Drug Treatment Systems in Prisons in Eastern Europe Discussed by AFEW Board Member

Council of Europe Co-operation Group to Combat Drug Abuse and Illicit Trafficking in Drugs published a new publication “Drug Treatment Systems in Prisons in Eastern and Southeastern Europe”. The publication sheds light into the situation of drug users among criminal justice populations and corresponding health care responses in ten countries in Eastern and Southeastern Europe: Albania, Bosnia-Herzegovina, Georgia, Kosovo, Macedonia, Moldova, Montenegro, Russia, Serbia, and Ukraine. AFEW‘s board member Vladimir Mendelevich is one of the contributors of the publication. 

The research project on drug-treatment systems in prisons in Eastern and South-East Europe looks in detail into the situation of drug users among criminal justice populations and the corresponding health-care responses in nine countries in Eastern and South-East Europe – Albania, Bosnia-Herzegovina, Georgia, Moldova, Montenegro, Russia, Serbia, “the former Yugoslav Republic of Macedonia” and Ukraine – and Kosovo. It was conducted between 2013 and 2016, and is a first attempt to collect relevant data on drug use among prison populations and the related responses in the nine countries and Kosovo.

Although the places chosen are quite heterogeneous in size, structure, legislation, economy, culture and language, they are all in a process of economic, social and cultural transition. This has triggered reforms of some of their prison systems and policies but it has also led to financial and political instability and lack of leadership due to frequent changes in the prison systems’ top management.

The full publication can be downloaded here.

Hepatitis A Prevails in Kyrgyzstan

Author: Olga Ochneva, Kyrgyzstan

Hepatitis Prevention Month to commemorate the World Hepatitis Day was organised for the first time in the history of Kyrgyzstan by the Ministry of Health in July this year. Over the recent years, the list of registered and allowed for import medications to treat hepatitis C has been expanded, the new clinical treatment protocol has been approved and a six-year target program to counteract viral hepatitis was adopted. Hepatitis is one of the leading causes of death among people living with HIV and higher-risk populations. Without a doubt, the discussion of availability of hepatitis diagnosis and treatment, introduction of treatment guidelines and implementation of the national viral hepatitis interventions will be an important part of the International AIDS Conference in Amsterdam in 2018. We discussed the reasons for the increased attention to the problem of hepatitis in KyrgyzstanIn with Nurgul Ibraeva, Chief Officer of the Department of Health Services and Medications Policy of the Kyrgyz Ministry of Health.

Statistics and the real picture

“The problem of viral hepatitis in Kyrgyzstan is growing every year. Blood-borne hepatitis B and C remain a challenging concern, as patients consult the doctors whey they already have advanced illness and complications, such as liver cirrhosis and cancer. During the Hepatitis Prevention Month, we raised awareness in the population about the need to get tested and offered discounted tests that were supported by private laboratories. Many people in Kyrgyzstan find the price for hepatitis testing (around $50) challenging, so patients often discover their disease at an advanced stage,” Nurgul Ibraeva says. “Following the official statistics, in the last five years 11,000–22,000 people with viral hepatitis were registered on an annual basis. Health services provide treatment to more than 2,000 patients with parenteral hepatitis (hepatitis B, C and D – author’s note), but we believe that the actual number of those infected is much higher: more than 250,000 people.”

Prevalence of hepatitis A is the highest. It accounts for 96% of the registered cases, with blood-borne hepatitis B coming second. According to the National Immunization Schedule, since 2000, hepatitis B vaccine is administered to all newborns free-of-charge. As a result, hepatitis B incidence had a fourfold decrease over the last 16 years. Currently, our health services register around 300–400 new cases of hepatitis B among adults annually, while incidence among children dropped to several isolated cases.

“Immunization brings its fruit. According to the Ministry of Health regulation, health workers exposed to blood should be vaccinated, yet no funds are allocated for it, and not every health worker can afford a vaccine,” Nurgul Ibraeva is saying. “Unfortunately, there is no vaccine against hepatitis C. Even if you use means of protection and take the necessary precautions, there is always a risk. Some health care staff remain untested, and it is our estimate that around 1000 health workers have hepatitis C.”

According to the Republican AIDS Center and the Research and Production Association “Preventive medicine” of the Kyrgyz Ministry of Health, in 2014–2015, the share of health personnel with hepatitis C in the general HCV prevalence amounted to 2.5%. The same percentage is attributed to the general public.

Hepatitis C prevalence is the highest among people who inject drugs (PWID). In 2010, 50% of all hepatitis C cases was registered among PWID. By 2015, this share dropped to 35%. Inmates are also among those especially vulnerable to hepatitis C. Over the last six years, 24–53% of all cases were identified in correctional institutions.

“Needle exchange services and opioid substitution therapy are available in Kyrgyzstan, including prisons,” Nurgul Ibraeva is telling. “Prevention programs strive to break the chain of transmission, but the share of infections remains high, even though we managed to stabilize the situation.”

As is the case with other population groups, key populations are still inadequately covered by diagnostic services. According to the official data, from 100 to 200 new cases of hepatitis C are annually registered in Kyrgyzstan. However, the estimated number of people with hepatitis C is much higher: 101,960 cases among the general population and more than 11,000 cases among people who use injecting drugs.

Availability of treatment

In April 2014, the coalition of non-governmental organizations under the initiative of the “Partner Network” Association of Harm Reduction Programs successfully lobbied changes in the Kyrgyz patent legislation. This allowed Kyrgyzstan to import and license generic medications to treat hepatitis C. Currently, a 12-week treatment course on the basis of an officially registered drug costs $615 for a generic and $1500 for the original.

“We have access to several licensed medications produced in China, Egypt and India,” Nurgul Ibraeva says. “If earlier treatment for one patient amounted to $15 000–20 000, today patients can choose medications they can afford. With the expansion of the list of available drugs, producers have been lowering their prices. Yet, patients still have to pay for treatment, which is a challenge for key populations.”

All imported medications have been included in the Essential Medicines List, which is a pre-requisite for the potential state procurement in the future. A Target Program to Address Viral Hepatitis for the period till 2022 has been approved, yet it does not guarantee treatment and does not have financial backing for the planned activities. At the same time, only among people living with HIV, the prevalence of parenteral viral hepatitis exceeds 14%. Over the past six years, the registered number of people with HIV and hepatitis C co-infection increased twofold and reached 701 cases in 2015. Advocates succeeded to include annual hepatitis C treatment for 100 people with HIV into the State Program for HIV Control. Treatment will be financed by the government for the period of five years. Besides, this year a Clinical Protocol for Diagnosis, Treatment and Prevention of Viral Hepatitis B, C and D has been approved. The document is aligned with the latest WHO recommendations and treatment regimens based on direct acting antiviral drugs that are widely available on the market.

Almaty is the first city in Central Asia to sign the Paris Declaration

Paris Declaration in Almaty was signed by Deputy Akim of Almaty city Murat Daribaev and UNAIDS Director in the Republic of Kazakhstan Alexander Goleusov

Author: Marina Maximova, Kazakhstan

The world movement, which already includes more than 70 major cities around the world, has reached Central Asia. The first city, whose authorities signed Paris Declaration with an appeal to stop AIDS epidemic on July 20, 2017, was Almaty. Signing of the declaration became possible and was organized within the framework of the project “Fast-Track TB/HIV Responses for Key Populations in EECA cities”, implemented by AIDS Foundation East-West in Kazakhstan.

Almaty is the largest city in Kazakhstan. It is cultural, financial and economic centre of the republic with a population of more than 1.7 million people. For many years it was the capital of the country. The megapolis, along with Pavlodar and Karaganda regions, has the highest rate of HIV infection in the country. Therefore, signing Paris Declaration gives Almaty opportunity and hope to improve the sad situation.

“This fact will undoubtedly attract city residents’ attention to HIV issues. People will get tested more actively, and will start their treatment in time if necessary. Almaty will participate in international health events and will have access to the most advanced achievements and developments in the field of HIV and AIDS. The best world practices will be included into the City Improvement Plan on HIV and tuberculosis until 2023. This will stop the growth of HIV epidemic and improve population’s health,” Valikhan Akhmetov, the head of the Almaty Public Health Department said during the ceremony of signing the declaration.

Sexual transmission of HIV increases

Today, there are more than five thousand registered HIV cases in the city. A quarter of the cases is observed among internal and cross-border migrants. For many years, the main route of transmission was parenteral. To stabilize the situation, the Akimat (regional executive body in Kazakhstan – editor’s comment) has introduced harm reduction programs targeted to key populations: people who inject drugs, sex workers, men who have sex with men. There are 18 syringe exchange points in the city and six friendly cabinets at polyclinics. This year, despite strong public confrontation, site for substitution therapy has been launched.

The trend of the HIV infection spread has changed dramatically in recent years. Today, the sexual transmission is already 65%. Infection, as doctors say, is now targeting general population, but people are still not aware of it and live as if it has nothing to do with them.

“It is very difficult for people from secured families and those who have good jobs to accept the positive HIV status. Women who live in a civil marriage, refuse to name their sexual partners. There can be another situation: imagine a girl coming to us with her mother, who claims that her daughter is a pure child, and she simply cannot have HIV infection,” Alfiya Denebaeva, deputy head physician of the Center for Prevention and Control of AIDS in Almaty is saying.

Some pregnant HIV-positive women do not take antiretroviral therapy (ART) because of the disbelief. Several years ago, there were cases in the city where mothers who did not believe in HIV-infection refused to take medicine, and their infants then died. Now there is an occasion to discuss this topic at the 22nd International AIDS Conference AIDS 2018 in Amsterdam, in which participants from Kazakhstan will also take part.

Regardless of what was mentioned before, Kazakhstani doctors manage to achieve high results. 99 percent of HIV-positive women give births to healthy children. There are several cases when HIV-positive women become mothers for the second and even third time. It is mostly possible thanks to mandatory two-time testing of every pregnant woman when timely diagnosis and starting of ART is possible to establish.

Almost 90% of PLHIV, who need treatment, receive ART

Regional Director of UNAIDS in Eastern Europe and Central Asia Vinay Saldana

In Almaty, testing and treatment of HIV infection is possible at the expense of the city and republican budgets. Back in 2009, the country was the first in Central Asia to start purchasing ARV drugs for adults and children. Today Almaty is the leader: more than 88% of people living with HIV (PLHIV) in need of ART, receive this treatment. This figure is higher than the same figure in the republic by eight percent. The megapolis is much closer to achieving AIDS targets 90-90-90 than any other city in the country: 90% of people living with HIV should be aware of their HIV status; 90% of people who are aware of their positive HIV status should receive antiretroviral treatment; and 90% of people receiving treatment should have a suppressed viral load that will allow them to stay healthy and reduce the risk of HIV transmission.

Another statistic data is showing the advantages of life-saving therapy. The effectiveness of treatment for PLHIV is more than 76%. Thanks to the early beginning of ART, there has been a 20% decrease in new tuberculosis cases among HIV-positive people. This is a very important achievement because the combination of HIV and tuberculosis infections is the main cause of death among PLHIV. Over the past year, this number has increased by 20%. The main reasons for this are late detection of HIV and amnestied patients, who arrive home from places of detention in critical condition. In every third case, the death was inevitable due to the specifics of the damage of the immune system and other organs. Mostly it was cancer or general body atrophy.

“Thanks to United Nations assistance, Kazakhstan has developed a new mechanism for purchasing ARV drugs. Only three years ago, we were spending several thousand dollars per year for a single patient. Now this cost is reduced to the minimum. Therefore, previously we could not advise people living with HIV to start treatment immediately, but now this treatment is available to everyone,” Vinay Saldana, Regional Director of UNAIDS in Eastern Europe and Central Asia is saying.

AFEW Shared Techniques of Relaxation in Kyrgyzstan

The community dialogue platform gathered for the summer school last week in Kyrgyzstan. This summer school was organised within ‘Bridging the Gaps’ programme. The director of programs of AFEW International Janine Wildschut attended the school. After some days of serious work in which the community discussed struggles they face in Kyrgyzstan and how they can come up with a united voice, a training on burnout syndrome and how to prevent it was arranged.

“For many community leaders life is hectic and full of stress. First of all, they do their work with their full heart, which makes them also more sensitive for the stories and troubles of people they help. Secondly, the community members were mostly not trained as managers and leaders of NGOs, and now they are carrying this responsibility with big feeling of commitment. Besides, daily life in Kyrgyzstan for many people consists of a lot of struggle: family responsibilities, economic challenges and little time for relaxation,” Janine Wildschut shares. “This results in feelings of stress, little division of private life and work and little awareness of spending time on hobbies or personal time. Besides, within NGOs there is not much awareness of the need for staff to relax, take holiday time, have some breaks or breathing exercises. Women seem to have more pressure than men, as women are the main caretakers of the household.”

Thіs summer school gave the community members an opportunity to become more aware of stress factors. For one week they were thinking more about themselves, exchanged their worries and learned relaxation techniques.

“As I am not drinking or taking drugs at the moment, I do not know how to relax since that normally was my relaxation,” says one participant of the training who stopped to use drugs. Most of the participants of the summer school also feel that it is very important to be together during such studies since it is the only opportunity for them to gather together outside of official gatherings.

Janine Wildschut shared her experience with stress and burnout. Some of her lessons were taken as eye opener for many.

“When your system stresses up, it “tells” you to run harder, and that is the moment to stop yourself and slow down completely,” Janine said. “To have a boss that understands that this is important and supports you taking a break sometimes is also very important. As the problems around you are a fact of life, you are the only one that can change how you handle this: with stress or by contributing the best you can, but not more than you can.”

Besides, on her trip in Kyrgyzstan, AFEW’s director of programs conducted a focus group about community advocacy to see if change in this area is occurring, what is required to have a greater involvement of the community, and how the dialogue platform contributes to that. Janine also interviewed community NGOs on the situation of shrinking space for CSOs in Eastern Europe and Central Asia. The situation in Kyrgyzstan nowadays is stable. Wider coalitions are initiated and hard work is done with the government to show the invaluable work that NGOs are doing.

Injectable Antiretroviral Drugs – a ‘Remarkable Milestone’

Long-lasting antiretroviral drugs injected monthly present a ‘remarkable milestone’ in treatment options for people living with HIV.

A long-lasting injectable antiretroviral treatment (ART) containing cabotegravir and riviliprine, administered at four- or eight-week intervals, is both as safe and effective at maintaining viral suppression as the same drug combination taken orally.

The results from the LATTE-2 study, an ongoing phase 2b clinical trial, were presented at the International AIDS Conference (IAS) on HIV Science last week in Paris, and published in the Lancet. It is the first study to investigate the safety and efficacy of a long-acting ART for HIV.

In the study, patients were brought to viral suppression with oral ART in an ‘induction phase’, and those who achieved viral suppression were randomly selected to three arms for maintenance therapy. After 96 weeks, viral suppression was maintained in 84% of patients receiving oral treatment, 87% in patients receiving the injectable contraceptive every four weeks, and by 94% in the eight-week group.

Cabotegravir is an investigational integrase inhibitor (INSTI) that has a long half-life, meaning it is active in the body for longer. It is also being considered for use in other clinical trials as a pre-exposure prophylaxis (PrEP).

Rilpivirine is a second-generation non-nucleoside reverse transcriptase inhibitor (NNRTI), developed to counteract mutations associated with HIV drug resistance in this class, and is approved for use only in combination with other antiretroviral drugs.

What are the benefits of long-lasting ART?

People living with HIV can now expect to live a near-normal life expectancy, where they have access to effective antiretroviral treatment, monitoring and support. But the positive benefits of treatment can only be realised when adhered to exactly as prescribed – which for HIV, means taking treatment every day, for life.

A range of factors can influence a person’s ability to stick to a drug-taking regime, so until a vaccine or a cure is found, new treatment delivery options are needed to ensure all patients can maintain high levels of antiretroviral drug concentration in their body, thereby achieving viral suppression and reducing the risk of HIV drug resistance.

In this study, participants revealed they felt free from their illness, with lead study author Joseph Eron Jr., M.D., saying at a press conference: “It’s surprising to me – patients at our site that are on the study – how much they appreciate not having to take pills. I think that’s something that I really didn’t calculate. There’s this kind of feeling of freeness from being bound to oral therapy every day.”

Mark Boyd, MD, of the University of Adelaide and David Cooper, MBBS, of the University of New South Wales, in an accompanying Lancet commentary said that the long-acting antiretroviral was a “remarkable milestone” for HIV therapeutics – but at some point there will be a “trade-off between the convenience of not having to adhere to oral therapy and the inconvenience and discomfort associated with injectable long-acting ART. It is possible that injectable ART will be more attractive the less one must be injected.”

Some people may find taking oral medication every day more convenient than having to see a healthcare professional to be injected on a monthly basis. Boyd and Cooper continued, “This is compounded by the fact that health-care systems are generally not configured to facilitate regular, recurrent injections in a timely and convenient way to people who are well. Changing this will take innovation, political will, and time.”

Nevertheless, the authors conclude that “long-acting injectables such as the cabotegravir plus rilpivirine regimen might represent the next revolution in HIV therapy by providing an option that circumvents the burden of chronic daily dosing.”

Source: AVERT

The EU Adopts Its Most Progressive Drug Action Plan Ever

Author: Peter Sarosi

Although it was without much fanfare that the European Commission, in July 2017, published the new Action Plan on Drugs (2017-2020), the drug policy community should celebrate it as a great achievement both for its progressive content and for the meaningful involvement of civil society in its preparation.

If there is a sign that the European Union is getting through difficult times, it’s the limited attention its new public policy initiatives receive. While the adoption of previous EU drug strategies and action plans has been well covered by the media, now, two years after the great migration crisis and one year after the Brexit vote, almost nobody noticed the adoption of the new EU Action Plan on Drugs. There was no press conference or press release. It seems drug policy is not a priority for decision makers these days – there are other topics occupying public attention. It’s a shame, because this is the most progressive drug policy document the EU has ever adopted. It is most needed, at a time when European drug markets have been undergoing cataclysmic changes, with the emergence of new drugs and new risks which require new responses and interventions.

The three-year Action Plan translates the goals of the seven-year EU Drug Strategy (2013-20)into concrete actions with clear responsibilities and performance indicators. This is the second action plan relating to the current drug strategy, the previous one (2013-16) having been evaluated by external evaluators, RAND and EY in 2016. The evaluation report, which also included civil society views, highlighted some very significant shortcomings of EU drug policies. It pointed out that among the five pillars of the EU drug strategy, demand and harm reduction significantly lags behind in terms of progress made in the period of the previous Action Plan. According to the evaluation, “there is room for improvement in implementation and access to risk and harm reduction measures across various Member States and… stakeholders from civil society expressed concerns about the extent and quality of these measures.“ Interviewed by the evaluators, these civil society representatives reported scaling down and closure of harm reduction programs, increasing rates of hepatitis C and HIV infections and high rates of overdose deaths among injecting drug users in some member states. Harm reduction should be expanded beyond injecting drug users, including drug checking and other safer nightlife initiatives. The report also emphasised that discussion about new cannabis policies, within and outside of the European Union, is missing at the European level.

The new Action Plan has been prepared with the involvement of the Commission’s expert group, the Civil Society Forum on Drugs. This diverse group of more than 40 NGOs represents various fields, perspectives and ideological approaches. As one of the Core Group members of the Forum, I had the pleasure of coordinating civil society responses to the evaluation of the old Action Plan and the preparation of the new. It has been the first time in the history of the European Union that civil society has been systematically and meaningfully involved in this process, with a significant impact on the final document.

These are a few highlights of the fields where civil society could have a significant impact:

HARM REDUCTION

Unlike the previous AP, this document lays great emphasis on scaling-up access to harm reduction programs – and not only the mainstream programs, such as opiate substitution and needle and syringe programs, but novel interventions such as naloxone distribution, drug consumption rooms, and drug checking are also mentioned. This is the first time that the EU has officially recognised these innovative programs. Another impact of the involvement of civil society can be seen in the list of performance indicators. These indicators were often vague in previous documents, but are much clearer now, for example by adopting indicators from the WHO’s technical guidelines, recommending the distribution of at least 200 sterile needles per injecting drug user per year. These indicators make governments more accountable.

GENDER, AGE AND OTHER FACTORS

The lack of gender- and age-specific services is a huge barrier to access to any kind of treatment or harm reduction programs in the EU. In many, mostly Western-European, member states, there is an increasingly ageing population of drug users who need other kinds of social and health support than those aimed at young people. Underage kids also need different services than adult people. Specific services for women and LGBTQ comunities are equally missing from many member states. Prisoners and asylum seekers often don’t have access to even the basic services which are widely available in the community. This AP addresses this problem and aims to close this gap. At least partly. There are still no specific interventions targeting LGBTQ people in the age of chemsex for example.

HUMAN RIGHTS

To integrate international human rights standards into drug policies has been a civil society demand for a long time. Last year’s UN report on the human rights impact of drug policies was a big success for civil society advocacy. Now our demands have also been met by the EU – this AP aims to create and implement tailored human rights guidelines and impact assessment tools for policy makers. This gives civil society an incredibly important opportunity to address system-wide incoherence when it comes to repressive law enforcement, criminally underfunded services and the human rights of people who use drugs.

CIVIL SOCIETY INVOLVEMENT

Although in most member states civil society plays a key role in implementing drug policies by providing services, there is a great diversity in how the same organisations are involved in policy formulation and evaluation. Only a few member states have formal mechanisms for civil society involvement. Objective 9 of the new AP requires not only the involvement of the Civil Society Forum on Drugs in the formulation, implementation, monitoring and evaluation of drug policies at the European level, but also the involvement of civil society in policy making at a national level. The AP also mentions that civil society should be involved in the preparations for the upcoming UN high level meeting on drugs, to be held in Vienna in 2019.  The CSF has created a working group to facilitate this process. What is still missing from the AP, despite our recommendations, is a reference to the need to involve people who use drugs in decision-making. Shame.

TACKLING PSYCHIATRIC DISORDERS 

Members of the Forum from several member states reported a gap in tackling psychiatric co-morbidites, also known as dual diagnosis, among people with drug dependence. The number of people suffering from this problem is increasing, but member states are not creating specific treatment resources to meet needs. We therefore welcome the Commission’s inclusion, under action 2.6, of the promotion of comprehensive community care, creating specialised resources to ensure continuity in treatment for these users.

QUALITY STANDARDS

The CSF has a thematic working group on quality standards, which produced a paper highlighting the challenges and gaps in implementing these services. It recommended the introduction of clear indicators to measure the implementation of quality standards for demand reduction. Action 3.10 require member states to involve civil society in the implementation of these quality standards. Although the AP does not mention it, the CSF is in the opinion that standards should be implemented and monitored with the meaningful involvement of service clients.

ALTERNATIVES TO COERCIVE SANCTIONS

While civil society almost unanimously supports it, there is unfortunately no consensus among member states about the decriminalisation of drug use. However, the AP requires member states to apply alternatives to coercive sanctions. The CSF recommends to member states that alternatives to coercive sanctions should include, where appropriate, a Restorative Justice approach, recognised to reduce reoffending and increase the satisfaction of victims. Moreover, alternatives to prison should be correctly evaluated in order to avoid a “net-widening” effect – that is, punishing more actions and persons than before. These measures should be gender-specific, and should ensure that prison is used as a last resort and punitive measures are not used for the simple use or possession of drugs per se. We therefore welcome the inclusion of “increasing monitoring and evaluations” as indicators within action 5.22.

EVALUATING ALTERNATIVE POLICIES

The external evaluators of the previous Action Plan on Drugs pointed out that “the omission of a discussion on recent trends in cannabis policy was noted by a wide range of stakeholders and represented one of the most frequent items raised when exploring whether there are any issues not covered by the Strategy.” We recommended that the Commission provide a comprehensive analysis of developments relating to cannabis policy models (eg. cannabis social clubs in Spain) and their impacts, as we originally requested. The final text of the AP is not as progressive as we had hoped: it only asks the EMCDDA to provide an update about cannabis laws in the EU. Upcoming EU presidencies need to create platforms and organise forums to enable civil society, the scientific community, and decision-makers to discuss alternative policies and their impact.

Is this document a breakthrough in European drug policy reform? No. I believe we can expect the real breakthroughs to happen at national and local level. But it is clearly a step in the right direction. What is really concerning is the lack of political commitment and adequate funding to implement the action plan. The weakness of EU action plans is that the Commission itself has no significant drug policy budget; it is therefore up to the member states to provide funding for most interventions. And several member states are far from committed to scaling-up services – not even committed to continue funding existing services. What we have seen in recent years is programs being curtailed or shut down, especially in the Eastern part of the EU. It is our role to remind EU institutions and member states that broken promises do not only undermine trust in democratic institutions, but also endanger the health and well-being of future generations.

Source: Drug Reporter

Harm Reduction: Redirection of Resources Needed

Why do we need action?

Harm reduction is an evidence-based and cost-effective approach to drug policy and practice that is about keeping people who use drugs, their families and communities safe and healthy.

Harm reduction is about saving lives and it works!

Yet many countries still do not provide harm reduction services. According to UNAIDS, between 2010 and 2014 only 3.3% of HIV prevention funds went to programmes for people who inject drugs.

Why now?

Harm Reduction International’s data shows that since 2014, no new countries have established needle and syringe programmes (NSP) and just three have introduced opioid substitution therapy (OST). Of 158 countries where injecting drug use is reported, over half (78) do not offer OST and more than a third (68) still do not provide NSP. In 2015, a UN target to halve HIV transmission among people who inject drugs by 2015 was missed by more than 80%.

These figures are a call to action.

By contrast, each year governments spend over $100 billion on drug control strategies that have little effect on demand for drugs or on those who profit from the drug trade. At the UN General Assembly Special Session on Drugs in 2016, governments showed a new willingness to rethink these approaches. But now they must rebalance their spending.

What are we calling for?

We are calling on governments to redirect 10% of the resources currently spent on ineffective punitive responses to drugs and invest it in harm reduction by 2020.

What we will this achieve?

Even this small redirection of funding could achieve big results.

A 10% redirection of funding from drug control to harm reduction by 2020 would:

  • End AIDS among people who inject drugs by 2030.
  • Cover annual hepatitis C prevention need for people who inject drugs. Globally. Twice over.
  • Pay for enough naloxone to save thousands upon thousands of lives every year from opiate overdose.
  • Ensure effective advice, healthcare and emergency responses in the face of newly emerging challenges.
  • Strengthen networks of people who use drugs to provide peer services and campaign for their rights.
What will happen if we don’t act now?

If the adoption of harm reduction in new countries continues at the current pace, it will be 2026 before every country in need has even one or two harm reduction programmes. In the meantime, thousands, if not millions, of lives will be lost.

Source: Harm Reduction International

Join AFEW at Harm Reduction International Conference in Montréal

AFEW International is taking part in 25th Harm Reduction International Conference that will take place in Montréal, Canada next week. AFEW’s executive director Anke van Dam and program director Janine Wildschut will take part in the side event on harm reduction.

The side event ‘Future Proofing Harm Reduction’ is supported by the Dutch Funded Harm Reduction Programs – Bridging the Gaps, PITCH and the Alliance Integrated Harm Reduction Programme (AIHRP). These three alliances are represented by Aidsfonds, International HIV/AIDS Alliance, International Network of People Who Use Drugs, AFEW International, and the Mainline Foundation. The side event will take place on Monday, 15th May, 2-3.30 pm at Mansfield II, Entry hall, Centre Mont-Royal.

AFEW will be represented by the talk by AFEW International’s program director Janine Wildschut with the talk ‘Shrinking space for civil society in the EECA region’ and AFEW Kyrgyzstan’s director Natalya Shumskaya who will talk about women who use drugs in Kyrgyzstan. More detailed program of the side event can be found here.

Harm reduction goes much further than HIV prevention, and contributes significantly to the quality of life of people who use drugs and to the realization of the Sustainable Development Goals (SDG). This side event, moderated by the Dutch Ambassador for Sexual and Reproductive Health and Rights and HIV/AIDS Lambert Grijns, will share examples from the variety of grassroots harm reduction projects currently funded by the Netherlands. Current challenges in harm reduction funding beyond HIV and framing programmes within the context of the SDGs will be discussed.

The theme of this year’s Harm Reduction International Conference is ‘At the Heart of the Response’, and the programme includes presentations, panels, workshops and dialogue space sessions on innovative harm reduction services, new or ground-breaking research, effective or successful advocacy campaigns and key policy discussions or debates.

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.