Substitution Maintenance Therapy in Ukraine: Can the Community Respond Effectively to the Challenges of HIV/AIDS?

Introduction Why SMT?

The language of the facts: Ukraine’s HIV/AIDS epi- In 2001 the World Health Organisation (WHO) iden- demic is the fastest growing in Europe. tified five key principles of HIV prevention among IDUs, including availability of clean injecting equip- Over the last three years the number of officially ment and access to SMT. registered HIV cases in Ukraine has almost doubled. SMT can be prescribed to those IDUs who meet the clinical criteria for opioid dependence according to Every day 48 people are diagnosed with HIV and the International Classification of Diseases (ICD- seven individuals die of AIDS. 10). Opiates are the most common illegal drugs used in Ukraine. After 10 years, injecting drug users (IDUs) and their sexual partners remain the most vulnerable group to HIV. - is a Modern approaches to HIV prevention among vul- Substitution maintenance therapy nerable groups were not available during these method to treat chronic opiate dependency years. and prevent the spread of HIV and hepa- titis B and C among injecting drug users Substitution maintenance therapy (SMT) has been proven to be one of the most efficient tools for HIV by prescribing the patient a non-injectable prevention among IDUs in many countries. These substitute drug (usually methadone or bu- methods are finally being applied in Ukraine. prenorphine) to be taken on a long-term

The aim of this policy brief is to inform politicians, basis. decision makers, national and international stake- holders, health care professionals, mass media and the general public about substitution maintenance therapy and its implementation in Ukraine from 2004 to 2007.

The briefing contains a concise summary of the achievements and conclusions so far, as well as the challenges, and looks ahead to the further develop- ment of this approach in Ukraine. 2008 Advantages of SMT: The Traditional Approach to Drug Dependency Treatment • reduces HIV and hepatitis B and C The situation is critical in Ukraine. in Ukraine prevalence rates among IDUs and The estimated number of IDUs in their partners the country ranges from 325,000 In Ukraine treatment of drug depen- to 425,000. Currently 63 percent of dency still relies on old Soviet-style • reduces illegal drug use and over- registered HIV cases among adults methods rather than international dose-related mortality are related to injecting drug use. standards and the principles of evi- dence-based medicine. Treatment • improves the physical and mental SMT in the World covers only about 10 percent of health of drug dependent patients, those who need it. and integration in society The implementation of SMT pro- grammes worldwide has more than The therapeutic approaches of • supports adherence to HIV and TB a forty-year history, starting in the government drug treatment clinics treatment 1960s in the USA, followed by Can- are still guided by protocols issued ada and the UK. by the Ministries of Health of the • reduces crime and undermines the USSR and Soviet Ukraine long profitability of illegal drug trafficking Today methadone or buprenorphine before 1991. SMT is accessed by almost a million • decreases government expendi- drug dependent people in 60 coun- Acting in compliance with an ture on criminal proceedings, im- tries, including 26 countries of the outdated treatment philosophy, prisonment of IDUs and treatment European Union, as well as North medical personnel focus on the of diseases resulting from illegal and South America, Asia, Australia patient’s rapid and complete drug use. and New Zealand. withdrawal from drugs, which is an unattainable goal for many drug SMT and the HIV/AIDS Among post-Soviet countries SMT dependent individuals. Epidemic is implemented in Lithuania, Latvia, Estonia, Moldova, Georgia, Azer- State institutions almost never The global HIV transmission rate baijan, Uzbekistan, Kyrgyzstan and employ cutting-edge approaches through injecting drug use is 10 per- Ukraine. to the prevention of risk behaviour cent. among IDUs. In October 2007 the first metha- In many countries of Western Europe done-based SMT programme was the HIV infection rate has been launched in Belarus. reduced significantly as a result of large scale-up of SMT programmes. Right to Treatment SMT and Ukrainian Legislation Usually drug treatment clinics offer The right of Ukrainian citizens to patients detoxification (treatment treatment is guaranteed by the Con- An SMT buprenorphine pro- of acute opiate withdrawal or ab- stitution. This applies to all Ukraini- gramme was initiated in Ukraine stinence syndrome, also known as an citizens, irrespective of the name in 2004 with the support of UNDP, ‘cold turkey’), but its effectiveness is and nature of disease. in pursuance of a Bill passed by extremely poor: at least 90 percent the Ukrainian Parliament follow- of patients relapse into drug use in Drug dependency is a chronic con- ing parliamentary hearings on the the first six months after detoxifica- dition that needs to be treated in ac- social and economic problems re- tion. cordance with the standards identi- lated to HIV/AIDS and drug abuse. fied by contemporary science and These hearings resulted in a series The practice of mandatory patient international best practice. of recommendations for Ukrainian registration which dates back to So- legislators. Constitution of Ukraine viet times is still prevalent in Ukrai- Article 49. SMT programmes fully comply nian drug treatment facilities, and Everyone has the right to health with the applicable legislation and every drug user seeking medical protection, medical care and are implemented pursuant to Item help at such a facility will be officially medical insurance. 12 of the National Programme for diagnosed with ‘drug-addiction’. …The State creates conditions HIV/AIDS Prevention, Treatment and Support for People Living with for effective medical services This generally leads to negative HIV/AIDS in 2004– 2008 approved accessible to all citizens. by Decree 264 dated 4 March 2004 consequences for patients. For Denying access to SMT for drug issued by the Cabinet of Ministers example, they will be automati- of Ukraine. cally registered with the police, and dependent patients is a violation of banned from taking certain jobs and lawful right to treatment and health The Government Portal, from driving. care. website of the Cabinet of Ministers “The illegality of the use of drug sub- of Ukraine, 14 May 2007, This mandatory registration system stitution such as methadone does not http://www.kmu.gov.ua increase the chances of reducing the sets up a substantial barrier to health Ukrainian law permits use of sub- number of HIV/AIDS. The Commis- care for IDUs who, fearing stigma sioner is alarmed by the spread of the stitute medications for medical pur- and discrimination, try to avoid drug virus and sees this as a potential ca- poses. treatment clinics or using social ser- tastrophe for Ukraine… It is the duty vices unless forced to do so. of Ukraine to provide treatment, estab- During 2005–2007 the Ministry of lish rehabilitation and social reintegra- Health of Ukraine issued a number tion services. The HIV/AIDS problem should be addressed urgently”. of decrees regulating implementa- tion of methadone and buprenor- From the Report by the Commissioner phine-based SMT programmes. for Human Rights Mr Thomas Ham- marberg on his visit to Ukraine 10 – 17 December 2006 (paragraph 196) Position of International In 2004 three UN agencies affirmed Joint position paper. Substitution Organisations the importance of substitution maintenance therapy in the man- treatment as a crucial element of agement of opioid dependence According to the conclusion of the the response to HIV and opiate and HIV/AIDS prevention International Narcotics Control injection. Board, the use of SMT does not Paragraph 23. Substitution contradict international drug control maintenance therapy is one of conventions. the most effective types of phar- macological therapy of opioid The above mentioned conventions dependence. There is consistent state that restrictive measures evidence from numerous con- should not impede treatment of drug trolled trials, large longitudinal dependent patients. studies and programme evalu- Many Governments have opted ations, that substitution main- in favour of drug substitution and tenance treatment for opioid maintenance treatment as one of the dependence is associated with forms of medical treatment of drug addicts, whereby a drug with similar generally substantial reductions action to the drug of dependence, in illicit opioid use, criminal ac- but with a lower degree of risks, is tivity, deaths due to overdose, prescribed by a medical doctor for and behaviours with a high risk a specific treatment aim. Although of HIV transmission. results are dependent on many factors, its implementation does not constitute any breach of treaty provisions, Cost–effectiveness of SMT: whatever substance may be used for Paragraph 44. According to such treatment in line with established several conservative estimates, national sound medical practice. The World Health Organization (WHO), the United Nations every dollar invested in opi- oid dependence treatment pro- Report of the International Narcotics Office on Drugs and Crime Control Board for 2003 (2004), INCB, (UNODC) and the Joint United grammes may yield a return of United Nations, paragraph 222 Nations Programme on HIV/ between $4 and $7 in reduced AIDS (UNAIDS): drug-related crime, criminal jus- In 2005 the main two drugs used in tice costs and theft alone. When SMT – methadone and buprenor- savings related to health care phine – were added to the WHO are included, total savings can Model List of Essential Medicines for use in the treatment of drug de- exceed costs by a ratio of 12:1. pendency. History of SMT in Ukraine The first evaluation of the SMT in Ukraine: Three Years pilot programmes in Ukraine Later The first pilot SMT projects in Ukraine demonstrated that SMT: started in 2004 at drug treatment As of April 2008, 756 patients in 23 facilities in Kherson and Kyiv with • achieved the same results as those cities of Ukraine have participated in support from the United Nations De- reported by evaluators of compara- SMT programmes implemented by velopment Programme (UNDP) in ble SMT projects implemented ear- the International HIV/AIDS Alliance Ukraine. These pilots had a limited lier in Western countries in Ukraine (Alliance Ukraine) with fi- number of clients. nancial support from the Global Fund • is a totally safe and technically sim- to Fight AIDS, Tuberculosis and Ma- Buprenorphine was chosen as the ple treatment method laria (the Global Fund). substitute drug for project clients because there was no registered • can work in Ukraine, which does Most programme patients have been methadone formulation in Ukraine not significantly differ from other drug dependent for over 10 years, at that time. At an early stage of countries where implementation of 60 percent are HIV-positive, the ma- the project, guidelines on adminis- SMT has helped contain HIV/AIDS jority are co-infected with hepatitis tration of buprenorphine were pub- epidemics amongst IDUs. C, and almost one fifth of them have lished and doctors were trained in TB. SMT prescription criteria and patient The achieved outcomes gave a One third of the HIV-positive patients follow-up. powerful impetus to further scale- are already receiving antiretroviral up of SMT programmes. therapy (ART) and a considerable Psychosocial support to project cli- number of them are being prepared ents was provided by a non-gov- Considering the positive results of to start this treatment. ernmental organisation. Patients the first two pilot projects, the Min- who were enrolled in the treatment istry of Health issued decree 161 The proportion of women in the ART programme suffered from a severe dated 13 April 2005 “On implemen- programme is 23 percent, whereas form of opiate dependence: without tation of SMT programmes at six women count for 33 percent of the a job or any legal source of income, government drug treatment clinics HIV-positive clients. they had to engage in criminal ac- in Ukraine”. tivities in order to satisfy their need Outcomes of the first two pilot This points to a need to refine and for drugs, the average daily cost of SMT projects achieved in the develop treatment services, as well which added up to about UAH 100. first six months (76 patients): as related outreach services, in order to ensure more tailored service deliv- • patient retention rate – The pilot SMT programmes were ery to meet the needs of HIV positive 70 percent accompanied by an evaluation per- women in the SMT programme. formed in the framework of a WHO • fourfold decrease in illegal study “Substitution therapy for drug opiate use and risk behaviours dependent persons and HIV/AIDS”. • crime rate among project patients dropped to zero. SMT Programme Successes

• Illegal opiate use among clients • 68 patients have returned to • medical professionals have ob- has reduced substantially their families, 73 patients have served the effectiveness of the found jobs programme, that buprenorphine • risk behaviours have reduced treatment is safe and efficient, fourfold • 56 lives have been saved* and have developed the skills re- lated to the clinical management • over a quarter of clients are re- • because of the SMT programme of SMT provision ceiving life-saving HIV treatment in 2006–2007 alone, illegal drug (ART); nearly 20 percent are re- traffickers lost about UAH 27 mil- • the attitudes of many patients ceiving treatment or follow-up for lion in illegal profits to the programme has changed TB from distrust to willingness and active participation.

*It has been calculated that the mortality rate among IDUs in the same age group is 16 per- cent; accordingly at least 80 people would have died without SMT, whereas in fact only 24 died. Prospects for SMT Implementation The SMT programme has received positive feedback from the general In the framework of the programmes It is planned to enrol 300 more pa- public and drug treatment special- run by the Alliance Ukraine with sup- tients in integrated methadone- ists. port from the Global Fund, in early based SMT programmes run in Dni- 2008 17 more medical facilities start- propetrovsk oblast with support from Importantly, these pilot SMT pro- ed implementation new buprenor- the William J. Clinton Foundation. grammes have proven to be much phine-based SMT programmes. more efficient than the traditional ‘re- Thus in 2008 coverage is planned for formative’ approach. In early April 2008 the first batch of more than 3000 patients with SMT methadone was delivered to Ukraine, programmes at 54 medical facilities Doctors have learnt that patient be- allowing 38 medical facilities to start in 23 oblasts of Ukraine. haviour is largely dependent on ac- implementing methadone-based pro- By July 2009 the number of patients curate assessment of the appropriate grammes for 2220 patients. receiving SMT will increase to 6000. drug dosage: when the dose is suffi- “Substitution therapy has long been cient, the patients are more likely to 150 more HIV positive patients will be recognised as the best international comply with the treatment regimen. enrolled in SMT programmes in Kyiv, practice to treat drug dependency and Odessa and Mykolayiv within a project prevent HIV transmission amongst in- jecting drug users due to its medical, Psychosocial support of SMT pro- supported by the US Agency for Inter- social and economic benefits. Why then gramme clients has also been suc- national Development (USAID). is it still not implemented in Ukraine?” cessful. The involvement of non- M. E. Polishchuk, Head of the Par- medical staff (psychologists, social liamentary Committee of Ukraine on workers, drug dependency counsel- Health, Mother and Child Care, 1 December 2003 lors) has been key to this success. Table. Number of patients receiving SMT supported by the Alliance Ukraine, including key characteristics. Increase in the number of patients from 2004 to 2008

Key characteristics TOTAL

Number of clients 756 including women 173

april Average age 35 Average drug history (years) 13,6

Number of clients with HIV, including those on ART 455/155

Number of clients with hepatitis B or C 485

Number of clients with TB 126

Average dose of buprenorphine (mg) 11 Personal Stories: Patients When I applied to a drug treatment My health improved significantly, and Their Parents clinic again, I was offered substitu- I overcame depression as well tion therapy. At that time I had no as I was no longer suffering from Oleg Voynarenko, 29, SMT idea what it was. I’ve only heard pain. I was ready to turn over a programme client, Kherson: some of my friends say that in for- new page. I knew there were “I started using drugs at school. eign countries they provide meth- many drug users in our city who Once I tried homemade opiates, adone to junkies free of charge, wanted to start SMT but didn’t I could never say “no” to them. and it just made me envious. have the chance to join the pro- At first I used them from time to gramme. time, but after a year I was tak- I was offered buprenorphine in- ing them every day or even sev- stead of methadone though. So my friends and I decided to eral times per day. However I However at that point I didn’t care set up a community-based drug still thought I could give them up what they gave me, as long as it user organisation which would whenever I wanted to. And one could keep me from shooting up. advocate for our rights and in day I found myself in a situation particular for greater access to when I had to give up: I was of- That’s how I became a client of SMT. With some support from fered a good job which required the first pilot SMT programme in others we registered the organi- lots of travel. I decided to kick Ukraine. It didn’t take too long to sation ‘Probuzhdennya’ (‘Awak- the habit on my own, but on the realise that this was the only thing ening’), which has been success- very first day I started feeling so that could help me. fully implementing social projects bad that I had to go to hospital. in Kherson for two years now. At first it was difficult to readjust. That’s how my long journey My old life rotated around drugs: Today, three years on, I am a through drug clinics and rehab find or steal money to buy drugs, totally different person: I have a centres began. Every time I start- find money for tomorrow and so job, I’m studying at university, my ed treatment, I was confident I on and so forth. Buprenorphine family and friends have already would never use drugs anymore. set me free from this ceaseless forgotten the narcotic nightmare And time after time I ended up us- merry-go-round. we lived in for so many years. ing again. My family and friends lost hope and were expecting the I started to get used to attending Whatever people might say, for worst to happen, because my my drug clinic regularly to receive users like me substitution thera- health deteriorated dramatically. I my tablets, and I even started py is the only chance not only to was detained by the police a cou- thinking about finding a job. save, but also to change our lives ple of times, and I thought I was dramatically.” going to go to prison or die soon. Iryna Sukhoparova, 48, mother Now they have all rebuilt their An excerpt from an open let- of an SMT programme client relationships with their families, ter to Ukrainian President Vik- at the Kyiv city drug treatment many of them have found jobs, tor Yushchenko written by SMT clinic: and they are no longer involved programme clients (4 December “My daughter and her husband in crime as they don’t need to 2007): have been patients of this pro- steal money to get another fix. gramme for almost two years. Be- “… At last we have an opportuni- fore they joined the programme, Among the programme patients ty to give up crime, into which we they had been using street drugs there are mothers with one or were forced by circumstances, for many years, in particular two children. Their children used and become active members of homemade opiates and heroin. to live with their grandparents. society. They were treated several times Today, thanks to substitution at drug clinics and rehab centres, treatment, the parents can bring While using SMT programme including Christian ones, but it up their children themselves and services most of us have man- was all in vain. take them to kindergarden and aged to quit illegal drugs, find school. jobs, receive treatment and bear Only their enrolment in the sub- children, availing ourselves of the stitution maintenance therapy They tell me proudly about their same opportunities as all other programme has enabled them to children’s success in school and citizens of Ukraine. return to a full and normal life. particularly in sports. Jointly with other parents of the However we can show even bet- Kyiv-based SMT programme Here are just a couple of the most ter results, provided that SMT we surveyed 70 patients whose commonly repeated statements programmes work in accordance drug history ranged from 10 to 17 by the programme clients who with international best practices, years. took part in our survey: are evidence-based and tailored to the most pressing needs of They have experienced in full all • “My mother never thought it their clients…” the negative consequences of would ever be possible” this severe disease: they’ve had • “My parents have started to trust troubles with the law, some of me again” them have served prison terms, • “I’ve come to understand that I they have many chronic illnesses love life and that there’s nothing and a history of troubled relation- more important for me than my ships with their friends and rela- parents and my son.” tives. Methadone and • under Ukrainian conditions, metha- • if the dose is appropriate, it may be Buprenorphine done requires accurate and flexible taken once every two days dosing by a doctor, along with the • it is a prescription drug officially Today the most commonly used patient’s strict compliance with the sold in Ukrainian pharmacies; it is in- drugs in SMT programmes world- doctor’s orders (to prevent the risk of cluded in the National list of essential wide are methadone and buprenor- possible overdose, especially in the medical drugs and products (Decree phine. initiation phase). Effective metha- 400 of the Cabinet of Ministers of Although each drug has its strengths done delivery needs dosing guide- Ukraine, dated 29 March 2006) and weaknesses, four out of five pro- lines that are made on the basis of • it is more difficult and time-consum- grammes implemented worldwide individual need. Underdosing leads ing for medical staff to control sub- use methadone. to less favourable outcomes lingual administration of buprenor- • it is also available in Ukraine on the phine Methadone black market, where drug users use • there are no official guidelines in it intravenously It therefore has a Ukraine on administering buprenor- • methadone in Ukraine is 20 times bad reputation with law enforcement phine to pregnant women dependent cheaper than buprenorphine, thus agencies and the general public on opiates allowing treatment of a much high- • the drug is very expensive (today er number of patients. This creates Buprenorphine the average monthly cost of this treat- much greater potential for a sub- ment course for one patient adds up to stantial impact on the HIV/AIDS epi- • buprenorphine has a more favour- $170, while the cost of a comparable demic among IDUs in Ukraine able reputation than methadone methadone-based course is only $8) amongst the public and policy mak- ers in Ukraine

Table. SMT Drugs Officially Registered and Authorised in Ukraine Year of Name of drug/ brand name Drug formulation Manufacturing company № registration Injection solution, Kharkiv state-run pharmaceutical 1 Buprenorphine hydrochloride 1997 ampoules company ‘People’s Health’ 2 Buprenorphine/Ednok 2001 Sublingual tablets Rusan-Pharma Ltd, India 3 Buprenorphine Ethypharm 2007 Sublingual tablets Ethypharm, France Methadone Concentrated oral 4 2003 BUFA, the Netherlands hydrochloride solution Tablets, oral 5 Methadone/Methanol 2006 Pharmascience Inc., Canada solution Salutas Pharma GmbH/Hexal AG, 6 Methadone/Methaddict 2007 Tablets Germany L. Molteni e C. dei fratelli Alitti - 7 Methadone hydrochloride/ Molteni 2007 Oral solution Società di esercizio S.p.a., Italy Methadone Tablets; dispersible 8 2007 Mallinckrodt Inc., USA hydrochloride/Methadose tablets There are benefits and challenges SMT and Politics of Ukraine) and some communi- with both therapies. The substantial- ty-based organisations and faith ly lower cost of methadone suggests Because of their excessive propen- groups which promote total absti- much greater potential for scaling up sity to populist rhetoric and disre- nence from drugs. to national coverage of SMT. On that spect for professional opinion, until basis, Alliance Ukraine support the recently the majority of Ukrainian Although the National HIV/AIDS scale up of methadone in particular. politicians held negative opinions of Programme envisages implemen- Its modest cost and the substantial SMT. tation of SMT, political opposition evidence base demonstrating its ef- hampers full-scale programme de- fectiveness make it a high priority A number of times, certain political ployment. therapy to address HIV vulnerability forces in Ukraine have used their and opiate dependency in Ukraine. objection to methadone treatment The MoH of Ukraine has issued as a political argument against their new orders on SMT scale-up but Different people respond to metha- opponents during parliamentary these take time to be actually im- done and buprenophine in differ- election campaigns. plemented. ent ways. To meet these different needs, both drugs should ideally be Politicians have commonly used The Narcotics Control Board (NCB), available to treat opiate dependency moral or ideological arguments that despite being affiliated to the MoH, and to prevent HIV transmission. do not have a scientific basis re- has for a long time ignored MoH de- garding SMT. This has hindered the cisions to implement methadone- It is therefore recommended not to based SMT programmes and pub- restrict the choice of medication used course of SMT introduction, in par- in substitution treatment to buprenor- ticular methadone. licly voiced its objections. phine, but instead the government should do everything in its power to Many policy makers are dedicated to At the same time drug users regu- simplify the introduction and scale an abstinence-based solution to the larly report that drug smugglers are up of methadone maintenance treat- problem of opiate dependency. Usu- providing methadone powder on ment. ally they ignore the fact that the fail- the Ukrainian black market. Here we see an obvious paradox: Joint WHO/UNAIDS/UNODC Mis- ure rate is too high to promote absti- sion on Opioid Substitution Thera- nence-based treatment as a primary drug control measures are imped- py in Ukraine (November 2004) response to opiate dependency. ing treatment efforts, but have no While drug-free programmes should effect on illegal drug trafficking. be a necessary part of the opioid dependence treatment system, the The MoI and SSU consider the hy- role of methadone and buprenor- pothetical risk of government-pro- phine SMT should be key. cured methadone leaking into the black market more dangerous for The implementation of methadone- society than the fast-growing HIV/ based programmes still meets con- AIDS epidemic and the increasing siderable opposition from Ukrainian number of Ukrainians who are dy- law enforcement agencies (Min- ing without receiving the treatment istry of Interior, Security Service they so desperately need. Politicians speak about SMT Timeline: Key Advocacy June–July 2005 Facts and Events Related Ukrainian law enforcement agencies Some Ukrainian politicians, par- to SMT Implementation in attempt to ban the medical use of ticularly those who have relevant Ukraine methadone in Ukraine, but fail after medical training and education, are protests by NGOs and international aware of international best practices December 2003 organisations. and the efficiency of SMT and are A hearing on Ukraine’s response to willing to implement it. Politicians the HIV/AIDS epidemic and illegal November 2005 who are medically trained have drug use is held at the Ukrainian On behalf of the Government of been more open to a scientific and Parliament. Alliance Ukraine Execu- Ukraine the Minister of Health humane drug treatment policy. tive Director Andriy Klepikov empha- signs a cooperation agreement sises the need for SMT programme with the William J. Clinton Founda- “Substitution therapy is a requisite. Its opponents will say that drug us- implementation in Ukraine. tion, which includes a commitment ers should be ‘burnt, annihilated, or to implement methadone-based exterminated’. February 2004 Yet this is so unreasonable, one has SMT programmes in Ukraine. to be mentally ill to say it. Instead The Ukrainian Parliament passes a of avoiding the problem we should resolution to approve recommenda- try and solve it. Substitution therapy August 2006 has proved to be an efficient method tions put forth at the parliamentary Prime Minister of Ukraine Yuriy in many countries of the world. We hearing on Ukraine’s response to Yekhanurov signs Ukraine’s Country should make use of this experience the HIV/AIDS epidemic and illegal in Ukraine.” Proposal to The Global Fund to Fight drug use, including the need for AIDS, Tuberculosis and Malaria for Andriy Shkil, Ukrainian Member of SMT implementation. Parliament, 2004 the 7th round of funding. The pro- posal includes a commitment to pro- “Methadone-based therapy indeed April 2004 vide access to SMT for 3000 people reduces the flow of illegal drug traf- Ukrainian Prime Minister Viktor ficking and helps resocialise drug us- by the end of 2007. ers and reduce their involvement in Yanukovych signs a new National crime. The most vocal opponents of HIV/AIDS Programme for 2004– methadone must be those who either December 2006–November 2007 knowingly or intuitively are anxious 2008, which inter alia provides for The government of Prime Minister about the potential decrease in illegal SMT programme implementation. Viktor Yanukovych supports activi- drug profits; that is, drug traffickers and corrupt officials.” ties aimed at implementing metha- March 2005 done-based SMT programmes by Sergiy Shevchuk, Ukrainian Mem- Methadone and buprenorphine ber of Parliament, March 2005 issuing a number of necessary de- are included in the WHO Essential crees. Despite the diversity in opinions, Drugs List. For the first time in the history of in- different political parties in Ukraine dependent Ukraine, the government have one thing in common: whenev- April 2005 earmarks national budget funds to er their members served as govern- The Minister of Health issues the treat 300 patients with SMT. ment ministers they all voiced their first order on implementation of SMT The Minister of Health of Ukraine support for SMT programme imple- programmes in six cities of Ukraine. signs a series of orders that regulate mentation and scale-up. SMT programme scale-up, including methadone-based projects. December 2007 International Cooperation The issue of methadone-based SMT programme implementation The Global Fund remains the big- The International Narcotics Control is for the first time considered at a gest donor supporting Ukraine’s Board (INCB) at the request of the meeting called by the President of response to the epidemic: about national Narcotics Control Board in Ukraine. two thirds of all HIV/AIDS preven- February 2007 approved Ukraine’s In response to the results of the tion and treatment programmes in total demands for methadone (pro- meeting on 12 December, the Presi- the country are funded with Global cured for medical purposes) which dent issues a decree aimed at elimi- Fund money, including SMT pro- was estimated at 193 kilograms. nating existing barriers to SMT pro- grammes. gramme scale-up. This allows Ukraine to freely import On 18 December the NCB in con- The following international organi- the drug from a country of origin sultation with the SBU issues a cer- sations provide financial as well in compliance with the strict rules tificate authorising import of the first as technical support to SMT pro- specified by international drug con- batch of methadone to Ukraine to gramme implementation in Ukraine: trol conventions. be used in SMT programmes. Challenges to SMT “Substitution therapy is no magic bul- let. However at this point there’s no • US Agency for International De- Implementation better approach for countries with velopment (USAID) fast-growing AIDS epidemics.” • The Clinton Foundation HIV/ The existence of supportive national Dmytro Tabachnyk, AIDS Initiative legislation, as well as a fair number Vice Prime Minister of Ukraine, • World Health Organisation of trained professionals who are will- 4 December 2007 • Joint United Nations Programme ing to share their experience, gives January 2008 on HIV/AIDS (UNAIDS) us good reason to believe that in the An amended version of the Law • United Nations Development near future most opiate dependent ‘On narcotic drugs, psychoactive Programme (UNDP) in Ukraine people in Ukraine will have access substances and precursors’ comes • United Nations Office on Drugs to high-quality treatment. into force. The new law mentions and Crime the concept of drug-related harm re- • Open Society Institute/ Interna- At the same time, despite the prog- duction as one the key strategies of tional Harm Reduction Develop- ress made and the accumulation of government drug policy. ment Programme good evidence for the effectiveness The law also cancels the govern- • French and Italian Red Cross. of SMT, there are still certain barri- ment’s monopoly on the use of nar- ers to programme scale-up. These cotic drugs for medical purposes, A joint WHO, UNAIDS and UNODC can be divided into two types: which opens the door for NGO- mission that visited Ukraine in late based implementation of SMT pro- 2004 recommended providing ac- grammes. cess to SMT for at least 60000 opi- ate dependent patients in the near- est future (that is, to approximately 70 percent of officially registered drug dependent people in Ukraine). Legal and Logistical Barriers though they are ‘chained to their 2. It is estimated that currently only clinic’, unable to go outside their 10–15 percent of drug dependent The procedure for the use of narcotic city to study, travel or visit relatives. people will seek help at drug treat- drugs within medical facilities is reg- ment facilities. This small proportion ulated by decrees of the Cabinet of 3. If a patient is hospitalised at an- points to some of the inadequacies Ministers and orders of the MoH of other medical facility which is not of the current system: the restric- Ukraine. These were created at a licensed to supply narcotic drugs tive mandatory patient registration time when SMT implementation was for medical purposes, he or she will system which forces drug users to not on the government’s agenda, so have to stop their substitution treat- disclose their illicit drug use, the specific issues related to SMT provi- ment. As a result many patients discrimination experienced by drug sion were not taken into account. A have to refuse treatment for other users in those facilities, and the inef- great number of restrictions hinder chronic conditions. fectiveness of the therapeutic meth- large-scale implementation of SMT ods employed in government drug programmes and may have a nega- 4. SMT is not available in detention treatment facilities. tive impact on the efficiency of treat- centres and prisons where large ment programmes. numbers of drug users are in acute 3. Drug treatment professionals need of drug dependency treat- have still not accepted the idea of These restrictions include: ment. treating drug dependent patients in accordance with harm reduction 1. A ban on the use of low-con- 5. The number of Ukrainian doctors principles; they have no experience centration oral methadone solution who have been trained in SMT pro- of working in multidisciplinary teams, administered with the help of a dis- vision is still insufficient. In addition, which as well as doctors include so- penser. This is the most common health personnel report that direc- cial workers and psychologists. way to administer methadone to pa- tors of drug treatment clinics are tients worldwide, because medical still not sufficiently motivated to train 4. Driven by economics, directors of staff can easily control the process. their medical staff in SMT provision. drug treatment clinics often prefer to work with a set number of in-pa- 2. A ban on distribution of substitute Psychological and Economic tients, rather than develop out-pa- drugs to outpatients for take-home Barriers tient services. The only quantitative use without medical supervision. indicator used to evaluate a govern- Even stable patients who strictly 1. Because of limited government ment clinic’s efficiency is a set num- comply with the treatment regimen support for SMT programmes, pa- ber of beds that are occupied for a and could use the substitute drug at tients and doctors feel insecure set number of days. A clinic has to home on their own are deprived of and fear that the treatment may be achieve this target to be eligible for this option. stopped at any point due to lack of further government funding. This This overstretches medical facilities funding, delayed supply of the sub- system acts as an incentive to only and makes life difficult for clients stitute drug, or even prohibition of provide in-patient services, rather who also go to work and have to SMT by the government. than out-patient or outreach servic- travel considerable distances every es which are more cost-effective. day to get to the clinic and receive treatment. Patients report feeling as 5. Because of strict internal policies Recommendations for medical staff, protecting against the risk of legal liability even in case • Competent state bodies, • Implement all provisions of of minor incompliance with the pro- first of all the Ministry of the National HIV/AIDS Pro- cedure for handling narcotic drugs for Health of Ukraine and rel- gramme relating to SMT roll- medical purposes, directors of drug treatment clinics are afraid to imple- evant oblast and local ser- out. Ensure support for the ment SMT programmes and eventu- vices, should lead the imple- enforcement of relevant or- ally refuse to do so. This problem is mentation and scale-up of ders of the MoH of Ukraine, exacerbated by inconsistent and in- existing SMT programmes in including fulfilment of the complete government regulations. order to ensure an adequate government’s commitments and timely response to the to the Global Fund. 6. Providing treatment, care and sup- HIV/AIDS epidemic. port to people who use drugs has only • Review and amend the poli- limited public support. Many Ukraini- ans think that SMT is too expensive • Replicate good practice in cies and procedures regulat- to provide to drug users who have “no effective SMT implementa- ing the use of narcotic drugs one but themselves to blame for their tion and by the end of 2008 within medical facilities in disease” while many people with other provide access to SMT for order to remove the existing chronic illnesses also need treatment 6000 opiate dependent pa- legal barriers to provision of and adequate financial support. Pub- tients with a particular focus SMT in accordance with the lic education about the society-wide on enrolment of HIV-positive best international practices. benefits of treating drug dependency men and women, because is lacking. they are the key driving force • Actively promote NGO 7. Staff of drug treatment clinics are behind increasing HIV/AIDS and drug user community often unwilling to treat drug users hu- incidence in Ukraine. participation in SMT pro- manely, or as people with equal rights gramme design, delivery, to services. This undermines the po- monitoring and planning tential for successful treatment. of further service improve- Given the experience accumulated ment. 8. Finally, some directors of AIDS thus far and the technical expertise Centres and TB clinics consider provided by many international implementation and rollout of SMT organisations, it is valid to say that programmes to be the sole responsi- substitution maintenance therapy bility of drug treatment clinics. How- can become a powerful strategy to ever it has long been proven that contain the epidemics of HIV/AIDS integration of SMT services into the and hepatitis B and C in Ukraine. work of AIDS and TB clinics signifi- cantly improves the effectiveness of substitution maintenance treatment. Key Messages

• Treatment and prevention of HIV/AIDS • All patients with chronic opiate dependency should is primarily the responsibility of medical have access to SMT regardless of their HIV status. professionals, working with their patients, who make informed decisions about what • Social and psychological support to patients on SMT drugs should be used to treat their patients can significantly improve treatment effectiveness. based on the best evidence. • Ukraine should draw on international best practice • Law enforcement and regulatory agencies and lessons learnt by other countries that have should not impose barriers to or restrictions managed to halt the spread of HIV/AIDS among IDUs. on SMT programme scale-up. Their role is to fight illegal drug trafficking and to monitor • SMT programmes should be funded by the the legal use of narcotic drugs. government, not only by international donors.

• SMT providers should rely upon a relevant • Scale-up of a methadone-based SMT programme and updated legal framework that regulates will help to significantly reduce the cost of other the use of narcotic drugs within medical prevention and treatment programmes and save facilities. money in the national budget.

Covering 6000 patients with SMT services in 2008-2009 will allow Ukraine to start designing a truly effective response to the challenges of the HIV/AIDS epidemic.

Substitution Maintenance Therapy in Ukraine: Can the Community Respond Effectively to the Challenges of HIV/AIDS?

© International HIV/AIDS Alliance in Ukraine Circulation 3000 5 Dymytrova St., building 10A, 03680 Kyiv Free distribution Tel.: (+380 44) 4905485 Authors: Fax: (+380 44) 4905489 Sergiy Dvoryak (Ukrainian Institute on Public Health Policy) e-mail: [email protected] Pavlo Skala (International HIV/AIDS Alliance in Ukraine) http://www.aidsalliance.kiev.ua Design: Andrei Mukhin Translation from Ukrainian: Dmitriy Vozniyk Proof-reader: Lily Hyde

This publication was produced by the International HIV/AIDS Alliance in Ukraine with the financial support of the International HIV/AIDS Alliance (United Kingdom). Photos used in this publication have been made during major advocacy events in 2004-2007, as well as include photos of current SMT programs, patients and their parents from Kyiv, Odesa, Kherson.

Many thanks to Yuriy Kobyshcha, Irina Grishaeva, Susie McLean, Daniel Wolfe, Matt Curtis, Olga Golichenko, Olexandr Lebega, Leonid Vlasenko, Sergiy Krylatov, Irina Romashkan, Olexandr Libanov, Illya Podolyan, Oleg Voynarenko, Iryna Sukhoparova for their comments, feedback and photos.