CARDIFF, CALIFORNIA – Russia and Ukraine account for roughly 90% of the 1.5 million people estimated to be infected with HIV in Central and Eastern Europe. On a recent trip to these countries, and despite repeated requests, no politician or public-health official in either country would meet with me. None returned the phone calls, faxes, or e-mails that I sent after I returned home.
Both countries have epidemics driven by injecting drug users (IDUs) who share needles and syringes, the most efficient way to transmit HIV. Yet proven methods exist to slow the spread of HIV by IDUs.
If IDUs inject heroin or related opiates – as is primarily the case in Eastern Europe – establishing opiate substitution programs with methadone or buprenorphine can dramatically slow HIV transmission. The success of such programs also depends on establishing needle/syringe exchanges at convenient locations, both to provide clean equipment and to draw users into the healthcare system. As the third leg of the stool, IDUs need counseling.
This trio of policies forms the foundation of what’s known among health-care professionals as the “harm-reduction package.” Russia and Ukraine, however, spend no money on harm reduction.
International aid supports harm-reduction efforts in both countries on a modest scale: most of the money comes from the Global Fund to Fight AIDS, Tuberculosis, and Malaria. But Russia, owing to a rise in its national income, no longer is eligible for HIV/AIDS Global Fund grants.
A group of non-governmental organizations (NGOs) in Russia that has run a harm-reduction effort with Global Fund money received assurances from the government that it would continue to bankroll the work once that money ran out. But last fall the government reneged, and the Global Fund issued the group an emergency grant for two years. Cash-strapped Ukraine, which remains eligible for Global Fund help to combat HIV/AIDS, also relies entirely on NGOs – most created by affected communities – to run its harm-reduction programs.
Aside from shaky funding, the harm-reduction efforts in Russia, and to a large degree in Ukraine, lack a fundamental tool: opiate-substitution treatment. Russia bans the use of methadone outright. “There is no evidence that use of methadone and buprenorphinefacilitates treatment of drug addicts,” declared Olga Krivonos, head of the Department of Medical Aid and Healthcare Development at Russia’s Ministry of Healthcare and Social Development, in March 2009. Ukraine, which legalized the import of methadone only in December 2007, had a mere 5,000 people receiving it when I visited.
“There is a large body of scientific evidence on the effectiveness of substitution treatment vis-à-vis HIV/AIDS,” concluded the World Health Organization, the United Nations Office on Drugs and Crime, and the Joint United Nations Program on HIV/AIDS in a 2004 policy brief. The US Institute of Medicine weighed in on the issue in a 2007 report: “Given the strong evidence of its effectiveness in treating opioid dependence, opioid agonist maintenance treatment should be made widely available where feasible.”
The popular explanation for lack of action in Russia and Ukraine is that their governments view IDUs as criminals, rather than people with a disease, and adopt an informal let-them-rot policy. Indeed, police regularly harass users (and people who help them), making matters worse. Many countries outside the region take a similar stance.
But it’s more complicated in Eastern Europe. A leftover Soviet distrust of outsiders colors many opinions, and there’s an oft-repeated claim that the culture is different: an intervention that works in the West might fail in the East. There is also a suspicion that dirty capitalist pigs want to profit from the sale of opiate substitutes, regardless of whether they work.
This is as silly as contending that antiretroviral drugs won’t work in the region, and that treating HIV is all a giant plot on the part of big pharmaceutical companies. Humans are humans. Harm reduction works everywhere, and the main financial benefactors are the countries themselves, which see reduced spread of HIV, drops in crime, and people returning to work.
Playing ostrich about harm reduction does not harm only IDUs. HIV-infected IDUs of course have sex with non-users. Pregnant HIV-infected IDUs transmit the virus to their babies, and sometimes – shockingly often in Russia – abandon their newborns, relinquishing them to the state. The people infected by IDUs also can infect others sexually, further fortifying the bridge into the “general” population.
In July, Vienna hosted the 18th International AIDS Conference, attracting nearly 20,000 people. Speakers included Austrian President Heinz Fischer, Bill Clinton, Bill Gates, and South Africa’s Deputy President Kgalema Motlanthe. Organizers held the meeting in Vienna specifically because it is “the gateway to Eastern Europe,” and they hoped to involve the region more than ever. For the first time, all proceedings were translated into Russian. But no high-level Russian or Ukrainian official attended.
A “Vienna Declaration,” endorsing harm reduction – and emphasizing drug policy based on science, not ideology – was launched at the meeting, and gathered more than 10,000 signatories. But the most influential Eastern European signatory was the First Lady of Georgia, a country whose estimated 2,700 HIV-infected people account for just 0.018% of the regional total. Judging by their governments’ indifference, the remaining 99.982% of the HIV-infected people in Eastern Europe – and all those they place at risk of harm – can just rot.