Russia and Methadone

On paper, Maksim Popov looks like a modern day saint; Psychologist, HIV activist and head of Uzbekistan based NGO Izis. Yet reality sees him sentenced to seven years in prison for the promotion of (all those well-known sins) safe sex and attempting to prevent the spread of HIV. Ironically, thanks to Uzbekistan’s contradictory policies, he is now living amongst many of the people he was trying to help. Incongruous as that may be, the imprisonment of this enthusiastic and effective educator has raised serious questions as to the lack of real progress being made in Eastern Europe and Central Asia to create an effective discourse on drug policy.

With UNAIDS estimating around 1.5 million people live with HIV in Eastern Europe and Central Asia, it’s not as if governments can afford to start banging up the people who are working to see this number drop. Not surprisingly, this vicious circle brings us back to Russia, and more importantly, a complete lack of understanding of drugs. Sharing injection equipment is three times more likely to transmit HIV than sexual intercourse, yet, despite the UN’s endorsement of methadone substitution therapy – a harm prevention strategy used in many countries around the world – 2005 saw Russian narcologists sign a memorandum against the use of the treatment. Restricting access to methadone substitution treatment in Russia is a basic violation of human rights, so how can Russia still be saying ‘no’?

It doesn’t take a genius to understand the scale of the problem in Russia. Human Rights Watch estimated as many as one million Russians used heroin in 2007, whilst the Federal Drug Control Services source unofficial estimates as high as 2.5 million people, almost 2% of the population. Without meaning to state the obvious; that’s an impressive market waiting to be sold a product.  With an estimated 80% of HIV in Russia found in current or former drug users, the statistics begin to create a depressing picture. 

There is no denying that this is a global issue; millions of people inject drugs on a daily basis in over 150 countries around the world, yet Asia and Eastern Europe contain the largest injecting populations. Russia stands proud at the top of the table for having the fastest growing HIV epidemic in the world. Maybe we should print them a certificate. According to the International Harm Reduction Association (IHRA) report of 2009, “Since 2001, the number of people living with HIV in the region has more than doubled,” when you start projecting that into the future, you realise how much Russia needs a hero.

Enter Victor Ivanov, Russia’s ‘Drug Czar’. So bold is he in his policies that he might concede to a bit of experimentation with treatments in some ‘regions’ of Russia. Of course, he refuses to provide the federal support needed to implement an actual methadone substitution programme.  Exactly the strength of policies Russia needs to cure an epidemic. Perhaps not. Europe’s passionate response? Carel Edwards, Director of the EU Commission Drug Policy Coordination, emphasises that the EU’s position is the “exact opposite of what Mr Ivanov said on all accounts.” 

Not exactly hero material then.

Hungarian Civil Liberties Union footage, at the Second Eastern Europe and Central Asia AIDS Conference 2008 (EECAAC), exposes the Russian government’s attitude for what it is; restricting the use of treatment that could literally save lives. Considering Russia has potentially the world’s largest heroin market, an area of the world where the trade of needles is synonymous with guerrilla tactics, how many more people need to die before they consider taking action? 

Russian concerns centre around the introduction of another drug into an already vulnerable Russian market. Anya Sarang, a drug policy expert from Russian Harm Reduction Network, insists that this is an idealist sentiment at best. Methadone is already an established drug within Russian street trade, its introduction is likely to have about as much impact as an anti-alcohol campaign. We’re talking about a country where teenagers buy window-cleaning fluids because its cheaper than a £2 bottle of vodka.

Would it be too cynical to mention the words ‘old ideology’ at this point, or are there deeper economic concerns? Activists speculate that the influence of lobbying pharmaceutical companies within the Russian market is having a negative effect. Methadone is a relatively cheap drug with, therefore, little lobbying potential – could this be linked to the lack of Russian narcologist interest? Profit over health…Not exactly a real shocker.

Ivanov’s blasé attitude is frustrating enough, but what really gets the heat rising is the fact that methadone substitution treatment actually works. Ukraine is a fantastic example of the successful human impact of this type of intervention, reducing the risk of illegally acquired injected drugs, and in turn reducing the impact of associated HIV infection. Yet, despite these success stories, Ivanov still claims there is no evidence of its scientific effectiveness, “During the use of methadone treatment in Ukraine, Belarus and the Baltic States, we see only the worsening of the drug situation.” 

The experts tend to disagree. Audrone Astrauskiene, director of the Drug Control Department in the Republic of Lithuania, reported positive results from the programme’s implementation in her country, where HIV infections have significantly reduced in the last five years. More time might be needed for conclusive evidence, yet substitution treatment and related services in Lithuania has led to a decrease in new HIV cases from 70% in 1995 to 30% present day. Perhaps someone should tell Ivanov that his sources are having him on. 

Enter the IHRA 2009 report confirming the potential success of OST treatments: “Russia and Ukraine combined are home to 90% of the region’s injecting drug users, but the two countries have employed quite different responses.” Whilst Ukraine appear to have responded positively, initiating methadone prescription in 2008, Russia, home to an estimated two million injecting users, has only 69 needle and syringe exchanges across the country – a pathetic statistic considering it is the largest country in the world. 

Clearly Russia aren’t responding to tactful statistics and scientific evidence. Perhaps the international community’s language needs to get a bit more colourful.

Future Perspectives

Release, the UK’s national centre of expertise on drugs, believes policies must evolve in order to better regulate and restrict the negative effects of drug use. A drug free World has never, and will never exist, and Russia is no exception. As the experience of Maksim Popov has highlighted, even an association to the world of drugs can lead to a life of extreme stigma and marginalisation. 

Kind-hearted activists, however, are the least of Russia’s problems. Access to harm reduction strategies, according the IHRA, is a fundamental human right, “Individuals who use drugs do not forfeit the right to the highest attainable standard of health.” With the XVIII International AIDS conference being held in July, UNAIDS feel confident that the epidemic in Eastern Europe will be a key focus. The conference’s theme ‘Rights Here, Right Now’, emphasises the importance of Human Rights work in responding to the epidemic. Yet the Russian Federation disagree that Human Rights is linked to HIV prevention in the context of drug control policies, and are unlikely to change their position against universal access to HIV prevention methods. How are we meant to promote change in a country so stubborn it refuses to help itself?

If you want to stop the HIV epidemic in Eastern Europe, taking a hard-line is not the answer, you need to clean up, literally, the way users use drugs. “People using drugs have a right to access the best possible option for HIV prevention, care and treatment,” said UNAIDS Executive Director Michel Sidibé at a recent press conference. Calls for effective harm reduction approaches are echoed in higher places. UN Secretary-General Ban Ki-moon agrees, “No one should be stigmatised or discriminated against because of their dependence on drugs.” 

Fair statement, but is that enough to put pressure on the Russians to change their policy?

With up to 10% of all HIV infections occurring through unsafe injection, measures are needed to provide better access to treatments the world over. Craig McClure, director of International AIDS Society, highlights that “both methadone and buprenorphine are listed in the World Health Organisation’s list of essential medicines,” a guideline of medicines that should be included in every country’s health care Veto allowed.  

“For me, not giving the right to people to have access to services, when those services can save lives, is a violation of human rights,” argues Sidibé. In his words, it’s that simple. Globally, the situation looks bad enough; according to UNAIDS on average only two needles and syringes are distributed to the worldwide community of injecting drug users every month. Yet in Russia, this is non-existent. How can the international community be so active on certain violations of human rights – think Burma, think Afghanistan – and still stay silent on these restrictions in Russia? It might not seem as dramatic as going to war, but believe me, those affected are equally likely to be staring death in the face. No-one is endorsing drug use, but if we really want to reverse the HIV epidemic, access to sterile equipment and suitable treatments needs to be established as a basic human right; the right to save a life.