1. Harm reduction in social and medical care for people who use drugs in the new environment
Michel Kazatchkine
UN Secretary General’s Special Envoy on HIV/AIDS in Eastern Europe and Central Asia

2. People who use drugs: illicit drugs
People who inject drugs
Non-problematic use; problematic use; dependence
Life-long; intermittent; current use and/or injection
Variety of substances: depressants, stimulants, hallucinogens
Drugs are procured through criminal markets

3. People who use drugs: licit drugs
Most « drugs » are « drugs » !
Opioids for treatment of pain
Benzodiazepines for treatment of anxiety
Stimulants for alertness
Cannabinoids for treatment of spastic diseases
Drugs are procured on legal regulated markets

4. Harm reduction
Interventions, policies and messages that aim at reducing harm without requiring that harmful behaviors be eliminated
Nicotine patches, light beer, seat belts, helmets for cycling or skiing

5. Harm reduction
“Addiction is a primary, chronic disease… characterized by an inability to consistently abstain…
Like other chronic diseases, addiction can involve cycles of relapse and remission”.
American Society of Addiction Medicine

6. Harm reduction interventions
Compelling evidence of effectiveness
In combination with antiretroviral treatment (ART), NSP and OST:
Reduce HIV transmission
Reduce HCV transmission
Decrease mortality
Promote initiation of and compliance with ART
Reduce drug-dependency
Reduce crime and public disorder
Highly cost-effective

7. Harm reduction interventions
Needle and syringe distribution
Opioid substitutive therapies
Supervised injection sites
Safer injection education
Medical heroin prescription
Naloxone distribution
Adapt interventions to evolving context of drug use

8. Environment in EECA, 2017
Repressive legislation and policies on drugs across the region
Repressive law enforcement and over-incarceration. Fear of violence from police is associated with lower capacity for risk reduction
High levels of stigma and discrimination, including in healthcare settings
Major treatment gaps for addiction, HIV infection, hepatitis
Low coverage of harm reduction
Fast growing HIV, HCV epidemics primarily driven by unsafe injection drug use
Clash of evidence and ideologies
Use of health (harm reduction) as a political tool
Significant issues around financial sustainability of programs

9. Health is politics
Drug policies heavily relying on prohibition law enforcement hamper access to OST and NSP.
Methadone is illegal in the Russian Federation and Turkmenistan; it is not available in Uzbekistan.
High rates of incarceration for drug related offences in most countries in the region.
Low / very low proportion of national HIV budgets devoted to prevention and to vulnerable groups.
Discontinuation of OST in Crimea following annexation.
Discontinuation of OST in the Donbas associated with ongoing conflict and government restrictions on the delivery of humanitarian aid in the conflict areas.

10. « Drugs have harmed many people, but wrong government policies have harmed many more »
Kofi Annan, 2015

11. Harm reduction policies
Policies to fight stigma, including in health care settings. Means more advocacy and more empowerment of people by civil society and community organizations
Re-define drugs as a health and social issue
Close the treatment gap*: Expand capacity, reduce barriers to entry and retention, increase flexibility, integrate services
* less than 1/10 patients suffering from dependences - all dependencies - have access to care worldwide

12. Planning treatment of dependence
A continuum: screening-brief intervention-diagnosis-treatment-rehabilitation-relapse prevention-harm reduction
Close to where people need it, e.g. primary care
Abstinence cannot be the only objective of treatment

13. Harm reduction policies
Integrate medical, social and community harm reduction services
Does not mean having all services in one place; aim at medical and social hubs
Integrate harm reduction into health reforms: harm reduction as a fundamental approach to healthcare for all vulnerable populations

14. 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 Nov;25(6):
Int J Drug Policy Nov;25(6):
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.

15. Prisons: a high risk environment in EECA
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
Overcrowding; poor physical conditions; poorly trained and often corrupt prison staff
Unsafe injection drug use and unsafe sex; High prevalence of TB and MDR-TB
No access to harm reduction in detention settings, with a few exceptions (Moldova, Kyrgyzstan)
No integration of services in the penitentiary sector and services in the community

16. Harm reduction policies
Stop incarcerations of minor drug-offenders
Decriminalize drug use and possession
Move towards government-regulated drug markets

17. 2016 recommendations on decriminalization
Abolish death penalty for all drug-related offences
End all penalties - both criminal and administrative – for drug possession for personal use. To criminalize people who use drugs is ineffective and harmful, and undermines the principle of human dignity and the rule of law
Implement alternatives to punishment for low level non-violent actors in the drug trade
UN member states to remove the penalization of drugs as a treaty obligation under the international drug control system
States to explore regulatory models for all illicit drugs and acknowledge this to be the next logical step in drug policy reform following decriminalization

18. Opioid substitution therapy program in Dnipropetrovsk, Ukraine (Natalia Kravchenk / Alliance 2013)

19. Outreach in Moscow, run by activists. 2013