Central Asia and Eastern Europe

"The EECA region is home to an estimated one quarter of all people who inject drugs worldwide and has the fastest growing HIV epidemic related to unsafe injecting. The United Nations Office on Drugs and Crime (UNODC) estimates the total number of opiate users in EECA is between 3.4 and 3.8 million people¹⁹. The UN Reference Group on HIV and Injecting Drug Use also suggests that there are around 3.7 million people who inject drugs in the region, with Eastern Europe having the highest regional prevalence of injecting drug use worldwide²⁰.

"Yet although these challenges and trends have been evident for more than a decade, drug laws and implementation policies have not eased in most countries. Most laws and policies remain punitive and repressive, thereby leading to further stigmatization of and discrimination against people who use drugs as well as increased health harms. Rigid law enforcement and criminalization also have financial consequences, especially for governments. Aggressively pursuing people who use drugs, prosecuting them and imprisoning them is costly. It also has little success in the ultimate goal of reducing drug use in general, let alone among those imprisoned—the vast majority of whom return to using in the absence of comprehensive, evidence-based treatment support such as harm reduction. The health impacts of failing to prioritize policy reform are also costly. The costs of treating people living with HIV and other chronic health conditions are far greater over time than preventing infections in the first place."

"Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan comprise the central Asian sub-region, home to nearly 60 million ethnically heterogeneous people, distributed across a geographic area of nearly 4 million km2 (table 1).^1–5 These five countries are classified as transitional economies by the World Bank, with Kyrgyzstan, Tajikistan, and Uzbekistan having gross national incomes of less than US$650 per head, less than 20% of their pre-independence levels.⁶"

"There have been substantial increases in both trafficking and use of illicit drugs in central Asia, driven by its geographic position along drug-trafficking routes from Afghanistan, domestic opium production in the south of the sub-region, and prevailing socioeconomic conditions.^{6,14,21,41,42} Although injection of heroin or home-made opiates (eg, so-called khanka) predominates, stimulant injection has also substantially increased, with 69% of IDUs in one Kazakhstan study⁴³ reporting methamphetamine use. Injecting drug use has driven the HIV epidemic in central Asia so far, accounting for 50–70% of cumulative HIV cases. Reported HIV cases among IDUs increased substantially between 2002 and 2006, with increases of 82 cases (482%) in Tajikistan, 323 (130%) in Uzbekistan, 662 (132%) in Kazakhstan, and 39 (30%) in Kyrgyzstan⁴⁴ and HIV prevalence among IDUs is increasing across the sub-region.³¹ However, HIV surveillance among IDUs is subject to selection bias, often focusing on registered IDUs who have longer injecting histories or are more likely to be in contact with health services.³² Sentinel surveillance data suggest HIV prevalence of about 7% among IDUs in Kyrgyzstan (ranging from 2% in Bishkek to 13% in the Osh province), 4% in Kazakhstan, and 16% in Uzbekistan and Tajikistan overall,³² but outbreaks of HIV among IDUs in specific cities have recently been reported, resulting in substantially higher prevalence (table 3). For example, in Dushanbe, HIV prevalence among IDUs rose from 3·9%49 in 2001 to 12% in 2004⁴⁴ and 24% in 2006,⁴⁴ whereas in Karaganda, Kazakhstan, HIV prevalence has reached 19%.³¹ Rapid and substantial increases in HIV infections have recently been reported in western Siberia, Russia, with increases of up to 700% mostly among IDUs;⁵⁰ increasing HIV prevalence has also been reported among IDUs living in Kazakhstan along the Russian border.⁵⁰"

"Prevalence of hepatitis C virus (HCV) and of syphilis among IDUs can indicate the extent of risky injecting and sexual behaviours respectively. HCV prevalence among IDUs exceeds 60% in Tajikistan and Uzbekistan and 70% in parts of Kazakhstan, and up to one in six IDUs have syphilis (table 3).^31,55,58 Female IDUs are particularly vulnerable to infection with HIV, HCV, and STIs, because of the exchange of sex for drugs or money and risky injecting behaviours:52,59 28% of female IDUs in a study in Dushanbe, Tajikistan, had syphilis (75% of whom reported transactional sex) compared with 13% of men,55 and in a study in Kazakhstan, female IDUs were 2·3-times more likely to be HIV positive than men and had a syphilis prevalence of 11% compared with 5% among male IDUs.³⁷ The estimated 20–24% of male IDUs who have sex with female sex workers also underscores how these risk groups intersect.^32,47,56,57"

"The problem of injecting drug use and the related increase in the number of diagnosed HIV infections remains of high importance in the Republic of Tajikistan. According to official statistics, 7,135 drug-dependent persons were registered in the Republic as of January 1, 2012.

"It should be noted that these figures do not reflect the actual situation. According to an estimate by the AIDS Projects Management Group (APMG), made using calibrated empirical data and the data on registration in the drug service, the number of IDUs in Tajikistan should be estimated at 25,000, with a possible range of 20,000-30,000 (AIDS Projects Management Group, 2009).

"The number of registered heroin-dependent persons in Tajikistan between 1997 (the beginning of the epidemic of heroin use in Tajikistan) and 2011 is 5,755."

"There are approximately 40,000 people who inject drugs in Georgia, but only 4,000 of them are covered by harm reduction services. OST [Opiate Substitution Treatment] and NSPs [Needle and Syringe Programs] are largely funded through Global Fund; they cover only a few regions and at best cover up to 10% of people in need⁷⁸. The state budget of Georgia allocates just $700,000 for treatment programs for people who use drugs at the same time that $10.5 million per year is spent enforcing rigid drug criminalization policies (as noted previously in this report). The skewed priorities are extremely costly from a public health and budget perspective, as criminalizing people instead of supporting them in effective drug treatment not only costs more money but increases health risks."

"The rapid spread of HIV among IDUs in central Asia has been aided by high prevalence of risky behaviours; 50–70% of IDUs share injecting equipment, purchase pre-filled syringes, or draw-up from common containers, and the use of condoms is low (table 4).^{6,32,34,52–55} Specific drug preparation practices might also increase risk, with blood used in the preparation of so-called vtoryak, a solution obtained by reprocessing materials after preparation of khanka; however, vtoryak was used by less than half of IDUs in a 2002 study in Kazakhstan.³⁷ Studies have shown average durations of injecting of 3–9 years among IDUs, the average age of whom is decreasing.^34,55–57 In Tajikistan, recent initiates were twice as likely to be HIV infected than those with longer injecting histories, suggesting riskier behaviours46 and potentially less use of harm reduction services than older, more established IDUs."

"Russia is an extreme case in many ways given its strict legal prohibition on any form of OST whatsoever for any reason. It is not entirely alone, however. In most other EECA countries, governments’ inability to allocate funds for harm reduction programming (including OST [Opioid Substitution Treatment]), HIV treatment and even treatment for hepatitis C is determined not by insufficiency of national funding, but by inadequate national priorities. Political leadership is lacking in support of prevention services for people who inject drugs, and as a result international donor mechanisms are the biggest source of funding for evidence-based services for people who use drugs. Yet the reach and effectiveness of donor investments are limited by existing law enforcement policies that do not create supportive legal environments for protecting the health of people who inject drugs."

"Although there are fast-growing HIV epidemics across central Asia, Uzbekistan has the largest number of people with HIV and is experiencing a particularly deteriorating situation (table 2).^1,16,21–23 The number of people newly diagnosed with HIV has increased more than 11 times in Uzbekistan between 2001 and 2006 compared with four times in Kyrgyzstan and Tajikistan.²⁴ Young people have been most affected by the HIV epidemic: in Uzbekistan 8413 (64%) of 13,146 cumulative HIV cases have been among people aged 34 years or younger,²⁵ in Kyrgyzstan 773 (57%) of 1357 cases are in those younger than 30 years,26 and in Kazakhstan 891 (45%) of 1979 cases registered in 2007 were in the 20–29 year age group.²⁷ The predominant HIV genetic subtype in central Asia is subtype A, as it is in eastern Europe, distinguishing the epidemic in this sub-region from that in western Europe, where subtype B predominates.^28–30"

"As of December 31, 2011, a cumulative total of 3,846 HIV infections had been diagnosed in the country, with HIV infections among males comprising 77.7% and among females 22.3%. The incidence of HIV (diagnosed infections) is 43.4 per 100,000 members of the population. HIV infections were registered in 66 out of 68 districts of the country. The total number of AIDS-related deaths is 552 (14.4.% of diagnosed HIV cases). The estimated number of people infected with HIV has been put between 6,800 and 10,000. Furthermore, in recent years, the number of new HIV infections diagnosed among women has increased almost 2 to 3 times. Thus, in 2005, newly diagnosed HIV infections among women made up 8.5%, whereas they made up 20.2% in 2011.
"By the end of 2011, in terms of the cumulative total of HIV infections diagnosed in the country, 52.6% were transmitted intravenously; 29.8% were transmitted through unprotected sexual contact; 1.5% were transmitted from mother to child, and for 15.7% the transmission mode was unknown. The prevalence of HIV infection is over 5% among some of the most-at-risk population groups, such as IDUs, indicating that Tajikistan has a concentrated HIV epidemic."

"Incarceration often makes things worse. Drugs are widely available in most prisons, and HIV transmission is a serious risk given the difficulty in obtaining clean injecting material and other prevention commodities such as condoms. In Tajikistan, for example, the number of HIV cases in prisons is steadily rising. Personal testimonies indicate that heroin is fairly easy to find now in prisons⁸¹.

"Data from Kyrgyzstan also suggest that drugs are widely available in prison settings, with reports of drug use varying from 20% to 50%⁸². Prisoners often reportedly have injected dimedrol, a particularly caustic and dangerous substance, and suffered life-threatening injuries."

"The imprisonment of 1,605 people detained in 2008 on the basis of positive drug tests in Georgia cost $4.7 million, and overall costs for imprisonment in the country continue to surge in response to new, punitive policies. In the past few years the prison population has increased four-fold (from 6,000 to 24,000)⁸⁶."

"In Kyrgyzstan prisons, people who use drugs have no access to effective drug treatment in prison settings due to the low coverage of such services. With no alternatives, inmates often get involved in criminal activity in order to sustain drug use. Involvement in such gangs often continues after release, especially if an inmate has debts stemming from drug use⁸⁷."

"HIV testing within prison populations has been widespread in central Asia, reflecting sentinel surveillance and mandatory testing policies. HIV prevalence among prisoners ranges from 2% in Kazakhstan to nearly 7% in Tajikistan (figure 2). By the start of 2007, more than 25% of cumulative registered HIV cases in Kazakhstan were in prisoners, and in Tajikistan, a fifth of the registered HIV population are prisoners;^32,64 these proportions reflect HIV-testing policies, criminalisation of illicit drug use, and high rates of risk behaviours among prisoners, both inside and outside prison settings.⁵⁹ In central Asia, 5–25% of prisoners are estimated to have drug dependence⁴³ and up to 70% share injecting equipment.^32,69 In one study in Kazakhstan,³⁶ the prevalence of syphilis among prisoners in temporary detention was 5%. The prevalence of tuberculosis among inmates is 60–100-times higher compared with the general population, with high tuberculosis mortality.⁶⁴"

"As of the end of 2011, 49 needle and syringe programmes were operating in Tajikistan through the trust points, including 21 trust points for IDUs (based on the premises of treatment and prevention facilities) that were supported by UNDP within the framework of the implementation of GFATM grants, and 28 trust points supported both through GFATM grants and CARHAP/DFID, PSI, OSI, and Red Crescent Society projects. Geographically, NSPs are available in 28 sites of the 68 districts of the country.
"In 2011, 2,200,000 needles and syringes were distributed in the country, which translates into 88 needles/syringes per IDU (based on the total estimated number of IDUs in the country). Cumulatively, 15,871 clients were reached by harm reduction services in 2011, making up about 63% of the estimated number of IDUs in Tajikistan (National Coordinating Council on Prevention and the Fight against HIV, TB, and Malaria in the Republic of Tajikistan, 2012). Specifically, about 6133 IDUs were reached by needle and syringe programmes in 2011 (Burkhanova and Ibragimov, 2012). The provision of harm reduction materials to all programmes is done exclusively through GFATM funding, and at the present moment there are no alternative sources of funding, which jeopardises the future sustainability of harm reduction programmes in the country (National Coordinating Council on Prevention and the Fight against HIV, TB, and Malaria in the Republic of Tajikistan, 2012)."

"With financial support from national Global Fund grants and cooperation from international organisations, prevention efforts are scaling-up across central Asia, largely concentrating on IDUs and female sex workers. Harm reduction efforts for IDUs have been impeded by legislative barriers and a lack of strong political support, including hard-line policing and punitive laws on drug use.^34–36 However, Kyrgyzstan has made substantial progress in harm reduction, reflecting the explicit political support received and removal of some legal barriers.^35,43 Some central Asian countries have achieved medium coverage of IDUs with low threshold services, mainly through Trust Points and outreach; for example, coverage has reached 61% in Kyrgyzstan and about 35% in Kazakhstan and services include provision of clean needles and syringes, and condoms and VCT or referral for HIV testing. However, coverage with needle and syringe exchange programmes (NEP) and opioid substitution therapy (OST) remains suboptimum in central Asia (table 4).⁸³ Efforts are ongoing to scale-up harm-reduction activities and Kazakhstan now has a pilot OST programme, with a pilot planned in Tajikistan, although the pilot in Uzbekistan was recently closed by the government.³⁵ In Kyrgyzstan, OST has been available since 2002 and recently became available to prisoners, along with NEP.⁴³ A recent study suggested that awareness of HIV services among IDUs is highest in Kyrgyzstan at 70%, is around 50% in Kazakhstan, and lower than 10% in Tajikistan.³⁴"

"In 2009, the Government of Tajikistan reviewed and supported the request of the Ministry of Health of the Republic of Tajikistan regarding the introduction of a pilot project of opioid substitution therapy (OST), initially for 200 patients. In accordance with the resolution of the Government, the Ministry began to implement the project. In June 2010, the Ministry of Health, with financial support from the GFATM and UNODC, opened the first OST centre in Dushanbe, at the Republican Clinical Narcology Centre named after Prof. M. G. Gulomov. By the end of 2011, 102 patients, including 7 women, were receiving OST at that centre. The second OST centre was opened in the city of Khudjand, Sogd Province, in December 2010, with 52 patients (including 3 women) receiving OST there by the end of 2011. The third centre was opened in Khorog in June 2011, with 44 patients (including 1 woman) receiving OST there by the end of 2011 (Nidoev, 2012).
"In Dushanbe, the following eligibility criteria for the OST programme are reportedly being used: age over 18, the presence of an opioid dependence diagnosis, a confirmed history of injecting drug use, a history of failures in drug treatment, and the capability to provide informed consent.
"According to an evaluation conducted among OST patients in Dushanbe in October 2011, 94% of the participants in the programme reported improved family relationships; the number of employed patients rose to the level of 50%; the number of patients adhering to antiretroviral (ARV) therapy increased threefold; 98% reported a lack of legal problems in the past 30 days.
"The OST programme in Tajikistan continues to be funded through grants received from international organisations."

"Eastern Europe, the Commonwealth of Independent States, and significant parts of Asia are experiencing explosive growth in new HIV infections, driven largely by injecting drug use (UNAIDS, 2006). While the primary route of transmission in most of these areas is sharing of contaminated injecting equipment, sexual and perinatal transmission among IDUs [injecting drug users] and their partners also plays an important and growing role. In many highly affected countries, rapid growth in the number of IDUs infected with HIV has already created a public health crisis. Countries where the level of HIV infection is still relatively low have the chance -- if they act now -- to slow the spread of HIV."