Harm Reduction in Ukraine

Ukraine Methadone Clinic

After the Orange Revolution in 2004 Ukraine won praise for adopting a drug substitution programs. Previously many ex-soviet states had opted against substitution programs with Russia leading the way claiming that it merely means the substituting of one drug for another. This has led to rampant rates of HIV with some sources saying that as much as 2% of the Russian population may have HIV many of which have got it from non-sterile needles. Some even say that up to 65% of those in Russia with HIV may have gotten it from sharing needles.

Ukraine due to its perceived status as a ‘satellite state’ to Russia had up to the Orange Revolution opted not to use any drug substitution programs and therefore also had a major problem with a HIV epidemic. In Ukraine 1.2% of the adult population have HIV which is quite high when you compare that statistic with other nations such as the USA (0.47%), UK (0.1%) and Japan (0.01%). That means Ukraine currently has a higher percentage of their population infected with HIV than Sudan (1.1%) and many other countries who are always thought of having a very high HIV rate. In Ukraine as it currently stands there are just over 5000 injecting drug users which have gone onto a substitution program with plans to increase than to 20,000 users by 2014 though that now seems highly optimistic.

The use of harm reduction programs have been proven by many studies to have a declining effect on HIV rates, it has long been known for instance that the sharing of needles helps spread HIV. The same is true for drug substitution therapy where by giving drug users alternatives such as methadone it firstly prevents the need for sharing needles but secondly it helps drug users stay off stronger drugs such as heroin and provides a safer alternative whilst preventing symptoms of withdraw. Due to the fact that drug substitution programs have had so many positive studies and results many countries have adopted OST (Opioid Substitution Treatment) programs including the likes of Iran who have had a drug substitution program since 1999. However places like Russia, despite the tsunami of evidence, still reject the principle of substitution programs and as a big power in the region it has been able to shape the drug policies of states around it.

Ukraine’s status as a sort of beacon of harm reduction in Eastern Europe has begun to change though, for the worst. Many point to the new Ukrainian president and the accusation that he is more Russian leaning than his predecessor. Many activists now claim that the doctors and patients are being singled out by the police and that is firstly making doctors more cautious about helping such programs but secondly it is also putting off drug addicts from using these treatments for fear of the police. Critics of this crackdown say that it makes no sense to discourage and crackdown on programs which have been proven to work and this could have a big impact on Ukraine’s fight against HIV infection rates.

Economically it makes sense to employ harm reduction policies such as substitution programs. Studies with a focus primarily on Ukraine have shown that harm reduction in Ukraine can be very effective. One study used Ukraine and worked out what was the most cost effective way of treating and preventing Ukraine’s HIV epidemic and decreasing the infection rates.

The study showed that HIV positive IDU’s (injecting drug user) had a lower quality of life than HIV positive non-IDU’s. The use of methadone substitution increased the quality of life of an IDU compared to a non-IDU by an astonishing 50%! As well as measuring the quality of life when comparing IDU’s to non-IDU’s the study also showed the best way to prevent HIV infections.  The top way was a “high methadone substitution therapy, high ART (antiretroviral therapy)” program. The second best way to prevent HIV spreading was solely methadone substitution therapy. In fact the study showed that a high methadone substitution plan alone would prevent 2,970 IDU HIV infections and 1,730 non-IDU HIV infections.

The authors of the study concluded that methadone substitution in Ukraine would be the most cost effective way of preventing HIV with the benefits increasing with the scale of the project. What was even more startling was that methadone substitution would not only prevent HIV infections in IDU cases but it would also help prevent non-IDU infections. The study also goes on to warn that neglecting IDU’s in a national program will undermine any attempt to control the spread of HIV especially in Ukraine where there are a lot of the HIV infections which originate from IDU’s. In essence Ukraine’s only option to fight high HIV infections is to provide treatments for drug users a policy that disregards this group of people has very little chance of succeeding.

Another study about Ukraine showed that drug substitution treatments in Ukraine had a retention rate of 75% compared to the non-drug substitution treatment which had a retention rate of only 33.3%. The study also talked about the fact that those on OST treatments in Ukraine were having success in finding and maintaining jobs and thus had a better chance of contributing towards society.

Despite the evidence that OST in Ukraine would be beneficial and cost effective there definitely seems to be some political lethargy amongst those in charge. There does not seem to be any real interest in continuing to increase the number of people in OST despite the fact that it is one of the best ways to reduce HIV in Ukraine, some may even argue it is the only way to tackle Ukraine’s HIV problem.

Police have been accused by activists of raiding drug substitution centres without reason taking fingerprints of patients, photographing patients, illegally searching the homes of patients and confiscating medical documents.  This blatant disregard for patients actively discourages others from seeking treatment. At the same time the police have been targeting the doctors who run and work at these clinics two of which have been facing trials for drug trafficking and breaking narcotic laws. This combination of harassment and prosecution has made many doctors weary of wanting to help such programs.

Police say that they are just trying to make sure drug laws are obeyed but HIV and drug related charities believe it is a fundamental shift from a positive drug policy of harm reduction to one which mirrors that of Russia where some are predicting that HIV rates could rise to 10% of the population primarily down to Russia’s drug policy. There is also suspicion of corruption on the part of the police with some commentators such as Pavlo Skala from the International HIV/AIDS Alliance saying that they believed that the corrupt parts of the police are helping drug lords stop the program. This accusation stems from the fact that there is a belief that drug lords are unhappy with the loss of customers which has come from harm reduction. This has led to drug lords apparently bribing the corrupt elements of the Ukrainian police.

Ukraine still has the highest rates of HIV in Europe so slowing down or closing down treatments like substitution programs is ill advised especially when the effectiveness of harm reduction has been proven and used throughout the world even in places like Iran and China (95,000 in OST) where drug laws are considered strict they are being used because of its effectiveness. The blame as Russia normally seems to imply is not solely on America’s failure to control the drug trade in Afghanistan but it is more about the fact that many Eastern European countries and Russia have blindly taken the view that criminalisation rather than treatment is the way to solve their drug problems. This despite the overwhelming international community consensus that methadone is a viable and useful tool in harm reduction and the reduction in IDU HIV infections.

The fact that almost all harm reduction programs are funded by NGO’s in Ukraine is also telling. The government seems to suffer from a lack of willpower to create change and to see the long term benefits of methadone in particular. When 60 people a day are being infected with HIV in Ukraine and with an ARV (Antiretroviral drug) shortage it is even more important to try and prevent the spread of HIV instead of trying to treat what could have been prevented. A paper by Bruce for the International Journal of Drug Policy said that delaying treatment will only result in a higher chance of an individual acquiring an infectious disease and thus becomes “more costly to the individual in terms of mortality and more costly to society as a whole” and this is exactly what is happening in Ukraine.

The criminalisation of drug users is a big problem in Ukraine and lots of the former soviet states the problem being that harm reduction programs in prisons in places like Ukraine is fairly limited despite the fact that prevalence of HIV in prisons is quite high, where at least 7% of all inmates have HIV. Again it does not make economic sense for the Ukrainian government not to provide proper methadone treatment in prisons. A study in Australia by Warren and Viney illustrates this by saying in their paper that the benefits of methadone outweighs the cost of providing it in prison especially when you take into account hepatitis c infections and HIV infections within prisons.

Ukraine needs to increase its drug substitution programs but as well as that they need to make sure that it is more accessible. There is an estimated 295,000 heroin users in Ukraine 5,000 of them are on substitution programs it is a start but it is a small drop in the ocean. Eastern Europe has the fastest growing HIV epidemics in the world (UNAIDS) it is time that Ukraine and places like Russia finally realise that the best way to prevent HIV and the medical costs associated with it is to provide relatively cheap large scale OST in the form of methadone if just 25% of IDU’s in Ukraine had methadone substitution then 4,700 HIV infections could be prevented each year. It is cost effective, it has been proven to significantly reduce drug use, drug related crimes and HIV infection in both IDU and non-IDU’s so why is the Ukrainian government not harnessing the full potential of OST?