BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g3118 (Published 8 May 2014)
Ten years ago 170 000 people in the Russian Federation had HIV.1 The estimated number is now 1.2 million.2 More than 2% of men aged 30-35 are infected, says Vadim Pokrovsky, the head of the Russian Federal AIDS Centre. Russia now accounts for over 55% of all new HIV infections reported in the European region.3
This epidemic was mainly caused by injecting drug use, but it is now spreading to the general community. And it could have been avoided if Russia had implemented large scale harm reduction programmes including opioid substitution therapy (OST).
Treatment with methadone or buprenorphine and the provision of clean needles have saved the lives of millions of injecting drug users worldwide in the past 30 years of the HIV/AIDS epidemic.4
Drug injectors in Ukraine have had access to harm reduction, including OST, for 10 years, and nearly 9000 clients were reported as of March 2014.5 Such programmes had begun to reverse Ukraine’s growing HIV/AIDS epidemic.6
The Ukrainian Center for Disease Control said that in 2013 some 8000 people in Crimea were infected with HIV. OST has helped to manage the epidemic in Crimea, but after Russia’s recent annexation of the peninsula it announced a ban on the supply of such drugs to the region. This will bring unnecessary suffering to the people of Crimea and is a blatant example of health policy being hijacked for political ends rather than being led by evidence.
Russia’s federal law on narcotic and psychotropic substances, introduced in 1997, prevents the medical use of methadone, and buprenorphine is prohibited for treating drug dependence.7
Key Russian specialists in the treatment of drug dependence and officials in law enforcement have openly opposed OST, and the director of the Federal Drug Control Service has repeatedly claimed that it has not been scientifically shown to work.8
The International HIV/AIDS Alliance in Ukraine, the civil society organisation that leads action in the country, said that since mid-March the dosages of substitution drugs had been gradually reduced by half, with the aim of detoxification.
Patients received methadone and buprenorphine until the end of April, and OST provision officially stopped on 1 May. The alliance said that preliminary information from most of the surveyed sites in Crimea that offered OST showed that about 80 patients wished to leave Crimea to continue treatment. Of these patients, 32 were taking antiretroviral drugs and seven had tuberculosis. They all needed financial support for housing, food, and transportation.
The legality of Russia’s move has been questioned because its constitutional law on the incorporation of Crimea included a transition period until 1 January 2015. During this period Crimean law may continue to apply; but Russia’s new law also derecognises Crimean laws that conflict with the Russian constitution. Recent pronouncements by the peninsula’s deputy prime minister and deputy minister of health—namely, that OST is illegal and that treatment approved by Russia should be used—seem to have sealed OST’s fate (see box).
But OST works, and it is recommended by the World Health Organization, the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the United Nations Office on Drugs and Crime as part of a comprehensive range of services for people who inject drugs.9
The United Nations recommends OST coverage for at least 40% of people with opioid dependence.10 Methadone and buprenorphine are designated as essential medicines by WHO, and their value in managing drug dependence, preventing HIV, supporting treatment adherence for HIV and tuberculosis, and reducing crime and public disorder related to drugs, is well established.11 In the European Union about half of heroin users receive OST, the European Monitoring Centre for Drugs and Drug Addiction has said.
The Western world and Australia embraced harm reduction as a public health measure in the early 1980s, and governments of all political and cultural persuasions worldwide have since incorporated such policies in their responses to their own national HIV epidemics.
Eastern Europe is home to the fastest growing HIV/AIDS epidemic in the world. In 2013 the Russian Federation and Ukraine accounted for about 90% of newly reported HIV infections in the region.2
OST programmes are provided through Ukraine’s state health service. The Global Fund to Fight AIDS, Tuberculosis and Malaria—the major donor for harm reduction worldwide—pays for these programmes. But in Crimea, amid a tense environment of suspended bank accounts and tight border control, the future of this support is unclear. Now in the second month of the crisis in Crimea, non-governmental organisations say that they are operating without funding.
Crimea’s HIV prevention programmes include needle exchanges, covering 14 000 people, and OST for people who inject drugs, as well as programmes aimed at sex workers and at men who have sex with men. Many of these services are limited, however, if available at all in Russia.
In Crimea treatment with methadone and buprenorphine started in 2006, and as of March this year 800 clients were receiving OST.5 The multisectoral approach to harm reduction reflects different patient needs including drug dependence, HIV, and tuberculosis.12
The Canadian HIV/AIDS Legal Network said that Russia could pilot OST because the law may permit the use of narcotic drugs and psychotropic substances for scientific research. And at least two cases concerning the lack of access to OST in Russia are pending with the European Court of Human Rights13 14; Russia has been under the jurisdiction of this court since 1998.15
But we already know that OST works. Politics has won out over science—and doctors, scientists, and humanitarians are right to feel abhorrence that a new human tragedy has been imposed on Crimea.
The end of opioid substitution therapy (OST) in Crimea:
16 March. Crimea held a referendum
18 March. The Russian president, Vladimir Putin, signed an agreement to annex Crimea and the city of Sevastopol to the Russian Federation
20 March. Viktor Ivanov, head of the Russian Federal Drug Control Service, announced his intention to end OST as his first priority, focusing on methadone16
22 March. Crimea adopted Russia’s constitutional federal law that incorporates it into the Russian Federation
24 March. The Crimean de facto Ministry of Health asked the Ukrainian health minister to provide drugs so that treatment could continue. UNAIDS suggested that the UN transport the drugs to the Crimean border
25 March. Civil society organisations and experts including the Nobel laureate, Françoise Barré-Sinoussi, who discovered HIV, asked the heads of UN agencies to intervene
1 April. The Ukrainian cabinet asked the State Service on HIV/AIDS, Tuberculosis, and Socially Dangerous Diseases to look for ways to continue to provide OST to Crimea’s 800 patients
2 April. While visiting Crimea Viktor Ivanov confirmed Russia’s urgent intention to end OST in Crimea.17 An emergency meeting in Crimea resolved to “find a solution for the care of 803 Crimean inhabitants who are methadone clients”18
7 April. Moscow city council discussed the “dangers of using methadone” and agreed to write to President Putin to express concern over possibly prolonging methadone use in Crimea, said the website of Lyudmila Stebenkova, the head of the council’s health committee. The Russian chief drug specialist, Dr Brun, is quoted to have said that methadone was a medicine for the poor and that the Russian approach of rehabilitation resulted in remission rates of 48% in one year. Moscow council proposed “methodological and other support” to Crimean drug users19
7-8 April. Protests about banning OST were held in front of Ukrainian and Russian embassies in Crimea, Ukraine, Russia, Moldova, Lithuania, and Georgia
9 April. Crimea’s deputy prime minister, Rustam Temirgaliev, said that the peninsula would need help from Moscow’s experts to replace methadone with Russian drug treatment standards20
10 April. The Crimean deputy minister of health sent a response to the Ukrainian State Service on HIV that OST was illegal in Russia and that no support was needed, the International HIV/AIDS Alliance Ukraine reported
15 April. The UN, monitoring the situation closely and continuing to communicate with Russian and Ukrainian authorities to find solutions, sent a letter by the special envoy in the region to the Crimean deputy prime minister, asking him for an urgent meeting to seek solutions to the crisis
24 April. The Ukraine Anti-Narcotics Agency drew the issue to the attention of the Council of Europe
1 May. Crimea stopped OST provision
↵UNAIDS. 2004 report on the global AIDS epidemic. June 2004. www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2004/GAR2004_en.pdf.
↵UNAIDS. Report on the global AIDS epidemic 2013. www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2013/gr2013/UNAIDS_Global_Report_2013_en.pdf.
↵European Centre for Disease Prevention and Control. HIV/AIDS surveillance in Europe 2012. November 2013. www.ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=971.
↵Degenhardt L, Mathers B, Vickerman P, Rhodes T, Latkin C, Hickman M. Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed. Lancet2010;376:285-301. www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60742-8/abstract.CrossRefMedlineWeb of Science
↵Ukrainian Center for Socially Dangerous Disease Control of the Ministry of Health. Information on quantitative and qualitative characteristics of non-personalised data of substitution maintenance treatment as of 1 March 2014 [Ukrainian].
↵ICF International HIV/AIDS Alliance in Ukraine. Harm reduction wins the battle against HIV/AIDS in Ukraine. News release. 7 March 2013. www.aidsalliance.org.ua/ru/tenders/pdf/01q2013/03/Harm_reduction_wins_the_battle_in_Ukraine.pdf.
↵Russian Federation. Federal law: drugs and psychotropic substances. http://base.consultant.ru/cons/cgi/online.cgi?req=doc;base=LAW;n=147329.
↵Drug Reporter. The same old Russian lies against methadone. 2 April 2014. http://drogriporter.hu/en/sameold.
↵World Health Organization. Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. 2009. www.who.int/substance_abuse/publications/opioid_dependence_guidelines.pdf.
↵World Health Organization, United Nations Office on Drugs and Crime, UNAIDS. WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users (2012 revision). www.who.int/hiv/pub/idu/targets_universal_access/en/.
↵Consensus statement of the reference group to the United Nations on HIV and injecting drug use 2010. www.unodc.org/documents/hiv-aids/publications/2010_UN_IDU_Ref_Group_Statement.pdf.
↵Subata E. Opioid substitution treatment in Ukraine. 31 December 2013. Commissioned by the ICF International HIV/AIDS Alliance in Ukraine (available on request).
↵Andrey Rylkov Foundation for Health and Social Justice. Ivan Anoshkin’s complaint to the UN special rapporteur on the right to health regarding the lack of evidence based drug treatment in Russia. 3 January 2012. http://en.rylkov-fond.org/blog/ost/rost/anoshkin-complaint/.
↵Andrey Rylkov Foundation for Health and Social Justice. Activist Irina Teplinskaya, who recently filed a complaint against Russia to UN, was planted with drugs. 23 August 2011. http://en.rylkov-fond.org/blog/drug-policy-and-russia/drug-policy-in-russia/teplinskaya/.
↵Federal Law of 30 March 1998 N 54-FZ: On ratification of the Convention for the Protection of Human Rights and Fundamental Freedoms and its Protocols [Russian]. http://base.consultant.ru/cons/cgi/online.cgi?req=doc;base=LAW;n=18263.
↵24 World. FDCS in Crimea intends to deal with methadone therapy [television interview in Russian]. 20 March 2014. http://mir24.tv/news/society/10105992.
↵Federal Service of the Russian Federation for Narcotics Control. On the organization of anti-drug activities in the Crimean Federal District [Russian]. 2 April 2014. http://fskn.gov.ru/includes/periodics/speeches_fskn/2014/0402/104829810/detail.shtml.
↵Federal Service of the Russian Federation for Narcotics Control. Decree signed on the establishment of a regional anti-drug commission in Crimea [Russian]. 3 April 2014. http://fskn.gov.ru/includes/periodics/news_all/2014/0403/210129871/detail.shtml.
↵Lyudmila Stebenkova. Members of Moscow City Duma/Council are against methadone [Russian]. 7 April 2014. www.stebenkova.com/Депутаты-Мосгордумы-против-метадона/.
↵Highlights in Russia. Moscow will abandon Crimea methadone [television interview in Russian]. 9 April 2014. www.69rus.org/more/7023/.