Transcript Diapositive 1 - View the full AIDS 2016 programme

The HIV/AIDS and drug use crisis in
Eastern Europe and Central Asia
Professor Michel Kazatchkine
Global Commission on Drug Policy
UN Secretary General Special Envoy on HIV/AIDS in
Eastern Europe and Central Asia
HIV in Eastern Europe and Central Asia
• An expanding HIV epidemic, largely driven by unsafe injection
drug use; heterosexual transmission now also a major
component of epidemic growth
• Access to antiretroviral treatment remains low, particularly for
key affected populations
• HIV prevention is not accessible at sufficient scale
• Access to harm reduction inexistent or very limited
• Health systems are vertical and provider-centered
• High levels of stigma and discrimination; numerous structural,
cultural, societal and political obstacles to the AIDS response
• Low levels of co-operation between government and the nongovernmental sector
• Issues around financial sustainability of programs
HIV, HCV, TB/MDR-TB and drug use are major and closely
interlinked challenges in the region
• 25 % of the > 3.5 million people who inject drugs (PWID)
in the region are infected with HIV, with large variations
(10 - >50%) between and within countries.
• Over two thirds of PWID are infected with HCV..
• HCV co-infection rates among HIV-positive PWID range
between 70 and 90 %.
• HIV-positive PWID have a two- to six-fold higher risk of
contracting TB; 80% of men with HIV and TB co-infection
are PWID. Almost all countries in the region are high
burden countries for MDR-TB.
Association between HIV and MDR-TB in Europe
TB surveillance and monitoring in Europe 2014. ECDC/WHO, Stockholm
Post et al, Journal of Infection (2014) 68, 259-263, (Belarus, Latvia, Romania, Russia & Ukraine)
Injecting drug use in EECA
• With the fall of the communist economic and
political system in the 1990s, unemployment,
poverty and crime increased dramatically in
Russia and throughout the post-soviet space.
• At the same time, new drug markets opened up
with increasing availability and demand for drugs.
• In the early 2000s, HIV/AIDS and drug-related
health issues emerged as pressing social and
public health challenges.
Rapid growth of the HIV epidemic among people who
inject drugs in the Russian Federation
• In the early 2000s, a number of NGOs started outreach and
needle exchange programs supported by international funds
• From 2010, Russia has increasingly been promoting
“traditional values”; drug use was increasingly stigmatized.
“Foreign agent laws” promoted. Government has been
categorically opposing harm reduction in all national and
international fora.
• There is an estimated 5 M drug users in the Russian
Federation, of which 1.7 M are opiate users.
• Over 65% of all cumulated HIV cases since the beginning of
the epidemic are PWID. Prevalence of HIV among PWID
ranges between 20 and 70%. It is higher in large urban
settings.
Rapid growth of the HIV epidemic among people
who inject drugs in EECA is largely policy-driven
• A punitive approach to drug use, repressive drug
policies and prohibition law enforcement prevail in
the Russian Federation and across the region
• Fear of arrest and of violence from police is
associated with lower capacity for HIV risk reduction
• Lack of social and health services tailored to the
needs of PWID
• Harm reduction is not accessible, or not at the
needed scale for impact
Estimated annual numbers of syringes distributed per person who
inject drugs (PWID) and estimated number of opioid substitution
20%
40%
60%
treatment clients per 100 PWID0%(latest year)
Uzbekistan
Serbia
Russian Fed
Macedonia
Azerbaijan
Latvia
Kazakhstan
Belarus
Tajikistan
Armenia
Moldova
Georgia
Belarus
Poland
Kosovo
Azerbaijan
Armenia
Lithuania
Ukraine
Bulgaria
Latvia
Moldova
Kyrgyzstan
Ukraine
Romania
Albania
Bosnia-…
Serbia
Albania
Bosnia-Herzegovina
Uzbekistan
Georgia
Tajikistan
Lithuania
Czech Rep
Poland
Kazakhstan
Bulgaria
Estonia
Estonia
Kyrgyzstan
Montenegro
0
200
400
Number of syringes distributed per PWID a year,
2013 or latest year available
Based on country reported GARPR data to UNAIDS, 2014 & to EMCDDA, 2015
Macedonia
Czech Rep
Croatia
Percent of estimated PWID or opioid injectors who received
OST, 2014 or latest year available
Harm reduction: compelling evidence of
effectiveness
• NSP and OST reduce the sharing of injection equipment
and avert HIV infections
• In combination with ART, NSP and OST:
– Reduce HIV transmission
– Decrease mortality
– Promote initiation of and compliance with ART
– Reduce drug-dependency
– Reduce crime and public disorder
• Harm reduction interventions are highly cost-effective
A model to reduce HIV prevalence/incidence by
half over 10 years in St Petersburg
To halve prevalence:
• Not possible for just NSP
• Twice coverage needed to
halve incidence
*coverage just amongst HIV+ PWID
Vickerman P, Platt L, Jolley E, Kazatchkine MD,
Rhodes T, Int J Drug Policy. 2014
Nov;25(6):1163-73.
100%
50% decrease in HIV incidence
50% decrease in HIV prevalence
Required coverage of each intervention
To halve incidence:
• 79% on high coverage NSP
• 30-40% on paired
interventions
• 20% on all three
interventions
80%
60%
40%
20%
0%
NSP only
NSP+ART
NSP+OST
Intervention combination
NSP+OST+ART
Global commission on drug policy (2011)
12
Global commission on drug policy (2011)
13
Prisons: a high risk environment
• The Russian Federation and many countries in the
region have some of the world’s highest incarceration
rates
• Many prisoners wait for months in pre-trial detention
• Poor physical conditions; overcrowding; poorly trained
staff
• Unsafe injection drug use and unsafe sex
• High prevalence of TB and MDR-TB
• No access to harm reduction except in Kyrgyzstan, and
in Moldova.
Proportion of people incarcerated for drug possession
without intent to supply
Georgia
43%
Kyrgyzstan
61%
Latvia
44%
Lithuania
55%
Poland
48%
Russia
Tajikistan
72%
16%
Ukraine
Uzbekistan
67%
21%
Within-prison drug injecting practices among
HIV-infected inmates in Ukraine
Izenberg et al, IJDP, 2014
Coverage of clients with minimum package of services
(consultation + condom/syringe + info) in Ukraine in 2014
PWID
Estimate Reach
310,000
196,992
CSW
%
Estimate
63.5
80,000
MSM
Reach
%
37,061
46.3
Estimate
Reach
176,000
28,500
129 CSOs in almost 3,000 sites distributed
14.5 M condoms and 20.5 M syringes in 2014
PWID p/a
CSW p/a
MSM p/a
Syringes
143
--
--
Condoms
20
300
100
Lubricants
2
150
100
%
16.2
Non-governmental sector in EECA
• Few/ fewer registered civil society and communitybased organizations addressing PWID
• Restrictions on funding from international sources
• Foreign agent law, foreign grant registration
• No mechanisms to contractually engage the nongovernmental sector into an effective and
meaningful partnership for health
Financial sustainability
• As of July 2013, the Russian Federation is
classified as high income country.
• Most of the other countries in the region are
classified as middle income. International
support for HIV programs is decreasing and
new domestic funding is not keeping pace .
Health is politics
• Drug policies heavily relying on prohibition law enforcement
hamper access to OST and NSP.
• Methadone is illegal in the Russian Federation, Uzbekistan
and Turkmenistan.
• High rates of incarceration for drug offences across the region.
• Low / very low proportion of national HIV budgets devoted to
prevention and to most at risk vulnerable groups.
• Presidential Decree #6 2014 in Belarus enables access of the
Ministry of Interior to the personal data of people with drug
addiction officially registered in a health facility
• OST discontinued in Crimea following annexation.
• OST now discontinued in the separatist territories of the
Donbass in association with ongoing violence and government
restrictions on the delivery of humanitarian aid in the conflict
areas
Why should use and possession be
decriminalized
• Criminal sanctions or the threat of them constitute barriers
to access to social and health services
• Criminal sanctions also reinforce discrimination and social
disdain
• Criminalization of drug use results in police abuse and overincarceration of people who use drugs, including nonviolent offenders.
• A criminal record for a young person for a minor drug
offence can be a far greater threat to their wellbeing than
occasional drug use.
• Criminalization of drug use fuels violence and corruption
associated with organized criminal networks.
• Wasting huge sums on ineffective policies.
Drug user awaits interrogation,
Tajikistan
END CRIMINALIZATION OF DRUG
USE
END CRIMINALIZATION OF HIV
Photo; Hans Jurgen
Burkhart
22
ACKNOWLEDGEMENTS
UNAIDS
Eurasian Harm reduction network,
Peter Vickermann, London
Raminta Stuikyte, Isabela Barbosa,
and Geneva
Outreach in Moscow, run by
activists. 2013
Outreach in Moscow,
by activists. 2013