HIV and Drug Policy in Kaliningrad: Risk, Silence and the Gap between Human Needs and Health Services

Abstract

A Rapid Policy Assessment and Response (RPAR) intervention was conducted in Kaliningrad, Russia, to assess the impact of Russian drug policy on the health of drug users in the city and surrounding rural areas. In the RPAR, a team of Russian researchers worked with a Community Action Board (CAB) comprised of law enforcement officials, drug treatment providers, medical officers, NGO leaders, lawyers, judges, and others to collect and analyze laws and policies relevant to health risks in the target populations; existing data on the epidemiological situation and the operation of the criminal justice system; and 3) qualitative interviews with health care providers, lawyers, law enforcement representatives, NGO staff, drug users, sex workers and others who describing how the laws are put into practice. The RPAR uncovered a wide range of problems, including continuing high risk sexual and drug using behavior; lack of prevention and social services (or any concern for) drug users and sex workers; lack of effective, accessible drug treatment; and laws and law enforcement practices that interfere with public health. The reasons for the situation are many and complex, but the RPAR identified several key factors that could be dealt with in pragmatic, policy terms and through good management and coordination in Kaliningrad. At the deepest level is the stigmatization of drug use, which instills in users and non-users alike a false belief that nothing can (and perhaps should) be done. This disdain and discouragement is reflected in and reinforced by law, which categorizes drug users both as criminals and as patients with a right to treatment, and thence in law enforcement practice, which has become an almost complete bar to the development of effective services. Throughout Kaliningrad, there is an absence of public health interventions to prevent disease among IDUs and their sex partners, and a shortage of basic, quality drug treatment services. The CAB and the research team worked together to identify both national and local actions that could make a difference. National policy changes include: * Clarification of current policy on harm reduction and, if necessary, legislative action to eliminate any doubt that harm reduction programs, including NEPs, are legal in the RF * Elimination of the system of narcological registration * Legalization of long-term opioid agonist treatment with methadone, buprenorphine or other appropriate medicine, and an end to the state monopoly on pharmacologically assisted drug dependency treatment RPAR identified a large number of concrete, feasible actions that could be taken in Kaliningrad to immediately improve the well-being of drug users and the state of public health. These include: * Define the legal status of harm reduction programs at the level of the Kaliningrad region - i.e., the relevant health and law enforcement agencies should explicitly authorize harm reduction programs including NEP. * Learn about the international experience of harm reduction programs; include them in a regional strategy to counteract HIV-infection and to provide adequate funding to their work. * Ensure that drug users and sex workers, as the most vulnerable to HIV-infection, hepatitis and STIs, get access to prevention, including harm reduction programs with access to the injection equipment. * Provide vulnerable groups with free of charge testing with voluntary pre- and post-HIV test counseling. * Optimize existing capacity of medical care, social welfare and criminal justice systems for counseling of IDUs on the health risks and providing information on treatment options. * Ensure drug users real access to drug dependence treatment. These measures should include elimination of restrictions to enter drug treatment facility, including a waiting list. When entering in a drug treatment facility, stop the practice of encouraging drug users to enter short-term paid treatment, without providing information on drug abuse as a disease requiring prolonged treatment and rehabilitation. * Develop a simple, transparent procedure for deregistration. * Provide counseling on HIV-infection and other health risks related to drug use to all drug users undergoing drug treatment (detoxification) in state drug treatment facilities. * Provide adequate funding to drug dependence treatment facilities, including the provision of financing to rehabilitation programs implemented by NGOs. * Provide public and non-governmental organizations working in the field of HIV prevention among drug users and sex workers with adequate funding. This report explains the RPAR methodology, and then describes key findings and recommendations for action. Appendices include detailed information about RPAR methods and findings, including epidemiological and criminal justice data, and data on laws on drug dependence treatment, medical care and treatment services to HIV-positive people and HIV prevention among vulnerable groups.