Michel Kazatchkine: The time has come to implement harm reduction policies in Eastern Europe and central Asia

The evidence is clear, Eastern European and Central Asian countries should adopt opioid maintenance therapy and needle exchanges to curb HIV and Hep C outbreaks, says Michel Kazatchkine

September 13, 2019 from BMJ


For many years, evidence has shown the effectiveness of opioid maintenance therapy in the treatment of opioid dependence and the effectiveness of opioid maintenance therapy and needle syringe programmes in preventing HIV infection among people who inject drugs. [1,2] Recent evidence shows that both opioid maintenance therapy and needle syringe programmes can also prevent people who inject drugs from getting hepatitis C. [3]

The spread of HIV/AIDS among people who inject drugs and their partners has been contained in Western Europe, Australia, Canada, China and other countries of Asia, because interventions such as clean needle exchange and opioid maintenance therapy programmes became mainstream government health policy sanctioned by the World Health Organisation. 

Harm reduction is receiving increasing attention from policy makers across Sub-Saharan Africa. Unsafe drug injection is recognized as an underestimated component in preventing HIV and hepatitis C infection in vulnerable groups in high prevalence settings across sub-Saharan Africa and Asia. 

However, in Eastern Europe and central Asia, harm reduction policies are conspicuous by their absence, even though there are high rates of HIV and hepatitis C infection.  

The absence of harm reduction policies is conspicuous as rates of injecting drug use are persistently high in Eastern Europe and Central Asia, approximately four times that of the global average, although the trend is decreasing. [4] Heroin continues to be the dominant injected drug, but many countries in the regions are seeing increasing rates of injected stimulant use (metamphetamines). [5] 

People who inject drugs or have injected drugs at some point in the past continue to represent 40–50% of newly reported HIV diagnoses across Eastern Europe and central Asian region. [6]

Around 25% of the estimated 3.1 million people who inject drugs in the region are infected with HIV and 65% test positive for hepatitis C. [7]

Co-morbidities such as HIV-TB and HIV-hepatitis C co-infection have now become normalised in countries like the Russian Federation which accounts for around 80% of the region ‘s HIV infections. [8] 

The uptake of antiretroviral therapy (ART) has been increasing in the region in the past few years as the price of medicines has been decreasing and antiretroviral regimens have been simplified and standardised. Yet, only 35% of the estimated number of people living with HIV in the region currently access antiretroviral treatment, and that figure is only close to 10% for people who inject drugs. [9] Figures are much lower when it comes to treatment of hepatitis C with direct antiviral agents (DAAs). Other than the extensive hepatitis programme that is in place in Georgia, still less than 5% of patients access curative hepatitis C treatment across the region. [10]

Further evidence now shows that opioid maintenance therapy and needle syringe programmes are effective in preventing the acquisition of hepatitis C in people who inject drugs. A meta-analysis of data published in the last eighteen months shows that opioid maintenance therapy reduces the risk of hepatitis acquisition by 50% among people who inject drugs, while opioid maintenance therapy and needle syringe programmes reduce the risk of acquiring hepatitis C. [11]

The effectiveness of opioid maintenance therapy and needle syringe programmes in reducing the risk of HIV infection among people who inject drugs has allowed Western European countries to reduce the proportion of people who inject drugs among new HIV infections to less than 1-2%. Opioid maintenance therapy has further allowed a large number of people to regain normal family and working lives in the society. 

The Russian Federation accounts for nearly 80% of all new HIV infections in the region and modelling shows the potential benefit of introducing and scaling up these interventions in that country. [12] 

It is estimated that extending access to opioid maintenance therapy and needle syringe programmes to 50% of people who inject drugs, together with access to antiretroviral therapy for those in need, would result in a 53% and 76% reduction in the number of new infections within ten years in Omsk and Ekaterinburg, two cities with severe HIV epidemics associated with unsafe drug injection. [13,14] 

The epidemics of HIV and hepatitis among people who inject drugs and their partners continue to severely affect the Eastern European and central Asian region. Yet, we have evidence that opioid maintenance therapy and needle syringe programmes are effective at prevention. It is the right time for governments in the region to review the evidence, review their policies, and reign in their HIV and hepatitis epidemics. 

Michel Kazatchkine is the Special Advisor to the Joint United Nations Program on AIDS (UNAIDS) in Eastern Europe and Central Asia
Competing interests: None declared.

References

  1. WHO. https://www.who.int/substance_abuse/activities/treatment_opioid_dependence/en/
  2. Wodak A, McLeod L. The role of harm reduction in controlling HIV among injecting drug users. AIDS 2008; S2:s81-s92.
  3. Platt L, Minozzi S, Reed J, et al. Needle Syringe programs and Opioid Substitution Therapy for preventing hepatitis C transmission in people who inject drugs.  Cochrane database of systematic reviews 2017; 9: CD012021.
  4. UNAIDS. 2016. Prevention gap report. http://www.unaids.org/sites/default/files/media_asset/2016-prebetion-gap-report_en.pdf 
  5. Degenhardt L, Peacock A, Colledge S, et al. Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review. Lancet Glob Health 2017; 5:e1192-207.
  6. UNODC. World drug report. 2018. https://www.unodc.org/wdr2018.
  7. WHO. World hepatitis report. 2017. https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en 
  8. UNAIDS. Global AIDS update: miles to go: closing gaps, breaking barriers, righting injustices 2018. hhtp://www.unaids.org/sites/default/files/media_asset/miles-to-goen.pdf
  9. UNAIDS. 2016. Prevention gap report. http://www.unaids.org/sites/default/files/media_asset/2016-prebetion-gap-report_en.pdf 
  10. UNAIDS. Global AIDS update: miles to go: closing gaps, breaking barriers, righting injustices 2018. hhtp://www.unaids.org/sites/default/files/media_asset/miles-to-goen.pdf
  11. WHO. World hepatitis report. 2017. https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en
  12. Cepeda JA, Eritsyan K, Lyubimova A, et al. Potential impact of implementing and scaling up harm reduction and antiretroviral therapy on HIV prevalence and mortality and overdose deaths among people who inject drugs in two Russian cities: a modelling study. Lancet HIV 2018; 5: e78-87.
  13. Cepeda JA, Eritsyan K, Lyubimova A, et al. Potential impact of implementing and scaling up harm reduction and antiretroviral therapy on HIV prevalence and mortality and overdose deaths among people who inject drugs in two Russian cities: a modelling study. Lancet HIV 2018; 5: e78-87.
  14. Bekker LG, Alleyne G, Baral S, et al. Advancing global health and strengthening the HIV response in the era of sustainable development goals: the international AIDS Society-Lancet commission. 2018;18:7-53.


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Winds of hope on HIV/AIDS in Eastern Europe and Central Asia

February 20, 2018  BMJ

The announcement by UNAIDS that some 21 million people living with HIV are now on treatment uncovers an extraordinary achievement and one of the great global health milestones of this century.

It gives us hope that the other 15 million or so people living with HIV can also soon access antiretroviral treatment, and hope that we can begin to turn around the spiralling rates of HIV infection occurring in Eastern Europe and Central Asia (EECA). Much of the media coverage focused on the intransigence of the government of the Russian Federation to changing its prevention policies around HIV/AIDS, namely via the supply of clean needles and opioid substitution therapy (OST) such as methadone. And with the number of people living with HIV in Russia now officially exceeding 900,000 compared to 250,000 a decade ago, and people using drugs still representing over 40% of newly diagnosed cases, that criticism is fair.

However this focus also obscures the fact that in Eastern Europe and Central Asia, which has been much maligned over the past decade for its slowness in responding to the HIV/AIDS epidemic, we are now beginning to see strong hints that public health initiatives based on scientific evidence are taking on a legitimacy across the region.

On a political level we are seeing increased awareness and leadership, for example the Russian Federation government for the first time adopted a state HIV/AIDS strategy followed by an action plan 2017-2020.

There is growing national dialogue across sectors in Kazakhstan, Kyrgyzstan, and Moldova on the back of national multi-partner AIDS conferences held in both countries in 2016 and 2017. Very significantly, Kazakhstan has now successfully transitioned from external financing from the Global Fund to Fight AIDS, TB and malaria to cover the majority of costs for their AIDS response from domestic sources.

Truly encouraging too has been the decision by the Ukrainian cities of Kiev, Odessa, and Balsi in Moldova and Almaty in Kazakhstan to associate themselves as Fast-Track Cities committed to reaching the 90-90-90 treatment target by 2020, the aim of which is to ensure that, by 2020, at least 90% of people living with HIV know their status, 90% of all people diagnosed with HIV infection will receive sustained antiretroviral therapy, and 90% of all people receiving antiretroviral therapy will have viral suppression.

Finally, and hugely important, we are now seeing significant health system reforms in countries like Ukraine and Kazakhstan that are vital to responding to the AIDS and TB epidemics more effectively and efficiently.

This groundswell of change in the region has been building up for some time now and we are seeing the fruits of it beginning to emerge.

Quite remarkably, nine of the 12 EECA countries now implement national programmes around OST, with Uzbekistan currently considering its uptake. Russia and Turkmenistan are certainly isolated on this front, by not implementing a similar strategy.

Armenia and Belarus have now officially been declared by the WHO as having eliminated the transmission of HIV from mother to child.

Equally encouraging is the increase by 13% in antiretroviral treatment coverage across the region in the last two years. Armenia, Belarus, Kazakhstan, Georgia and Ukraine have already adopted a “Test and Treat” strategy and several more countries in EECA are currently pending approval.

Lastly and perhaps a strong indicator of commitment to respond to the epidemic across the region is the significant headway being made across the region to reduce the high prices of antiretroviral drugs. The positive steps being made in the region on HIV/AIDS provides genuine hope. We will need to build on these growing expectations if we are to successfully overcome the barriers that have come to define the epidemic in the EECA. Despite the progress, new cases and AIDS-related mortality continue to increase as a result of previous neglect and inadequate policies over the past fifteen years. Some 400 000 people do not know their HIV positive status, antiretroviral therapy coverage is still the lowest among any region of the world, and prevention programmes are poorly funded and fail to reach the majority of those vulnerable groups at high risk of contracting HIV, and who also continue to be stigmatizsed, criminalised, and often denied access to services.

The growing signs that we may be seeing perceptible changes in HIV/AIDS responses from governments across the EECA region is cause for hope for those at risk of and living with the disease. Those changes will definitely need to be predicated on respect for the human rights of all people to have access to health care if we are truly to change the trajectory of the HIV epidemic in EECA.

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Health in the Soviet Union and in the post-Soviet space: from utopia to collapse and arduous recovery

September 30, 2017, The Lancet

“At least in those days, I had no rent and no heating bill to pay, I had free access to doctors, and the state would make sure my children are educated and in good health”, says Evguenia, a babouchka I spoke with recently in Moscow.

Health is one of the areas where nostalgia for the Soviet Union is still common among Russians and people living in countries in the post-Soviet space. Most Russian adults alive today witnessed the dramatic deterioration of health care in the 10 years after the end of the Soviet Union. These people have seen the social safety net provided by the Soviet system abruptly disintegrate, inequities grow sharply, and elderly, sick, and disabled people become left behind while the country painfully and erratically transitioned from a planned economy to capitalism. Another reason for the lingering nostalgia is the persistent perception that health care should be provided by the central government, with little or no responsibility on the part of the individual.

The Soviet Constitution of 1936 stated that citizens of the Soviet Union have the right to health protection ensured by free, qualified medical care in state institutions. In the years after the 1917 revolution, Russia created a centralised and integrated state health-care system based on concepts introduced by Nicolaï Semashko, the People’s Commissar for Public Health from 1918 to 1930. The health-care system relied on an extensive network of primary care clinics and specialised hospitals staffed by large numbers of doctors and health-care workers, and it provided universal coverage, accessible to everyone, even in the most remote parts of the country. The improvements in health care during the first half of the 20th century were quite remarkable, with life expectancy in the Soviet Union in the 1960s similar to that in the USA.

However, the system rapidly deteriorated in the 1970s. Reduced funding from the central government and increasing bureaucratic and economic inefficiencies resulted in inadequate availability of medical drugs and technologies, poorly maintained facilities, worsening quality of health care, and falling life expectancy.

The transition of health systems from the Soviet facility-based model to patient-centered and decentralised standards of care is far from complete. Throughout the region, national funding allocations are based on number of doctors and beds (rather than on outputs). For example, tuberculosis care in many countries in the post-Soviet space is still provided through a hospital-centric system, where patients are admitted to hospital for standard tuberculosis treatment; not only is this system costly and inefficient, it has contributed profoundly to the rapid increase in the incidence of multidrug-resistant tuberculosis in the region. Public health budgets barely cover the salaries of health-care staff. Drugs are often paid for out of pocket, and bribes are often a way to access better quality service. The private health insurance market is expanding among urban middle-class employees as this population increasingly turns to private health-care networks.

Another key feature of health care in the post-Soviet context has been the dominance of treatment and curative approaches, with little focus on prevention and public health. The fast spread of the HIV epidemic in the region is attributable in part to this vertical, provider-centred, treatment-oriented system with almost no cooperation with the non-governmental sector and grossly inadequate attention to prevention.

Nevertheless, there are also reasons to believe that change is possible, even in the face of the tremendous health challenges in the region. But change is down a long and arduous road. The many sources of resistance include health-care professionals themselves, corrupted intermediaries who have been taking advantage of the system, and political elites who are reluctant to change structures they have benefitted from, directly or indirectly. This is well illustrated by the bitterness that prevails with respect to the current efforts of the Ukrainian Government to achieve radical public health reforms in the country. Some enlightened politicians and health professionals do recognise that the current system is both ineffective and unsustainable, and that health outcomes in the region are falling behind the rest of the world. Ordinary people are beginning to recognise that the Soviet model no longer understands or serves their health needs.

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Remarks given at the 40th Programme Coordinating Board meeting of UNAIDS in Geneva, June 27,  2017

Thank you Mr Chair.

Thank you Michel for your report and contextual analysis. Your words and those of the First Lady of Panama, strongly resonate for countries in Eastern Europe and central Asia.

Eight out of 12 countries in Eastern Europe and Central Asia, including the largest one, have been reporting a continuous increase in the number of new HIV infections and on an epidemic that continues to grow by about 10% per year.

Also of significant concern is the steady increase in the number of HIV-TB co-infections. The number of people living with HIV among newly diagnosed TB cases has doubled in the last five years; HIV-TB co-infection in the region, often means co-infection with resistant forms of TB.

Despite the acknowledged concentrated character of the epidemic, testing and access to prevention programs remains low among vulnerable groups of the population. Harm reduction programs for example, reach less than 10% of PWID in the region. Opioid maintenance therapy is now part of the national strategy in nine of the twelve countries of EECA but remains illegal in three.

Access to antiretroviral treatment also remains low, of less than 25% of those estimated to be in need, although these figures have been significantly increasing in several countries in the region in the last three years. The region has conducted strong and effective programs to prevent vertical transmission of HIV.

Stigma is high and many obstacles of societal, cultural, legislative and political nature remain. We still have much to do to ensure that the tremendous programmatic knowledge we have about how to respond to concentrated epidemics is more effectively translated into national strategies.

As a Special Envoy, I have conducted high level advocacy and dialogue to promote country-specific strategic priorities to fast-track the AIDS response. I focused on addressing the needs of key populations and on the issue of sustainable financing for the fight AIDS, TB, DR-TB and hepatitis in a region where funding from international sources has been diminishing or discontinued. More specifically, I also worked with local and international partners to ensure uninterrupted access to HIV and DR-TB treatment for people living in the conflict areas of Eastern Ukraine and for labor migrants in Central Asia.

It has been an honor to serve under Secretary General Ban Ki Moon whose commitment to the fight against HIV/AIDS and to the health of the most vulnerable I had learned and respected also throughout my years at the Global Fund. I welcome SG Guterres’s commitment to human rights and development.

I would like to particularly thank Michel for his support; thank the regional and country teams of UNAIDS, WHO, UNDP, UNODC, UNFPA and UNICEF for a truly excellent cooperation; thank the governments, civil society and community organizations in the region for a trustful relationship throughout these few years.

We need to maintain the international leverage and dialogue in the region.

I remain strongly positive, recognizing the progress that is being made, having faith in the wonderful people of the region and remaining confident that if we do what needs to be done, the fight against AIDS in the region will ultimately be won.

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The Shifting Diplomacy around Migration, HIV/AIDS and Tuberculosis in Central Asia

March 23, 2017, The Huffington Post 

Central Asia and the Russian Federation face a major intra-regional migration flow, home, as it is, to one of the largest labor migration corridors in the world, with hundreds of thousands of migrant workers moving from Central Asian countries to the Russian Federation and to Kazakhstan each year.[1] This migration flow of further concern given migrants’ increased vulnerability and poor access to HIV and TB prevention and care in host countries.

The Eastern Europe and Central Asia region is home to the fastest growing HIV epidemic in the world. Over the last five years, the number of new HIV diagnoses has more than doubled in Eastern Europe. In Russia alone, it is estimated that over a million people are living with HIV compared to around 250 000 a decade ago.[2] Nine Eastern European and Central Asian countries are also among WHO`s global list of Multidrug Resistant Tuberculosis (MDR-TB) high burden countries.[3]

In Kyrgyzstan, Tajikistan, Uzbekistan and also Armenia, substantial parts of the population are migrating to neighboring Kazakhstan and the Russian Federation for work purposes. Migration is clearly recognized as a risk factor for TB, MDR-TB[4] and HIV[5]. High mobility and seasonal migration patterns associated with poor living and working conditions, are contributing factors towards increasing migrants’ vulnerability and exposure to HIV and TB in the host country where they often experience significant barriers in accessing healthcare services.

For instance, over sixty percent of people who have been detected as HIV-positive in the last three years in Armenia, have, at one point, migrated to the Russian Federation for work. Non-governmental organizations in Kyrgyzstan and Tajikistan report evidence of a growing number of HIV infections among spouses of men who return from labor migration.

A recent report from the Central Tuberculosis Research Institute of the Russian Academy of Medical Sciences indicated that the proportion of TB and MDR-TB among migrants is 2.5 higher than in the general population.[6] Reduced access to health services and the fear of deportation if diagnosed with TB and HIV means that many diagnoses are being hidden or delayed.

Today, only a minority of HIV-positive migrants in the Russian Federation is accessing antiretroviral therapy (ART), while about 10 per cent of migrants are being tested for HIV and TB.[7] Despite pre-departure screening practices in the region for those requesting work authorization, many labor migrants are entering Kazakhstan and the Russian Federation without proper documentation in as much as there are visa-free travel agreements between countries. Scarce data on migrants’ health is an additional barrier to understanding how this group is affected by these diseases.

Notwithstanding, despite the barriers, there are also signs of cautious progress.

In the last few years, Kazakhstan has changed its policies, now ensuring access to full TB treatment for migrants irrespective of their legal status – and to MDR-TB treatment until the point that patients become sputum-negative. Although these clearly are progressive policies, many problems remain, including the conditions under which patients returning to their country of origin have to continue treatment to the end and the complexities of the patient referral system.

Under the auspices of the Kazakh Ministry of Health, with the support of the Global Fund to Fight AIDS, Tuberculosis and Malaria, bilateral agreements are being negotiated between Kazakhstan-Kyrgyzstan and Kazakhstan-Tajikistan on the access of migrant workers to TB care and treatment.

There is also progress in the Russian Federation around policies of both screening and requiring health insurance for migrants prior to entry on its territory. These policies allow for access to care of documented migrants at the site where they have registered for work. The downside to this measure however, is that many people are, however, emigrating for short period of times outside the registration system.

To reverse the rising HIV and MDR TB epidemics, the region will need to move forward on a number of fronts:

Firstly, there must be a halt to the deportation of migrants based on health status in the countries where it is still in practice. Currently, in too many instances in the region, a diagnosis of TB, MDR-TB or HIV means deportation, a practice that is widely known to be ineffective to public health, violate human rights, and may lead to drug resistant forms of infection.

Secondly, the region needs to ensure migrants’ have access to HIV services, including ART, and to full course TB/MDR-TB treatment in the host country. It will be vital that a funding mechanism be established to cover HIV and TB treatment costs for migrants who choose to stay in the host country to be treated.

Lastly, national and regional responses around infectious diseases like HIV and TB urgently need to be reviewed to include migrants as a vulnerable group.

It is no exaggeration to say that unless we see collective movement around the above fronts, all the ingredients of a brewing regional public health crisis will continue to bubble away.

—————————————

[1] IOM (2015) Mapping on Irregular Migration in Central Asia 2014, Astana, 2015.

[2] Unaids (2016) Prevention Gap Report.

[3] WHO (2016) Global Tuberculosis Report 2015.

[4] Dara M et al. (2012). Minimum package for cross-border TB control and care in the WHO European region: a Wolfheze consensus statement. The European Respiratory Journal, 40(5):1081-90. Published online 2012 May 31. Available at:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3485571/

[5] Unaids (2014) The Gap Report.

[6]Demikhova O, Nechaeva O (2016) Access of Migrant to Services on Early Detection, Diagnosis, Prevention and Treatment of Tuberculosis and Tuberculosis Associated with HIV Infection, Moscow, (In Russian : Вопросы доступа мигрантов к мероприятиям по раннему выявлению, диагностике, профилактике и лечению туберкулеза и туберкулеза, сочетанного с ВИЧ-инфекцией в странах СНГ) Available at : http://mednet.ru/images/stories/files/CMT/migranty.pdf

[7] Demikhova O, Nechaeva O (2016) Access of Migrant to Services on Early Detection, Diagnosis, Prevention and Treatment of Tuberculosis and Tuberculosis Associated with HIV Infection, Moscow, (In Russian : Вопросы доступа мигрантов к мероприятиям по раннему выявлению, диагностике, профилактике и лечению туберкулеза и туберкулеза, сочетанного с ВИЧ-инфекцией в странах СНГ) Available at : http://mednet.ru/images/stories/files/CMT/migranty.pdf

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