Access to health care for drug users as an effective tool for HIV control in Uzbekistan Azizbek A. Boltaev, M.D. Lici

1. Access to health care for drug users as an effective tool for HIV control in Uzbekistan Azizbek A. Boltaev, M.D. Licit and Illicit Drugs Seminar Supported by OSI IPF-Budapest, Award B9163 & IHRA

2. Injecting Drug Use and HIV in Uzbekistan • According to UNODC there are 61,000-91,000 drug users in Uzbekistan • 90% of estimated 22,000 of drug users in Tashkent use heroin as a drug of choice • 58% (~12,700) of them consume heroin everyday • 78% are practicing injection route of drug consumption

3. Injecting Drug Use and HIV in Uzbekistan • 82% of drug users may have shared injecting equipment • And only 6% of IDUs “have never risked” • 29.6% of all registered HIV individuals are IDUs • 89.3% of HIV cases registered during first 6 month of 2004 are blood burn infections

4. Barriers in access to health care • mistrust of drug users to Trust points and narcology service regarding their collaboration with militia (police) • inadequate or sometimes no provision with clean injecting equipment • absence of outreach work among IDUs; • absence of system of rewards or incentives for Trust points employees: very often doctors responsible for Trust points are not paid at all for this job and they try to transfer this job to another doctor.

5. Barriers in access to health care • sometimes employees of Trust points do not understand their mission, and some of them think that their primary responsibility is to register as many IDUs as possible and control their behavior: • One of key informants has recollected a case when one of new doctors of city-based Trust points as evidence of his excellent activity brought tens of letters signed by IDUs promising not to share their injecting equipment with peers!

6. Barriers in access to health care • NGOs, successfully accessing IDUs and offering SEP, were indicated as not sustainable institutions and totally dependent on financial support of international donors. • The longer drug use history the lesser care of their own health among drug users and health care seeking • Detox in official state owned clinics was indicated as highly inaccessible due to shortage of beds in hospitals and very undesirabledue to fear of being registered and as a result to get into the “black list” of police.

7. Barriers in access to health care • High threshold services limits utilization of the services by drug users • Often those who came to narcology dispensary to enter into treatment program are being refused due to that more than ¾ of beds in clinics are being occupied by those who are on compulsory treatment which may continue 3-6 months. • Police direct their efforts on seizure of drug users as crimes rather than drug dealers • Key informants know about lots of examples drug users were imprisoned by requests of relatives after several unsuccessful attempts to get off the needle with support of doctors or having difficulties to access a good addiction treatment. Informants believe that there are lots of IDUs are put into jails under mentioned circumstances.

8. Barriers in access to health care • No anti-retroviral treatment is available in Uzbekistan • No opioid maintenance therapy is available yet • Introduction of methadone in Uzbekistan depends on personal opinion and believes of officials from state drug control agencies. • General Practitioners lack of knowledge and skills to effectively work with patients who use drugs. Hence, very often doctors do not ask questions related to possible drug use history of the patient • Services for drug users provided by NGOs are concentrated mostly in Tashkent, the capital of Uzbekistan while very modest number or none of IDUs from cities and rural areas outside of the capital have access to such kind of services.

9. Barriers in access to health care • Different health services such as narcology, AIDS, SEPs, intensive care, Infection clinics, psychiatric hospitals are not integrated in HIV prevention efforts and in improving access to health care for IDUs and often don’t know about the services offered by partners • “Total abstinence from drug use or nothing” approach is dominated in drug treatment service • Services offered to drug users are designed without respect of their stage of change (Prochaska & De Clemente) and targeted only oh those who are in Determination\Preparation and Action stages. • In general there are no relapse prevention program is offered in Uzbekistan

10. Barriers in access to health care • Recent restrictions on NGOs activity with grants from international donors substantially limited number of drug services and coverage of vulnerable groups of people

11. What is Uzbekistan’s response to HIV epidemic?Current drug addiction & HIV/AIDS treatment programs • Uzbekistan has established a countrywide network of trust points (n=230) administered by AIDS Center to deliver harm reduction services as syringe exchange and condom distribution for IDUs and SWs (cover about 1% of estimated # of IDUs • Swiss Government finances two syringe/ needle exchange programs in Samarqand and Tashkent operated by local NGOs • Governmental Narcology Dispensaries have about 1600 beds to provide treatment of substance use disorders which mostly consists of detox with partial rehabilitation program which is ~60 times lower comparing to the # of estimated drug users needed treatment

12. Current drug addiction & HIV/AIDS treatment programs • AFEW had initiated several prison projects in Tashekent, Chirchik and Samarkand • USAID and OSI are running Program on drug demand reduction in Uzbekistan and Tajikistan • World Vision and JICA are operating a joint HIV prevention project with 10 trust points in Tashkent- city covering approximately 1800 IDU with syringe exchange service

13. Current drug addiction & HIV/AIDS treatment programs • Global Fund against AIDS, TB, and Malaria supported Uzbekistan’s grant proposal on “Scaling-Up the Response to HIV/AIDS and Tuberculosis in Uzbekistan: A Focus on Vulnerable Populations” with a over 25 million budget for the period of 2004-2007 • Two AA and AN self support groups operate in Tashkent and one in Angren. • One SMART-Recovery self help group operates in Bukhara

14. Are this programs effective? • We don’t know! • But WHY? • Very limited researches are conducted to investigate the effectiveness of drug treatment and HIV prevention programs in Uzbekistan • Substance abuse related services often cover very small group * of target population to have an impact on epidemiologic situation • Very often these services are not sustainable to estimate long term effects of intervention • Even when evaluation of effectiveness is planned, it is being implemented by the same service providers who are not interested in “bad results or poor effectiveness”

15. Are this programs effective?We don’t know! Why? • Evaluators usually don’t have necessary skills and/or knowledge to do a good research • Unreliable Soviet model of data collection & statistics in Uzbekistan substantially limits abilities of investigators • Substance abuse related services are not well integrated with each other • Importance of evaluation of effectiveness of interventions in improvement of services is underestimated by service providers and donors

16. Conclusions & Recommendations • During last 4 years number of registered HIV cases in Uzbekistan has increased over 1300 % • Injecting drug use plays a leading role in HIV transmission in Uzbekistan • Without effective responses Uzbekistan very soon may become a leader by HIV notification rate among all Central Asian countries • Treatment and HIV prevention (as SEPs) programs cover up to 600% less of all target population • Existing network of trust points in Uzbekistan DOES allow to provide syringe exchange program to majority of IDUs and to become an effective tool in control of HIV epidemic in the region

17. Acknowledgements • International Harm Reduction Association • Open Society Institute’s International Policy Fellowship and International Harm Reduction Development Programs • International Society for Addiction Medicine