Azizbek Boltaev Regional Advisor for Central Asia ICAP, Colombia University Social, structural and environmental determinants influencing scale-up of HIV prevention and treatment for people who use drugs in Central Asia

Regional Epidemiologic Profile Globally, Central Asia is one of the few regions where HIV prevalence continues to rise (UNAIDS, 2012). 0.8% - regional prevalence of non-medical opiate use in Central Asia 33% to 72% of all registered HIV cases in Central Asia are attributed to the sharing of injection drug equipment. 6.7% - regional-weighted HIV prevalence among PWID Over the last few years, sexual transmission of HIV has surpassed injection drug use

Historical context For decades, health interventions targeting PWID in Central Asia were limited to narcological care: – detoxification without psychosocial support – forced labor camps – long-term isolation from society – and heavy use of neuroleptics – enforced by police – stigmatizing social pressure – limiting the civil rights of drug-dependent persons.

Historical context (2) These interventions were initiated prior to 1990 under the former USSR government. But the violation of ethical principles and lack of empirical evidence of effectiveness of such approaches did not stop their application, even after the collapse of the USSR In the late 1990s, rapid growth of HIV among PWID inevitably impacted on the drug policies of every Central Asian nation. Currently, all Central Asia countries are signatories to the UNGASS Declaration

National coverage of PWID by HIV services COUNTRY ESTIMATED # of PWID Percentage of PWID receiving HIV services OSTARTNSEPHCT Kazakhstan 123,640 (RAC, 2011) 0,2%1,1%50%65% Kyrgyzstan 25,000 (UNODC, 2006) 4,2%0,7% 27% 54% Tajikistan 25,000 (APMG, 2009) 1,1%1,2% 18% 46% Uzbekistan 80,000 (UNODC, 2006) 0N/A31%29% Turkmenistan 33,000 (MOH, 2007) 000N/A

Structural Determinants Legal environment and policing Policies that discriminate and violate the civic and human rights of drug-dependent persons including those in treatment exist in all countries in the region. Harassment of PWID by law enforcement PWID for obtaining and possessing small amounts of drugs for personal use creates powerful risk environment resulting in underground drug use and inflate unsafe behaviors. Utilization of healthcare interventions by PWID is hampered due the police have access to medical data on patients treated at narcology clinics; deprivation of parental rights of drug-dependent persons.

Structural Determinants (2) Legal environment and policing – According to current legislation, information and education about safer drug use and sex can be used by authorities as proof of promotion of drug use and sex among youth, a criminally prosecuted offense. – Tajikistan has significantly increased the minimal weight of drugs after which criminal prosecution is enforced – Kyrgyzstan has made amendments to its existing regulations that replaced criminal prosecution with administrative charges for first time drug offenders

Social Determinants Stigma and Discrimination Being HIV positive is associated with serious stigma and discrimination often resulting in narrowing of social networks and support as well as substandard healthcare. Drug use also a non-welcomed behavior in CA societies but stigma and discrimination of PWUD is often dependent upon the severity of addiction and the person’s position in the social hierarchy. Patient’s HIV status and drug use often left without attention by healthcare providers.

Social Determinants (2) The role of community of PWID: With few exceptions, engagement of PWID in HIV prevention in Kazakhstan and Uzbekistan has been largely limited to harnessing active and former PWID in delivering prevention messages and tools. In contrast, in Tajikistan and (to a larger extent) in Kyrgyzstan PWID along with other MARP have been able to mobilize their peers in setting up community-based NGOs that not only effectively implement a wide range of HIV prevention activities, but also actively participate in the decision making processes on national and sub- national levels.

Social Determinants (3) The role of community of PWID: The NGOs established by former and current OST patients in Pavlodar, Kazakhstan and Bishkek, Kyrgyzstan are actively engaged in service planning, implementation, quality assurance and evaluations. In general, the role of PWID communities in biomedical treatment services such as ART and OST remains limited, which often results in poorer adherence due to unaddressed psychological and social problems.

Environmental Determinants Evidence-based public health practice Opioid Substitution Therapy in Central Asia has been, arguably, the most politicized healthcare intervention that continues to cause debates among professional and non-professional audiences. Opponents of OST promote abstinence-only approaches in the treatment of addictions and define OST as “immoral attempts to give patients a poison instead of real treatment” This has resulted in discontinuation of OST in Uzbekistan and delays in implementation and scale-up in Kazakhstan

Environmental Determinants (2) Evidence-based public health practice Restrictive enrollment criteria to OST; Lack of psychosocial support; and sub-optimal doses of methadone that result in lower retention rates in OST programs in Central Asia and concurrent misuse of psychoactive drugs The belief that PWID have poorer responses and adherence to antiretroviral therapy (ART) is widespread and results in late initiation or refusals to initiate ART to otherwise eligible PWID

Environmental Determinants (3) Funding for HIV prevention Most Central Asian countries continue to be dependent on external support for services targeting PWID, largely from the GFATM. Kazakhstan has been the only country in the region to allocate funds in its healthcare budget to explicitly support NSEP, ART and OST. DFID and World Bank that funded Central Asia’s NSEPs and other low-threshold HIV prevention services targeting PWID until ceased their funding in 2011.

Environmental Determinants (4) Funding for HIV prevention Aiming to fill the funding gap left by the closure UKAID ad WB programs, the US funds were channeled to Central Asia PEPFAR. However, the US Congress restricted the funding from being used to implement NSEPs. All Central Asian countries remain dependent on external donor support for capacity development of their harm reduction workforce and have no committed resources in their national healthcare budgets for such purposes.

Healthcare Related Constraints Human resources In Central Asia, curricula of medical schools still lack review of state-of-the-art, evidence-based approaches to care and treatment of drug dependence and HIV among PWID. Too often, workers in the medical field are no more knowledgeable about HIV services, particularly ART and OST, than those without a medical background.

Healthcare Related Constraints (2) Integration and coordination of HIV services HIV services are poorly integrated making it harder for PWID to move through a continuum of care, especially when they present with multiple medical problems. Often this leads PWID to drop-out from HIV care before or soon after initiating ART or even immediately after their initial HIV test. Example of poor integration: OST patients, who continued occasional risky injection practices, were unaware of the availability of a NSEP site in the same health care facility where OST was provided

Healthcare Related Constraints (2) Integration and coordination of HIV services Clinicians prescribing OST might not be aware of concurrent ART taken by their patients Where they are aware of their patients’ ART status, due to lack of basic knowledge about ART, narcologists often do not take any action to monitor ART adherence or adjust their patient’s methadone dose

Conclusions Until now c the countries of Central Asia have were mainly focused their efforts on scaling up the spectrum and availability of HIV prevention service sites. Little consideration was given to underlying reasons for drug users’ – continued engagement in risky behaviors; – low utilization levels of and poor adherence to available services, including OST and ART.

Recommendations In order to effectively decrease the epidemic Central Asian governments must constantly monitor and properly address all existing, as well as any new and emerging, social and structural factors that facilitate HIV risk among PWID and decrease their chances of enrollment and adherence to HIV prevention, treatment and care. Governments and donor communities need to expand policies and programs to motivate mobilization of PWID communities, along with other MARP, for active HIV prevention among PWID, their sex partners and drug risk networks.

Recommendations (2) Central Asian countries need to identify the best strategies to implement such combination interventions (OST, ART, NSEP) in the local context. In light of inspiring developments in “treatment as prevention commitment of national resources to programs aimed at early detection and treatment of new HIV infections among PWID represents the most effective public health investment.

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