allukrainian harm reduction association international centre for policy studies
Priorities in preventing HIV/AIDS– harm reduction strategy
kyiv 2005 This White Paper has been prepared under the “Policy Campaign for Harm Reduction” project. The project is the result of a joint initiative by the All!Ukrainian Harm Reduction Association (Kyiv) and the International Centre for Policy Studies (Kyiv), with financing from the International Renaissance Foundation (Kyiv) and the International Harm Reduction Development Program of the Open Society Institute (New York).
This paper was prepared by a group of experts: Andriy Bega, Oksana Remiga, Ihor Shevliakov, and Andriy Tolopylo.
We thank for preparing this policy paper to all project experts who provided comments and suggestions: Tetiana Afanasiadi, Natalia Baleha, Viktor Hrek, Yuriy Kalashnikov, Svitlana Khotina, Oleksandra Khudoba, Vadym Klorfain, Yuriy Lesiuk, Nadia Melnyk, Ivan Myroniuk, Mykola Ovcharenko, Serhiy Panasiuk, Svitlana Piven, Ghennadiy Razumov, Vladyslav Romanov, Mykhailo Rykhalskiy, Petro Vetrenko, Valentyna Yefimova, Natalia Yuzhna, and Olena Zahainova.
Special thanks to Serhiy Dvoriak, Director of the Ukrainian Institute of Public Health Policy; Alla Shcherbynska, Director of the Ukrainian Center for Preventing and Fighting AIDS; Pavlo Skala, advocacy specialist of the International HIV/AIDS Alliance; Tamara Tretska, consultant for the “Policy” project; and all other participants in the debates for their consultations and the materials they provided for the preparation of this paper and assistance in carrying out this project.
The project’s partners were community organizations who are members of the All!Ukrainian Harm Reduction Association that carried out this project in their own regions:
• Virus Rehabilitation Center for Drug Addicts, a charity fund, Dnipropetrovsk • Povernennia to Zhyttia [Return to Life], an oblast fund, Znamianka, Kirovohrad oblast • Krok u Maibutnye [A Step to Future], an oblast fund, Luhansk • Usi Razom [All Together] Center for Social and Psychological Information, a non!government charity fund, L’viv • Vykhid [Way Out], a local charity fund, Mykolayiv • Doroha Dodomu [Way Home], a local charity fund, Odesa • Svit Nadiyi [The World of Hope], a charity association, Poltava • Nadia i Spasinnia [Hope and Salvation], a charity fund, Simferopol • Zakarpattia Proty SNIDu [Zakarpattia against AIDS], an oblast charity fund, Uzhorod • Nova Simya [New Family], a charity fund, Chernivtsi • Klub Enei [Aeneas Club], a community organization, Kyiv
We thank the representatives of these organizations for their professional preparation of local public hearings on government policy issues: Larysa Anokhina, Inna Banakh, Valeriya Brych, Maksym Demchenko, Oleh Dymaretskiy, Olena Horiacheva, Ihor Kaminnyk, Halyna Kaminska, Larysa Melanych, Iryna Oros, Oleksandr Ostapov, Stanislav Pokutniy, Alla Shkreta, Mykola Shuliko, Leonid Vlasenko, Oleksandra Yatsiuk, and Serhiy Zhuk.
The opinions presented in this publication do not necessarily coincide with the positions of the experts who provided comments and participated in the discussion of this paper.
© All!Ukrainian Harm Reduction Association © International Centre for Policy Studies Contents
Overview ...... Incompatible policies make it impossible to overcome the epidemic ...... Efforts need to be coordinated ...... Services for drug addicts need to be increased ...... Why is current policy so ineffective? ...... How can this be fixed? ...... Why talk about harm reduction? ...... What is “harm reduction”? ...... Previous efforts ...... Why harm reduction a priority? ...... HIV and injecting drug users ...... Why is state policy so ineffective? ...... A six,step program ...... Information policy ...... Harm reduction programs ...... Rehabilitation and re!integration ...... Harmonizing HIV prevention and anti!drug policies ...... The war on stigmatization ...... Political leadership ...... Appendix . The results of public debates ...... The first round, January–February ...... Common ground ...... Special accents ...... Differences ...... The second round: April ...... Appendix . International experience in preventing HIV among IDUs ...... International efforts ...... Key harm reduction policy components ...... Conditions for effective harm reduction work ...... Appendix . The European context ...... List of abbreviations
AIDS – Acquired Immunodeficiency Syndrome ARV – Antiretroviral, a type of drug to combat HIV/AIDS AUHRA – All!Ukrainian Harm Reduction Association DFIDC – Department for Combating Drug Trafficking, Ministry of Internal Affairs DRT – drug replacement therapy HAART – Highly Active Antiretroviral Therapy HIV – Human Immunodeficiency Virus HR – Harm Reduction IDUs – injecting drug users MOH – Ministry of Health NEP – needle exchange points NGO – non!government organization PLHA – People living with HIV/AIDS UNAIDS – the joint United Nations Program on HIV/AIDS UNDP – United Nations Development Program UNICEF – United Nations Children’s Fund WHO – World Health Organization YSC – Youth Services Center
priorities in preventing HIV/AIDS—harm reduction strategy Overview
Ukraine is the leader in Eastern Europe and try have conspired to make it impossible to one of the world leaders in terms of the provide an effective response to the HIV spread rate of HIV. The numbers offer cold problem in Ukraine. comfort: in , Ukraine registered more than , new cases of HIV infection, a In other words, the spread of HIV has com! !fold increase of figures registered pounded the problem of illicit drug use in years back. Today, official statistics talk Ukraine because of the tendency of drug about more than , registered HIV!pos! users to share needles. About % of HIV itive Ukrainians, a !fold increase since infection cases have been registered among years ago. According to WHO estimates, injecting drug users (IDUs). however, the real situation is much worse: as many as .% of adult Ukrainians or The problem of illicit drug use is also , individuals could be HIV!positive. extremely urgent, especially when it goes in tandem with HIV infection. Each year, the The main pathway to the spread of this Ministry of Internal Affairs registers about infection is the injection of drugs. , new drug addicts. At the moment, its Unfortunately, traditional repressive soviet registry contains nearly , individuals. anti!drug policy, the lack of coordination of But the real number of drug users is much anti!drug and HIV preventive efforts, and higher. According to some estimates, it the lack of political leadership in the coun! could be as high as ,. Incompatible policies make it impossible to overcome the epidemic Today, drug users are simultaneously the Meanwhile, the Government’s declared focus of anti!drug policy and HIV!preven! approach to preventing HIV among IDUs is tion policy. But incompatible approaches to based on harm reduction principles, which policy!making in these two areas are making are based on a humane attitude to those suf! it impossible to effectively implement meas! fering from drug addiction. This approach ures to prevent HIV among IDUs. begins with a realistic evaluation of the spread of drug addiction in a society and, The approach to fighting drugs in Ukraine thanks to realistic measures, it makes it pos! is based on the old soviet paradigm. When it sible to lower the spread rate of infectious comes to drug addicts, this policy is limited diseases among IDUs and to reduce the neg! to voluntary or compulsory treatment and ative social impact of drug addiction. The criminal prosecution. The objective of such main measures are needle exchanges, the an approach is to totally eliminate drug resocialization of drug addicts, replacement abuse. It does not leave room for the legiti! therapy for those who cannot recover from mate existence of drug addicts in a society, opiate addiction, and public awareness cam! which means that there is no room at all for paigns. harm reduction measures.
This was determined by the HIV/AIDS Prevention Program for – approved by the July Cabinet Resolution, the National HIV Prevention Program for –, as well as the December Law “On preventing the Acquired Immunodeficiency Syndrome (AIDS).”
priorities in preventing HIV/AIDS—harm reduction strategy Efforts need to be coordinated The numerous sources of financing and port centers under Ukraine’s Ministry of variety of organizations implementing harm Youth and Sports. reduction programs need coordination at a high political level. Financing comes from However, the Government is not effectively State Budget funds and local budget funds carrying out the functions of coordinating and from international donors—a US $mn and overseeing the prevention of HIV, espe! grant from the Global Fund to Fight AIDS, cially when it comes to harm reduction. No Tuberculosis and Malaria and a US $mn government agency has a full picture of loan from the World Bank. Harm reduction ongoing programs in this area. As a result, programs are being implemented by both these seemingly serious efforts have not NGOs and a network of Dovira [Trust] sup! made a real impact on the epidemic. Services for drug addicts need to be increased Inaccessible and unaffordable drug addic! whom rehabilitation program did not help tion treatment, medical services and social are currently available only as pilot proj! assistance for addicts have a negative ects. impact on the situation with illicit drug use and the related spread of HIV and other The conflict between anti!drug and HIV infections. Rehabilitation services for drug prevention policies and insufficient fund! addicts are provided mainly by NGOs and ing make it impossible to expand programs they are either financially or geographical! that could really stem the epidemic. In ly beyond the reach of the majority of those short, the lack of a broad!based approach to who need them. Meanwhile, replacement drug addiction in government policy makes therapy programs for drug addicts who it hard to ensure even a minimal level of have been taking drugs for a long time and affordable and accessible treatment. Why is current policy so ineffective? . The Government’s Harm Reduction vention policies. This specifically affects Strategy is being implemented haphaz! the effectiveness of HIV prevention ardly, while medical and social services work: fearing prosecution, IDUs do not for drug addicts remain unaffordable. participate in prevention programs. This makes it impossible to reduce nega! tive impact of drug addiction, such as . The state is not coordinating or oversee! the spread of HIV. ing the implementation of HIV preven! tion policy, whether in terms of identify! . The government has not made any effort ing priorities or in terms of implement! to harmonize its anti!drug and HIV pre! ing and monitoring programs. How can this be fixed? . Information policy: to increase the . Harm reduction programs: to imple! awareness among the general pubic and ment them full!force, covering at least specialists alike of the modes of transmis! % of the target group. This means pro! sion of HIV and the ways to prevent it. viding:
priorities in preventing HIV/AIDS—harm reduction strategy a. sterile syringes and disinfectants to b. amending the table that determines individuals who inject drugs; what minimum amount of a given narcotic substance leads to criminal b. drug replacement therapy to individ! liability before the law; uals who suffer from opiate addic! tion; c. removing the number of cases opened on the basis of possessing c. information and educating the entire narcotic substances without the population, as well as carrying out intention of selling them from the list public awareness campaigns among of police performance indicators in drug users; the drug war;
d. easy access to social and medical serv! d. revising the way the police work with ices. drug addicts to include cooperation with harm reduction programs. . Social reintegration and rehabilita, tion of addicts: to improve access to . Eliminating the stigmatization of drug services. addicts and PLHAs: to develop a more compassionate attitude in the society. . HIV prevention and anti,drug policies: to make them more compatible by . Political leadership: to ensure the imp! removing obstacles to harm reduction lementation of HIV prevention and anti! measures. This includes: drug policies and organize national and regional coordination of HIV prevention a. amending Art. of the Criminal efforts; to institute mechanisms for Code, replacing imprisonment as the involving stakeholders in the formula! main punishment for the possession tion of state policy; establish workable of narcotic substances without the mechanisms for reporting on and allow! intention of selling them with a sim! ing public oversight of the implementa! ple fine; tion of policies once they are approved.
priorities in preventing HIV/AIDS—harm reduction strategy Why talk about harm reduction? What is “harm reduction”? Public health professionals use the term drug abuse but also on reducing daily “harm reduction” to describe a concept of harm from drug abuse; reducing or preventing the negative conse! quences to health associated with specific • Humanism: People cannot be con! behavior. According to WHO, harm reduc! demned for using drug because everyone tion (HR) in the context of drug addiction has a right to choose in a democratic soci! means preventing the transmission of HIV ety. Condemnation, prosecution and that occurs when users share needles and stigmatization make it impossible to carry syringes and other negative consequences of out effective prevention work with drug drug abuse to the individual and the society. addicts.
In public health, the harm reduction • Economy: HIV prevention is cheaper approach appeared as an alternative to the than HIV treatment. earlier approach of complete abstinence from drug use. This new approach is aimed at Experience in implementing HR programs those drug addicts who cannot be expected in Ukraine has shown that the cost of pre! to quickly give up drugs, although it does not venting a new case of HIV is about US $, deny the importance of giving up drugs as whereas the annual cost of treating and the ultimate goal. So, the definition of a caring for a single HIV patient is nearly harm reduction policy is: a policy or program US $,. aimed at reducing the negative health, social and economic impact of drug abuse without In European practice, harm reduction is an requiring the immediate giving up of drugs. element of both anti!HIV/AIDS and anti! drug policy. In particular, harm reduction is Although many drug addicts need a lot of part of anti!drug measures to lower demand time to give up their addiction, harm reduc! for illegal drugs, including primary preven! tion measures need to work immediately to tion, early detection, treatment, harm prevent the spread of the HIV epidemic. The reduction, rehabilitation, and resocializa! set of harm reduction measures is based on tion. As part of anti!HIV/AIDS policy, HR three principles: measures go hand!in!hand with measures to prevent HIV transmission by other means: • Pragmatism: Some part of the popula! sexual transmission and vertical transmis! tion will always use drugs, so state policy sion (Mother To Child Transmission— should be focused not only on fighting MTCT), and so on.
Ukrainian Center for Preventing and Fighting AIDS. Results of an analysis of the HIV/AIDS preven! tion program among IDUs in Odesa.
In , the average annual cost of treating one adult through a Global Fund grant was US $,; through Budget funds it was US $,, according to the Ukrainian Center for Preventing and Fighting AIDS.
Coordinated and Integrated Approach to Combat HIV/AIDS within the European Union and in Its Neighborhood. European Commission. Brussels. September C () .
EU Drug Strategy (–), Council of the European Union, November .
priorities in preventing HIV/AIDS—harm reduction strategy Previous efforts This White Paper is the outcome of govern! • How effective will this be to fight the ment policy research on stemming the spread of HIV? spread of HIV/AIDS among IDUs. The research was carried out by experts from the • What will society lose if these steps are All!Ukrainian Harm Reduction Association implemented? (AUHRA) and the International Centre for Policy Studies (ICPS). Work on the White • How will society benefit if these steps are Paper was accompanied by consultations implemented? with experts in HIV prevention and anti! drug measures and a series of public The overwhelming majority of participants debates involving a broad base of stake! rejected the first two options: maintaining holders. status quo and strengthening prosecution. According to stakeholders, neither will help The research, consultations and debates stop the HIV/AIDS epidemic. were organized in two stages. During the first stage, a Green Paper identified the According to participants, maintaining problem, outlined its scale and proposed status quo towards IDUs is likely to acceler! different strategies for its solution. More ate the spread of the epidemic, primarily than experts—specialists in law enforce! among and through IDUs. Although ment, social and healthcare areas represent! the implementation of some harm reduc! ing regions and various kinds of organi! tion policy elements might help reduce zations with a variety of aims—provided negative social consequences of drug addic! comments and suggestions for the Green tion, it cannot affect the situation as a Paper. whole.
The Green Paper was presented at public The most powerful argument against hearings that took place in cities during strengthening prosecution for drug abuse January–February . Each of the debates was the firm conviction among participants involved a broad base of stakeholders repre! that this approach will only drive the prob! senting government bodies, community lem into the shadows. Addicts will avoid any organizations, healthcare, social and law contacts with government agencies and will enforcement agencies, people living with find themselves effectively isolated from HIV, and former drug users and their rela! HIV/AIDS prevention and treatment pro! tives. Participants in regions were pre! grams. The negative consequences for sented with three policy options regarding Ukrainian society will only grow worse as a IDUs: result.
• maintaining status quo, which means Given that most interest groups that par, implementing a few components of ticipated in the debate support a harm harm reduction policy; reduction strategy, this White Paper was developed during the second phase, offer, • strengthening the prosecution of IDUs; ing a full,range plan of action to institute such a this in Ukraine. • introducing a full!strength harm reduc! tion policy. The White Paper outlines the problem, its roots and recommendations for overcoming The proposed options were considered the causes following the chosen strategy. from a number of positions: Experts also provided feedback on the
priorities in preventing HIV/AIDS—harm reduction strategy White Paper and it was then presented for public debates that took place in cities in April .
The results of the series of debates are sum! marized in APPENDIX I. The text of the Green Paper and a full report on the results of these debates can be found on the ICPS website at http://www.icps.kiev.ua/eng/ project.html?pid=.
priorities in preventing HIV/AIDS—harm reduction strategy Why harm reduction a priority?
Today, the spread of HIV/AIDS in Ukraine is in!hand with the prevention of HIV trans! among the fastest in Eastern Europe. Despite mission by other means, such as sexual trans! the efforts of NGOs, community organiza! mission and vertical transmission (mother! tions and international donors to actively to!child!transmission or MTCT). deal with this problem for a number of years, the trends are getting worse. Still, Ukraine Harm reduction needs to become the foun, can take control of the situation and reduce dation for a policy towards IDUs, both in the spread of the epidemic. If more time is the combat against drug trafficking and in wasted, however, this window of opportunity the prevention of HIV/AIDS in Ukraine. If will soon close. Ukraine does not make this choice soon, the projections of government policy will be dis! For more than years, the expansion of the astrous for the nation’s health. HIV epidemic in Ukraine was closely con! nected to users of injecting drug (IDUs). Experts believe that the Ukrainian govern! Most specialists connected in one way or ment should take the lead in this area. And another to this problem recognize the need this means there has to be high!quality pub! to immediately reconsider the current lic policy that: () clearly identifies goals and approaches towards IDUs and, of course, priorities; () responds, in terms of its con! anti!drug and anti!HIV policies. Primary pre! tent, to the current situation and develop! ventive measures alone can never be a full! ment forecasts; and () matches the condi! fledged response to the situation today. The tions for implementation, which in turn majority of experts agree that current trends include rules and regulations (legislation), in the spread of HIV/AIDS make it clear that institutions (agencies, organizations), harm reduction must become a priority. financing, those responsible for implemen! Harm reduction measures need to go hand! tation, and coordination. HIV and injecting drug users The spread of HIV/AIDS and related diseases times more than years ago. More than poses a threat to specific individuals, to the , Ukrainians have already died from domestic economy, to the labor force, to the AIDS. healthcare system, to the social infrastructure, and to the social security system. The vast However, the official statistics reflect only the majority of the HIV!positive in Ukraine are tip of the iceberg. According to estimates by young people aged –, that is, people in the joint United Nations Program on the prime of their lives in terms of physical, HIV/AIDS (UNAIDS), the number of HIV! creative and intellectual capacities. positive individuals in Ukraine in was estimated at about , people aged According to official data, the total number –—at least . % of the adult popula! of HIV!positive individuals registered since tion—while the number who have died from was , as of January —almost AIDS was projected at ,.
Evaluation of the possibility of developing programs to prevent HIV among IDUs. The UNICEF office in Ukraine and the Social Monitoring Center, with the support of UNAIDS in Ukraine and the International Renaissance Foundation. Research Manager O. Balakiryeva. Kyiv. . p. .
priorities in preventing HIV/AIDS—harm reduction strategy A comparison with Eastern European coun! ing a critical situation with the spread of tries and neighboring Russia (see TABLE ) HIV/AIDS. confirms the hypothesis that Ukraine is fac! Таble . Adults living with HIV in selected Eastern European and Asian countries
Country Estimated # of adultsliving Estimated # with HIV of adultsliving with HIV, per ,
Ukraine , Russia , Estonia , Kazakhstan , Hungary , Slovenia Czech Republic , Romania , Poland , Bulgaria Slovakia
Source: UNAIDS , http://www.unaids.org/ According to expert forecasts, if current than UAH mn every year just to treat and trends continue, the number of HIV!posi! take care of people living with HIV/AIDS tive could reach almost .mn individuals (PLHA). and the number of new cases of AIDS could be , by . Meanwhile, up to , From – on, injecting drugs have Ukrainians could die from this disease in been the key channel for spreading HIV in that same year. Moreover, those who die Ukraine. The reason is the risky behavior of from AIDS in will represent about % IDUs, which, in turn, is one of the symp! of all Ukrainians who died from it, and the toms of drug addiction. As a result, majority of AIDS victims will be under . HIV/AIDS is beginning to spread among other groups who have contact with IDUs. Assuming that government policy does not become any more effective than it is today, In addition to HIV/AIDS, the risky behavior by , Ukraine will have to spend more of drug addicts also contributes to the spread
O. Balakiryeva, Y. Galustian, O. Yaremenko, and others. The social and economic consequences of the HIV/AIDS epidemic in Ukraine: New forecasts. Kyiv. .
According to estimates of the Ukrainian Center for Preventing and Combating AIDS, Ministry of Health of Ukraine.
priorities in preventing HIV/AIDS—harm reduction strategy of other contagious diseases, such as hepatitis group requires urgent harm reduction steps B and C and sexually transmitted diseases in the IDU environment. (STDs). Additional social consequences are: the destruction of family ties and friendships, Injecting drug users constitute nearly % the growing rate of drug!related crime, high of all HIV!positive. According to statistical costs for treating both drug addiction and data, the share of IDUs among new contagious diseases, growing numbers of instances of HIV has been slowly declining, unemployable young people, the violation of although the actual number of new cases human rights, and violence towards drug of HIV among IDUs continues to grow addicts. These harmful consequences can be (see FIGURE ). seen every day in Ukraine and affect a grow! ing circle of Ukrainians. According to a study carried out jointly by the Ukrainian Center for Preventing and By the end of , Ukrainian police had reg! Combating AIDS and UNAIDS in Odesa istered , drug users, including , oblast over –, IDUs constituted who were suffering from addiction. However, more than % of all individuals who trans! official statistical data does not reflect the real mitted HIV through heterosexual rela! situation. According to expert estimates, the tions. IDUs involved in the sex business real number of drug users stands at ,. also play a major role in sexual transmission The spread of the epidemic among this of HIV.
According to data provided by the Social Monitoring Center and UNICEF in a publication called Evaluating the possibility of developing programs to prevent HIV among IDUs, the number of IDUs in Ukraine is growing steadily: the government had , registered addicts in ; by , this num! ber was ,. As a rule, the government registers individuals brought in by the police and turned over for mandatory medical examinations. In this case, the difference in numbers is explained by police statistics that divide drug addicts into two categories: () those diagnosed with drug addiction; and () those who allow non!medical use of narcotics.
Op. cit., Ukrainian Center for Preventing and Combating AIDS.
Among , officially registered new cases of HIV!positive adults in , , or % were IDUs.
Ukraine and HIV/AIDS: Time to Act. Ukraine Human Development Report for , Special Report, UNDP, , Kyiv, Ukraine, p. –.
priorities in preventing HIV/AIDS—harm reduction strategy Figure . Officially registered new cases of HIV, per month
, New cases of HIV New cases of HIV among IDUs ,
July July July April April April January January January October October October
Why is state policy so ineffective?
The extremely high pace at which decision!making process and the implemen! HIV/AIDS is spreading among IDUs and to tation of this policy by the Government, the the rest of the population is evidence that Verkhovna Rada or the general public. the government has not adequately re! sponded to the threat of this epidemic. The results of the study carried out as part Although, IDUs have been the main vehicle of this project and discussions with stake! for spreading HIV since , government holders make it clear that Ukraine does not measures to combat the drug trafficking have a consistent and well!thought drug and prevent HIV remain incompatible, policy. Legislation pieces and regulations resulting in a widespread epidemic today. often are largely declarative and are unsup! According to participants in the debate, ported by resources, containing elements of anti!HIV efforts will have little or no impact different—sometimes even contradictory— without a consistent harm reduction policy. approaches to illicit use of drugs and, thus, cannot possibly have a real impact on the The current system for making and institut! problem. ing policies allows the Government to make decisions that are not underpinned by In short, the main reasons why HIV/AIDS resources and clearly will not be implement! prevention programs remain largely ineffec! ed. In terms of harm reduction, this is par! tive are: ticularly true of decisions to provide access to treatment and preventive measures, to • Incompatible anti,drug and HIV pre, introduce drug replacement therapy, to vention policies. The emphasis in the publish social advertising related to current policy on primary preventive HIV/AIDS, and so on. Moreover, there are measures—prohibition and prosecution no effective mechanisms for overseeing the aimed at increasing fear of using drugs—
priorities in preventing HIV/AIDS—harm reduction strategy leads to distrust in harm reduction pro! leading to the reduced effectiveness grams. IDUs fail to take advantage of of harm reduction programs. such programs for fear of prosecution. Yet criminal prosecution of drug addicts • Drug replacement therapy on hold. does little to help them recover, at the DRT is an integral part of any harm same time as it interferes in the proper reduction strategy and is needed to implementation of harm reduction pro! lower the risk of contracting infections grams. transmitted through the blood, to reduce the crime rate, and to foster the • Insufficient funding for prevention. return of drug addicts to their commu! According to UNICEF estimates, the nities. Without DRT, it will be impossible state needs about UAH mn per year to overcome the epidemic among IDUs. for preventive measures among vulnera! Resistance on the part of the police, ble groups. The th National Program which has little professional basis, is the to combat HIV sets about UAH mn main obstacle to DRT. per year for this purpose, which only support existing programs, which cover • Medical and social services unafford, only –% of the target group. able and inaccessible. This makes it impossible to take preventive measures • No government coordination or over, among this target group. This is happen! sight. This is true both at the level of ing because there is no comprehensive identifying priorities and at the level of government program to provide such implementing and monitoring pro! services for drug addicts, existing reha! grams. With different sources of financ! bilitation services cost too much, and ing and a broad base of NGOs imple! stigmatization leads IDUs to reject these menting harm reduction programs, services. coordination and oversight are clearly needed. The lack of these at the central • No effective oversight of preparation and local levels leads to: and implementation. There is no full! fledged system to monitor the situation – a large portion of resources concen! or the efficiency and effectiveness of trated in “priority” regions and not measures taken within the framework of enough is channeled to “non!priori! state programs. None of the national ty” regions; HIV preventive programs contains goals expressed in specific figures and none – harm reduction programs planned was based on an analysis of previous according to available donor funds efforts. rather than proceeding from real needs; • Policy not based on reliable statistical data. According to many specialists, offi! – poor coordination among programs cial statistics on the number of HIV!posi! of various donor organizations, lead! tive individuals and the incidence of ing to duplication of efforts in some HIV/AIDS do not reflect the real situa! regions and areas—and lack of sup! tion. Moreover, different official sources port in others; give completely different data on the number of drug addicts. As a result, the – poor coordination among various Government does not have the full pic! agencies during implementation, ture about trends in the epidemic or
Op. cit., UNICEF.
priorities in preventing HIV/AIDS—harm reduction strategy information to evaluate the conse! illegal drug use and HIV!risking behav! quences of decisions it makes. ior are lacking among specialists. During public debates, even specialists admitted • Poor HIV,related awareness and know, that they were poorly informed about the how. Not only is the public ill!informed, principles and methods of harm reduc! but the knowledge and skills to prevent tion programs.
priorities in preventing HIV/AIDS—harm reduction strategy A six,step program
Analysis and debates with stakeholders show The harm reduction approach proceeds that Ukraine is facing two extremely urgent from the realization that it is virtually impos! problems: the epidemic of HIV/AIDS and sible for a society to completely get rid of the growing spread of drug addiction. These drug addiction, regardless of the means, are two different problems that happen to and the understanding that the harm to the intersect. Harm reduction strategy is an community and society need to be mini! effective tool to achieve both anti!drug poli! mized. To implement this strategy in full, six cy goals and healthcare goals. But while the sets of objectives need to be met in Ukraine: solution to these two problems includes this strategy, it cannot be not limited to it. The • To radically change information policy; set of measures proposed in this paper is based on an understanding of the role of • To fully implement all elements of a injecting drugs in the spread of HIV/AIDS harm reduction policy; and should be included in both the state anti!drug policy and its programs to prevent • To develop a system for the rehabilita! HIV and combat AIDS. tion and social re!integration of drug addicts; This strategy aims to: • To make anti!drug and HIV prevention • Provide drug addicts with more oppor! policies compatible by removing barriers tunities to control their health; to the implementation of harm reduc! tion measures; • Reduce the number of deaths related to illicit drug use; • To take steps to overcome the stigmatiza! tion of drug addicts and PLHAs; • Limit the negative consequences of the drug trafficking for society, such as the • To improve the overall system for devel! spread of HIV, hepatitis B and C, and oping, adopting and implementing poli! tuberculosis. cies in this area. Information policy Goals: Arguments:
• To raise public awareness of the modes During the public debates, participants of HIV transmission and ways to prevent noted the low level of public awareness infection; work in practically all aspects of HIV/AIDS and drug addiction as the № • To form a compassionate attitude in the problem in Ukraine. Ukrainian citizens in society towards the HIV!positive and general and even specialists are poorly IDUs; informed of the issues, appropriate behav! iors, available programs and approaches. • To increase the level of informedness Many medical workers are not psychologi! among specialists working with and con! cally prepared to work with HIV!positive tacting the HIV!positive and IDUs. IDUs.
priorities in preventing HIV/AIDS—harm reduction strategy This key component in the effort to prevent But in addition to limited resources, anoth! the spread of the epidemic has not been er issue is ineffective allocation. Despite all given enough attention. This is particularly the existing public awareness campaigns evident in the reluctance of the (see TABLE ), which have different sources Government to fund such important pre! of financing, goals are not being reached. ventive steps as information campaigns, This was confirmed by a survey carried out education and communication. The over! by state social services among different pop! whelming majority of resources are spent on ulation groups, including young people and purchasing testing systems and medications. children. Table . Informational support for HIV/AIDS issues during state air1time ()
State,run company # of information Length items of information items (in hours) National Radio , National Television . ( social ads) (. of social ads) Oblast and regional state television , .
Source: National Report on Implementing the Declaration on the Commitment to Combat HIV/AIDS, The main conclusion is that neither social high!risk groups and form a more com! advertising, nor special programs on televi! passionate attitude in the society towards sion nor publications in the press are target! PLHAs and drug addicts; ed for a specific audience or target group. Setting up a system to influence various con! • Introduce a subject called “Prevention sumer groups informationally and properly of Drug Addiction and HIV/AIDS” into considering their need for information and the public school curriculum or education programs could, within a short improve the delivery of the subject of period of time, form the necessary public health and healthy lifestyles in schools attitudes on key issues and affect decision! and medicine in post!secondary institu! making by politicians. tions. This effort should broadly involve NGOs involved in harm reduction and Recommendations: the prevention of HIV/AIDS, as well as self!help groups for drug addicts and • Develop targeted social advertising on PLHAs; avoiding HIV/AIDS and preventing peo! ple from getting into drugs. This also • Carry out a public awareness campaign means broad!based educational cam! in the media to cover the global fight paigns to reduce the stigmatization of against the epidemic;
According to a poll carried out for the National Report on Implementing the Declaration on the Commitment to Combat HIV/AIDS, only .% of young people aged – can properly describe ways to prevent the sexual transmission of HIV/AIDS and know how HIV is not transmitted.
priorities in preventing HIV/AIDS—harm reduction strategy • Develop and implement specific profes! • Develop and provide training for jour! sional social campaigns on preventing nalists to help them properly understand the spread of the HIV/AIDS epidemic the issues of drug addiction and and harm reduction strategies for work! HIV/AIDS and produce high!quality ers of government bodies at all levels, the informational products. police and educational facilities; Harm reduction programs All elements of a harm reduction strategy Centers. Financing is provided by donor were included in three National HIV/AIDS organizations and local budgets, with donor Prevention Programs. Yet, understanding of funding prevailing. Although it is possible the priority of this approach for Ukraine to get State Budget funds allocated for these remains strictly declarative and it is not services, this is not being done on a large being fully implemented. We propose a enough scale. number of steps to change this situation. The main goal of this activity is to counter! act the spread of infections transmitted . Provide IDUs with sterile through the blood and the sharing of syringes and disinfectants syringes by drug addicts among IDUs. Such infections include HIV/AIDS, hepatitis B Goals: and C and STDs. Needle exchange points provide drug addicts with sterile syringes in • To stop the transmission of contagious exchange for used ones, as well as disinfec! diseases through sharing injection tants and contraceptives. They also provide equipment; information and counseling. Drug addicts can also consult a psychologist, a medical • To expand the coverage of target groups worker or a lawyer to get information on through existing prevention services. issues that interest them and references for medical examinations or for treatment in a Arguments: drug rehabilitation facility, a local state!run HIV/AIDS prevention center or an STD No oblast in Ukraine has a network of points center. that can meet the needs of IDUs with suit! able medical instruments. Currently, nee! Outreach services provide prevention in dle exchange programs and outreach activi! places visited by IDUs on a peer!to!peer ties cover –% of IDUs, but a minimum basis. Outreach workers are, as a rule, for! of % need to be reached to affect the epi! mer or even current drug addicts who are demic. This part of the harm reduction insiders with the addict population and are strategy is handled mostly by NGOs, as well familiar with the drug sub!culture. They pro! as by Dovira counseling centers set up under vide basic consultations to members of such the state–run network of Youth Services communities on how to lower the risk of con!
For example, there is only one needle exchange point in Kyiv. There are three needle exchange points under Youth Services Centers in Odesa oblast, although a minimum of stations is needed. There are an additional one or two stations under civic organizations in the city of Odesa, which is not enough to cover even % of IDUs.
Executive bodies can only procure social services on the basis of legislation governing social services, in particular the April Cabinet Resolution № “Approving the rules for organizing and car! rying out tenders to allocate State Budget funds for providing social services.”
priorities in preventing HIV/AIDS—harm reduction strategy tracting HIV and other infectious diseases, () realistic estimates of IDUs numbers they disseminate hand!outs and sterile med! and projected coverage; and () realistic ical equipment, and they keep this commu! extrapolations of IDU needs for syringes, nity informed about opportunities to receive condoms and disinfectants; social, psychological or medical assistance from community and state!run organiza! • Open new needle exchange points tions. based on the needs and characteristics of each specific region, including per! The practical effectiveness of needle manent locations, mobile units, out! exchange programs has been confirmed by reach activities through AIDS centers, many studies. In particular, one study com! TB and drug dispensaries, clinics, and missioned by the Australian Department of pharmacies; Health analyzed data from cities of countries worldwide and showed convincing • Coordinate needle exchange points results: the spread of HIV dropped an aver! operating under various organizations at age of .% per year in cities that intro! the regional level; duced needle exchange programs and grew .% per year on average in other cities • Carry out targeted public awareness cam! that did not introduce such programs. paigns at the local level before opening needle exchange points and during their Recommendations: operation in order to () inform poten! tial clients; () prevent a hostile reaction For this component to be properly and of local residents; and () form a compas! effectively introduced, needle exchange sionate attitude towards this activity; programs must cover around % of IDUs. In Ukraine, this means quadrupling efforts • Expand the range of services under nee! in this area: dle exchange programs: a system of referrals to specialists, consultations of • Develop a set of standards for this work an addiction specialist and psycholo! and indicators for monitoring purposes; gists, free HIV tests, active cooperation organize regular monitoring and devel! with other medical specialists; opment of recommendations to raise the effectiveness of these efforts. Monitoring • Eliminate external barriers to this area of should not violate the principle of client activity, especially the behavior of police confidentiality. This work can be carried officers towards the target group. out by the All!Ukrainian Harm Reduc! tion Association; . Provide drug replacement • Define the legal status of needle therapy for IDUs, especially exchange programs at the state level: are users of opiates they a social service or charitable assis! tance? A definition is necessary to allo! Goals: cate Budget funding; • To abandon injections and reduce risky • Analyze the need for new needle behavior in terms of contracting HIV, exchange points in each region based on: preventing AIDS among IDUs;
Health Outcomes International, Return on investment in needle and syringe programs in Australia. Commonwealth Department of Health and Ageing, . http://www.health.gov.au/pubhlth/publicat/ document/roireport.pdf
priorities in preventing HIV/AIDS—harm reduction strategy • To reduce the use of illegal opiates and, for a long time, have been treated with no hence, lower the crime rate; success in the past, and are suffering from mental or somatic disorders (HIV/AIDS, • To lower the death rate from overdosing tuberculosis, and so on). There are also age and using toxic substances; restrictions: drug replacement therapy is not recommended for those under . • To ensure that HIV!positive IDUs follow their HAART!therapy regimen; An important point about DRT is that not only drug addicts benefit from it, but also • To lower the incidence of secondary dis! the society, as this therapy tangibly helps eases among IDUs; lower the pressure of social and economic problems related to drug abuse, such as • To reduce the cost of opiate addiction to public funding for hospitals, penitentiaries drug addicts, their families and the soci! and the police. ety as a whole, through all the above. As of , some , individuals are in Arguments: drug replacement therapy programs world! wide. From to , the number of Methadone therapy is a widely and well! patients who were undergoing methadone known method for treating drug addiction. treatment grew %. In particular, the num! Research and monitoring of assistance have bers grew .% in Great Britain, % in provided convincing data that methadone France, .% in Austria, and % in treatment effectively contributes to lowering Norway. More recently, buprenorphine ther! the use of prohibited drugs, the death rate apy has become very widespread: about and the risk of HIV. , individuals are undergoing bupre! norphine therapy in France alone. Still, DRT is only one among a number of methods to treat opiate addictions. Applying The Ukrainian Government and the DRT in no way excludes other methods, Verkhovna Rada have understood that drug including counseling, psychotherapy and replacement therapy is a highly effective other social and psychological approaches, preventive method. Indeed, provisions to detoxification, treatment with opiate antago! the effect are included in the February nists and other psychopharmacological VR Resolution №!І “On recom! means. A doctor is responsible for choosing mendations of the Verkhovna Rada hear! the specific form of treatment. In other ings on ’Social and Economic Problems of words, the proposition is not that all opiate HIV/AIDS, Drug Addiction and Alco! addicts enter DRT. The criteria for applying holism in Ukraine’” and the March DRT should be strictly limited to those Cabinet Resolution № “Approving the addicts who have no prospects of recovery Concept of a Government Action Strategy to through other methods. These are mostly prevent the spread of HIV/AIDS until individuals who have been taking such drugs and the National Program for HIV preven!
Methadone is a synthetic opiate that is usually administered orally in liquid form. This drug is most frequently used in treating heroin addiction. Methadone was included in the list of narcotic substances whose sale is limited according to the May Cabinet Resolution № approving the list of nar! cotic substances, psychotropic substances and precursors.
On average, about % of heroin!dependent patients undergo replacement therapy in EU countries.
About , were in the US and up to , in Europe, according to estimates of the European Monitoring Center for Drugs and Drug Addiction, Report for .
priorities in preventing HIV/AIDS—harm reduction strategy Studies in many countries confirm that DRT results in a number of positive outcomes: • Slowing the spread of HIV/AIDS through injecting drugs.
• Injecting opiate users who are living with AIDS and need HAART can be prepared by stabilizing their social and psychological states. HAART requires discipline and unswerving daily and hourly adherence to all medical instructions from a patient, that is, it requires a patient to be committed to treatment. It is practically impossible to achieve this with a patient who is on a daily hunt to obtain a dose of drugs because of addiction. Thus, to make addicts committed to treating AIDS, first, they need to cope with their craving for drugs. This can be achieved through drug replacement therapy.
• Methadone treatment rarely shows negative side effects and usually allows considerable improve1 ment in health indicators. About % of those who receive this therapy respond positively.
• The death rate among addicts in DRT is –% of the rate among those not involved in such programs. Pregnant women receiving DRT more rarely have complications—both mother and fetus— than those not in this kind of therapy.
• DRT is more effective than no treatment, placebo and detox, which is used as a separate form of treatment, in terms of how long addicts stay in treatment and the reduction of their heroin intake.
• Very high crime rates were registered among drug users before their involvement in treatment. After one year of methadone treatment, rates went down by almost %. The most positive results were registered during the treatment process and right after it ended. But noticeable improvement can be observed for several years after the treatment was stopped. Indicators connected to drug1related crim1 inal behavior appear to shrink significantly.
• According to estimates, every dollar invested into addiction treatment programs can help a com1 munity save up to US $– based on such factors as lower losses to drug1related criminal behavior, thefts and robberies. Hand1in1hand with this, spending on criminal trials should also decline. If the cost of medical assistance is factored in as well, overall savings can exceed spending at a ratio of :.
• Although DRT is viewed as merely a treatment of symptoms that does not eliminate the need for reg1 ular doses of a drug, currently there is no effective alternative to such a treatment for longterm addicts. Medical research has shown that detoxification is absolutely ineffective: afterwards, % of addicts return to taking opiates. Rehabilitation programs have a success rate of no more than %. Moreover, they are costly, making it difficult to provide them to many addicts.
• In addition to preventing HIV and treating drug addiction, replacement therapy programs are an effective method to reduce trafficking by reducing demand for drugs. Thus, if , individuals whose daily dose is – ml join a DRT program, their demand for drugs represents about ,–, kg per year (. х , х = ,). This is a significant figure, given that the Ministry of Internal Affairs reported that , kg of illegal narcotic substances were seized from dealers in . Other calculations are also available. A pilot project in drug replace1 ment therapy in Ukraine showed that clients used an average of UAH 1worth of opiates per day. It is easy to see that one program treating addicts effectively deprives drug dealers of UAH , per month or UAH .mn per year. It is clear that DRT will certainly find resist1 ance under such conditions.
priorities in preventing HIV/AIDS—harm reduction strategy tion, assistance for and treatment of the the Treatment and Rehabilitation of HIV!positive and those suffering from Addicts of Opiates,” which have been AIDS for –.” Recently, the Health approved by the Health Ministry. Research Minister signed a Decree “On developing shows that the prescription of key replace! and improving drug replacement therapy ment therapy medications is in line with to prevent HIV/AIDS among IDUs” that Ukrainian legislation. Moreover, there is envisages the introduction of drug replace! now a set of regulations that directly point ment therapy using the drug Yednoc in five to the need to introduce DRT. Further oblasts. steps include:
Replacement therapy programs have not • Examine the possibility of manufactur! previously been implemented in Ukraine ing replacement drugs (buprenorphine for a number of reasons. The main one is and methadone) in Ukraine to reduce lack of understanding and resistance to the cost of treatment and the burden of replacement therapy on the part of many expenditures shouldered by the society; narcotics specialists, heads of drug over! sight committees, the Interior Ministry, • Revise certain Health Ministry regula! and other government agencies monitor! tions intended to track narcotic sub! ing trafficking in narcotic substances. The stances so that they cannot be used as idea of financing such programs is not seen replacements in medical practice; as an opportunity to reduce harm from drug abuse for the society as a whole. • Provide information, training and internships for different interest Because the issue of drug replacement groups: narcotics specialists, doctors therapy remains unresolved, centers for from HIV/AIDS centers, and workers preventing and combating HIV/AIDS in related health departments; effectively cannot provide HAART services to active IDUs, since protocol requires that • Develop a mechanism for overseeing they have at least days of treatment with and coordinating at the regional level DRT before the main treatment can com! those organizations that implement mence. DRT programs, which would include medical and social facilities and the Recommendations: Interior Ministry;
DRT was included in the HIV Prevention • Establish conditions for providing DRT Program. Ukraine developed recommen! at drug addiction centers and offices, dations called “Methadone treatment in HIV/AIDS prevention centers and
The April Ministry of Health Decree №.
Replacement therapy programs have been implemented only on a pilot basis to date. A buprenor! phine replacement therapy program was introduced at the Poltava oblast drug addiction center. Patients were given the opportunity to use this medication free!of!charge from – months, a short!term course of treatment, up to months, a medium!term course. Seven patients were involved in this pro! gram for one year, a figure that is really insignificant, given the , registered addicts in the region. A replacement detoxification program in which patients receive buprenorphine to remove withdrawal symptoms for the first – days proved very popular among IDUs and involved nearly patients for a year. Such programs have also been also implemented in Kremenchuk, Lubny and Luhansk.
priorities in preventing HIV/AIDS—harm reduction strategy infectious diseases hospitals. This Recommendations: means providing licenses to work with narcotic substances; to buy, import and • Carry out regular public awareness cam! distribute replacement drugs and med! paigns in the media to highlight the ications in the necessary amounts; goals and approaches of harm reduc! tion policy in Ukraine; • Institute the positions of an infectious disease doctor and a narcotics doctor at • Carry out targeted public awareness drug addiction centers and HIV/AIDS campaigns on harm reduction at the prevention centers to dispense medica! local level in order to: () inform poten! tions and replacement drugs for HIV! tial beneficiaries; and () form a posi! positive drug addicts in conjunction tive attitude towards such activities; with HAART; • Set up a cross!sector database of organi! • Develop a strategy to involve IDUs who zations that work with drug addicts and meet certain criteria in DRT programs. the HIV!positive and of the services that they provide through the Dovira consul! tation centers or HIV/AIDS centers. . Public awareness campaigns Develop and introduce a mechanism and education for providing this information.
Goals: . Provide easy access to social • To provide public support for harm and medical services reduction; Goals: • To provide information to IDUs and to their closest circles on preventing risky • To ensure the right of every individual behavior; to receive medical assistance;
• To broadly disseminate information • To encourage drug addicts to practice about organizations that work with drug safe behavior. addicts and the HIV!positive and about services that they provide. Arguments:
Arguments: Opiate addictions are frequently accompa! nied by social problems. The most com! Disseminating information is the key factor mon are the lack of an official place of resi! in effective prevention of HIV/AIDS as a dence and wrong or missing documents. whole. The public awareness component The majority of IDUs are unemployed. plays an important role in any harm reduc! However, few of them apply to employment tion strategy by involving the target group centers or receive social unemployment in preventive measures. This component benefits, and most cannot apply for subsi! also ensures understanding and support dies for residential services. Resolving for harm reduction among the general these problems would significantly reduce public. the negative consequences of drug addic!
priorities in preventing HIV/AIDS—harm reduction strategy tion. However, Ukraine still lacks accessible On the other hand, access to opiate anal! social services for IDUs. gesics, especially for replacement therapy and palliative treatment of drug addiction, Although the country has a network of HIV/AIDS and TB is very much over!regu! social facilities that work with IDUs, their lated. A complicated system of permits for number and the quantity of services they the use of narcotic analgesics makes medical provide fail to meet actual needs. specialists reluctant to provide access to opi! ates at their medical facilities. In , Another serious problem is accessible med! among TB and HIV service facilities, only ical services for IDUs. Quite often, it is very had a license to use narcotic analgesics. difficult for an IDU or an HIV!positive indi! vidual to receive first aid or to have an Recommendations: operation. The reasons for this include stigmatization, negative attitudes and a • Introduce a full!ranged system of med! lack of professionalism among come doc! ical and social assistance for drug addicts tors. The other side of the coin is that IDUs that will encompass detoxification, reha! are reluctant to turn for assistance for fear bilitation, drug replacement therapy, of disclosure and being forced to regis! and psychological and social support tered with the police. programs;
Drug addiction services tend to be inacces! • Analyze the needs of drug addiction cen! sible and low quality. This is because fund! ters in each region of Ukraine and match ing for drug addiction centers and staffing the number of such facilities to actual and specialists at such centers have been needs; cut back since independence. The govern! ment allocates only UAH per day for the • Inform IDUs about medical and social treatment of a single drug addict, although services and access to them, and about high quality treatment in a hospital costs their rights; UAH – per day. • Set up a system for regulating the use of One organizational issue is that the system narcotic substances in treatment facili! of medical aid for IDUs is isolated, lacking ties that will make it possible to provide an integrated approach and ties to other DRT and palliative care in the amounts centers, especially tuberculosis and HIV necessary for treatment purposes; centers. Currently addiction services are not components of a comprehensive strategy for • Introduce DRT through HIV/AIDS pre! the medical, social and economic rehabilita! vention centers and drug addiction cen! tion of drug addicts. Given the seriousness ters; of the HIV epidemic, isolating drug addic! tion and HIV services in this way has led to a • Ensure equal access to antiretroviral crisis of medical support to IDUs. (ARV) treatment for IDUs living with HIV;
Tertiary prevention among risk groups, in particular among IDUs, is provided by the network of Youth Services Centers that have been set up in all oblast centers. With the support of UNICEF, these state!run centers implement the “Preventing HIV/AIDS among Young IDUs” program. The responsibilities of the Dovira counseling points under the YCS are to: () provide the necessary knowledge and develop skills related to safe behavior in terms of HIV/AIDS among young IDUs; () train social workers, volunteers and leaders of target groups in harm reduction and peer!to!peer strategies; () provide young IDUs with individual means of protection, such as syringes, antiseptic towelettes and condoms; and () create a social environment that would display a compassionate and unbiased attitude towards IDUs.
priorities in preventing HIV/AIDS—harm reduction strategy • Introduce a complete set of measures to • Expand insurance programs to include protect social and medical professionals all medical and social services personnel working with IDUs from possible risks who work with IDUs in case they contract when they provide qualified assistance to HIV while providing assistance. IDUs and people living with HIV/AIDS; Rehabilitation and re!integration Goal: income, nor clothes. With no opportunity for professional support, relatives of drug • To help addicts give up drugs and return addicts abandon them in the end. There are to normal life in their communities. numerous instances of family violence towards drug addicts. In short, if this com! Arguments: ponent is not included in government HIV/AIDS policy, an important link will be A necessary element of any harm reduction missing. Without this link, most IDUs will strategy is developing support systems to have no alternative except for methadone. re!integrate and rehabilitate drug addicts. But rehabilitation programs that cost The rehabilitation system is poorly devel! US $–, per month deprive many oped because of high costs combined with drug users of a chance to give up their poor performance. An analysis of the finan! addiction. Without developing a rehabilita! cial requirements to set up a network of tion system, DRT may not have the desired rehabilitation centers shows that a single impact. Yet, despite a Cabinet Resolution rehab center with a program aimed at com! giving the green light, the system is at an plete withdrawal from narcotics can effec! embryonic stage and is mostly developing tively treat an average of only – indi! through the efforts of NGOs. The standard viduals per year. Moreover, the cost of this provision on the Tvoya Peremoha [Your treatment will be at least UAH ,–, Victory] rehabilitation center never became per patient per month, including daily an effective tool for developing a network of maintenance, salaries for qualified person! drug rehabilitation centers. nel, equipment, medications, and so on. According to actuarial calculations, –% International experience indicates that an of patients become indifferent to drugs and individual must participate in a rehab pro! do not return to abuse. With some , gram for up to two years and then the right drug addicts in Ukraine, this means that at kind of social services have to support this least ,–, addicts need to be treat! person from one to three more years. In ed per year. To do so, Ukraine needs at least Ukraine, the rehabilitation of addicts rehabilitation centers with a total budg! amounts to detoxification and a “psycholog! et of about UAH .bn. ical adjustment” program at a treatment facility that lasts from two weeks to two Yet financing such a rehabilitation network months at most. There are no institutions is too costly for a healthcare system that was that might take care of addicts for the peri! allocated only UAH bn in . In short, od when their ties with their families are the State Budget cannot fully cover needs at destroyed and they may be de jure regis! the state level. Moreover, there is not the tered as residing somewhere but de facto necessary number of qualified specialists in have neither shelter, food, source of Ukraine who can work at such facilities.
Serhiy Dvoryak, A Nutritious Environment for the Virus or Why haven’t we started to treat drug addic! tion with methadone, Replacement Therapy, UNAIDS.
priorities in preventing HIV/AIDS—harm reduction strategy Recommendations: ernment bodies can legitimately use State Budget resources to finance rehab pro! Because of high costs, the government cur! grams; rently cannot support rehabilitation pro! grams that aim at complete withdrawal from • Set up a register of rehab centers with a narcotics at a level that will make them afford! description of their services and a system able for all who need them. This means it will under which a doctor can prescribe treat! have to focus on other tasks first: ment in such centers or at least provide information about them; • Set up an environment to encourage the development of non!government rehabil! • Analyze possible forms of public, private itation centers. This includes providing and donor capital to fund the rehabilita! state support, ensuring the conditions for tion system, and to develop appropriate sustainability (social services enterprises) recommendations. and partnering with private capital; • Set up special shelters for drug addicts • Provide independent evaluations and where they could find temporary protec! oversight of the quality of rehabilitation tion and receive certain kinds of assis! services; tance;
• Develop recommendations for the • Develop educational programs and teach! approach to developing rehab centers ing materials for training rehabilitation based on the experience of different types specialists at post!graduate educational of rehab programs, especially !Step facilities; Programs, Narcotics Anonymous—the regulations on these centers, how they • Organize workshops for decision!makers, operation, staffing); social workers and various specialists in drug addiction and HIV/AIDS. • Establish licensing for rehab programs to provide social services so that local gov! Harmonizing HIV prevention and anti!drug policies
Goals: • To reduce high caseloads of courts and sentence enforcement agencies; • To reduce the number of cases when individuals who are addicted to drugs • To make the police more effective in are unreasonably fined or sentenced for combating established organized crime violations; rings engaged in drug trafficking;
• To return the confidence of vulnerable • To enforce adherence to the law in the population groups in government bod! activity of the police itself and to reduce ies, especially in the police, to improve violations of human rights, especially access of such groups to prevention, with vulnerable groups. treatment and support and to raise the effectiveness of these activities;
priorities in preventing HIV/AIDS—harm reduction strategy . Changing the grounds . Reducing penalties for for criminal prosecution activities involving drugs Arguments: without the intent of selling
IDUs suffering from addiction have a strong Arguments: psychological and physiological need for drugs. Because of their sickness, they will Today, Ukraine still uses the long!outdated continue to take narcotic or psychotropic practice of holding a person criminally substances on a regular basis, regardless of responsible under Sec. of Art. of the any threat of punishment. They need at least Criminal Code, pertaining to illegal produc! a minimum dose to avoid withdrawal symp! tion, purchase, possession or other activity toms, which cause terrible physical and psy! involving a relatively small amount of drugs chological suffering. without the intent of selling, and according to Sec. of the same , pertaining to The Criminal Code of Ukraine does not “especially dangerous substances” without anticipate liability for drug abuse. Yet, offi! the intent of selling. Thus, under current cial statistics indicate that about % of legislation, simple possession of more than criminal cases on sales of illegal drug are gm of hemp or gm of opium poppy filed under Art. , which refers to the stor! stems (“straws”) is sufficient grounds to land age of such drugs without the intent of sell! an individual in prison for up to three years. ing. More than % of those accused under Yet the vast majority of those pursued under this Article are registered with drug addic! this Article are drug addicts who, according tion centers. In other words, these cases to the EU position, are victims of drug!relat! involve the storage of several grams or sever! ed organized crime. As a rule, such individ! al cc’s of a drug although these amount to uals cannot adequately defend their rights. no more than an individual dose. Cases involving the storage of especially large In , Ukrainian police uncovered , quantities of illegal drugs constitute a minis! drug!related crimes, a .% increase on cule portion in the total number of criminal the , offences registered in . At cases. the same time, the number of documented drug deals grew only .%, from , to Prosecuting individuals who suffer from ,. In other words, the “growth” of drug addiction for such a minor offence these indicators came as a result of holding does little in terms of prevention but only ordinary users criminally responsible for worsens the condition of these addicts. possessing drugs for personal use. Statistically, for every two drug addicts offi! Recommendations: cially registered in Ukraine (, indi! viduals), one criminal case was launched in • Amend the definition of the lower limits . In some oblasts—Cherkasy, Kharkiv, in the table of illicit drugs that lists L’viv, Poltava, Zakarpattia, and Zhytomyr—, “small,” “large” and “especially large” the number of trafficking cases launched in amounts of narcotic or psychotropic was equivalent to or even higher than substances or precursors approved by the number of registered addicts. the August Ministry of Health Decree №. This applies specifically to As for “priority drug!related crimes,” in individual doses for addicts, which , the relative weight of documented should be determined by a competent drug deals was %, vs .% in , while drug commission. the share of “qualified drug!related
priorities in preventing HIV/AIDS—harm reduction strategy crimes”—drug deals, loitering in hangouts, addicts are the most likely to commit crimes. inducing into drug addiction, drug theft, According to police officials, drug users are organizing drug laboratories, and launder! the main channel for dealing in drugs and ing drug!related money—dropped from % spreading drug abuse, so they see a policy of to .%. prohibition and enforcement as the most appropriate in this area. Still, this approach Recommendations: fails to consider medical aspects of the prob! lem. • Draft and submit to the Verkhovna Rada a bill to amend Sec. of Art. of the Current regulations include a requirement Criminal Code by removing sentencing that police agencies submit regular reports in the form of imprisonment and replac! on a number of indicators. One of these ing it by sentencing in the form of com! indicators is the number of criminal cases munity work. Also supplement Art. launched with regard to drug trafficking. As to state that such alternative sentencing a result, police officers are motivated to can be for a period longer than current! increase the number of new cases. Similarly, ly permitted under Sec. of Art. and investigative agencies want to avoid fines for to identify drug addicts as subject to this failing to produce the necessary numbers alternative form of punishment; and sometimes will launch criminal investi! gations without proper grounds. Built on lit! • Introduce alternative forms of punish! tle hard evidence, such cases easily fall to ment, such as free community work or pieces at first court session and the judge other alternatives. Consider the possibil! generally decides that no guilt has been ity of instituting mandatory participa! proven and the defendants are released. Of tion in the !Step program or other course, this does not concern the investiga! rehabilitation programs. tive agency, since it has “fulfilled” its “task”— producing the necessary performance num! . Improving the police bers. performance evaluation system The ineffectiveness of the current system of using performance indicators that lead to Arguments: ordinary drug addicts being prosecuted is confirmed by the number of sting opera! The participants concluded that police work tions carried out, where the deliveries and to combat drug addiction is ineffective sales of drugs are done by undercover cops. because it focuses too much on drug users and addicts alone. The vast majority of crim! For instance, in , the police carried out inal cases to combat drugs involve holding more than , undercover purchases and addicts criminally responsible for possessing deliveries of drugs, about % of the or producing drugs for personal use. This total number of drug!related crimes. In kind of policy does little to treat drug addic! Ukrainian anti!drug legislation and world tion: it only makes addicts fearful and dis! practice, however, these two methods to trustful of government institutions, margin! combat drug trafficking are normally used alizes them even more, and puts them to infiltrate drug traffickers, especially beyond the reach of preventive efforts. Of organized rings. As a result, the number of course, law enforcement agencies are of a undercover operations in the US and EU different opinion: they see the fight against countries is quite limited, not in the thou! drug users as one of their priorities because sands. By contrast, Ukraine uses these oper!
Statistics from the Department for Combating Drug Trafficking, Ministry of Internal Affairs.
priorities in preventing HIV/AIDS—harm reduction strategy ations to entrap mostly ordinary users who It is hard to overestimate how important it is are in possession of or selling a few grams of that the police not only not counteract nee! a drug. dle exchange points and outreach activities but actively support such critical efforts. Significantly, the police do not keep appro! Another important element is effective priate statistics on the “quality” of criminal cooperation between police officers and cases in this category. NGOs running harm reduction programs in jointly organizing public awareness and Recommendations: education campaigns on preventing HIV/AIDS and other infectious diseases in • Gradually change the police perform! the IDU environment, personal prevention ance evaluation system. During the first and health protection to keep medical and phase, stop launching of criminal cases other staff from contracting HIV while ful! under Art. , possession or use without filling their professional duties. the intention to sell, from police per! formance indicators. During the second Recommendations: phase, develop and institute a perform! ance evaluation system that is appropri! • Analyze legislation that regulates the ate to combating serious drug trafficking. proper action of police officers towards drug addicts, identify regulations that • Shift the accent to exposing crimes relat! contradict other Ukrainian laws and ed to trafficking—especially importing international human rights and anti! onto Ukrainian territory—, manufactur! HIV/AIDS commitments, in particular ing and wholesale production, and the in terms of these types of activity. Amend inducement of minors to use drugs, away these regulations or cancel them. from private use. In this way, the govern! Harmonize Interior Ministry regulations ment will shift police efforts away from with EU standards, which is also impor! individuals who use drugs to the crimi! tant in the context of eventual integra! nals and rings who deal in drugs and fos! tion into the EU; ter drug addiction in Ukrainian society. • Based on specific decisions, develop amendments to relevant regulations or . Improving police regulation new regulations that of necessity reflect and practices Ukraine’s laws and international human rights commitments. These should Arguments: include: a mechanism for the Ministry of Internal Affairs to participate in an Ukraine has committed itself to protecting appropriate fashion in developing and the rights of the HIV!positive and drug implementing state programs to combat addicts and to providing them with social the spread of drug addiction and support. But actual police practice is nar! HIV/AIDS; a mechanism that obliges rowly focused on detaining drug addicts, the police to cooperate with executive seizing narcotic substances, registering agencies and civic organizations that addicts, and determining whether to prose! work in this area at both the national and cute or merely fine them. local levels; and the commitment of the police not to interfere in the activities of Currently, the community and charity such organizations. For example, this organizations that implement harm reduc! can take the form of a principled agree! tion programs provide the lion’s share of ment not to organize raids on drug preventive measures and support for IDUs. addicts around needle exchange points
priorities in preventing HIV/AIDS—harm reduction strategy or to set up police ambushes around eases in the IDU environment, the meth! such stations, as has been the practice, ods for individual prevention and for the and the commitment of police officers protection of personnel from contracting not to prosecute or detain outreach HIV the line of duty; distributing special! workers—which often happens in reali! ized hand!outs on preventive methods ty—but to support their important work; among police personnel, and encourag! ing their further dissemination by police • Forms of cooperation should include: officers in preventive work with drug exchanging information; organizing se! addicts. The staff of such police depart! minars and workshops for employees of ments can refer IDUs to local NGOs that police agencies by specialized NGOs; are carrying out harm reduction pro! involving qualified medical personnel to gram, to be registered and receive coun! cover issues related to the modes of trans! seling on preventive measures, and to mitting HIV and other dangerous dis! obtain social and rehabilitation services. The war on stigmatization Goals: of this should be a lower level of discrimina! tion against IDUs and PLHAs. Services pro! • To protect rights of IDUs and people liv! viding appropriate legal aid can be set up ing with HIV/AIDS (PLHA); under NGOs that implement harm reduc! tion strategies, HIV!service organizations, • To form a compassionate attitude and self!help organizations for drug addicts towards those HIV!positive and IDUs in and PLHAs. Ukrainian society. Recommendations: Arguments: • Carry out broad!based public awareness To eliminate the discrimination against campaigns in the media to inform peo! IDUs and PLHAs that exists in Ukraine ple about these issues and provide spe! today, a complex policy aimed at two key cialized courses in public schools and objectives should be instituted: post!secondary institutions;
• Raising the level of informedness among • Develop and implement a series of work! the general population about drug shops for employees of police depart! addiction and HIV/AIDS and the way ments across all levels. The aim is to pro! they are propagated; vide explanations and information that might help develop a more compassion! • Establishing liability for violating the ate attitude towards IDUs, drug addicts rights of drug addicts and HIV!positive and people living with HIV/AIDS; individuals, especially if such violations are based on discrimination against • Hold workshops for police department them. staff to improve their level of informed! ness on harm reduction; The enforcement of such liability and pub! lic reports about it should ensure that indi! • Set up a network of services providing viduals guilty of discrimination against free legal aid to drug addicts and the IDUs and the HIV!positive will be loath to HIV!positive, who belong to the most violate their rights for fear of incurring neg! vulnerable social groups. The aim ative consequences themselves. The result should be to provide IDUs and PLHAs
priorities in preventing HIV/AIDS—harm reduction strategy with effective assistance in protecting domestic security services from the their rights and legal interests and to Interior Ministry, Prosecutors’ Offices, establish the liability of those guilty of the Office of the Ombudsman, relevant violating the rights of such individuals. Government and Verkhovna Rada com! This legal aid operation should involve mittees, and the media. Political leadership Goal: – analysis of possible alternatives for achieving stated goals and analysis of • To increase the effectiveness of govern! current concerns and consultations ment policies by improving procedures with stakeholders; for developing, adopting, implement! ing, and monitoring policies in this spe! • Revise the system for coordinating activ! cific area. ities and establish a single mechanism to fulfill three key tasks: Arguments: – to agree state policy for preventing All the recommended government policy HIV/AIDS in the medical, social and components are interdependent in the cur! education spheres, and for combat! rent situation. That is, if the police stop ing the spread of drugs; prosecuting drug addicts, it will not have the desired overall impact, unless there is an – to ensure effective public participa! active network of social facilities and centers tion in formulating policy in this where drug addicts can receive medical and area; social assistance. Conversely, all efforts to provide rehabilitation and re!integration for – to coordinate priorities, programs drug addicts will fail if IDUs are afraid to and the amounts of donor assistance turn to state!run facilities for fear of arrest. used in this area.
To effectively implement the new state poli! • Provide the regulatory, methodological cy, first of all, the process of making and and logistical base to run a unified coor! implementing policy needs to be revised. dination mechanism; This must be done fairly urgently, especially because this kind of work has to be cross!sec! • Set up a single coordination agency in tor and program!based. the regions that will manage funds from all sources of financing: the State and Recommendations: local budgets, charitable organizations, and donors. This agency would take in, • Improve informational and analytical distribute and oversee that money is support for the development and institu! spent for designated program purposes. tion of national and regional HIV pre! It would also be responsible for making vention programs through: sure that the goals, numbers and indi! cators set in a given program are – obligatory analysis of the progress of reached. The performance of this the situation, its roots, and the results agency should be reviewed by both gov! of previous programs; ernment bodies and independent audi! tors appointed by the donors. The – analysis of available resources and agency should include appropriate rep! barriers and impact analysis; resentatives of government bodies and
priorities in preventing HIV/AIDS—harm reduction strategy services, as well as NGOs with regional • Improve the quality of statistical data by experience; updating the methods for tracking drug addicts and the HIV!positive and for car! • Adopt a State Concept for an Anti!Drug rying out research, specifically by apply! Policy that is consistent with HIV/AIDS ing the monitoring and evaluation meth! prevention policy and includes a harm ods proposed by the UN; reduction strategy: • Approve the list of statistical indicators – organize debates and consultations necessary to monitor the application of with stakeholders on the concepts of preventive measures and the provision of anti!drug and HIV prevention poli! assistance and treatment to the HIV!pos! cies; itive and PLHAs, and relevant models and procedures for monitoring; – make current government programs consistent with the approved con! • Institute a full!scale program!oriented cepts of anti!drug and HIV preven! method for Budget financing of govern! tion policies. ment programs in this area.
priorities in preventing HIV/AIDS—harm reduction strategy Appendix . The results of public debates
The first round, January–February Over January– February , the addiction centers. The “community organi! International Centre for Policy Studies zations” group included representatives of (ICPS), jointly with the All!Ukrainian Harm NGOs and of the target group: current or Reduction Association (AUHRA), held a former drug addicts, their relatives and series of public debates called “A New Harm PLHAs. Each event was attended by to Reduction Policy” under the “Policy individuals. Campaign for Harm Reduction” project in Kyiv and other Ukrainian cities. The goal The first round of debates identified the of these debates was to develop a common positions of the main stakeholders: vision of harm reduction policy and to identi! fy the positions of different stakeholders • Government; regarding problems and their solutions. Participants also considered at a Green Paper • Doctors; prepared by AUHRA and ICPS specialists with the assistance of outside experts from the • Police officers; project. The events were organized by region! al organizations that are members of AUHRA. • Social workers;
The schedule of the first round of debates: • Community organizations.
January—Luhansk, Poltava, January— Participants in each group were asked to Dnipropetrovsk, Znamianka, January— consider six key questions: Odesa, January—Chernivtsi, Mykolayiv, January—Simferopol, February—L’viv, • What should be the goals and priorities Uzhorod, February—Kyiv, of government HIV prevention policy? What indicators can confirm the success All debates followed the same format: the of policy in this area? presentation of the Green Paper, presenta! tions by experts, and group work on issues • Why is HIV prevention among drug proposed by the organizers. Depending on users not working? the number of stakeholders participating, groups were formed using different princi! • What are the pros and cons of continu! ples in different cities. Where there were ing with the current policy? more than three representatives of the police and social agencies such as the Ministry of • What are the pros and cons of increasing Family and Youth, the Ministry of Labor and prosecution for drug use? Social Policy, the State Center for Youth Social Services, they worked in separate • What are the pros and cons of instituting groups. Otherwise, they were mixed in with a harm reduction policy? other officials in a group called “government representatives.” The group called “doctors” • What are other HIV prevention policy was mostly staff at AIDS centers and drug options?
priorities in preventing HIV/AIDS—harm reduction strategy Common ground According to most participants, the key pri! which reduces the effectiveness of preventive orities of a policy towards IDUs are to reduce measures that much more. The majority of the spread of HIV and other diseases and to groups also mentioned a related problem change the government approach towards that needs to be tackled—stigmatization. IDUs from prosecution to prevention, treat! ment and rehabilitation. The most frequent! Stakeholders repeatedly mentioned the low ly mentioned goals were: to cover % of level of informedness about this issue IDUs through harm reduction programs, to among the general public and the role of expand harm reduction programs to small the community in dealing with it. This is towns and villages, to ensure a high!quality among the most important gaps in the cur! and affordable rehabilitation system for rent policy. drug addicts, and to improve the quality of public awareness campaigns. Much was said Participants mentioned other drawbacks in about the importance of improving primary the existing policy: its declarative character measures to prevent drug addiction in and the lack of funding. Specifically, partici! Ukrainian society, especially among young pants spoke about the lack of proper state people, of coordinating policies and of pro! rehabilitation programs for drug addicts viding appropriate financing. and replacement therapy programs, albeit these were announced by the government. In the opinion of participants, the success of Without such programs, it will be impossi! a given policy might be confirmed by five key ble to have any impact on drug addiction indicators: stabilized/reduced rate of spread and the spread of HIV. Participants gave of HIV, falling numbers of IDUs, the num! mostly negative assessments to the approach bers of IDUs reached by harm reduction serv! to combating drug trafficking currently ices, the quality and affordability of such serv! taken by the police, who mostly hunt drug ices, and the stability and funding volumes addicts, instead of drug dealers. Such an provided for harm reduction programs. approach, noted participants, not only failed to contribute to the fight against drug Participants singled out two main reasons trafficking, but actually undermined med! for the ineffectiveness of HIV prevention ical efforts to prevent HIV. among IDUs: inadequate funding and lack of coordination of efforts among various Positive aspects of the current policy agencies and NGOs. As a result, the amount include the government’s recognition of and quality of preventive measures are not harm reduction programs, however nomi! enough to have any real impact on the situa! nally. Participants also mentioned evidence tion. The majority of participants men! of cooperation between NGOs and govern! tioned the poor quality of primary preven! ment bodies and the beginnings of proper tive measures against drug addiction understanding of the problem among gov! because of the low quality of public aware! ernment officials. ness campaigns and educational programs on this subject. The prospect of increased police pressure on IDUs had a very negative reception Representatives of government and NGOs from participants. Although such an singled out another problem: the lack of approach can indeed isolate IDUs from trust in government agencies and in medical society somewhat and serve as an incentive and social facilities. As a result, the target to quit drugs for some users, it will never! group for harm reduction programs does theless push the problem even further into not use the existing services and programs, the shadows, strengthen criminal activity,
priorities in preventing HIV/AIDS—harm reduction strategy and make the prevention of diseases in this tion among the general public, delayed extremely vulnerable group virtually introduction given the current epidemic sit! impossible. uation, the lack of specialists, and insuffi! cient and unreliable funding. The main advantages of expanding harm reduction programs, according to partici! In addition to harm reduction programs, pants, were the possibility of having a real participants said that a great deal more impact on the spread of HIV and related dis! attention needed to be paid to primary pre! eases, improving contact with the target ventive measures for both HIV and drug group, the possibility of returning IDUs to addiction in a number of ways: targeted pub! normal community life and of motivating lic awareness campaigns for various groups them to give up drugs. In the opinion of par! of the population, better preventive activi! ticipants, the risks of implementing harm ties in schools, and the promotion of reduction programs include: negative reac! healthy lifestyles. Special аccents
The groups of doctors said one problem is organizations and cooperation between that drug replacement therapy (DRT) is NGOs and government institutions as neces! unregulated. Although nearly all the doc! sary to stop the HIV epidemic and reduce the tors from drug therapy services who partici! extent of drug addiction in Ukrainian society. pated in the debates were prepared to intro! duce DRT, at the moment there are only a Doctors, social workers and NGOs noted number of pilot projects in this area because that one factor in Ukraine that complicated the police do not understand the purpose of their work was very little access to drug methadone treatment. At the same time, the addicts. Another factor is that they have to majority of drug rehabilitation centers have get the approval of local police officials in long been using other narcotics in detox order to be able to carry out preventive programs and some of them in local pilot measures and treat drug addiction and DRT programs. HIV/AIDS at the local level.
Groups with a mix of doctors and police offi! It was clear in the course of the discussions cers mentioned the risk of trafficking of that there was a definite lack of understand! replacement drugs while DRT was being ing among some participants of the objec! introduced, opportunities for abuse and tives of DRT and the meaning of the term corruption, and the possibility that replace! “resocialization.” Some government officials ment therapy might foster new cases of drug seemed to believe that drug replacement addiction. therapy programs and social rehabilitation of IDUs were incompatible, although harm Groups of NGOs that are implementing reduction work in other countries has harm reduction programs with the financial shown shows that DRT is one of the first support of international donors emphasized steps to start the process of integrating drug the need to gain government support for addicts back into their communities. Other NGO efforts in HIV prevention, specifically officials frankly admitted to knowing noth! by allowing NGOs to participate in govern! ing about the objectives and approaches ment tenders for providing services in this used in harm reduction. Doctors noted that, area. They see stable and reliable state fund! while harm reduction was an important ele! ing of harm reduction efforts implemented ment in fighting the HIV/AIDS epidemic, it by both government and non!government could not resolve the overall problem.
priorities in preventing HIV/AIDS—harm reduction strategy Differences The main gap in positions was between drug users, not drug dealers: court statistics police representatives and the rest of partic! show that the overwhelming majority of ipants in these debate. Police officials think criminal cases are launched against individ! that making drug users criminally responsi! ual users for storing or making small ble is not overly repressive, as it is aimed amounts of narcotic substances for their mostly against drug dealers. As far as they personal use. The negative consequences of are concerned, all drug users are also poten! this are reduced effectiveness of preventive tial criminals and have to be isolated from work, lack of trust in harm reduction pro! the rest of society, so prohibition and con! grams among drug addicts, and the waste of trol are in the public interest. law enforcement resources in fighting users rather than professional dealers. The rest of participants pointed out that police actions are aimed mainly against The second round: April Over – April , ICPS and AUHRA . What resources are necessary to imple! held the second series of public debates on ment these steps? harm reduction policy. The goal of this round was to discuss proposed steps to intro! . What barriers exist to doing this and how duce such a policy, to identify the positions can they be eliminated? of stakeholders as to priority activities and risks, barriers and resources. At the hear! Among top priority steps, most groups ings, participants also considered a draft across all cities most frequently named cre! White Paper in all Ukrainian cities. ating the necessary conditions for a policy to be effectively instituted. These institutional The schedule of the second round of public steps include: proper coordination of debates: efforts, adequate funding for harm reduc! tion programs, training for specialists, and April—Kyiv, April—Poltava, Znami! oversight of program implementation. anka, April—Dnipropetrovsk, Luhansk, Community organizations also emphasized April—Odesa, April—Chernivtsi, the need to establish the status of harm April—L’viv, Mykolayiv, April—Simfe! reduction programs as a social service and ropol, Uzhhorod. involve NGOs in implementing state pro! grams. This debate followed the same format as the first round. Participants were asked to con! At the same time, priority was given to pub! sider four key questions: lic awareness campaigns to increase informedness among the general popula! . Are the steps proposed by the White tion, promote healthy lifestyles, and encour! Paper enough to introduce a harm age a compassionate attitude towards drug reduction strategy? What steps would addicts and PLHAs. you add, remove or change? According to participants, another impor! . What should be done first of all and who tant step was to provide access to treatment should do it? Single out three to five for drug addicts. In particular, participants steps that are, in your opinion, the top said that the development of rehab centers, priority. social services providers, and access to
priorities in preventing HIV/AIDS—harm reduction strategy drug replacement therapy for those who government workers and the general pub! need it. lic.
Changing the nature of police work with The major barrier to introducing DRT is drug users was also mentioned as a priority. lack of support form the public and govern! Specifically, participants spoke about the ment officials. The introduction of drug need to lower the level of criminal prosecu! replacement therapy for drug addicts was tion of drug addicts, to shift accent from the main discussion issue. These discussions arresting drug addicts to going after pro! showed that, first of all, there is no shared fessional drug dealers. understanding of policy goals towards drug addicts. Opponents of DRT mostly believe According to participants, having enough that drug addicts cannot live in a communi! financial and human resources are the key ty, that they should be isolated from society factor to implement harm reduction strat! and forced to undergo treatment or be egy. The genuine lack of such resources locked in jail. But the majority of partici! and unregulated status of harm reduction pants think that DRT needs to be instituted programs are the primary barriers to as it can help deal with both the problem of implementing this strategy. Finally, there is the HIV epidemic and the problem of crime a serious lack of support from the both associated with illicit drug use.
priorities in preventing HIV/AIDS—harm reduction strategy Appendix . International experience in preventing HIV among IDUs
To be effective, government policy in pre! resources, to be based on an appropriate venting HIV/AIDS among IDUs must meet infrastructure, and to include instru! three conditions: ments for monitoring, evaluating and adjusting goals and implementation • be based on up!to!date harm reduction instruments; approaches and experience; • be based on reliable data on the current • like any other policy, be clearly formulat! situation, to reflect the actual situation ed, define clear goals and a clear imple! in the country, especially as to drug mentation plan, and provide a mecha! abuse and the spread of HIV, popular nism for coordinating efforts among all attitudes towards the issue, traditions executing agencies. It also has to be sup! and approaches to solutions, and exist! ported by financial and human ing resources and restrictions. International efforts The main international documents on pre! drug addiction are regulated by a number of venting HIV are the UN International other international documents as well. The Guidelines on HIV/AIDS and Human International Convention on Narcotic Rights and the UN Declaration of Drugs of recognizes the social and Commitment on HIV/AIDS, which are economic threat to humanity of drug addic! based on long experience with combating tion and emphasizes the need to pay special the HIV epidemic around the world. These attention to providing drug addicts with documents recommend states to follow the medications, support and appropriate treat! principle of upholding human rights in ment. fighting the epidemic, as the most vulnera! ble pockets of any population tend to be The UN Declaration on the Guiding marginalized groups such as IDUs, whose Principles of Drug Demand Reduction rights are most frequently violated. The idea was adopted in to focus specifically on of these recommendations is that upholding the problem of drug addiction. The human rights, such as the right to non!dis! Declaration emphasizes that programs to crimination, to work, and to accessible med! reduce demand for illicit drugs should ical and social services significantly increas! cover all prevention areas: from discourag! es the effectiveness of prevention work. ing the initial use of drugs to reducing the negative social and personal consequences The fight against drugs and the prevention of drug use for a person and the society as a and reduction of the negative impact of whole.
International Guidelines on HIV/AIDS and Human Rights, Geneva/New York, .
The UN Single Convention on Narcotic Drugs of , Art. .
The UN Declaration on the Guiding Principles of Drug Demand Reduction of , Art. .
priorities in preventing HIV/AIDS—harm reduction strategy To assist governments in developing and Populations adopted by the World Health instituting policies for preventing HIV Organization Regional Office for Europe. among IDUs, international organizations These documents were developed in have developed such documents as the UN response to the spread of the HIV/AIDS Position Paper on Preventing the epidemic among IDUs and contain consis! Transmission of HIV Among Drug Addicts tent and detailed strategic approaches to and a program document called the counteracting this epidemic among drug Principles of HIV Prevention in Drug!Using users. Key harm reduction policy components
Policy components that, according to WHO main goal of DRT is to reduce illicit drug recommendations, have a good potential to use, to lower the level of risky behavior, such reduce individual and social harm from as using dirty syringes and needles, and, as a drug abuse are: result, to reduce the risk of contracting HIV. WHO recommends including methadone or other DRT programs in the general . Providing IDUs with clean national anti!drug strategy as one of the injecting tools and disinfecting therapy options, especially in counties substances where heroin or other opiates are widely used and providing access to methadone This means access to sterile needles and programs for people who use opiates, espe! syringes and disinfecting materials with the cially intravenously and show risky behavior help of free needle exchange programs or in terms of HIV transmission. WHO also rec! non!prescription sales at drug stores; access ommends introducing national rules and to programs that work actively among drug recommendations for involving IDUs in addicts and other services and institutions; DRT programs and organizing such pro! unlimited access to needles, syringes and grams in combination with educational pro! disinfecting materials for IDUs without any grams on HIV to reduce risky behavior in strings attached, such as providing personal general, providing psychological and social identification information. Many studies support as a component of DRT programs confirm that such programs are effective at to improve both the physical and emotional destroying the chain of virus transmission. health of patients and thus to improve Such services also serve as points where drug broader social indicators, such as reducing users can be given information and get criminal behavior and increasing employ! involved in rehabilitation programs. Needle ment. exchange programs also work to prevent other undesirable consequences of drug abuse, by collecting used needles and . Ensuring easy access to social syringes, and storing and destroying them and healthcare services safely. Offering drug addicts access to social and medical services helps them adapt and stick . Offering IDUs the choice to to HIV!safe behavior, which can lead to sig! undertake drug replacement nificant preventive results. An important therapy point is to provide IDUs living with HIV access to antiretroviral treatment. This com! This is a way to provide medically supervised ponent includes access in terms of location treatment of opiate addiction by using and accessibility by public transport; First replacement drugs such as methadone. The Aid and crisis intervention services with
priorities in preventing HIV/AIDS—harm reduction strategy minimum restrictions as to hours and days; disinfecting substances, and condoms services that ensure confidentiality and data should be distributed among high!risk protection; services for all possible users, groups, and used injecting instruments and regardless of age, sex, race, ethnic origin, instruments for producing drugs should be culture, ideology, or religious beliefs; servic! collected. Special services are needed for es that are not restricted according to the drug addicts in terms of problems with state of mental or physical health of the per! accommodations, legal issues, finances, son, even if they are HIV!positive; services family issues, HIV, HIV testing, and so on. that can be used regardless of financial or Some programs should be aimed at special employment status; services that don’t population groups, such as sex workers who require a specific legal status of the patient; use drugs. Meanwhile, close contacts should and services that offer counseling and assis! be established with appropriate community tance for preventing HIV among IDUs. groups and services so that they can help with the integration of drug addicts into the . Working actively among IDUs local community. This includes ongoing awareness campaigns among drug addicts to help them change . Public awareness campaigns their behavior or avoid dangerous behavior and education while using drugs. Materials should include information on how dangerous drug use This includes education for the general pop! and sharing syringes are, and practical ulation to reduce the stigmatization of high! advice on how to behave more safely. Also, risk groups; identifying high!risk groups; contact should be established with hidden information!sharing work among IDUs and populations of drug users and counseling their immediate environment to prevent on HIV!risky behavior provided, including risky behavior; training personnel from med! information about safer sex and safer meth! ical and social services facilities with an ods of drug use. Sterile needles, syringes, emphasis on primary medical assistance. Conditions for effective harm reduction work
For harm reduction policy to work effectively, ment, respectful and understanding the human rights of IDUs need to be respect! attitudes, good access to treatment and sup! ed and active steps taken to reduce the mar! port make it more reasonable to expect that ginalization and prosecution of HIV!vulnera! IDUs will use the services offered by harm ble groups. The criminal prosecution and reduction programs and will have incentive stigmatization of drug addicts by society only to change their behavior to be less risky. increases their marginalization, making The first step to establishing these condi! them unavailable to preventive efforts and tions has to be that harm reduction policy rendering harm reduction policy ineffective. reduces or stops criminal prosecution for personal drug use and institutes meas! Protecting IDUs from discrimination and ures to reduce the stigmatization of IDUs. establishing an open and friendly environ!
priorities in preventing HIV/AIDS—harm reduction strategy Case study: Harm reduction in Poland Talk of harm reduction strategies began in Poland back in –. However, the first needle exchange programs financed by the Ministry of Health and Social Welfare were launched in , after HIV began to spread among IDUs. The program was carried out through counseling stations run by MONAR, an NGO. The first outreach programs were launched in . The first needle and needle exchange program that was not limited to distribution, was initiated by MONAR in Krakow in . Nowadays, these programs are financed by the National Bureau for the Prevention of Drugs Addiction or international donors. They are now available in all major centers where there are drug addicts in Poland. In addition to injecting equipment, these programs distribute condoms and information about the dangers of injecting drugs and safer sex. They also do public awareness campaigns to spur drug addicts to undergo drug addiction treatment.
Methadone replacement treatment was launched in Warsaw at the Institute of Psychiatry and Neurology in as a pilot program for patients. Over the next years, similar programs were launched in Krakow, Lublin, Poznan, and other cities, once the Sejm, Poland’s legislature, adopted a Law on counteracting drug addiction in .
By late , people were participating in methadone replacement programs. Currently, new pro1 grams are being prepared to launch in different parts of Poland.
Because these measures were taken in time, the number of people living with HIV in Poland, according to unofficial estimates, is only about ,, whereas similar estimates for Ukraine are as high as ,.
Source: National AIDS Center of Poland, http://www.aids.gov.pl/.
priorities in preventing HIV/AIDS—harm reduction strategy Appendix . The European context
According to the European Commission’s health risks associated with drug Coordinated and Integrated Approach To dependence; Combat HIV/AIDS, the Council of the EU’s recommendations on the prevention • emphasizing outreach work methodolo! and reduction of health!related harm associ! gies to involve groups that are beyond ated with drug dependence, and the UN the reach of existing program; and WHO, harm reduction programs are an effective tool to combat drugs and prevent • providing replacement therapy in combi! infectious diseases. Clearly, such programs nation with psychological and social sup! should be expanded. port, with the understanding that a wide variety of different treatment options European Union countries view harm should be provided to drug abusers; reduction as a part of anti!drug poli! cy aimed at reducing demand for drugs • providing imprisoned drug addicts with and the negative consequences of drug services similar to those offered outside addiction for the society as a whole. the prison system; Although there is no evidence that the expansion of illicit drug use declined, full! • distributing and exchanging syringes, scale implementation of harm reduction condoms, and disinfecting materials, measures in European Union states has including setting up programs and nee! helped reduce health risks and the rate of dle exchange points; drug!related deaths. EU policy presents harm reduction as a set of steps that • arranging emergency services to handle includes: overdoses;
• informing and counseling to drug users • integrating health and social services; to promote risk reduction and to facili! tate access to appropriate services; • training for professionals responsible for the prevention and reduction of health! • involving local communities and fami! related risks associated with drug lies in the prevention and reduction of dependence.
Coordinated and Integrated Approach To Combat HIV/AIDS Within The European Union and in its Neighborhood, European Commission, Brussels, .. C () .
Council Recommendation of June on the prevention and reduction of health!related harm associated with drug dependence, OJ L , //, p. .
EU Drugs Strategy –, EU Drugs Strategy –.
EU Drugs Strategy –, Brussels, November , p. .
Ibid, Council Recommendation.
priorities in preventing HIV/AIDS—harm reduction strategy