Transcript As of the end of 2003, an estimated 37.8 million people

…at what cost ?
Ten year review:
 Law enforcement at the expense of public health
and human rights
 Major HIV epidemics among IDU
 Lack of drug treatment and abuses in the name
of drug treatment
 What about women?
Law enforcement practices block drug
users’ access to public health services
 In Russia and Ukraine, police often
harass and arrest drug users who
attempt to obtain health information
and sterile syringes from drug stores
and legal syringe exchange sites.
 In China, police are known to wait by
syringe distribution points to arrest
drug users. Outreach workers have
been followed and detained.
 In the U.S., studies have found that
drug users who were afraid of being
arrested were more than one and a half
times more likely to report sharing
needles.
Law enforcement approaches associated
with police use of excessive force and
human rights violations
 Drug enforcement in China, Kazakhstan, Russia, and Ukraine,
has been associated with police extortion and violence against
suspected drug users.
 In Thailand, a federally ordered police crackdown resulted in
reports of thousands of extra-judicial killings of suspected drug
users. Many of those arrested report that police planted drugs
in their pockets, forced them to sign false confessions, or
threatened to arrest them simply for not being enrolled in drug
treatment.
 In Kazakhstan, police come to drug-dealing points to conduct
body cavity searches, which women IDUs report lead to sex in
exchange for the return of seized drugs.
HIV Epidemics:
Mostly or Almost
Entirely among Drug
Users, FSU
 As many as 1.7 million
people are living with HIV
in Eastern Europe and
Central Asia
 Injection drug use is the
single most significant
driving force behind the
epidemic in the region
 IDU accounts for more
than 70 percent of
cumulative HIV cases in
Eastern Europe and
Central Asia
HIV Prevalence In
UKRAINE:estimated 1.5%
(the highest in all of Europe)
Source: UNAIDS Global Epidemic Update, 2006
Photo: Jacqueline Mia Foster
HIV among drug users
IDUs as Share of Total HIV Cases
select low/middle income countries
2006
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
83%
62%
70%
52%
44%
China
Russia
Ukraine
Malaysia
Vietnam
Deadly Denial: Barriers to HIV/AIDS
Treatment for People Who Use Drugs in
Thailand (Thai AIDS Treatment Action Group
and Human Rights Watch)
 Thai authorities have provided minimal support for
harm reduction services for drug users.
 The few existing harm reduction programs are
seriously undermined by the government’s ongoing,
repressive anti-drug campaigns.
 Police regularly interfere with drug users’ efforts to
seek health care by harassing clients outside of drug
treatment centers.
 Police also use possession of sterile syringes, or
presence at a methadone clinic, as a basis for
harrassment or arrest.
Percent of IDUs Reached by Needle/Syringe
Exchange Programs
Select CIS Countries, December 2005
60%
50%
40%
33%
30%
21%
20%
10%
9%
7%
5%
3%
5%
less than 1%
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0%
Note: UNAIDS recommends 60% coverage for effective HIV prevention among IDUs
Sources:
IDU Estimates: UNODC HIV/AIDS unit, September 2005 (midpoint estimates, data collected 2002-2005); WHO/UNAIDS October 2005
(Ukraine)
Coverage Estimates: Open Society Institute/ Soros Foundation network (Armenia, Azerbaijan, Georgia, Kyrgyzstan, Tajikistan); UNAIDS
2006 (Russia); HIV/AIDS Alliance (Ukraine); GFATM and program reports (Uzbekistan).
U.S. in the global debate
 Federal ban on funding needle exchange
 PEPFAR unable to fund needle exchange.
Currently funding some substitution treatment
for HIV positive drug users
 U.S. very active in drug control arena in its
opposition to harm reduction in general and
needle exchange specifically – often results in
perception that harm reduction doesn’t exist in
the U.S.
Photo: Dan Bigg
Photo: Jacqueline Mia Foster
Methadone
 Categorization as Schedule 1 (1961
Convention) not suited to data and
realities of 2005
 No comment by INCB on countries that
ban the treatment
 Methadone proven to reduce injecting
& demand for illegal opiates, and
increase adherence to ARV treatment
Perpetual Pilot
 Poland has over 40,000 opiate users but
only about 1000 methadone treatment slots
 Compare neighboring Germany- 120,000 to
150,000 heroin users and roughly 65,000
people in substitution therapy
 Kyrgyzstan, Azerbaijan, Georgia, similarly
slow to scale up
No substitution treatment at all
 Russia—1/2 million+ opiate users, no
substitution treatment. Russian policies often
influence neighboring countries.
 Tajikistan still considering, but not treatment
 Methadone written into the Kazakh Global
Fund proposal but no medication for patients
Methadone Maintenance Clinic (China)
FEWER THAN 1% of IDUs IN NEED RECEIVE
SUBSTITUTION TREATMENT
(Low/middle income countries with majority of registered HIV infections
among IDUs, Oct. 2006)
1,980,000
2,000,000
1,800,000
1,600,000
Estimated
number of IDUs
1,400,000
1,200,000
1,093,000
1,000,000
800,000
600,000
397,000
400,000
200,000
206,000
15,678
15,000
0
220
Russia
Ukraine
0
China
Iran
Patients
receiving
substitution
treatment
Over-Control Makes Treatment
Inaccessible
 Treatment philosophy organized around often unrealistic
goal of complete abstinence
 Waiting lists, age limits, requirement of documented
attempts at abstinence, review by commission
 Prohibitive fees passed to patients; corrupt staff demand
bribes
 Police interference
 Lack of take-home doses disrupts lives
 Punitive urine testing and body searches
 HIV-positive status preference—creates “perverse
incentive”, denies HIV-negative IDUs crucial prevention
tool
Other drug treatment?
Patients’ views in Russia
A recent survey of 988 injection drug users in 10 Russian regions by
the Penza Anti-AIDS Foundation found that a majority of patients
have tried to stop drug use at least once using detox and/or
residential rehabilitation services.
Number of attempts to stop drug use
5 or more
Between 1 and
4
Never
No Response
Other findings
 Half the people surveyed reported abuses while
undergoing treatment, including beatings, limitation of
freedom of movement, prohibitions on visits by
relatives, and doctors’ refusal to provide painkillers.
 Breaches of confidentiality and registration as drug
user serious obstacles to seeking drug treatment.
 Drug treatment clinics charge substantial fees for their
service and shift the responsibility for failure of
treatment on patients and their families. Vicious cyle of
detox - brief remission – relapse—detox again.
 Disappointment in spectrum of services lowers patient
expectations.
Abuses in the name of “treatment”
 No international standards for evidence-based drug
treatment
 Any intervention, no matter how inappropriate and
ineffective can be considered “drug treatment”
Photos courtesy Jimmy Dorabjee
CAGES AS
TREATMENT
Photo courtesy Jimmy
Dorabjee
Locked wards as treatment
Moscow Substance Abuse Hospital #17, 46 dead,
December 2006
http://news.ntv.ru/99430/
Women and drug use
Global inattention to women drug users:
UNODC 2006 World Drug Report, which relies in large
part on national self-reporting, makes more references
to the female cannabis plant (14) than to women drug
users (5)
This despite assertions in 2005 report that number of
women drug users was increasing and injection-driven
HIV epidemics were feminizing.
Preliminary results of assessments in
Russia, Ukraine, and Georgia
Stigma and lack of integrated services are key obstacles to care
 In Georgia, women IDU so stigmatized that they are afraid to
speak about drug use even with other drug users
 Vertical transmission rates in Ukraine in 2000-2004 compare with
those in Western Europe before the introduction of perinatal
antiretroviral treatment. Here and in Russia, many avoid prenatal
care due to stigma and only seek care once in labor
 Stigmatization from reproductive health and drug treatment
providers lead to minimal access to methadone treatment, the
“gold standard” for pregnant opiate users, women often forcefully
counseled into abortion
Sex work and drugs
The link between sex work and drug use is strong
 Some use drugs to cope with harsh conditions
of being sex workers; others turn to sex work to
support their drug use.
 44% of sex workers in Moscow
inject drugs (Epi of Inf Dis, 1998)
 In Tashkent, non-IDU sex
workers had HIV prevalence of
10% and IDU sex workers
had HIV prevalence of 28%
(UNAIDS/WHO, 2005).
HOW ARE WE DOING?
 Governments treat drug users like drugs: as something
to be controlled and contained
 Mass incarceration, forced institutionalization and
registration are a norm
 Harm reduction not anywhere near required scale
 None of the most affected counties have national scale,
effective substitution treatment, and most do not have
pilot programs
 Instead, punitive, abusive interventions are considered
“drug treatment”
Thank you
[email protected]