Field Note

Averting Disaster - Strengthening Harm Reduction in the former Soviet Union

By Daniel Wolfe, Deputy Director, International Harm Reduction, Development Program, Open Society Institute

The twin epidemics of HIV and injecting drug use have had perhaps their most lethal effects in countries in the former Soviet Union, where policy-makers and health providers face the challenge of HIV epidemics overwhelmingly concentrated among injecting drug users (IDUs). IDUs represent the largest share of HIV cases in Russia and Ukraine, Moldova and Belarus, the Baltic states, the Central Asian Republics, and the Caucasus [see Figure 1]. Ukraine, with an estimated 370,000 HIV infections, now shares with Estonia the dubious distinction of the highest HIV prevalence in Europe. Russia has an estimated 940,000 HIV cases, with more than eight in 10 of all registered cases among young drug users. Virtually all have been infected in the last 15 years.

Structural Determinants of IDU/HIV Infection
Independence brought greater freedom from the Kremlin to many former Soviet republics, but it also brought economic disruptions, mass migration, ethnic conflicts, and shredding of social safety nets. Afghanistan’s rise as the world’s largest opiate producer meant sharp increases in opiates trafficked over the newly opened borders of the former Soviet states. Where trafficking began, injection drug use and new cases of HIV have followed.

Most of the newly independent states retained Soviet era approaches to public health that blurred law enforcement and medical care. Laws commonly call for IDU registration, compulsory medical examination, and criminal penalties for HIV transmission. Limited funding for medicines or trainings of health-care personnel, and harsh consequences for possession of even small amounts of drugs, have resulted in IDU reluctance to seek services and the aggregation of large numbers of prisoners in environments where drug use continues without available means of HIV prevention. In Russia, from 1998 to 2004, heroin left in a used syringe was punishable by prolonged incarceration, making prisons so crowded that inmates were forced to sleep in shifts. HIV prevention programs were often limited to a chain link fence separating HIV-positive prisoners from the rest. Injection equipment, shared among as many as 40 inmates, passed frequently back and forth.



Commitments to needle exchange programs made by NGOs or ministries of health and supported by international grants have meant little to ministries of the interior, whose police continue to station themselves near needle exchange points or methadone clinics. In Central Asia, parents have watched their children die of drug overdoses, fearing that calling the ambulance might bring the police instead.

Generalization about countries of the former Soviet Union is of limited use, given wide variation between regions and countries. Still, they face the common challenge of coping with exploding IDU epidemics. Russia and Ukraine, which in 2006 together accounted for more than 90 percent of all estimated HIV cases in the region, offer insights about the perils and possibilities of national and international response.

Russia: Chipping Away at the Iceberg
UN agencies estimate HIV infections to be somewhere between 940,000 and 1.4 million. Russian officials, by contrast, doggedly focus on the visible tip of the iceberg, insisting that the actual number is far closer to those officially registered: 388,871 as of May 2007. Even those who recognize a larger HIV burden, such as Federal AIDS Center head Vadim Pokrovsky, reported a slowing of the epidemic and an increase of women infected via sex, rather than drugs. Analysts such as Murray Feshbach of the Woodrow Wilson International Center for Scholars note that the reported drop in IDU cases correspond to a sharp reduction in HIV tests and a rise in cases whose origins went unrecorded. Between 2000 and 2003, the number of HIV tests administered by Russia fell by nearly 3 million, and half of new cases were logged without noting the route of transmission.

Reported rates of HIV infection began climbing again in 2006, as did government commitment. In 2006, President Putin increased the federal AIDS budget by 20- fold, and in 2007, more than doubled it again to $289 million.

Russian AIDS advocates, including harm reduction NGOs and the increasingly well-organized networks of IDUs and people with HIV point out that new federal commitments have yet to include measures ensuring that the increased funds reach those at greatest risk. The federal government actually lowered its support to needle exchange from the six programs funded in 2006 to only three in 2007. Local governments have funded needle exchange, but insufficiently to contain an epidemic now found in 82 of 89 regions. In Moscow, for example, the city with Russia’s largest number of people living with HIV, there is no needle exchange program.

Drug Treatment Suffers a Similar Fate
Treatment for chemical dependence, a necessary component of efforts to contain injection-driven HIV epidemics has suffered a similar fate. Russian law requires that medical treatment for addiction be provided only by clinics of narcology, a subdiscipline of psychiatry particular to the former Soviet Union, yet deprives narcologists of the most effective tools for addiction treatment. Methadone and buprenorphine, medications currently prescribed to more than 800,000 opiate injectors in Europe, the United States and Australia, remain illegal in Russia, with authorities such as chief narcologist Nikolai Ivanets campaigning actively against them.

Treatment in Russia often consists of several weeks of detoxification under heavy sedation. Its lack of effectiveness makes drug treatment a revolving door that provides money to narcologists but has little lasting effect for patients. A 2007 survey of needle exchange clients in 10 cities found that 91 percent had tried to stop drug use at least once, and that nearly two in three clients of narcological clinics returned to drug use within a month. IDUs who cannot afford to pay for treatment are required to register on government lists and can be denied drivers’ licenses, public housing, or child custody. While Russia’s compulsory treatment system collapsed with the Soviet Union, the mentality that views drug users as objects to be controlled and contained remains firmly in place. In 2006, 44 young, mostly HIV-positive women and two nurses perished in Moscow Substance Abuse Hospital #17, where they struggled helplessly against barred windows and locked doors to escape a fire on the ward.

Ukraine: NGOs Lead the Way
The first country in the former Soviet Union to experience a widespread HIV outbreak, Ukraine has also been a regional leader in harm reduction and HIV treatment. The country has a well-established and highly organized network of people living with HIV whose advocacy helped highlight government ineptitude and get the country’s first Global Fund grant transferred to a non–governmental organization. Syringe exchange programs supported by the Global Fund have grown from a handful to more than 250 points covering an estimated 110,000 IDUs across the country – although definitions of “coverage” appear to emphasize quantity over quality. Recent innovations include a pharmacy-based exchange in Kiev that operates 24 hours a day, as well as a peer-based approach that draws on drug users’ social networks to bring the increasing numbers of injectors of vint, a homemade amphetamine, into contact with harm reduction.

While Russia has used registration requirements to constrain NGOs from receiving international support, the Ukrainian response to HIV is largely NGO-led and internationally funded. A $151 million Global Fund grant, given jointly in 2007 to the International HIV/AIDS Alliance and the All Ukrainian Network of People Living with HIV/AIDS, is the largest ever awarded in the former Soviet Union. More than half of the funds will support HIV prevention, and the grant includes measures such as drop-in centers and integration of addiction and HIV treatment to increase the access of active drug users to antiretrovirals.

Although not banned as in Russia, methadone and buprenrophine, a linchpin for both prevention and treatment of HIV among IDUs, remains minimal in Ukraine. Buprenorphine treatment began in 2005; by 2007 nearly 550 individuals in the capital and eight regions were receiving medication, though without the takehome doses or pharmacy prescriptions that are the norm in Western Europe or the United States. Under pressure from the All Ukrainian Network of PLWHA and other local advocates, the minister of health and the deputy prime minister for humanitarian issues have signed orders to authorize provision of methadone, a more affordable medication, and to allow expansion of treatment to some tuberculosis and HIV treatment centers. Ukraine has yet to address the absence of substitution treatment in hospital wards, which essentially forces patients who get sick with HIV to give up the most effective treatment for their opiate dependence.

Law Enforcement and Public Health Approaches at Odds
Tension between police and public health approaches also exists in Ukraine. In April 2007, each patient in a support group at an Odessa buprenorphine clinic had a story of police harassment. “We have changed,” one patient noted, “but the police have not.” Needle exchange points report regular police harassment, including extortion and use of painful withdrawal symptoms to coerce confessions for unsolved crimes. A project supported by the International HIV/AIDS Alliance is educating police about antiretroviral medication after reports that officers, insisting that any pills in the possession of drug users must be illegal, confiscated them.

While Russia relaxed its drug penalties, in Ukraine, those caught with small amounts of opiates are imprisoned in facilities where drug use continues and where needles, sometimes sharpened by inmates with glass, are shared repeatedly. The UN Human Rights Committee decried Ukrainian prison conditions in 2006, pointing to the high incidence of HIV/AIDS and tuberculosis among detainees. HIV prevalence among those incarcerated rose from 9 percent in 2003 to 14 percent in mid-2006. HIV treatment in prison is limited, and methadone and buprenrophine are unavailable. Despite several memoranda committing to pilot needle exchange in two correctional facilities, the state penitentiary department has yet to start such programs.

In countries where IDUs command little political power, the willingness of international donors to target aid specifically to harm reduction may determine whether IDU epidemics are contained or continue to spread. The presidency of the European Union called this July for expansion of methadone, buprenrophine, and needle exchange in the EU. Countries to the East can only hope that foreign aid agencies will adopt similar priorities. President Bush’s May 2007 proposal for a $30 billion, five year global AIDS program, which sets new targets for HIV prevention made no mention of change to the ban on use of federal dollars for needle exchange. Substitution treatment, however, can be paid for, as can all the services that “go around” the needle.

Whether in the former Soviet Union or the international community, some people charge that harm reduction is morally suspect and that giving someone a clean needle or a dose of methadone is giving up on their ability to live a drug-free life. At a recent international conference, the chief physician of the Russian penitentiary system publicly derided methadone as “the road to defeat.” These claims ignore both the successes of harm reduction in reducing HIV infection, and the toll taken by the HIV epidemics exploding in Russia and her neighbors. In the former Soviet Union, the terrible moral, social, psychic and economic costs of allowing drug users and their families to be devastated by HIV have yet to be fully reckoned.

For further information contact: dwolfe@sorosny.org.

To Top