Transcript International Harm Reduction Conference

Social, structural and environmental determinants
influencing scale-up of HIV prevention and treatment
for people who use drugs in Central Asia
Azizbek Boltaev
Regional Advisor for Central Asia
ICAP, Colombia University
Regional Epidemiologic Profile
• Globally, Central Asia is one of the few regions where
HIV prevalence continues to rise (UNAIDS, 2012).
• 0.8% - regional prevalence of non-medical opiate use in
Central Asia
• 33% to 72% of all registered HIV cases in Central Asia
are attributed to the sharing of injection drug
equipment.
• 6.7% - regional-weighted HIV prevalence among PWID
• Over the last few years, sexual transmission of HIV has
surpassed injection drug use
Historical context
• For decades, health interventions targeting PWID
in Central Asia were limited to narcological care:
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detoxification without psychosocial support
forced labor camps
long-term isolation from society
and heavy use of neuroleptics
enforced by police
stigmatizing social pressure
limiting the civil rights of drug-dependent persons.
Historical context (2)
• These interventions were initiated prior to 1990 under
the former USSR government.
• But the violation of ethical principles and lack of
empirical evidence of effectiveness of such approaches
did not stop their application, even after the collapse of
the USSR
• In the late 1990s, rapid growth of HIV among PWID
inevitably impacted on the drug policies of every Central
Asian nation.
• Currently, all Central Asia countries are signatories to the
UNGASS Declaration
National coverage of PWID by HIV services
COUNTRY
ESTIMATED #
of PWID
Kazakhstan
Kyrgyzstan
Tajikistan
Uzbekistan
Turkmenistan
123,640 (RAC, 2011)
25,000 (UNODC,
2006)
25,000 (APMG,
2009)
80,000 (UNODC,
2006)
33,000 (MOH, 2007)
Percentage of PWID receiving HIV services
OST
ART
NSEP
HCT
0,2%
1,1%
50%
65%
4,2%
0,7%
27%
54%
1,1%
1,2%
18%
46%
0
N/A
31%
29%
0
0
0
N/A
Structural Determinants
Legal environment and policing
• Policies that discriminate and violate the civic and human
rights of drug-dependent persons including those in
treatment exist in all countries in the region.
• Harassment of PWID by law enforcement PWID for
obtaining and possessing small amounts of drugs for
personal use creates powerful risk environment resulting in
underground drug use and inflate unsafe behaviors.
• Utilization of healthcare interventions by PWID is
hampered due the police have access to medical data on
patients treated at narcology clinics; deprivation of parental
rights of drug-dependent persons.
Structural Determinants (2)
Legal environment and policing
– According to current legislation, information and
education about safer drug use and sex can be used by
authorities as proof of promotion of drug use and sex
among youth, a criminally prosecuted offense.
– Tajikistan has significantly increased the minimal weight
of drugs after which criminal prosecution is enforced
– Kyrgyzstan has made amendments to its existing
regulations that replaced criminal prosecution with
administrative charges for first time drug offenders
Social Determinants
Stigma and Discrimination
• Being HIV positive is associated with serious stigma and
discrimination often resulting in narrowing of social
networks and support as well as substandard healthcare.
• Drug use also a non-welcomed behavior in CA societies
but stigma and discrimination of PWUD is often
dependent upon the severity of addiction and the
person’s position in the social hierarchy.
• Patient’s HIV status and drug use often left without
attention by healthcare providers.
Social Determinants (2)
The role of community of PWID:
• With few exceptions, engagement of PWID in HIV
prevention in Kazakhstan and Uzbekistan has been
largely limited to harnessing active and former PWID in
delivering prevention messages and tools.
• In contrast, in Tajikistan and (to a larger extent) in
Kyrgyzstan PWID along with other MARP have been able
to mobilize their peers in setting up community-based
NGOs that not only effectively implement a wide range of
HIV prevention activities, but also actively participate in
the decision making processes on national and subnational levels.
Social Determinants (3)
The role of community of PWID:
• The NGOs established by former and current OST
patients in Pavlodar, Kazakhstan and Bishkek, Kyrgyzstan
are actively engaged in service planning, implementation,
quality assurance and evaluations.
• In general, the role of PWID communities in biomedical
treatment services such as ART and OST remains limited,
which often results in poorer adherence due to
unaddressed psychological and social problems.
Environmental Determinants
Evidence-based public health practice
• Opioid Substitution Therapy in Central Asia has been,
arguably, the most politicized healthcare intervention
that continues to cause debates among professional and
non-professional audiences.
• Opponents of OST promote abstinence-only approaches
in the treatment of addictions and define OST as
“immoral attempts to give patients a poison instead of
real treatment”
• This has resulted in discontinuation of OST in Uzbekistan
and delays in implementation and scale-up in Kazakhstan
Environmental Determinants (2)
Evidence-based public health practice
• Restrictive enrollment criteria to OST;
• Lack of psychosocial support; and
• sub-optimal doses of methadone that result in lower
retention rates in OST programs in Central Asia and
concurrent misuse of psychoactive drugs
• The belief that PWID have poorer responses and
adherence to antiretroviral therapy (ART) is widespread
and results in late initiation or refusals to initiate ART to
otherwise eligible PWID
Environmental Determinants (3)
Funding for HIV prevention
• Most Central Asian countries continue to be dependent
on external support for services targeting PWID, largely
from the GFATM.
• Kazakhstan has been the only country in the region to
allocate funds in its healthcare budget to explicitly
support NSEP, ART and OST.
• DFID and World Bank that funded Central Asia’s NSEPs
and other low-threshold HIV prevention services
targeting PWID until 2011. ceased their funding in 2011.
Environmental Determinants (4)
Funding for HIV prevention
• Aiming to fill the funding gap left by the closure UKAID ad
WB programs, the US funds were channeled to Central
Asia PEPFAR.
• However, the US Congress restricted the funding from
being used to implement NSEPs.
• All Central Asian countries remain dependent on external
donor support for capacity development of their harm
reduction workforce and have no committed resources in
their national healthcare budgets for such purposes.
Healthcare Related Constraints
Human resources
• In Central Asia, curricula of medical schools still lack
review of state-of-the-art, evidence-based
approaches to care and treatment of drug
dependence and HIV among PWID.
• Too often, workers in the medical field are no more
knowledgeable about HIV services, particularly ART
and OST, than those without a medical background.
Healthcare Related Constraints (2)
Integration and coordination of HIV services
• HIV services are poorly integrated making it harder for
PWID to move through a continuum of care, especially
when they present with multiple medical problems.
• Often this leads PWID to drop-out from HIV care before
or soon after initiating ART or even immediately after
their initial HIV test.
• Example of poor integration: OST patients, who
continued occasional risky injection practices, were
unaware of the availability of a NSEP site in the same
health care facility where OST was provided
Healthcare Related Constraints (2)
Integration and coordination of HIV services
• Clinicians prescribing OST might not be aware of
concurrent ART taken by their patients
• Where they are aware of their patients’ ART status, due
to lack of basic knowledge about ART, narcologists often
do not take any action to monitor ART adherence or
adjust their patient’s methadone dose
Conclusions
• Until now c the countries of Central Asia have were
mainly focused their efforts on scaling up the spectrum
and availability of HIV prevention service sites.
• Little consideration was given to underlying reasons for
drug users’
– continued engagement in risky behaviors;
– low utilization levels of and poor adherence to
available services, including OST and ART.
Recommendations
In order to effectively decrease the epidemic
• Central Asian governments must constantly monitor and
properly address all existing, as well as any new and
emerging, social and structural factors that facilitate HIV
risk among PWID and decrease their chances of
enrollment and adherence to HIV prevention, treatment
and care.
• Governments and donor communities need to expand
policies and programs to motivate mobilization of PWID
communities, along with other MARP, for active HIV
prevention among PWID, their sex partners and drug risk
networks.
Recommendations (2)
• Central Asian countries need to identify the best
strategies to implement such combination
interventions (OST, ART, NSEP) in the local context.
• In light of inspiring developments in “treatment as
prevention commitment of national resources to
programs aimed at early detection and treatment of
new HIV infections among PWID represents the most
effective public health investment.
Thank you!
Email me at: [email protected]
[email protected]