How Ukraine is tackling Europe’s worst HIV epidemicBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3538 (Published 13 July 2010) Cite this as: BMJ 2010;341:c3538
In May this year a doctor was detained by police on 42 charges of drug dealing at a clinic in Odessa, southern Ukraine. But the drug was the opioid substitute buprenorphine, and the recipients of Illya Podolyan’s prescribing were opioid dependent patients who were legally registered with the clinic to receive this treatment. The incident is likely to do with overzealous police and an error in the clinic’s licence rather than drug trafficking.1 2
Substitution maintenance therapy is proved to reduce risk of HIV infection in drug users.3 Although about 5550 patients legally receive the treatment in Ukraine, it remains controversial, largely as a result of the influence of narcology, a subspecialty of Soviet psychiatry that considers that drug dependence must be solved through abstinence. In Russia methadone and buprenorphine remain illegal.
Dr Podolyan’s ongoing detention is the latest and most worrying example of undulating friction between law enforcement agencies, patients who use illicit drugs, and the people who provide medical support and the gap between government policy and its implementation. “From the beginning enforcement agencies opposed substitution treatment. They said, ‘You will have drugs on the street . . . the government becomes a drug dealer,’” explained Pavlo Smyrnov, a deputy director at the International HIV/AIDS Alliance in Ukraine.
This non-governmental organisation and the All-Ukrainian Network of People Living with HIV are leading Ukraine’s response to its HIV epidemic. In 2004, the Global Fund for AIDS, Tuberculosis, and Malaria awarded the Ukrainian government a grant of about $98m (£65m; €77m) over five years. However, the fund soon stopped payments because of budgetary irregularities and a “lack of transparency” and uniquely decided to channel its grant through civil organisations.
Prevention of transmission in high risk groups—people who inject illicit drugs, men who have sex with men, women who sell sex, prisoners, and street children—may prevent the epidemic becoming established in the general population, where it would be much harder to tackle. Progress has been made, despite ignorance, corruption, and outdated medical and legal policy.
Roots of the problem
Eastern Europe and central Asia, particularly Ukraine and Russia, have some of the fastest growing HIV epidemics in the world. An estimated 1.5 million people in the region were infected in 2008, up 66% since 2001.4 The primary driver for the epidemic is unsafe injecting practices, such as sharing needles, among young and poor recreational drug users. In Kiev, for example, almost a quarter of people who inject drugs are thought to be HIV positive. 5
In 1991, when the Soviet Union dissolved and communist rule ended, the security of universal jobs for life and pensions disappeared. As the economy collapsed use of alcohol and illicit drugs rose. Illicit drugs injected in Ukraine are often made at home by small scale dealers. When native opium poppies are in season a homemade opioid, “shirka” or “hanka,” can be extracted from the plant after the seeds have been harvested.
Year round, cheap amphetamine-like stimulants—for example, “vint” (methamphetamine), “jeff” (methcathinone), and “boltushka” (cathinone)—can be made using remedies that contain ephedrine or pseudoephedrine for sale over the counter at pharmacies or on the black market. In addition to the risk of HIV and other infectious diseases from sharing needles, the preparation of these drugs may be hazardous, and the composition of the impure product is unknown.
Ukraine has an estimated 290 000 drug injectors, and although they are concentrated in cities, there are many in harder to reach rural areas.6 The country also may have the highest prevalence of HIV in Europe: at the beginning of 2010 an estimated 360 000 people aged 15 and older were infected, a prevalence of 1.3% among 15-49 year olds.5 6 Registrations at medical facilities show that only a quarter of infected people are aware of their status. As a comparison, the United Kingdom has an estimated 77 000 HIV positive residents, 0.2% of the adult population, and three quarters know they are infected.7
Kiev AIDS Centre is part of one of the city’s municipal hospitals in a suburb 10 km to the west of the city centre. Its 25 inpatient beds for patients with advanced AIDS and other diseases, particularly tuberculosis, are full. It has busy day clinics for counselling and testing for HIV and other sexually transmitted infections. And it provides treatment for people already infected with HIV, including antiretroviral drugs. Since 2005 a substitution therapy clinic has operated from the site, and it serves 354 clients, who get methadone and buprenorphine. Any further efforts to prevent HIV, such as outreach to populations at risk, are largely beyond its remit.
State run clinics cannot effectively champion HIV prevention in drug injectors and sex workers. “Both these groups are outside of the law, so it’s difficult for government organisations to work with them. The only official outreach they can provide is through the police, who either lock them up or take money,” said Mr Smyrnov.
Drug users, sex workers, and people with HIV may also be reluctant to present to medical facilities because of the need to register, the cost, and for fear of mistreatment because of stigma. Health care in Ukraine is state funded, but patients must pay for tests and treatments. Blood testing might cost 250 grivnas (about £20, €24, or $30) and a magnetic resonance scan 100 grivnas. In addition, the salaries of state employed healthcare professionals are low, and bribes from patients are expected.
The Global Fund’s support for AIDS prevention is largely channelled through the International HIV/AIDS Alliance in Ukraine, which uses the money to fund, strengthen, and create non-governmental organisations in the community that work at the coalface of the epidemic. These are often led by peers so that they know how to reach their target populations. They also make agreements with medical facilities and enrol nurses and doctors to perform testing in settings close to users, with referral for free treatment purchased with Global Fund money. Alliance organisations are estimated to reach 52% of drug injectors in the country (150 000 a year).
Club Eney (Narcotics Anonymous), for example, has an office at the Kiev AIDS Centre. Volodya Moiseev, its director and a former drug user, had just finished speaking with a teenage girl when I met him. “Her mother, an injector herself, was worried her daughter may have started injecting, and she wanted me to speak to her. But I don’t think she’s injecting.” Clients who come to the hospital for medical services can dispose of dirty needles and syringes and take clean ones, spirit wipes, condoms, and sachets of lubricant—in addition to having jasmine tea and a chat.
Eney also runs an ambulance—a converted minibus that can take the services to hard to reach injectors and commercial sex workers. Facilities include rapid HIV testing, gynaecological examination, testing for other sexually transmitted infections, and psychological services. Depending on the target population, the bus may be staffed by a nurse, a gynaecologist, a psychologist, and social workers. Eney also has a drop-in centre in a flat in a residential block in a poorer suburb of the city, where various groups can meet for support and to receive materials for safer injecting and sex.
Another room in the AIDS centre is the office of the Vertical group. It also hosts support groups in a flat in a residential building, this time near the AIDS centre. Here clients can also borrow reading books, use the internet to find work, and wash themselves and their clothes. Twice a week a doctor comes to perform rapid HIV testing. And legal advice is available. “Clients are often harassed by the police . . . and they disturb the work of social workers as well. They come to needle exchange points and harass social workers. Because of a lack of legislation and what we had in Soviet times injecting drug users are not seen as medical patients; they are seen as criminals. We need to change the attitude of society at large,” says Denys Kudelya, who runs the project.
Dmytro, one of 2300 clients who uses Vertical each year, lives 15 minutes away by bus and attends support groups three times a week. He started injecting drugs 25 years ago when he was 15 years old and served 10 years in prison, where support and treatment were lacking. It’s difficult to organise services for injecting drug users in prisons because there is still official denial about the problem, but organisations can distribute condoms and information.
Ten years ago Dmytro found out that he had HIV. Then the annual cost of antiretrovirals was $12 000, and the state could not afford to provide them. “I needed to sell my flat to get that kind of money. Now I get my drugs for free. I don’t have to live on the streets. I don’t have to steal.” he says. “We live in a totalitarian state. Drug users were prosecuted, but now it is changing, but it doesn’t change in essence. The state doesn’t do anything. Either it lacks funds or it lacks the will.” And he believes that the changes wouldn’t have occurred without finance and pressure from the international community. Because the Alliance launched an antiretroviral treatment programme, which was handed to the government in 2009, 16 000 people now receive antiretroviral drugs, up from 250 in 2004. An estimated 92 000 people need the drugs.5
Step by Step is another peer led organisation that works to reduce harm among drug users. “The problem is we have no substitution treatment for stimulant users. We don’t have much to offer. We tell them to come here and get education and skills to protect themselves and to spread the word among their peers,” Svitlana Tyschenko, the director at the centre in the northwest of the city, said. Young stimulant injectors are supported through self help group meetings, where they might spend time creatively, making a magazine or writing a song. “We don’t focus on drug use, we focus on HIV prevention,” the social worker says. Social workers are paid about $200 a month to exchange needles on the street near dealers’ homes, at pharmacies where drug ingredients are bought, or at locations where dealers distribute drugs and users inject. They also follow walking routes where they are likely to meet users. Step by Step encourages its clients to distribute clean needles and condoms to friends in return for small amounts of money, food, or other goods such as toiletries.
Step by Step also works with pharmacies to provide clean needles for free. Drug users can register and obtain a card. On presentation of the card at participating pharmacies, users can get clean needles, condoms, lubricant, and spirit wipes at no cost, no questions asked. Eleven pharmacies in Kiev are signed up to the project. Drug users who are carrying the card may be less likely to be harassed by police if they are stopped while carrying needles.
The Alliance’s work may be having an effect. New cases of AIDS decreased for the first time in 2006, and deaths from AIDS have begun to stabilise, which indicates that antiretroviral treatment is working. There are also fewer HIV cases being recorded among drug users, particularly young drug users and those who have been injecting for a short time.
However, doctors such as Illya Podolyan are still being harassed. Police have also suspended opioid treatment programmes and forced the disclosure of confidential records. These actions are disincentives to doctors to work in substitution and patients to present for treatment. “For months I have been questioned by the police. Each time the detective charges me with new counts of alleged drugs trade and breach of legislation relating to narcotic drugs circulation. All of the accusations have to do with a simple fact that I happen to treat patients in the framework of a state supported programme.” said another doctor, Yaroslav Olendr, whom police have banned from leaving his home city.1
A gap between high level government policy and its implementation on the ground; a history of punitive response and stigma towards drug users; general ignorance of the evidence supporting harm reduction; a high turnover and poor training of local police officers; and the ease with which police can meet arrest targets by focusing efforts on vulnerable drug users go some way to explain Ukraine’s situation. In presidential elections early this year the candidate more sympathetic to Russia, Viktor Yanukovych, won. But rather than look to Russia, for the sake of the HIV epidemic in Ukraine, he must instigate reforms that support the evidence based response that has already started to work.
Harm reduction in Ukraine
290 000—Estimated injecting drug users in Ukraine
71—Alliance Ukraine supported organisations in 24 regions of Ukraine providing HIV support to injecting drug users
150 000—Injecting drug users covered by Alliance Ukraine supported programnmes
140 000—Visits for clean needles to 109 pharmacies countrywide
56 488—Visits to 11 mobile clinics countrywide for rapid HIV testing
5400—Patients enrolled in methadone substitution programmes
Cite this as: BMJ 2010;341:c3538
I thank Tetiana Deshko, Galina Naduta, Olga Burgay, and Kostiantyn Pertsovskyi in Kiev, and Sarah Wheeler in Brighton, International HIV/AIDS Alliance, and Olga Kravchenko for translation.
Competing interests: This article was written in response to a visit to Ukraine organised by the International HIV/AIDS Alliance but paid for by the BMJ.
Provenance and peer review: Commissioned; not externally peer reviewed.
For a related podcast see http://podcasts.bmj.com/bmj/2010/07/09/methado-methadont-methadone/, and video see http://bmj.com/video/
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