SUMMARY OF FACT FINDING MISSION TO TAJIKISTAN
Maitland J. "Aaron" Peak – Peak Options Consulting
For Soros Foundation – Open Society Institute,
International Harm Reduction Development Program
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The Soros Country Office questions the UN’s commitment to harm reduction. There is no UNAIDS Country Program Adviser to coordinate the UN co-sponsors international nongovernmental and national organizations. Little has been done to organize meetings of agencies and professionals in the drug use and HIV sectors. (Ref. 11)

The Deputy Director of International Affairs from the Ministry of Health spoke vaguely of drug use and HIV and did not appear terribly concerned. However he wholeheartedly welcomed support from Soros Foundation in the form of condoms and syringes. He hoped the good working relationship with Soros would continue. (Ref. 9)

The drug user’s perspective can be summarized by Muzzafar’s recommendation to open more narcology dispensaries for drug treatment. He would also like to see mobile units and uniformed people doing outreach without the involvement of the police, handing out information, condoms, and syringes. Blood tests should not be done on users, as they can get three years in jail for positive results. Many users have heard about HIV, HBV, HCV, and STDs and know how they are transmitted but none have ever seen actual people with these diseases.

Muzzafar believes that international assistance should be focused on the youth involved in drugs. Youth begin trafficking in order to be sure of a drug source for themselves. Mass media should be used to convey drug treatment information and information about the harms associated with drug use. Billboards might help, too, since users walk long distances to find drugs. (Ref. 10)

The fact finding mission did not meet with the German Technical Cooperation (GTZ). GTZ considers Tajikistan less advanced than Kazakhstan and Kyrgyzstan, due to political problems. Thus they run a single project in the country on small and medium agriculture enterprises. Interesting possible linkages with GTZ are explained in the Kyrgyzstan report.

Observations and Recommendations

The fact finding mission. The Soros Foundation office was extremely helpful, the most helpful of the three countries. A new interpreter had to be found to replace the one assigned to the job.

Recommended: The Soros Foundation office needs additional computers; and it should contact the Asian Harm Reduction Network and the Eastern European Harm Reduction Network for materials and reports on harm reduction. The telephone, electric, and heating systems need improvement.

Primary health care. Harm reduction was continually referred to as needle exchange. During the mission, however, it became clear that a more comprehensive and long-term approach was desired in the form of primary health care for the drug using community, including vein care and sterilizing and dressing infections and abscesses. Printed materials should be developed to explain the relationship between injecting drugs and HIV, hepatitis, TB, and nutrition. Some primary health care measures have been undertaken by Soros grantees but they do not have resources for first aid materials or literature. The primary health care component is the most utilized of the harm reduction programs in Asia. It helps bridge the gap between the drug using community and medical services as well as leading to trust among the users. Primary health care can be a catalyst to promote safer practices and to discuss sensitive issues of sexual infection and physical and mental well-being. Appropriate, non-discriminating medical facilities and staff should be identified for use by drug users. Likewise, outreach "volunteer" workers should be chosen carefully to be the most credible with their peers.

Recommended: A standardized protocol for a primary health care component to all harm reduction programs needs to be developed and implemented. This would include supplies such as plasters, gauze, tape, medical utensils, antibacterial ointments, creams for scabies and fungus, disinfectants, and wide-spectrum antibiotics. Training in referral systems and networking would be necessary. Appropriate IEC materials should be developed with succinct and understandable messages on TB, hepatitis B and C, nutrition, overdose management, abscesses, and respiratory infections.

Commitment by the international donor community and United Nations. There is only a limited amount of actual support that can be relied on in the coming year. UNAIDS does not have a Country Program Adviser in Tajikistan and probably will not appoint one. UNDP’s HIV/AIDS focal point person, who does not have much knowledge of HIV prevention, surveillance, and blood safety, was concerned that the two UN harm reduction programs already in place would end at the end of 2000 rather than be funded by Soros Foundation. Instead, Soros is developing its own programs. Ms. Zuhra Halimova, executive director of the Soros Foundation, claimed that the UN had not kept colleagues up to date on current reports in the field and that the UN projects are top-heavy. I concur with Ms. Halimova that it is best for Soros Foundation New York to develop and implement harm reduction programs independently of the UN system. If the UN programs indeed end, perhaps qualified staff and volunteers could be recruited for Dushanbe. The UN Resident Representative, Mr. Mattew Kahane, did not express a need for collaboration at the field level but did express interest in continued support from Soros Foundation. He felt that UNICEF was not allocating enough funds to address HIV although they apparently plan to run a study on HIV and STDs among children in the near future.

An interesting discussion revolved around the sustainability of programs. Some felt that programs should be supported for a long enough time for the government to generate sufficient support to take over the initiatives. The UNAIDS Regional Representative (in Kazakhstan), however, feels that pulling back support for HIV projects will force the government to step in. UNAIDS, incidentally, views harm reduction as drug abuse prevention rather than HIV and STD prevention and believes that the needle exchanges by NGOs are not sustainable. The UN has worked with the government to create effective and sustainable policies. The mandate of UNDCP, which has contributed the most funding to HIV and drug use prevention, has been to develop a drug control agency as there was none in Tajikistan.

The director of the drug control agency, Major General Rustam U. Nazarov, welcomed assistance from the Soros Foundation to realize a comprehensive harm reduction initiative that includes appropriate modalities for drug treatment. He spoke of collaborating with the National AIDS Center to develop a rehabilitation center. Law enforcement and drug control personnel would be more willing to collaborate with harm reduction programs if they included primary prevention and treatment options. While Nazarov deferred demand reduction questions to the Ministry of Health, the Ministry of Health deferred to the narcology dispensaries, raising questions as to the Ministry of Health’s commitment to drug use and infectious disease.

Recommended: Since UNDCP is becoming more involved in primary drug prevention among youth and drug treatment, the UNDCP and the Soros Foundation should collaborate on harm reduction. Together they could provide a comprehensive harm reduction initiative that includes reducing infectious diseases as well as providing options for those who wish to stop using drugs. This collaboration would benefit drug users and provide a point of common interaction for the Soros Foundation and the drug control and law enforcement communities. The Soros Foundation’s involvement in treatment modalities would ensure an active voice for drug users. This would also help advance the controversial methadone initiative. UNDCP has proven its commitment through funding and Mr. Aziz, who will be re-locating to Dushanbe, is knowledgeable about the Ministry of Interior and law enforcement but would like to be involved in the social support of drug users.

Equipment and materials: The staff of Save the Children Fund – US explained that the medical houses often do not have basic equipment or medications or informational materials on prevention measures.

Recommended: The Soros Foundation should explore the possibility of producing more IEC literature for the harm reduction programs and distribute them to the medical houses in the most affected areas. SCF/US could help identify appropriate medical houses and key staff.

Medecins Sans Frontieres – Holland: MSF does its work in the psychology dispensaries and seldom works with drug users. They have, however, done extensive training of medical staff, psychologists, and social workers on patient care, counseling, and long-term mental care.

Recommended: The Soros Foundation should explore the possibility of collaborating with MSF/H on trainings, especially counseling and coping mechanisms. This would be helpful for the harm reduction staff and also MSF/H, which would learn about drug use and infectious diseases.

German Technical Cooperation Agency (GTZ): GTZ’s involvement in Tajikistan is limited and the region’s best opportunity for collaboration with the Soros Foundation is with the Kyrgyzstan office. Once harm reduction programs are well established GTZ might have particular strengths, such as developing "job clubs," to add.

Recommended: The Soros Foundation Medical Division should initiate a monthly meeting of the UN, INGOs, NGOs, government, bi-lateral donors, and embassies to develop a plan of action, forge new partnerships and exchange information on the HIV/AIDS situation for drug users. Soros need not organize each meeting, but it could provide a venue for the meeting which could also be a harm reduction resource library. The Medical Resource Office already has this space, and the objectives agree with the terms of reference put forth in the recent strategy for the medical division. The Soros Foundation should look into acquiring the library materials and even medical equipment and supplies from the Medical University in Khujand which is to be closed by the government.

Treatment: Since the government focuses on detoxification, many people would like to see the Soros Foundation provide sustainable, realistic, and affordable drug treatment. Only three dispensaries are operational and they are inadequately staffed and inadequately trained in the latest treatment modalities. The staff would like to have access to literature and upgrade the narcology dispensary resources. Prohibitively expensive medications, in short supply, must be paid by the patient.

Recommended: A workshop should be developed by the Soros Foundation for narcology dispensary staff to discuss harm reduction methodology and ways to establish manageable and sustainable treatment. The involvement of UNDCP and other authorities would benefit the progress of harm reduction as a comprehensive initiative.

Overdose: Many people in Tajikistan are concerned about the high rate of heroin overdose and the lack of literature and methods to prevent it. Toxicology personnel should be invited to the above-mentioned trainings which should include segments on preventing overdose.

HIV testing: Testing is rarely conducted at the harm reduction trust points due to limited funding for HIV testing kits. The director of the National AIDS Center suggested that sufficient amounts of blood should be taken during testing so that Hepatitis B and C, syphilis, and gonorrhea can also be tested. The Center for Disease Control – Atlanta is assessing the rate of viral hepatitis in Central Asia and would like to discuss collaborating with Soros Foundation.

Conclusion: The mission was informative and the Soros Foundation is in a position to provide a comprehensive harm reduction program with the three projects that it is implementing now. For the further expertise of grantees and staff, more orientation of the modalities of harm reduction must be offered.

Recommended: An experience exchange and study tour should be conducted in the south and southeast regions of Asia to visit programs known for best practice approaches of primary health care, care for people with HIV/AIDS, drug substitution, law enforcement training, and orientation on harm reduction. Visits to the UNAIDS and UNDCP regional offices will demonstrate collaborative efforts between governments and non-governmental organizations. A list of seven participants was developed with the input of the Soros Foundation staff. Ms. Galina Roitberg should be included as an interpreter; and a colleague who is the National Project Manager for harm reduction programs in Vietnam might also be included. I am available to set up logistical requirements and meetings.

References

1. Soros Foundation Tajikistan: Zuhra Halimova, Executive Director, Zarina Adullaeva, and Tatiana Abdushukurova.
2. Save the Children Fund – US: Dr. Yosaf Hayat, Manager, and Ahmed Munier, Field Office Director.
3. Medecins Sans Frontiers – Holland: Deborah Cunningham and Marie Skinnider, Medical Coordinators.
4. Drug Control Agency: General Major Rustam U. Nazarov, Director.
5. UNDCP Country Office: Rasoul Rakhimov, Program Officer, Sergey Ratushnyy, CTA in Tajikistan, and Alexis Kasskoff, CTA in Tajikistan.
6. National AIDS Center: Dr. Muratboku Beknazarov, Director.
7. Meeting with grantees of harm reduction programs in Dushanbe, Khorog, and Khujand; and National AIDS Center.
8. UNDP: Mattew Kahane, Resident Representative, and Nargis Azizova, National Program Officer – HIV/AIDS.
9. Deputy Health Minister for International Affairs, Dr. Rakhmatullo Azizovich.
10. Dushanbe Narcology Dispensary: Dr. Gulchehra Bobonaza Rouna Khasanova, Dr. Svetlana Mihailovna Valyavskaya, and drug users.
11. Soros Foundation Tajikistan: Zuhra Halimova, Executive Director.
12. Site visit to Khugan-tube with Elena Khasanova, Deputy Chief Dushanbe Narcology Dispensary, to Khugan-tube Narcology Dispensary, Dr. Alijon Nazarov, Chief Psychology/Narcology Dispensary, Dr. Nodira Divlyatova, Health Care Monitor.

1. Zarina Abdullaeva, Medical Coordinator, Soros Foundation, Dushanbe.
2. Muratboku Beknazarov, Director, National AIDS Center (Dr.), Dushanbe.
3. Murtazakul Khidirov, Chief Psychiatrist, National Drug Control Agency, Dushanbe.
4. Marifat Abdullaeva, Director of HR project (Dr.), Khugand.
5. Tolibjon Ahmedov, Coordinator of HR project (Dr.), Khugand.
6. Vafonazar Alinazarov, Director of HR project and instructor with "Volonter" NGO, Khorog.
7. Maram Asismamadov, Coordinator of HR project and instructor with "Volonter" NGO, Khorog.

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.

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Posted March 1, 2001 © Eurasianet
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