Structural Barriers to HIV Prevention and Treatment Among Drug Injectors in Odessa, Ukraine

1. Structural Barriers to HIV Prevention and Treatment Among Drug Injectors in Odessa, Ukraine

2. The HIV Epidemic in Ukraine In 1995, the WHO characterized Ukraine as a low prevalence country. By 1996, all 25 regional capitals in Ukraine reported HIV, primarily among drug injectors. In some cities, rates of HIV among IDUs rose from nearly zero in 1994 to more than 50% two years later. Today, Ukraine is the most HIV-affected country in Europe and Central Asia, with an estimated 440,000 infected between the ages of 15 - 49, or 1.63% of the population in this age range.

3. The HIV Epidemic in Ukraine The actual number of people living with HIV is thought to be much higher. The World Bank and International AIDS Alliance in Ukraine estimate that as many as 820,400 will be infected by 2014 and that 140 Ukrainians will die each day, 75% between 20 and 34 years of age and half women. The majority of HIV infections are among those in the most active reproductive age (20 – 34), contributing to the decline in Ukraine’s population from 47,000,000 in 2004 to 45,986,000 in 2006. Some project the population to decrease up to 40% by 2050.

4. Why the rapid increase in HIV?

5. 1) The social and economic disintegration that followed the collapse of the Soviet Union in 1991. With the withdrawal of the Soviet Union in December 1991: Police controls became ineffective, drugs more readily available, and corruption uncontrolled. In the first 5 years following the demise of the Soviet Union, the magnitude of the illicit economy was estimated to have tripled, reaching more than 40% of the gross national product from 1994 through 1995. Locally produced opiates and amphetamines proliferated. Registered drug users increased from 30,000 to 63,000 between 1990 and 1996. State-supported services, including health care, were reduced or eliminated.

6. 2) The injecting practices of IDUs in Ukraine. Ukraine IDUs typically inject drugs drawn from a common container. Opiates, (liquefied poppy straw) purchased from dealers, who are typically injectors, are obtained by extracting the solution from a common container with the user’s needle/syringe, or with the dealer’s needle/syringe, and front or backloading into the user’s syringe. Pseudo-ephedrine, purchased through pharmacies, is usually prepared by groups of users and drawn from shared drug mixing containers. In addition, sharing needles/syringes and other drug paraphernalia is common. The most typical product used to clean syringes is urine.

7. Why is the epidemic continuing to escalate?

8. As recently as 2005, Ukraine had no public health information service, no HIV prevention policy, no substance abuse treatment, no sex education in schools, and no dissemination strategy to address the HIV/AIDS epidemic. Perhaps, more significantly, the stigma of drug use and HIV infection, resulting not only in discrimination but in the denial of critical services and outright brutality, is responsible for the epidemics’ continued escalation. The result: Drug injectors in Ukraine are afraid to carry clean syringes and practice safer needle hygiene, leading to hurried injections and risky needle practices.

9. HIV Prevalence Rates in the Cities We Have Worked In HIV HIV HIV City Population Baseline 6 months Total Kiev 2,765,500 34% 2% 36% Odessa 1,080,000 53% 12% 65% Donetsk/ 1,500,000 20% 8% 28% Makeyevka Simferopol 340,600 19% 15% 34% Nikolayev 505,900 55% 14% 69%

10. Structural Barriers to HIV Prevention & Treatment with IDUs in Ukraine

11. Purpose 1. To gain an understanding of the way in which IDUs and HIV-infected IDUs are regarded and treated in Odessa using in-depth semi-structured interviews with officials from law enforcement, the medical community, social services, the legal establishment and pharmacists. 2. To assess IDUs’ experiences with officials from law enforcement, the medical community, social services, the legal establishment and pharmacists through focus groups with HIV-infected and non-infected IDUs and female sex workers who are IDUs. 3. Using survey methods, a) measure the frequency to which IDUs encounter barriers and discrimination related to HIV and drug use; b) assess the extent to which having HIV is related to experiencing these barriers; and c) assess the relationship between structural barriers and unsafe needle practices.

12. Methods Semi-structured interviews were conducted by teams of two, a Ukrainian and an American, and led by the Ukrainian. Tape recordings were not allowed. While questions varied by group, everyone was asked a series of 5 “core questions”. Those interviewed included: Law Enforcement – Oleg Semeryk & Tom Brewster (N = 10) Medical Community – Sergey Dvoryak & Jane Kennedy (N = 12) Social Services – Sergey Dvoryak & Mark Royer (N = 6) Legal Establishment – Oleg Semeryk & Bill Wendt (N = 9) Pharmacists – Sergey Dvoryak & Mark Royer (N = 3) Total N = 40

13. Focus groups were led by Bob Booth & Tom Brewster and were tape recorded. Groups included: HIV infected women N = 7 HIV infected men N = 8 HIV negative women N = 7 HIV negative men N = 8 HIV infected couples N = 6 Female sex workers N = 6 Total N = 42

14. Qualitative Research Findings

15. Findings What is your opinion about providing treatment to IDUs with HIV or at risk of HIV, including maintenance medications such as methadone? Police: “I do not sympathize with the drug user. Everyone can make a choice in their life to use or not to use drugs.” When asked about ST in prisons: “Drug users/dealers lose their rights in prison. Officially there are no drug users in prison because there cannot be drug use in prison, so there is no ST in prison because there are no drug users.”

16. Legal: “Treatment is too soft and too voluntary. There is not forced treatment.” Users: “Substitution therapy is a good thing. We like it but the programs are not well designed because the drug user can’t get a supply of the medicine to take home. Can’t work and find time to get daily dose. It would be better if the pharmacies gave it out. More clinics are needed. There are only three ST sites in the Odessa area.” “Police will oppose it because they will lose their source of income money provided by us. This is why the police are against it.”

17. Some drug users have stated that they have been beaten by police because they are drug users. Have you heard of this happening? Police: “Yes, sometimes abusers are beaten in order to get confessions from them. Police use psychological and physical techniques for the purpose of confessions.” “The facts are that police beatings are greatly exaggerated. Police never beat a person for using drugs. In the process of arresting a drug user if they fight back or attempt to get away, the police will use force to hold them; this may be interpreted as a beating.”

18. Legal: “The police treat IDUs the same as everyone else, but they are hated a little bit more. IDUs exaggerate the level of police brutality. There are some arrest quotas, but there are limits on them. I have heard that police take money from IDUs then return drugs to the users. The police who work the Department of Illegal Drug Trafficking are often drug users and drug dealers. Police do have a room where those who are apprehended are interrogated. IDUs don’t have to be tortured, just take their drugs from them and they will confess. Police do use electrical shock and a gas mask and withhold air as part of their interrogation tactics.”

19. Users: “Yes, the police took my hands and taped them together. They beat me with a stick so bad I had blood in my urine. They did this because I would not talk about another drug user”. “I know someone who died from the police. After the police killed him at the station they put him in a car with a syringe in his hand to make it look like an O.D.”

20. Do drug users know that they can complain about being beaten to the authorities and there will be an investigation? User: “This legislation does not work; it makes it worse if you complain about being beaten. Police officials pass on that you complained to street police and you get beaten much worse so drug users do not report this”.

21. Have you ever been forced to have sex by the police? (13/20 females - 65% - said “yes” and 100% had heard of it) “Police violate our human rights. They abuse and humiliate us. They do not treat users as people. Police are not afraid of getting HIV when they have sex with users.”

22. Do you see any barriers that prevent IDUs with HIV or at risk of HIV from getting medical services and accessing HIV prevention programs? Police: “I don’t see any barriers. These people (drug users with HIV) don’t want services and that is why they don’t get them.” “There are no barriers. The main barrier is the drug user’s lack of desire to get treatment.” Legal: “ There are no such barriers.”

23. Users : “The dealers are in collusion with the police; the dealer tells the police when and where they will make a sale so the police are waiting when the IDU buys the drugs and police arrest them, take the drugs, threaten the IDU and sell the drugs back to them.” “The police hang around pharmacies and wait for users to buy needles. After the addict purchases the needles the police follow them and take their needles, requiring that they be paid in order to get them back. This is how they make money. The police also work near the drug sale points.

24. “If they find new syringes they force the drug user to pay 20 hrynia to keep the new syringes. It happens if you have drugs too – you can pay to keep the drugs.” “We don’t want to steal, but we have to pay the police.” “I know someone who died from the police. After the police killed him at the station they put him in a car with a syringe in his hand to make it look like an O.D.”

25. Quantitative Research Findings

26. 58.59 49.64 32.71 28.45

27. 83% 45% 42% 35% 22% 9%

28. 15% 20% 7% 4%

29. 15% 24% 7% 9%

30. 85% 78% 51% 22%

31. 41% 20% 25% 10%

32. 32% 13%

33. Logistic Regression to Predict HIV+

34. Summary • Clearly, the drug using practices of IDUs in Odessa contributes to their high rates of HIV infection. • However, police enforcement practices also are responsible for these rates: • 24% reported being beaten/tortured by police • 24% avoided carrying clean syringes for fear of police • 17% avoided pharmacies due to fear of the police • 57% hurried injections due to fear of the police • The ‘risk environment’ drug users in Odessa face must change if the epidemic is to be controlled.