HIV Among Drug Users in Poland

HIV among Drug Users in Poland: The Paradoxes of an Epidemic Kasia Malinowska-Sempruch Submitted in partial fulfillment of the requirements for the degree of Doctor of Public Health in the School of Public Health 2013 COLUMBIA UNIVERSITY © 2014 Kasia Malinowska-Sempruch All rights reserved 2 ABSTRACT HIV Among Drug Users in Poland: Paradoxes of an Epidemic Kasia Malinowska-Sempruch Since 1988 when the first HIV positive drug user was identified in Poland, for close to two decades, the predominant route of HIV transmission has been through injecting drug use. In mid 2000s, Polish officials reported that injecting drug use no longer contributed to incrasing HIV incidence. The consequences of such a statement are that many of the structural and personal risks associated with HIV infection go unaddressed, that drug users are neglected by HIV prevention efforts, that HIV treatment is not made available to drug users and that the policy environment does not adequately support effective public health initiatives. This case study is based on documentation, archival records, interviews, participant observation, and physical artifacts shows that these assertions were made, and continue to be repeated, in a highly political context. Poland is a post-socialist state with strong neoliberal leanings, and it is highly invested in successful integration with the European Union. Powerful Catholic Church serves as an important backdrop. While people considered “at risk” now have more freedom to conduct their lives, they also have a set of neoliberal expectations and religious pressures placed on them. Country’s geographic location adds to this complexity – situated between “Old Europe” where HIV problem has been successfully contained and the former Soviet Union, where the HIV incidence among drug users is the highest in the world, Poland attempts to align itself with the success of the West. Furthermore, examination of the available data suggests that the assertions made by Polish officials omit numerous variables. My research shows that even though Polish leadership in the area of HIV and drug policy wishes to resemble Western Europe, Poland does not meet international standards for the prevention of HIV transmission. The interviews I conducted, as well as the review of the literature on drug and HIV policies and programs suggest that these services are scattered, often unavailable, and that their number is stagnating, at best, and in some cases, even decreasing. This maybe a direct result of lack of engagement of drug users in their design. Excluded from the discussion of risk, drug users are thus not the focus of prevention efforts. Based on gathered data, there are seven crucial issues that require immediate action if Poland is to manage HIV prevention and care for people who use drugs in a manner consistent with the international standards. The areas requiring action are: a change in the drug policy from the current very punitive approach, expansion of needle and syringe programs and other harm reduction services, improved data collection and an increase in the availability of HIV testing, scaled-up substitution treatment, improved quality of other forms of drug treatment, greater investment in civil society organizations, improved access to HIV treatment, and educational and training efforts that encourage greater attention to HIV related matters across disciplines. 3 TABLE OF CONTENTS Introduction: The End of HIV Infections for Injecting Drug Users in Poland? 5 Methodology 33 Drug Use and Drug Policy in Poland 40 Drug Treatment and Harm Reduction in Poland 76 Poland’s HIV Policy towards Injecting Drug Users and its Implications 115 Crucial Issues for the Future of HIV in Poland 162 Conclusions: Human Rights and Public Health 181 Appendices : Persons engaged and timeline of major events 195 4 Chapter One: Introduction -- The End of HIV Infections For Drug Users in Poland? In 2006, at a meeting at the Polish Parliament, the director of the National AIDS Center reported that injecting drug use no longer contributed to the HIV and AIDS crisis in Poland. Two years later, the Director of Poland’s National Bureau for Drug Prevention reiterated this assertion. This assumption is highly significant to the epidemic as a whole because, since 1988 when the first HIV positive drug user was identified, the predominant route of HIV infection in Poland has been through injecting drug use. The consequences of such a statement by Poland’s drug and HIV policy leadership are that many of the structural and personal risks associated with HIV infection go unaddressed, that the focus is removed from injecting drug use as a factor leading to HIV infection, that drug users are subsequently neglected by HIV prevention efforts, that HIV treatment is not made available to drug users and that the policy environment does not adequately support effective public health initiatives. My research shows that these assertions were made, and continue to be repeated, in a highly political context. Poland is a post-socialist state with strong neoliberal leanings, and it is highly invested in successful integration with the European Union. Powerful Catholic Church serves as an important backdrop. Furthermore, similarly to other parts of the world and regardless of political period, drug use and HIV have been viewed and responded to with a political agenda. Country’s geographic location adds to this complexity – situated between “Old Europe” where 5 HIV problem has been successfully contained and the former Soviet Union, where the HIV incidence among drug users is the highest in the world, Poland attempts to align itself with the success of the West. Figure 1. HIV Prevalence in Europe and former Soviet Union (UNAIDS, 2013) Furthermore, my research shows that even though Polish leadership in the area of HIV and drug policy wishes to resemble Western Europe, Poland does not meet international standards for the prevention of HIV transmission. Availability of services and their quality are closely aligned with the political context – humiliation of patients as a tool of “treatment” in abstinence centers, as well as very high threshold opioid substitution serve as powerful examples. The interviews I conducted, as well as the review of the literature on drug and HIV policies and programs suggest that these services are scattered, often unavailable, and that their number is stagnating, at best, and in some cases, even decreasing. This maybe a direct result of lack of engagement of drug 6 users in their design even though elsewhere, the literature shows that involving persons who use illicit drugs in discussions about relevant interventions has been instrumental in controlling the HIV epidemic (Friedman, 2007). As Outlined by Parker (2000b) and Degenhardt (2010) the national and local politics and policies contribute to the structural risk, especially in area of drug policy. Farmer suggests that the war on drugs is one of the newer ruses for managing inequality and criminalizing poverty (2005). Neither Poland’s drug nor HIV policies acknowledge that the resources that determine the extent to which people are able to avoid risk are, in fact, fundamental social cause of disease (Link, 1995). Instead, the limited discourse that exists is focused on controlling risk factors at the level of the individual, and emphasizing personal responsibility. With politics increasingly focusing on “law and order” paradigm, the few services that are still available are increasingly hostile towards public health goals. As explained by one of my interviewees, “In the narrative of the Polish HIV epidemic, drug users are the voiceless actors. They make every effort to disappear from public view. One has to make a conscious effort to want to see them. There are no active users in Poland complaining about the lack of services.” Excluded from the discussion of risk, drug users are thus not the focus of prevention efforts. 7 Several international guidelines1 on drug use related matters discuss the public heath interventions and policy context required for effective HIV prevention. These guidelines suggest that the following components are necessary for successful national HIV prevention efforts among people who use drugs: needle and syringe distribution and/or exchange; outreach services such as condom and other paraphernalia distribution; provision of STI and other disease screening and treatment; referrals to or direct provision of housing, food and clothing; substitution treatment; other evidence-based drug treatment; HIV testing and treatment, and overdose prevention. All of these interventions must be multilayered and properly funded. They must also be delivered in a non-punitive policy environment that emphasizes public health rather than criminal justice since it is widely recognized that the fundamental social causes of a disease determine the extent to which people are able to avoid risk (Link, 1995). Data from numerous international studies demonstrates that the rate of HIV transmission has decreased as the result of concerted efforts (Parker, 2000b; EMCDDA, 2011), many of which aim to empower people at risk. Global HIV prevention efforts frequently adopted strategies focused both on upstream factors, for example access to HIV medicines and targeted media WHO/UNODC/UNAIDS position paper: Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention; Joint UNAIDS statement on HIV Prevention and Care Strategies for Drug Users; UNODC/WHO discussion paper – Principles

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