The HIV/AIDS and drug use crisis in Eastern Europe and Central Asia Professor Michel Kazatchkine Global Commission on Drug Policy UN Secretary General Special Envoy on HIV/AIDS in Eastern Europe and Central Asia

HIV in Eastern Europe and Central Asia An expanding HIV epidemic, largely driven by unsafe injection drug use; heterosexual transmission now also a major component of epidemic growth Access to antiretroviral treatment remains low, particularly for key affected populations HIV prevention is not accessible at sufficient scale Access to harm reduction inexistent or very limited Health systems are vertical and provider-centered High levels of stigma and discrimination; numerous structural, cultural, societal and political obstacles to the AIDS response Low levels of co-operation between government and the non-governmental sector Issues around financial sustainability of programs

HIV, HCV, TB/MDR-TB and drug use are major and closely interlinked challenges in the region 25 % of the > 3.5 million people who inject drugs (PWID) in the region are infected with HIV, with large variations (10 - >50%) between and within countries. Over two thirds of PWID are infected with HCV.. HCV co-infection rates among HIV-positive PWID range between 70 and 90 %. HIV-positive PWID have a two- to six-fold higher risk of contracting TB; 80% of men with HIV and TB co-infection are PWID. Almost all countries in the region are high burden countries for MDR-TB.

Association between HIV and MDR-TB in Europe TB surveillance and monitoring in Europe 2014. ECDC/WHO, Stockholm The map shows the percentage of MDR in all TB cases with DST results (%) in the European Region in 2010 This study from Ukraine showed that the risk of drug resistance MDR TB is as almost double in prisons than other sectors. Post et al, Journal of Infection (2014) 68, 259-263, (Belarus, Latvia, Romania, Russia & Ukraine)

Injecting drug use in EECA With the fall of the communist economic and political system in the 1990s, unemployment, poverty and crime increased dramatically in Russia and throughout the post-soviet space. At the same time, new drug markets opened up with increasing availability and demand for drugs. In the early 2000s, HIV/AIDS and drug-related health issues emerged as pressing social and public health challenges.

Rapid growth of the HIV epidemic among people who inject drugs in the Russian Federation In the early 2000s, a number of NGOs started outreach and needle exchange programs supported by international funds From 2010, Russia has increasingly been promoting “traditional values”; drug use was increasingly stigmatized. “Foreign agent laws” promoted. Government has been categorically opposing harm reduction in all national and international fora. There is an estimated 5 M drug users in the Russian Federation, of which 1.7 M are opiate users. Over 65% of all cumulated HIV cases since the beginning of the epidemic are PWID. Prevalence of HIV among PWID ranges between 20 and 70%. It is higher in large urban settings.

Rapid growth of the HIV epidemic among people who inject drugs in EECA is largely policy-driven A punitive approach to drug use, repressive drug policies and prohibition law enforcement prevail in the Russian Federation and across the region Fear of arrest and of violence from police is associated with lower capacity for HIV risk reduction Lack of social and health services tailored to the needs of PWID Harm reduction is not accessible, or not at the needed scale for impact

Estimated annual numbers of syringes distributed per person who inject drugs (PWID) and estimated number of opioid substitution treatment clients per 100 PWID (latest year) Here we show both the estimated annual numbers of syringes distributed per person who inject drugs (PWID) and estimated number of opioid substitution treatment clients per 100 PWID (in the latest year for which data is available with ranges). RS*: red line to indicate the level recommended by WHO/UNODC/UNAIDS We clearly see that countries are not implementing harm reduction interventions to scale – with poor coverage of needle syringe programmes and opioid substitution therapy Percent of estimated PWID or opioid injectors who received OST, 2014 or latest year available Based on country reported GARPR data to UNAIDS, 2014 & to EMCDDA, 2015

Harm reduction: compelling evidence of effectiveness NSP and OST reduce the sharing of injection equipment and avert HIV infections In combination with ART, NSP and OST: Reduce HIV transmission Decrease mortality Promote initiation of and compliance with ART Reduce drug-dependency Reduce crime and public disorder Harm reduction interventions are highly cost-effective

A model to reduce HIV prevalence/incidence by half over 10 years in St Petersburg To halve incidence: 79% on high coverage NSP 30-40% on paired interventions 20% on all three interventions To halve prevalence: Not possible for just NSP Twice coverage needed to halve incidence *coverage just amongst HIV+ PWID Vickerman P, Platt L, Jolley E, Kazatchkine MD, Rhodes T, Int J Drug Policy. 2014 Nov;25(6):1163-73. Int J Drug Policy. 2014 Nov;25(6):1163-73. Controlling HIV among people who inject drugs in Eastern Europe and Central Asia: insights from modeling. Vickerman P1, Platt L, Jolley E, Rhodes T, Kazatchkine MD, Latypov A.

Global commission on drug policy (2011)

Global commission on drug policy (2011)

Prisons: a high risk environment The Russian Federation and many countries in the region have some of the world’s highest incarceration rates Many prisoners wait for months in pre-trial detention Poor physical conditions; overcrowding; poorly trained staff Unsafe injection drug use and unsafe sex High prevalence of TB and MDR-TB No access to harm reduction except in Kyrgyzstan, and in Moldova.

*Slide changed* Probably orally you could mention that drug crimes remain one of the main crimes and reasons for people’s imprisonment. In Georgia, massive drug testing continues and drug use per se can lead to imprisonment. In many countries from Ukraine to Belarus, from Georgia to Lithuania, traces of drugs already classify the action from misdemeanor to a crime punishable with imprisonment. Drug policies remain measured by the number of crimes detected and people who use drugs – with drug traces in their blood or in their syringes – are an easy target to show success of drug policies. **EHRN data sources** Number of drug crimes registered or people convicted for drug crimes vs those crimes/convicts in case without intent to supply, i.e. really minor minor drug crimes Figures are based on latest publicly available data that could be found in open-source publications, with some information dated back to 2009 and other as recent as end of 2012; For figures where data on persons convicted for drug offences in a given year were not available, data on registered drug offences were used (i.e. Lithuania, Poland, Uzbekistan); Data for Kyrgyzstan on cases of possession without intent to supply are based on possessions of narcotic drugs in the amount below or equal to 10 grams – a much higher threshold which was arbitrarily chosen by the Kyrgyz researchers to realistically differentiate between ‘users’ and ‘traffickers’ and which explains the very high proportion of cases assumed by the researchers to represent possession without intent to supply

Within-prison drug injecting practices among HIV-infected inmates in Ukraine Based on a survey among 97 HIV infected adults recently released from prisons in two major Ukrainian cities. Those who shared their syringes – shared with an average of 4.4 other injectors. Izenberg et al, IJDP, 2014

129 CSOs in almost 3,000 sites distributed Coverage of clients with minimum package of services (consultation + condom/syringe + info) in Ukraine in 2014 PWID CSW MSM Estimate Reach % 310,000 196,992 63.5 80,000 37,061 46.3 176,000 28,500 16.2 129 CSOs in almost 3,000 sites distributed 14.5 M condoms and 20.5 M syringes in 2014 PWID p/a CSW p/a MSM p/a Syringes 143 -- Condoms 20 300 100 Lubricants 2 150

Non-governmental sector in EECA Few/ fewer registered civil society and community-based organizations addressing PWID Restrictions on funding from international sources Foreign agent law, foreign grant registration No mechanisms to contractually engage the non-governmental sector into an effective and meaningful partnership for health

Financial sustainability As of July 2013, the Russian Federation is classified as high income country. Most of the other countries in the region are classified as middle income. International support for HIV programs is decreasing and new domestic funding is not keeping pace .

Health is politics Drug policies heavily relying on prohibition law enforcement hamper access to OST and NSP. Methadone is illegal in the Russian Federation, Uzbekistan and Turkmenistan. High rates of incarceration for drug offences across the region. Low / very low proportion of national HIV budgets devoted to prevention and to most at risk vulnerable groups. Presidential Decree #6 2014 in Belarus enables access of the Ministry of Interior to the personal data of people with drug addiction officially registered in a health facility OST discontinued in Crimea following annexation. OST now discontinued in the separatist territories of the Donbass in association with ongoing violence and government restrictions on the delivery of humanitarian aid in the conflict areas

Why should use and possession be decriminalized Criminal sanctions or the threat of them constitute barriers to access to social and health services Criminal sanctions also reinforce discrimination and social disdain Criminalization of drug use results in police abuse and over-incarceration of people who use drugs, including non-violent offenders. A criminal record for a young person for a minor drug offence can be a far greater threat to their wellbeing than occasional drug use. Criminalization of drug use fuels violence and corruption associated with organized criminal networks. Wasting huge sums on ineffective policies.

END CRIMINALIZATION OF DRUG USE END CRIMINALIZATION OF HIV Drug user awaits interrogation, Tajikistan Photo; Hans Jurgen Burkhart

ACKNOWLEDGEMENTS UNAIDS Eurasian Harm reduction network, Vilnius Peter Vickermann, London Raminta Stuikyte, Isabela Barbosa,Vilnius and Geneva Outreach in Moscow, run by activists. 2013 Outreach in Moscow, run by activists. 2013