Commentary: the Value of PrEP for People who Inject Drugs

Authors: Rosalind L Coleman and Susie McLean

Corresponding author: Rosalind L Coleman, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.

INTRODUCTION

HIV prevention is currently insufficient for many populations who inject drugs and who continue to bear a disproportionate burden of HIV. Across all regions, the prevalence of HIV for people who inject drugs is up to 50 times the rate of the rest of the adult population and people who inject drugs account for 30% of all new HIV infections outside sub-Saharan Africa. This inadequacy of HIV prevention is most prominently illustrated in Eastern Europe and Central Asia, where new HIV infections are up 57% compared with 2010 and more than half of these new infections are among people who inject drugs.

Pre-exposure prophylaxis (PrEP) can effectively prevent HIV when introduced in an enabling combination HIV prevention programme and chosen by people at high risk of infection. The integration of PrEP into public health programmes has been presented as an opportunity to strengthen HIV prevention for key populations when implemented in a context of linked action for human rights, supportive laws and violence prevention. PrEP is recommended as a choice for people who inject drugs by the American Centres for Disease control and in the recent WHO recommendation, but some critiques of the value and or effectiveness of PrEP for people who inject drugs are emerging, including from consultations with people who inject drugs. These consultations, co-ordinated by the International Network of People who Use Drugs (INPUD), brought together 75 representatives of people who inject drugs from 33 countries, predominantly from Eastern Europe and Central and Eastern Asia to discuss policy and programme considerations of PrEP in their situations. The implementation challenge is to design PrEP strategies that are context specific and differentiated for key populations in all their diversity, including for people who inject drugs.

The risk of HIV transmission for people who inject drugs exists in a context of other adverse health events and the high HIV rates reflect their broader health problems that include hepatitis C (HCV) and other blood-borne diseases, overdose, vein damage and tuberculosis. Much of the health risk associated with injecting drug use is exacerbated by poverty, inequality, criminalization, violence and discrimination.

WHO, UNAIDS and UNODC have defined and endorsed a range of harm reduction interventions to address and prioritize HIV and related health needs of people who inject drugs. Key interventions include needle and syringe programmes (NSP) and opioid substitution therapy (OST) to reduce unsafe injecting and manage drug dependency, as well as the promotion of condom use, facilitated access to testing and treatment for HIV and other sexually transmitted infections, TB, and HCV, and naloxone provision to prevent overdose, supported by appropriate information, education and communication interventions, and “critical enablers,” such as supportive laws, anti-discrimination interventions, interventions to make health services more accessible and acceptable to people who use drugs and anti-violence interventions. This set of interventions represents the formal list of evidence-based “harm reduction” interventions around which significant consensus lies as evidenced by their endorsement by international, regional and national organizations and governments. This harm reduction approach responds to a wide range of adverse health needs, is relatively inexpensive to implement and can have a high impact on HIV and HCV transmission, Despite this, only half of all countries that report injecting drug use provide OST and even fewer offer NSP. Where these interventions are available, they are often provided at an insufficient scale to have a public health impact.

Lack of scale of these evidence-based interventions results from a number of factors: lack of funding and prioritization, the design and delivery of services that are not targeted to reach key populations and structural barriers that prevent people who use drugs from accessing services. These factors shape the wider risk environments of people who inject drugs and constitute a form of structural violence, when associated with repeated incarceration; compulsory registration on official lists as drug users; and high rates of violence, police harassment, homelessness and poverty.

People who inject drugs will need to know about, believe in and value PrEP, alongside other interventions such as clean needles and OST. Without consideration of the sometimes violent and hostile environment in which these harm reduction services are delivered, people who inject drugs may not embrace PrEP and instead view it as a reductionist and potentially destabilizing intervention that could divert attention away from existing harm reduction services.

DISCUSSION

Concerns expressed about PrEP by people who use drugs underline the importance of identifying particular policy environments, geographies and sub-populations of people who inject drugs and their sexual partners for whom PrEP may be of value.

PREP AND HARM REDUCTION SERVICES

The people who inject drugs who were involved in the consultations agreed that, in a context where other key harm reduction services were in place, PrEP would be a desirable option for some people who inject drugs. It was felt, however, that in countries with the highest injection-drug-associated HIV burden, the reality was far from being realized. Respondents expressed opposition to any introduction of PrEP that was not part of an effort to strengthen broader harm reduction and social justice programmes.

Any new intervention, including PrEP, should strengthen broader health promotion and combination HIV prevention approaches, bolster any existent effective interventions and respond to the diverse needs of the population. A comprehensive combination HIV prevention programme includes condom and lubricant provision, immediate initiation of antiretroviral therapy and the offer of PrEP and also supports related interventions such as harm reduction programmes for people who inject drugs and voluntary medical male circumcision (VMMC) for men in eastern and southern Africa.

HIV prevention spending for key populations such as people who inject drugs in low- and middle-income countries is heavily dependent on international financing which is flattening while domestic funding for key populations is low. A change in donor priorities could destabilize existing harm reduction programmes if they compete for limited funding. This threat is intensified by weak policy and financial support by many governments who have permitted harm reduction programmes that are funded by external sources but who show no or limited commitment to funding harm reduction from national budgets when donors retreat. In contexts where harm reduction programmes are politically unpopular, PrEP could present a convenient and “magic bullet” intervention that allows governments to claim that they are addressing HIV prevention, whilst reducing funding and policy support for other evidence-based harm reduction interventions that people who inject drugs need and prioritize. The ethics of providing PrEP when HIV treatment access for people who use drugs is so poor was also questioned at the consultations.

In any situation, PrEP can only be economically and clinically effective when it is funded as part of an accessible and comprehensive HIV prevention and treatment programme.

PREP, DRUG USE AND SEXUAL TRANSMISSION OF HIV

People who inject drugs account for a disproportionate share of HIV burden whether attributable to injection drug use or in combination with sexual transmission. There is a complex and fluid interaction between the injection or other use of drugs and increased sexual HIV transmission risk. People who inject drugs report low levels of condom use. In Eastern Europe and Central Asia, where half of new infections are among people who inject drugs, 6% of new infections are among sex workers and one-third of new infections are among clients of sex workers and other sexual partners of key populations. Therefore, PrEP has possible value in the social and sexual networks of people who inject drugs where the incidence of HIV is high. These people might include the sexual partners of people who inject drugs, non-opioid drug users who also inject but for whom there is no established substitution treatment and others within the wider drug-using community who are unable to negotiate safe sex, including both women and men who inject drugs and who have sex with men, people who inject drugs and sell sex, transgender people and those who are vulnerable to sexual violence or exploitation. Given what we know of the overlap and double HIV burden of sex work and injection drug use, there is a need for synergy and a broad approach to harm reduction programming. This could include the offer of PrEP to address both sexual and injection-related health risks. The one trial of PrEP that was specific to people who inject drugs was not able to differentiate between the prevention of sexual- and injecting-related HIV transmission.

Consultations with these linked populations could identify additional situations where PrEP might be valuable. Some parallels may be drawn from the views of sex workers who also experience stigma and discrimination that prevents them from engaging with health services. A comprehensive literature search found an “enthusiasm” to use PrEP among sex workers in China, Peru, sub-Saharan Africa and the United States if it were to be distributed through user-friendly services and promoted with non-stigmatizing information and adherence support. This view is tempered with the caution that PrEP introduction should benefit sex workers and their immediate community and not be introduced only for the public health impact in the general population. For some, debate on PrEP promotion provides an opportunity to engage with policy makers on human rights.

This reaction found an echo from a North American INPUD consultation participant and emphasizes the notion that PrEP services should be in step with the varying needs and desires of the priority population for whom it is intended.

It is important to remember that people who inject drugs have the same sexual rights and sexual health needs as those in the general population and that in contexts where HIV transmission is at least partly driven by unsafe injecting in combination with risky sex, HIV prevention impact achieved for people who inject drugs can influence HIV transmission dynamics in the wider population.

PROVISION AND UPTAKE OF PREP

For all criminalized and highly marginalized (key) populations, an enabling environment where their voices can be heard, supported by legislation and zero tolerance for violence, is vital to meet HIV prevention targets and ameliorate many other adverse health events. Where these conditions are still lacking, their absence is a huge constraint to achieving better health and quality of life. Without them, improved services can remain under-utilized and inefficient since key populations will often remain underground for fear of arrest or violence. A person’s request for PrEP can require the disclosure of sometimes illegal and risky practices, along with repeated contact with sometimes hostile health services. In conditions such as these, people who are at substantial risk of HIV exposure and who could benefit from PrEP are unlikely to seek it for fear of discrimination, breaches of privacy, criminal sanctions or other threats.

The history of rights-based health interventions, including for people who inject drugs, has advanced through a series of small victories. The requirement to attend to the context, practices and priorities of key populations applies to all HIV programme implementation, and the emergence of interest in PrEP presents an opportunity to examine these factors more deeply. Current focus and debate on PrEP implementation provides an opportunity for people who inject drugs who are interested to shape the development and design of PrEP services. Health planners and decision-makers will need to engage with people who inject drugs and their sexual partners in order to understand their interest in PrEP, and how any such interest can be integrated with broader prevention services and, for example, the need for drug dependency treatment, overdose treatment, HCV and HIV treatment and the need for protection from human rights violations.

CONCLUSUIONS

PrEP is best understood as an additional potential HIV prevention option for some people who inject drugs and their sexual partners in specific circumstances. The challenge is to ensure that the potential of PrEP is not undermined by narrow and overly biomedical understandings of its value, removed from the real lives of those most at risk of HIV exposure. Harm reduction programmes are intended to address a range of interests and needs, and it is likely that harm reduction programmes could be an effective implementation platform for PrEP for people who inject drugs. (From data and experience of using the medicines in HIV treatment, no interaction is expected between PrEP containing tenofovir/emtricitabine or tenofovir/lamivudine and heroin, methadone or methamphetamine).

PrEP can be an opportunity to harness a specific intervention for longer term public health and human rights outcomes. PrEP will realize its HIV prevention potential if it is introduced in a way that complements and strengthens existing harm reduction and health promotion activities, if it contributes to reducing discrimination and empowers key populations at risk of HIV infection. Creating opportunities to hear from and engage with people who use drugs about their interests, needs, values and preferences regarding HIV prevention, alongside wider health and other needs, is a priority for health programmers and decision-makers. These are some of the factors that will ensure the potential of PrEP for people who inject drugs is realized in a variety of real-world settings.

Full abstract & sources: www.jiasociety.org

Beyond Resistance: Drugs, HIV and the Civil Society in Russia

The speech given by Anya Sarang, the President of the Andrey Rylkov Foundation, at the side event Reducing the harms of drug control in Eastern Europe and Central Asia which took place during the 60th annual meeting of the Commission on Narcotic Drugs on 17 March 2017 in Vienna. 

In 2016 the UNAIDS reported that the HIV epidemic has been taken under control in most countries of the world. The countries of Eastern and Southern Africa have reached a 4% decline in new adult HIV infections, the rates of which were also relatively static in Latin America and the Caribbean, Western and Central Europe, North America and the Middle East and North Africa. At the same time, the annual numbers of new HIV infections in Eastern Europe and Central Asia increased by 57% with Russia responsible for 80% of the new cases. There are only a few countries in the world where HIV keeps rising, and Russia has the fastest rate. According to the Federal AIDS Centre, around 300 people get infected, and 60 people die of AIDS every day. As of August 2016, the number of registered HIV cases was 1,060,000 while the estimates go beyond 3 million. And according to the Ministry of Health, only 28% of patients in need receive antiretroviral therapy.

The main group affected by the HIV in the country is people who inject drugs (PWID). From 1987 to 2008 about 80% of HIV infections were related to unsterile injections and still in 2015 almost 55% of the new cases are among drug users.  Since the beginning of the epidemic, over 200,000 people with HIV have died, the primary cause of death being co-infection with tuberculosis. According to WHO, Russia is among top countries with the highest burden of TB including its multidrug-resistant forms.  Another deadly co-infection is hepatitis C: its prevalence among people who use drugs reaches 90% in some cities. And drug users are entirely excluded from any treatment programs.

The reason for such a dramatic dynamic in public health is the Russian government’s failure to address the HIV epidemic, especially among the people most affected. The Russian government is notoriously negligent to the issue of HIV, vigorously adherent to the most repressive and senseless drug policies and openly resistant to evidence-based internationally recommended harm reduction programs and opioid substitution treatment with methadone and buprenorphine. The government not only fails to provide the financial support to these programs, it explicitly opposes them in the State strategies, such as the National drug strategy. At the same time in the past several years, the international support to HIV prevention has also dramatically shrunk. Due to the aggressive line of the Russian government towards the international aid and unkept promises to allocate own resources towards the epidemic, most international donors have left the country. That resulted in 90% decrease in the coverage of needle and syringe programs. Back in 2009, we had 75 harm reduction projects reaching out to 135.000 clients, and in 2016 there are only 16 projects to reach out to 13.800 individuals which is less that half percent of the estimated number of people who inject drugs. These few remaining projects are supported by the Global Fund to Fight AIDS, tuberculosis, and malaria, but even this symbolic support expires by the end of this year, and there are no new sources on the horizon.

To make the situation even more tragically absurd, in 2016 the Russian government started to attack non-governmental organizations that provide prevention services to people who use drugs and to LGBT. In one year alone, eight AIDS organizations were registered as “Foreign Agents” based on the fact that they receive funding from the Global Fund. Inclusion into the list means four times more reporting, expenses for administrative work and increased risks of fines and administrative charges. It also means that the organizations will not be able to receive any money that comes from the governmental sources.

All of the above has created the situation when the AIDS Service NGOs are blocked from the potential governmental funding while at the same time, most international donors have terminated their support to the Russian NGOs. Some donors, including USAID and several UN agencies, had to cease their operations in Russia due to the government pressure, a supporter of advocacy and human rights initiatives in the area of public health, the Open Society Foundations have been blacklisted by the authorities. But many potential donors also believe that a) situation in Russia is hopeless, and there is no way to improve and b) that their support may exacerbate the risks for the NGOs. Our organization believes that its necessary to provide more truthful information to the international partners about the situation in Russia and possibilities to express support and solidarity.

Our team works since 2009 providing daily health services on the streets of Moscow to people who use drugs. We do outreach work to sites where drug users get together, where we give our HIV prevention materials: sterile needles and syringes, condoms, rapid tests for HIV and Hep C, peer counseling, and support as well as referral to various health institutions. We see from 10 to 30 people daily, and last year alone almost three thousand people contacted our small service. We carried out more than 300 consultations on HIV and hepatitis, and in the last three years, we received reports of 735 lives saved with Naloxone we provide to the clients to prevent deaths from overdoses. We also run a street lawyers project, helping drug users to stand for their rights and dignity, providing them with legal skills and empowerment to represent their interests in courts and state institutions. We have a team of 4 lawyers and around 20 social workers and volunteers. We also provide secretarial support to the Forum of people who use drugs in Russia and facilitate documentation and submission of reports on human rights abuse to the state parties as well as the international human rights bodies. Several strategic litigation cases that came out of the Forum’s work aim to improve the legal context in Russia with regards to access to health and justice, including a case currently under review by the European Court of Human Rights on lifting the ban on opioid substitution therapy in Russia and in Crimea.

In 2016 our organization has been registered as a Foreign Agent, and we were subjected to a fine for not volunteering ourselves into the registry. There was some skepticism concerning our ability to continue the work with this status, but we didn’t want to lose our services because of the bureaucratic inadequacy of the Ministry of Justice. We have challenged their decision in court which surprisingly supported us by finding the Ministry’s decision illegal and lifting the fine. We are still listed as a Foreign Agent, but we also fight this decision by the legal means including, if necessary in the European Court of Human Rights. With the help of our partners and supporters, we have generated a fiscal security fund to sustain our work in case of financial sanctions on behalf of the Ministry. We have also received a lot of support for our cause from the mass media and the general public, including the recently started parliamentary debates on the inadequacy of application of the Foreign Agents law to the AIDS prevention NGOs.

Our experience and the experience of like-minded organizations demonstrate that it is still possible to provide AIDS and drug services in Russia, even in the context of political suppression of the NGO work. The only and the most important condition is the commitment to the protection of rights and health of our community. We are learning by doing and hope to develop creative approaches and a practical model of operations for organizations or groups who find themselves in similar politically restricted circumstances not only in Russia but other countries of our region.

We believe that the western NGOs and governmental organizations should not ‘give up on Russia.’ In fact, now more than ever we need the support and solidarity to continue our work and keep saving lives, health, and dignity, despite the political oppression.

Side Event: Addressing and Reversing the Harms of Drug Control in Eastern Europe and Central Asia

Side Event ‘Addressing and Reversing the Harms of Drug Control in Eastern Europe and Central Asia’ was organised by AFEW International, the Canadian HIV/AIDS Legal Network, the Andrey Rylkov Foundation for Health and Social Justice, and the International Drug Policy Consortium during the 60th Commission on Narcotic Drugs in Vienna in March 2017.

Richard Elliot (Canadian HIV/AIDS Legal Network): To provide a public health overview. Punitive approaches to drug control in the region are rife. But also resources and energy are devoted to law enforcement, rather than public health. Unbalanced situation. In many countries, criminal provisions impose liability for possession for personal use. Even if there’s no criminal sanction, the administrative penalty is used as a platform for rights abuses. Illegal searches, arbitrary detention. In terms of procedural rights, repeated instances of improper procedures in terms of handling of evidence, inaccurate investigation, inflation of quantities of possession, coercion through violence, fostering/inducing withdrawal to extract confessions. There is a general failure to consider someone’s drug dependence when deciding how to apply the law. The right to health is widely affected. There’s a cruel irony in the fact that the criminalisation of people who use drugs is coupled with lack of access to treatment for dependence. Criminalisation pushes people away from services, which are scarce themselves (OST, ART, NSP) or completely absent. There is a case on Russia’s denial to provide OST before CEDH. This denial violates the provisions on torture, privacy and discrimination of the European Convention on Human Rights. Both the ECOSOC and HRC have expressed concern about Russia’s refusal to offer OST. In prison settings, the situation is even more acute. In some countries, bureaucracies also create barriers to access. Ex.the confluence of multiple health conditions is something that sometimes public health systems in the region are incapable of handling. Beyond this, there’s an issue of access to opiate pain medication. Also, women are disproportionately affected by these policies. For instance, even if WHO guidelines have established OST during pregnancy is viable and advisable, many countries prohibit it; adding gender discrimination to the list of abuses in the name of punitive drug control.  The right to privacy of people who use drugs is also consistently violated, including the release of medical records to the public. What to do? Abolish all criminal and administrative liabilities for possession for personal use of illicit substances. Improve access to legal aid services. Work with law enforcement to reduce punitive and torturous practices. Stronger legal foundation that facilitates access to harm reduction and treatment service. Increase funding. In many domestic legal orders, the constitution stipulates human rights protection; they should be expanded to people who use drugs.

Anya Sarang (Andrey Rylkov Foundation): Russia is probably the epicentre of abysmal drug policy that fuels AIDS epidemic in our region. The HIV epidemic is progressively under control according to WHO. Relatively static numbers for new infections in most regions of the world. But new HIV infections are sharply increasing in our region. Russia has the fastest growing HIV epidemic in the world. The Federal AIDS Centre in Russia reports every day 300 people get infected with HIV. Everyday 60 people die of AIDS in Russia.  Estimates 3m infected. Official numbers suggest less than 1/3 have access to ART. 10 years ago, 80% of cases were related to injecting drug users. It’s still 55%.  The primary cause of death related to AIDS is tuberculosis. One of the few countries where tuberculosis is still a major killer for people with HIV. Hepatitis also a significant co-morbitidy that adds to the burden of disease. Russia is openly resistant to evidence-based internationally-recommended practices, programmes and treatment. Not only does the government refuses to finance these, it opposes them. The national strategy describes NSP as a threat to the counter-drug strategy. Most international donors left the country. 90% decrease of harm reduction programmes in Russia as a result. From 104 programmes to 16. There is no new sources of support on the horizon. During the 2016, 8 organisations have been included in the list of “foreign agents”, including ours, because we receive foreign funding. It means the organisations cannot receive any money from governmental sources. It is necessary to provide more truthful information to the international community and donors.  We provide support for drug users through outreach services, provide sterile needles and syringes, peer counselling and support, referral to health services. Almost 3000 benefited from our services. 736 lives saved as a result of naloxone distribution. The Street Lawyers programme documents human rights abuses and provides support to access legal services. Strategic litigation cases. The experience of the Foundation and like-minded organisations demonstrate it is still possible to provide services. We are committed to the protection of the rights of our community.

Victor Sannes (Ministry of Health and Social Welfare of the Netherlands): We value a balanced approach between public health and law enforcement efforts. We’ve come to realise there has been a disproportionate accent on the law enforcement aspect. It’s not about choosing between approaches, but combining them. There’s no “one size fits all solution”. A public health approach requires the deployment of a wide range of initiatives: prevention efforts to avoid or delay uptake as much as possible, risk and harm reduction interventions, etc. The basis of this policy lies in the law enforcement policy. The police were fed up in the 1970s, as the country dealt with street heroin use and related challenges. The Dutch government implemented comprehensive harm reduction interventions. And these policies are implemented with the collaboration between institutions and agencies, as well as people who use drugs, is fluid.


Question 1: What can the international community do to improve the quality of life of people who use drugs in Russia?
Anya Sarang:
 We sometimes have a feeling of isolation. Donors say we cannot do anything. It is important to remind GF donors and board, as well as other donors, that there’s still a need and good work being done on the ground. WE have evidence about our direct impact on people’s lives through our distribution of condoms and naloxone.
Richard Elliot: Important to use international mechanisms to keep attention on this situation. Monitoring state compliance with human rights, etc. At CND, underscore slow-motion genocide of people who inject and use drugs. Denying OST despite the evidence of the death that this produces is on a par with extrajudicial executions and the death penalty.

Comment by the Russian representative:

1) The first question should be “what is prohibited and allowed in Russia”? We cannot allow for activities that are not legal in our country. Last year Russia adopted a new national strategy on combating HIV/AIDS epidemic. We hosted Michel Kazatchkine, to visit some cities in Russia. He decided which cities to visit. He examined the new strategy. His opinion is that the situation improved. He will visit Russia again in a couple of years and compare. We are open for discussion on this particular issue.
2) If some activities are prohibited, we do not allow civil society representatives to continue these activities. Each and every country does the same. There is a huge scope of activities with regards to UNODC/WHO HIV Unit Technical Guide that Russia implements. OST is prohibited. We don’t treat drug users with another substance containing drugs. But we use naltrexone, an opioid antagonist, which blocks receptors. It’s a medication, not a drug.
3) We provide people with a whole range of measures on demand reduction and they work.

Richard Elliot
– If you withhold treatment that is evidence-based, and this leads to the death of hundreds of thousands…I think it’s not a mischaracterisation, to say it’s akin to genocide.

Source: CND Blog

Ikram Ibragimov: “AFEW-Tajikistan is the Only NGO with HIV Rapid Testing Services in the Country”

Фото ИкромThe activities of AIDS Foundation East-West Tajikistan for already 15 years are directed into improving the health of key populations at higher risk of HIV infection. Last December HIV voluntary counselling and rapid testing point was opened in in the representative office of RPO AFEW-Tajikistan in the city of Qurghonteppa. Director of AFEW-Tajikistan Ikram Ibragimov tells about the achievements of the testing point and the organisation in general.

– How was the year of 2016 for AFEW-Tajikistan? What new and important things happened?

– The year was full with events. We changed the statute of the organisation, and we made the areas and directions of its activities wider. We also developed and approved the strategy of the development of the organisation for the medium term, strengthened the partnership and cooperation with governmental and non-governmental organizations in the health sector. We have our own new premises for our office. We renovated it, and have been working there for three months already. In November of the last year we elected the management of the organisation – the board, the audit committee and the director – for the years of 2017-2021. Generally speaking, I would say that 2016 was successful for us.

– Just recently you opened HIV voluntary counselling and rapid testing point in Qurghonteppa. Why did you choose this city to be the “base” for it?

– Our second office is situated in Qurghonteppa. That is why we decided to open HIV voluntary counselling and rapid testing point on the premises where key groups of population are already provided with the direct services. By the way, now we are the only NGO in the country that has such service. Besides, one of the main routes of Afghan drug traffic goes through Khatlon region and that is why drug addiction level in the region is high. People who use drugs are the main target audience for us. As a rule, donors and partners work in the capital and on the North of the country. We decided to go South.

HTC center 3– What are the first results of HIV voluntary counselling and rapid testing point?

– Starting from December, 1 and up until December, 31 there were 18 people tested for HIV: 9 men and 9 women. Thanks God, there were no new cases of HIV found. People find out about our testing point from our website, media, business-cards that we disseminate, information from the clients who visit the centre themselves. Mostly, our visitors are representatives of key populations.

– At the end of 2016 you developed a draft of multilateral agreement on cooperation in the field of prevention of socially significant diseases in Khatlon region and the provision of medical, social and legal services for vulnerable groups. What does it mean?

– This agreement means the cooperation with different organisations that provide complex services (medical-psychological, social, legal and others) to key populations on many levels. The agreement is created on the existing epidemical situation with taking into consideration the socially significant diseases in Khatlon region in Tajikistan. It is planned that 46 government and non-government organisations of the region will become the members of the agreement. We strive to create favourable conditions for the clients of our social support services, so that they can get high-quality, timely and free services of certain specialists. The service should be affordable. Therefore, this memorandum is intended to lower the difficulty of access to services for key populations, and to create a basis for the integration of various services “under one roof.” This is so-called principle of “the single window.”

– What are AFEW-Tajikistan’s plans for 2017?

– As I mentioned before, last year we agreed upon the strategy of the organisational development for 2017-2019. Therefore, all our plans are directed into reaching the quality indicators of this strategy.

Bridging the Gaps in Women’s Hostel in Kyrgyzstan

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Leila and Sofia live in women hostel in Bishkek

Five-year-old Sofia is playing with her mother’s telephone. The girl is sitting on the floor and is listening to the music. She is switching between the songs, watching videos, and trying to find her favourite track. There are four beds in a small room. At some moment, the girl puts the phone away and asks: “Mom, what will Santa bring me?”

“What would you like, dear?” she hears from her mother, and the broad smile appears on her face. “I would like him to bring me a kitten. I will feed it with milk.”

When the girl is smiling, she has cute dimples on her cheeks. She brings a toy – plastic alphabet with the buttons. She presses the letters and repeats them. Sometimes she gets the letters wrong, and then the mother asks her to do it again.

TELLS ABOUT HIV TO NEW FRIENDS

Sofia and her forty-year-old mother Leila live in the hostel that operates in the centre of adaptation and socialization of women – injecting drug users in the public fund Asteria in Bishkek, Kyrgyzstan. Leila was recently released from prison.

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Leila is teaching Sofia an alphabet

“I do not have any relatives; I was raised in the orphanage. I got to prison when I was pregnant, and my daughter was born there,” Leila tells. “Now I work in the kitchen or wash the floors. Recently I went to Turkey, and wanted to find a job there, but I do not know Turkish language, and that is why it did not happen. By education, I am a seamstress and a pastry chef, but it is hard to find a job because I am HIV-positive. I am being asked about my diagnosis all the time, and I always have to go through medical examinations. Now I have found a job as a nursemaid, but I do not have anyone to leave my daughter with. She has to go to kindergarten, but all of them here are not free of charge. I will have to spend almost whole salary to cover the pay for kindergarten… I am currently waiting for the cash advance to pay.”

Leila says that she tells her new friends about her diagnosis, even though she does not always want to do it.

“I think, people with my disease should talk about it, and warn others as well. Now I also bring other people to get tested. I am telling them they have to do it, and that it is free of charge,” Leila says. “Of course, people treat me different when I tell them about my diagnosis. Yes, it is unpleasant, but I am happy that in this way I do something nice to others. Everybody should know such things.”

PRAYING FOR ASTERIA

Leila is worried that the hostel in Asteria can be closed. In that case, the woman can end up on the street. She does not have anywhere to go to.

“I should not be complaining; we have everything here. The main thing is the roof over your head,” the woman smiles and hugs her daughter. “I am very comfortable here. We receive medical treatment, there is a place to sleep, to do laundry. Every Sunday we go to church. In the church I always pray for this house, for people who help us here, and ask God that the organization has donors.”

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The head of Asteria Iren Ermolaeva shows the rules of the hostel

Leila says that she would like to move from the hostel in the future, but she does not have such possibility yet. She dreams of her own home, family, and work. She also wishes that the hostel will never close. People who work in Asteria have the same desire.

“We indeed often have problems with financing. Every year we do not know what to expect in the next one,” the head of the public fund Asteria Iren Ermolaeva says. “Our public fund is working since 2007, and the hostel – since 2009. We would like to have the whole range of services, but there is not enough financing these days. We know how to find the approach to women, we know how to create friendly atmosphere so that a woman would want to change her life for better herself, and we would like to use this knowledge. We feel sorry for our clients, and we would like to help them more.”

DREAMING ABOUT OWN HOUSE

Workers of Asteria also dream about purchasing the house where they will place the centre of adaptation and socialization of women – injecting drug users and the hostel. They have already found funds for the future house renovation, but cannot find money for its purchase.

“Then we would be able to have social entrepreneurship, maybe some little farm. In that way, we could at least not depend on donors in food,” the coordinator of the social services of the fund Tatiana Musagalieva is saying. “Until now, we rented all three houses for our centre.”

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Asteria workers Iren Ermolaeva (on the right) and Tatiana Musagalieva say that their organisation often has problems with financing

Thanks to “Bridging the Gaps: Health and Rights for Key Populations” project from Public Foundation “AIDS Foundation East-West in the Kyrgyz Republic”, in 2016 Asteria could support four beds in the hostel. The project also helped with medicine and warm food.

“People often come to us to eat, to do laundry,” Iren Ermolaeva says. “Around 300 women come through our centre during one year. Leila, for instance, came here after she was released from prison. She has got all the necessary services, clothes, shoes, and got medical examinations. Leila was imprisoned for five years, and, now, due to the conditions that we have, she adapts and integrates into society. In this way, she becomes more confident in herself, can find a job and build her future.”

Irina Used Drugs and Became a Social Worker

irinaIrina Starkova started to use drugs in 1980’s in Osh city in Kyrgyzstan. She tried all the drugs that were available at that time starting with opium, ephedrine and finishing with heroin. She began to use drugs with her husband who was just released from prison.

In 1983, Irina gave birth to a son. “I was happy, but even that did not stop me from drug usage. I couldn’t imagine life without drugs, – Iryna says. – In 1990, I was imprisoned for the first time. After that, I was imprisoned for three times more. In total, I was in detention for almost 11 years, and it was all for the drug use.”

Thus, her son grew up mostly without his mother. Irina’s parents were raising him up. In 2000, she was visited by a specialist from the AIDS Center. He took her blood for HIV testing, and a week later Irina got to know that she was HIV positive. At that time, she had very little information about her diagnosis. “I didn’t know how to live and was afraid of people and relatives condemn, – she remembers. – But I began to shoot up even more drugs. I thought that I will die soon because of HIV…”

Nine years ago, when she was released from prison for the last time, her mom and son got to know that Irina was HIV positive. Their reaction was very unpleasant: Irina’s son said that he did not need a mother, and that she was his shame, and her mother was afraid to live with her in the same apartment. Therefore, Irina was forced to leave to Bishkek, the capital of Kyrgyzstan.

In Bishkek she also found heroin, and it all lasted until she went to rehabilitation in NGO “Ranar” where she got helped. “I don’t use drugs for 9 years already, – she says. – In 2009, I was tested for HIV one more time and I found out that I am healthy and I have no positive status. They explained me that this was an erroneous result. I did not know whether to laugh or cry, because all these years were a nightmare for me. What would have my life been if I knew that I was not sick…”

When Irina went back to Osh, she visited women center “Podruga” (“Girlfriend” in Russian) to receive their services. “Podruga” was established to combat HIV, AIDS and STIs in the Kyrgyz Republic among vulnerable groups. The organization is also is active in HIV/AIDS advocacy and human rights. Now, for three years already, Irina is working in the organization as a social worker. She helps women who use drugs.

Starting Methadone after 18 Years of Using Drugs   

IMG_269244 years old Makhmad asked for support of the social workers of “Bridging the Gaps” program implemented in Qurghoonteppa city in Tajikistan after he experienced 18 years of injecting drugs and had several ineffective attempts of stopping using them. He was seeking for some assistance in his drugs dependence treatment.

“I have heard about methadone many times, but did not believe that it can help me, even though many of my “colleagues” in the streets were telling about its positive effects. During my communication with social workers of AFEW-Tajikistan, I received all the answers to my questions. They told me everything about opioid substitution therapy (OST) and all aspects of using of methadone. I decided to try this treatment myself,”– Makhmad says.

Before entering OST program, Makhmad faced many problems in his everyday life and with his family. “Frankly, I never thought about my family and my kids. All my thoughts were about how to find drugs”, – he says. Thanks to “Bridging the Gaps” program support, Makhmad passed medical observations, got needed tests and afterwards was included in OST program that was implemented by state detox center of Qurghoonteppa.

“After some time of participation in OST program I felt positive changes. First of all, I stopped to think about how and where to find my dose of heroin. Besides, my relations with family members improved. I have also found the job. I feel myself healthy and I can say it with a confidence that everything is good in my life. When I now see people I know who are still using drugs, I explain them that methadone is something that can really help us”, – Makhmad tells.

Social workers of AFEW-Tajikistan are continuing to provide assistance to Makhmad. In return, he does some volunteering work for AFEW, and together with the social workers Makhmad is informing people who use drugs about available services within “Bridging the Gaps” program in Qurghoonteppa.

“Bridging the Gaps: Health and Rights of key populations” project is funded by the Ministry of Foreign Affairs of the Netherlands is implementing in Qurghoonteppa by AFEW-Tajikistan Branch in Khatlon region. People who use drugs or are affected by HIV epidemic can receive client management and HIV prevention services including assistance in initiation and adherence to treatment. Only in the first half of 2016, 84 PUDs were provided by AFEW-Tajikistan’s assistance to pass needed medical observations on free of charge base and 16 of them finally were included in OST program.

Dutch Student Researched Families of People Who Use Injected Drugs in Ukraine

2007_Russia_DrugsA qualitative study “Family members of the people who inject drugs should promote the positive image of harm reduction services” was recently made by the graduate student of Vrije Universiteit Amsterdam Sandra Hagoort, and AFEW in Ukraine.

Master of Health Sciences Sandra Hagoort explored the role of the family of people who inject drugs (PWID) in the utilization of harm reduction services and how could the family stimulate those people to increase the uptake of harm reduction services in Ukraine. With the help of AFEW-Ukraine in the capital city of Kyiv, Sandra disseminated the surveys and did interviews with the family members, PWID and people who work with PWID.

Sandra chose Ukraine for her research because of the incidence and prevalence rates of HIV that are still high in EECA region. “This number is especially high among people who inject drugs which was the group I wanted to focus on, – Sandra says. – I did my study according to the conceptual model which is mainly based on the behavioural model of Andersen. Most important aspects of this model are the population characteristics and the external environment of the PWID.”

HIV is indeed an increasing problem among the PWID in Ukraine. Harm reduction is an evidence based approach which has been proven to reduce the incidence of HIV among PWID. These services are available in Ukraine, however, the uptake is low because of stigma and discrimination. To overcome this barrier, the family of the PWID might play a stimulating role to use more harm reduction services.

“You always hear about HIV in Africa, but I thought, EECA would be a different and interesting angle. I remember the interview I had in Ukraine was with the mother of someone who uses drugs, – Sandra Hagoort says. – During the interview with the mother, I realized that we forget to assist family members of people who use drugs. This was also confirmed by the social workers later on. I realized that the mother was close to despair about how to help her son.”

As a result of her studies, Sandra Hagoort found out that emotional and practical support were both provided by the families of PWID. Moreover, attitude and knowledge were important themes. Stigma towards IDUs as well as to family members of IDUs was reported. The fact that PWID who are under 18 years old are not allowed to obtain harm reduction services without parental consent was also considered as a barrier. In order to increase the uptake of harm reduction services, the communication between the PWID and their families should be improved. This can be done by family counselling in which both parties can express their needs and more support can be provided. After that, a positive attitude towards harm reduction services has to be created. The best way to do this is that family members themselves promote the positive image of harm reduction services.

Now Sandra plans to publish the results of her study in a scientific journal.

AFEW: High Standards in Service Delivery

The new social bureau of AIDS Foundation East-West in Tajikistan attracts diverse key populations for respectful attitude, quality services and professional counselling

In 2014, AIDS Foundation East-West (AFEW) officially opened its branch office in the Khatlon region (in the city of Qurghonteppa, formerly Kurgan-Tyube). This branch office aimed to expand prevention, treatment, care and support services for key populations at high risk of acquiring HIV and other infectious diseases.

Map_Map

Prior to 2014, AFEW had never provided direct healthcare, social, psychological or legal services to key populations. Instead, AFEW supported local community organisations by increasing their capacity and providing them with the skills and knowledge to offer such services. Whilst AFEW plans to continue providing technical assistance to local non-governmental organisations (NGOs), opening its own social bureau will allow AFEW to significantly increase the coverage of quality services aimed at assisting key populations.

THE HIV SITUATION AND LOCAL CONTEXT

High unemployment rates persist in Tajikistan. Official figures indicate that 2.6% of the economically active Tajik population currently have no job, whilst many Tajik migrant labourers returned home following the Russian economic crisis. According to World Bank data from 2014, one-third of Tajikistan’s population lives below the poverty line.

khatlon

In Qurghonteppa the major source of income for the locals is bazaar

Tajikistan lies along the primary transit routes of Afghan drugs making their way to Russia and eventually Europe. The Tajik–Afghan border stretches for 15 000 km, a considerable portion of which lies along rugged mountain terrain, ideal for trafficking. According to official data from 2005, officials seized 4676 kg of opiates illicitly trafficked. Since then, the volume of narcotics exported from Afghanistan has continually increased. Between 2010 and 2015, authorities seized 31 696 kg of illicit drugs.

The availability of drugs, and the high rates of poverty and unemployment in Tajikistan, relate to other demographic characteristics and statistics in the country. For example, in 2004, the estimated number of sex workers reached more than 14 000 individuals. As of 2015, unprotected sexual contact accounted for nearly 62% of all newly registered cases of HIV.

Considering these factors, AFEW chose the location of its social bureau deliberately. The Khatlon region stands as the most densely populated area in Tajikistan. According to Republican AIDS Centre data, since 2013, this region is home to the highest number of new HIV cases.

SOCIAL BUREAU STAFF

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Staff meeting at AFEW social bureau

AFEW’s head office in Dushanbe — Tajikistan’s capital — took matters related to human resources for the new social bureau quite seriously. Of primary importance, setting and maintaining high standards for the social bureau received particular focus since the facility would serve as an example for other NGOs. Today, AFEW is genuinely proud of its branch office staff given how well-known and respected they are within Qurghonteppa and the surrounding region.

Until recently, Tursunpulod Norkulov, PhD (on the right) worked as the chief physician at the Regional AIDS Centre. Today, Dr Norkulov serves as a project specialist at AFEW’s social bureau. His nurse at the AIDS Centre, Kurbongul Alimova (middle) — also a trained biologist and virologist — works as a social worker within the bureau. Clients seeking services from AFEW know both Dr Norkulov and Ms. Alimova from their work at the AIDS centre. Clients also confess to experiencing better attitudes towards those seeking services at AFEW compared to elsewhere. Each individual consultation or group meeting traditionally begins with inquiries about the client’s health, exchanging news from one’s private life and a discussion about any successes and problems the client recently experienced.

JurabekJurabek is one of the most active participants of such meetings. In the past, this 48-year-old man used drugs. He now works at AFEW as an outreach worker. Jurabek knows all of the places in town where people who use drugs typically congregate, and many of those who use drugs know him. In 2015, he reached 190 individuals through his work, 14 of whom joined the opioid substitution therapy (OST) programme.

Jurabek: ‘People who use drugs do not believe in substitution therapy, because drug dealers tell them that the state is deliberately handing out methadone in order to get rid of drug users in a year or two. But, of course, this is not true and only serves to keep their clients buying street drugs. Every time I hear this myth, I tell them my own story—that I myself was on methadone, began to feel well and have now stopped taking methadone completely.’

Alisher, another AFEW outreach worker, uses the same approach when working with people living with HIV. Many are afraid to initiate treatment for HIV, or quit soon after they start it because they lack accurate information about antiretroviral treatment.

Alisher: ‘I work with HIV-positive families, and visit them together with my wife. The AIDS centre provides us with information on those who have quit treatment. The most important elements to this work consist of trust and communication. My wife and I explain to them everything that we did not hear ourselves when we needed it: information related to the side effects of treatment, the importance of continuing treatment and so on.’

CLIENTS

Zhanna-42-SW-Kurgan_smallZhanna (42), a sex worker, divorced her husband when he found another woman when working as a migrant labourer in Russia. Finding herself alone with two young children, she became a sex worker to support herself and her family. When the opportunity arises, Zhanna also cleans houses.

She visited the social bureau initially when it opened, and continues to visit it regularly now. Here, she picks up informational brochures, takes part in information sessions and group consultations or simply comes to chat with other clients. Social worker Kurbongul regularly accompanies Zhanna during her consultations for various tests and consultations at the women’s health and infectious disease clinics. Every three months, Zhanna undergoes HIV testing.

‘I love myself and value my health,’ she said. When asked if she always uses condoms, Zhanna said that she doesn’t always with her regular clients.

She said, when she suggests that her clients use condoms, they suspect her of having a sexually transmitted infection.

Zhanna: ‘Then, I explain to them that it is for my own protection, because not all diseases have visible symptoms, including HIV.’

In future, Zhanna hopes to find a permanent job. Now, she is busy gathering the paperwork necessary to work as a kindergarten teacher.

Sharifbek-and-Bobo1Sharifbek Safarov (left) is 54 years old. He is a Master of Sport on the national wrestling team, a six-time Tajik champion and a Candidate for Master of Sport in judo. For many years, he worked as a wrestling coach. The difficult economic situation, as well as the instability resulting from the civil war in Tajikistan between 1992 and 1997 and the flow of drugs from neighbouring Afghanistan contributed to many young people, including Sharifbek, picking up heroin use.

Sharifbek: ‘For a pair of rubber galoshes, dealers doled out a half kilo of opium.’

In June 2014, Sharifbek met an outreach worker from AFEW’s branch office in the Khatlon region. After Sharifbek underwent an HIV test and screening for tuberculosis, he was offered enrolment in an OST programme.

Thanks to OST and support from social workers, Sharifbek returned to his favourite job. Today, his wrestling programme includes around 70 teenagers, for which he receives a salary from the state. In addition, his methadone dosage is gradually decreasing. With a diploma from a sports college, despite his age, Sharifbek also hopes to complete further higher education training and receive a diploma from the Sports Pedagogical Institute.

Together with his friend, Bobokhuja Badridinov (right)—who is also a client of the OST programme—they often visit AFEW’s branch office to take part in the group sessions with active drug users. In doing so, they explain the advantages of OST and the resulting positive changes to their own lives.

‘Methadone has literally saved us. We can work and feed our families. There is no need to look for drugs. It means there are fewer health risks and chances that we will get into trouble with the law.’

Shodi-MSM-Kurgan-dancer-waiter-volunteer-has-boyfriend_smallShodi (24) is a volunteer at AFEW’s social bureau. He conducts thematic mini training sessions for men who have sex with men and accompanies them to the AIDS centre and infectious diseases clinic. Nearly 20 individuals attend training sessions.

With his boyfriend, whom he met on a popular social network, Shodi regularly undergoes HIV testing. Whilst the couple has been together nearly three years, their parents remain ignorant of their relationship—they think that the two are simply good friends.

Shodi: ‘In Tajikistan, every man must marry a woman. Marriage also awaits both of us. However, this won’t be a problem for us—we will continue our relationship as always.’

In addition to his work at AFEW’s social bureau, Shodi also works as a waiter at a local cafe. When asked by his boss, Shodi performs Indian and Tajik national dances.

Whilst AFEW’s social bureau provides services to all key populations, the majority of its clients consist of people who use drugs. None of those who use drugs holds a permanent job and almost all of them served time in prison. Many clients come directly to the social bureau upon release from prison carrying AFEW’s business cards in their hands. Since September 2014, AFEW has regularly conducted training sessions for prisoners in two colonies in the Khatlon region, preparing individuals for release and reintegration into society. These activities fall within the framework of the Start Plus transitional client management programme. Currently, 26 individuals are enrolled in the programme, the main activities of which consist of AFEW informational sessions on the prevention of tuberculosis and HIV, personal hygiene and healthy lifestyles.

group

Clients come to AFEW’s social bureau for consultations on HIV and other infectious diseases. Here, they may also receive legal counselling and referrals to health centres. Many individuals visit the social bureau simply to chat with each other whilst drinking tea or playing ping-pong.

safetySoon, clients may undergo HIV testing on the premises of the social bureau. In September 2015, the Tajik Ministry of Health issued an order allowing on-site testing based on an AFEW initiative. To provide HIV testing services, public organisations must offer all of the necessary testing infrastructure (i.e., a separate room, equipment and materials) and the staff must complete a relevant training programme. AFEW has already met all of the requirements, including approval from the Blood Centre to handle blood samples. To begin testing, AFEW needs to amend its statute, which is also underway.

Many clients’ primary challenge centres on their lack of employment. Whilst most clients possess only a secondary education, nearly all have hands-on construction, electrical, welding and carpentry skills and experience. Many clients are willing to work in the garden to grow their own fruit and vegetables to sell, raise poultry or rabbits or initiate small-scale production of paving stones for instance. Clients argue that such opportunities would significantly change their lifestyles, habits and behaviour.

CO-OPERATION WITH STATE AGENCIES

plan

Training plan with the police

AFEW’s partnership with the Ministry of Justice’s Punishment Implementation Department to increase prisoners’ awareness of HIV prevention stands as one example of successful cooperation with state agencies. In May 2015, Tajikistan’s Interior Ministry turned to AFEW with a request to organise information sessions on HIV prevention for police personnel. Accepting this request resulted in a total of 566 police officers from district stations completing a training session. Analysis of completed pre- and post-training mandatory questionnaires demonstrated a significant improvement in knowledge about HIV and the means of prevention amongst attendees. Police training will continue in 2016.

FUTURE PLANS

We may safely say that AFEW’s branch office in the Khatlon region has hit the ground running. For such a small organisation, its list of accomplishments for just two years is rather impressive. With its multiple achievements, AFEW plans to expand its work amongst and for this region’s key populations.

Abdumadzhid Saitov, AFEW social bureau’s co-ordinator: ‘As we expand, we will try to accommodate as many of the wishes of our clients. For example, we will develop a library for them towards self-education, offering interesting and educational films. Unfortunately, we cannot address all of their wishes in the nearest future—for example, creating a dormitory for our homeless clients remains a bit beyond our reach. To organise such a place, we would need significant financial resources and qualified personnel.’

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Why UNGASS matters for young people who use drugs in Ukraine

By Elena Voskrenskaya, Director AIDS Foundation East-West (AFEW) Ukraine

DSC00159Today’s youth, tomorrow’s key populations?

For many years, people who use drugs in Ukraine, especially those younger than 18 years, have been facing serious barriers that prevent them from accessing support services. The strict drug legislation, resulting from the global war on drugs, aims to punish people who use drugs rather than tackle the drug dealers. Moreover, the discriminating attitude of service providers and the lack of understanding within communities leave thousands of young people without proper treatment and care.

Care in a friendly environment

Although nowadays adults have better access to harm reduction, which is the most effective method to prevent HIV, children and adolescents who use drugs are left without this support in Ukraine. Also fear of being punished discourages young people to seek medical, legal and other services. The traditional available methods are limited to promoting immediate abstinence from drugs, in most cases with involvement of parents and schools and by informing the police. AFEW-Ukraine embraces innovative approaches. For four and a half years in four regions of Ukraine, we support services that give proper care in a friendly and encouraging environment. The aim is to support young people who use drugs in dealing with challenges and adjusting to life – no matter whether she or he stops using drugs or not. The method works because the services are based on consultations with community representatives and are aligned to the needs of young people.

‘I wanted a thrill’

The Compass Drop-In Centre in Kharkiv is one of the locations that offers services to young people. Oleksandr (17), a client of the centre, told me about his experiences: ‘I tried drugs for the first time when I was 14. Well, the very first time I was 11. I was bored, I wanted a thrill. I got in with the wrong crowd and it was normal. Then I started to suffer from paranoia and panic attacks. My dad is a policeman. But now my relatives really support me coming to the centre. I am more communicative with them now and I have more friends – I communicate more. This has a lot to do with the psychological support I have received here.’ Svitlana, another client of the Drop-In Centre, added: ‘I can’t remember being happy as a child, but I’m happy in the centre.‘

UNGASS

Maryna, psychologist in the centre in Kharkiv, explains that UNGASS is important for the people who use drugs and for the service providers: ‘If any declaration or action plan is adopted globally, it might help us in dealing with the local authorities. And when there is a certain strategy employed by a huge number of stakeholders, this will benefit initiatives for young people at the local level.’

Watch the video ‘Today’s youth, tomorrow’s key populations?’ about young people who use drugs in Ukraine