trafficking to Russia and Europe, have experienced very large increases in illicit drug use including injecting drug use in recent years. According to UNDCP, opiate use prevalence may be approaching 1% of the population older than 15 years. In Temirtau in Kazakhstan, a city of 200,000, at least 3,000 of the 32,000 young people between 15 and 29 years are believed to be injecting drug users. As in Russia and the Western NIS, heroin is gradually replacing home made opiates as the most commonly injected drug.

The very big and growing populations of primarily young drug injectors in the Central Asian republics are at high and immediate risk of HIV infection. Furthermore, the dramatic increase in sexually transmitted infections (STIs), with gonorrhea and syphilis incidence rates exceeding 380 reported cases per 100,000 in Kazakhstan in 1997, and 396 cases per 100,000 in Kyrgyzstan is a strong indicator of the big potential for a second wave of sexually transmitted, large scale epidemics of HIV in the general population.

National responses to HIV/AIDS and injecting drug use

From 1987 and onwards Republican Aids centres were set up throughout the then Soviet Union, including the Central Asia Republics, focusing on mandatory mass HIV screening – based on a traditional ‘identify and control the carrier’ approach. Similarly, STI care and drug abuse treatment services, also inherited from the Soviet era, are characterized by vertical structures at national and local levels, and by controlling and repressive approaches with no guarantee of anonymity and confidentiality.

In the treatment of STIs, hospitalization has been preferred to ambulatory treatment and contract tracing and registration are compulsory. The governmental rehabilitation and detoxification programmes are largely insufficient for the number of drug addicts, and have little, if anything to offer other than punitive approaches. Injecting drug users remain strongly stigmatized, considered criminals by the public – a stigma which unfortunately often is reinforced by governmental campaigns against drug trafficking, which tend to blur the difference between drug addiction and drug trafficking.

Consequently, the specialized STI, HIV/AIDS and narcological institutes were and are still largely unable to establish contact and credibility with vulnerable groups such as injecting drug users, sexworkers and men who have sex with men – On the contrary such groups remain underground, shunning contact with health and social services.

The response from UNAIDS Cosponsors and Secretariat.

The Joint United Nations Programme on HIV/AIDS (UNAIDS), established in 1996, brings together seven cosponsoring UN agencies – UNICEF, UNFPA, UNDP, UNDCP, UNESCO, WHO and the World Bank – in a concerted effort to lead, strengthen and support expanded responses to HIV/AIDS at all levels. As elsewhere, UNAIDS operates in the Central Asian republics through UN Theme Group on HIV/AIDS, including the country-based staff of its seven Cosponsors and other key partners such as bilateral and nongovernmental organizations. The five Theme Groups in Central Asia are supported by a UNAIDS Country Programme Adviser, based in Almaty, Kazakhstan, and the Secretariat in Geneva.

Since 1996, the assistance of the UNAIDS Cosponsors and Secretariat has moved gradually from the initial stage of awareness raising and advocacy towards a focus on support to the development of sustainable and strategic national responses to HIV/AIDS. Significant efforts have been to advocate a shift from punitive, coercive approaches towards the adoption of approaches, aiming to enable and empower affected and vulnerable groups to reduce HIV risk behaviour. Also, efforts have been made to support the development of national capacities and structures for a strong, multisectoral responses and supportive legislative and policy environments for HIV prevention.

In response to the first outbreak of HIV among injecting drug users in Central Asia, occurring in 1997 in Temirtau, Kazakhstan, local authorities and oblast parliament adopted, on a pilot basis, legislation and regulations, which enabled the establishment of a pilot project on harm reduction the same year. In 1998 a series of rapid assessments and responses on HIV and injecting drug use were implemented in five cities in Kazakhstan, Kyrgyzstan and Uzbekistan. Subsequently, pilot projects in terms of so-called harm reduction trust points have been set up in all five countries, providing needle exchange, counselling, access to anonymous and confidential HIV and STI testing, condoms and information materials. As elsewhere in Eastern Europe, the International Harm Reduction Development Programme of the Open Society Institute has been the key driving force, supporting 13 projects in year 2000.

The pilot projects have clearly demonstrated their relevance and the high demand for such services, yet at the same time the shortcomings. In Kazakhstan more than 70% of the clients request access to drug treatment, but the existing capacity is grossly inadequate and the cost of the services well beyond what drug users can afford. According to the national Kyrgyz AIDS centres, the existing trust points in Osh and Bishkek, while providing services for three to four times as many clients as initially envisaged, only reach about two percents of the IDU population. In countries like Uzbekistan, where the trust points are new, few drug users seek them of fear of being arrested by the police. In this case, outreach by volunteers – often former drug users themselves – has been the only option.

In all five countries efforts have been made to address and integrate HIV prevention among injecting drug users in the context of strategic and multisectoral national plans. Aiming to strengthen national ownership, the plans are formulated at country level by multisectoral teams through a process of situation analysis, review of the national response, consensus and commitment building, and priority setting.

Conclusion

While substantial progress have been made in the countries in terms of raising awareness, promoting a paradigm shift from coercion towards empowerment, modifying legislation and developing strategic and multisectoral national plans, the current response remains highly insufficient and only a fraction of what is required to prevent large scale epidemics in the Central Asian republics.

Perhaps understandably, so far more attention and resources of the international community have been devoted to combating the international drug trafficking from through and from the region through law enforcement approaches.

There is a need for a much stronger international response to support the newly independent states in Central Asia in preventing what threaten to become a major public health and socio-economic disaster. This would render current efforts to curb drug trafficking and move the socio-economic development forward very difficult. Such an effort should include a massive short term financial assistance to scale up current responses, and be based on the following principles which have been suggested by the UNAIDS Cosponsors, notably UNDCP and WHO, and the Secretariat, as guiding for a UN system wide response:

• Drug abuse problems cannot be solved simply by criminal justice initiatives. A punitive approach may drive people most in need of prevention and care services underground. Where appropriate, drug abuse treatment should be offered, either as an alternative or in addition to punishment. HIV prevention and drug abuse treatment programmes within criminal justice institutions are also important components in preventing the transmission of HIV. Protection of human rights is critical for the success of prevention of HIV/AIDS.
• The ability to halt the epidemic requires a three part strategy: (i) preventing drug abuse; (ii) facilitating entry into drug abuse treatment; and (iii) establishing effective outreach to engage drug abusers in HIV prevention strategies that protect them and their partners and families from exposure to HIV, and encourage the uptake of substance abuse treatment and medical care.
• HIV prevention should start as early as possible, and comprehensive coverage of the entire targeted populations is essential.

A Central Asian Initiative on HIV/AIDS is being prepared this Spring which will bring together USAID, Open Society and other donors, the UNAIDS Cosponsors and Secretariat as well as local governments and NGOs in a concerted effort to scale up current responses. In the context of the national strategic plans, the initiative will address existing policy and legislative barriers, and seek to achieve the following strategic priorities:

To expand HIV prevention among injecting drug users to a minimum of 60%

To strengthen prevention and care of sexually transmitted infections

To develop comprehensive health promotion programmes for vulnerable young people

The initiative will be launched at a Central Asian Conference on HIV/AIDS, tentatively scheduled for April this year.

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Posted March 1, 2001 © Eurasianet
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