|Drug Abuse and HIV/AIDS: Lessons Learned - Case Studies Booklet - Central and Eastern Europe and the Central Asian States (UNAIDS, 2001, 113 p.)|
The human immunodeficiency virus (HIV) is efficiently transmitted by the sharing of contaminated injecting equipment. Addressing this issue is, however, not a simple matter. The social nature of drug-injecting, the complex dynamics of sharing and the interaction of drug use with high-risk sexual behaviour present a considerable challenge for the design of effective responses. In the present booklet, examples are provided of how initiatives to address this complex problem have been developed in Central and Eastern Europe and the Central Asian States. In so doing, the lessons learned in the practical work of programme development are identified in order to assist in the design of future activities.
In global terms, drug injection, because of the health and social problems associated with it, remains the biggest cause of morbidity and mortality resulting from the abuse of drugs. Injecting drug use is the main, or a major, mode for the transmission of HIV in many countries of Asia, Europe, Latin America and North America. While precise figures can be difficult to obtain, research has shown that HIV can spread through drug-using populations with remarkable speed and can stabilize at very high rates.
While in parts of both Europe and the United States of America, higher levels of heroin abuse have recently been accompanied by an increase in non-injecting modes of transmission, the number of countries throughout the world reporting the existence of injecting drug users and HIV infection among them continues to grow.
Numerous studies have found drug users to be disproportionately likely to be involved in the sex industry or to engage in high-risk sexual activity. Drug-injecting also contributes to an increased incidence of HIV infection through the transmission of the virus to the children of drug-injecting mothers, and through sexual contact between drug injectors and non-injectors.
Deciding on the implementation of intervention strategies to prevent HIV infection among injecting drug users is one of the most urgent questions for policy makers. Studies have demonstrated that HIV transmission among injecting drug users can be prevented, and that the epidemic has been slowed and even reversed in some cases.
Meeting the challenges of dealing with drug abuse and HIV/AIDS requires institutional commitment at the national and local levels, the involvement of the wider community in planning and implementation, adequate needs assessment, the provision of training programmes for the acquisition of new skills, increasing the availability of a wide range of services, evidence-based practice, and the establishment of monitoring and evaluation systems.
The ability to halt the epidemic involves a three-part strategy: (a) prevention of drug abuse, especially among young people; (b) provision and facilitation of access to drug abuse treatment; and (c) establishment of effective outreach to engage drug users in HIV preventive strategies that protect them and their partners and families from exposure to the virus and encourage the uptake of substance abuse treatment and medical care. A comprehensive strategy to reduce drug abuse and the spread of HIV would offer a broad range of measures, including comprehensive programmes for youth and primary prevention of drug abuse.
Experience around the world indicates that a comprehensive package of measures must be used to prevent the spread of HIV among injectors. There is a need to link such measures with existing health and social services and raise awareness among, and educate, injectors and their sexual partners about HIV risks and safe practices; provide sterile injecting equipment; make available drug treatment programmes; provide HIV-infected injectors with access to counselling, care and support and to information about sexually transmitted infection; and provide condoms. Moreover, local communities, including the drug-user community, must be mobilized and participate fully for such a package of measures to work.
No single element of the package is likely to be effective if implemented on its own. Among the main characteristics of successful HIV preventive programmes is that they are offered to their target groups as part of a continuum of care. They provide appropriate referrals which may include, but are not limited to, substance abuse treatment, HIV counselling and testing, family planning, testing and treatment for sexually transmitted disease (STD), risk-reduction or relapse-prevention counselling, mental health counselling, testing for tuberculosis, womens health services, and HIV early intervention services. They also address other basic needs of the target groups, such as housing and food, so that HIV prevention may be considered a priority concern.
Profound social and economic change in Eastern Europe and Central Asia has created conditions that make the countries in these regions particularly vulnerable to drug use and the spread of HIV. The present booklet, which is largely aimed at policy makers and practitioners, presents an overview of lessons learned and challenges for the future.
The case studies in each chapter provide detailed information for practitioners on the current policies and practice of HIV prevention among injecting drug users from 1l countries in Central and Eastern Europe and Central Asia (Belarus, Bulgaria, the Czech Republic, Hungary, Kazakhstan, Lithuania, Poland, the Russian Federation, Slovakia, Slovenia and Ukraine). Twenty case studies illustrate how drug abuse and HIV preventive strategies and intervention concepts have been introduced into specific national and local contexts, and the responses to a number of important challenges.
In its first three chapters, the booklet presents 20 case studies, grouped according to the focus of the projects concerned: fieldwork, political mobilization and strategy development, and training and networking. Despite many common elements in intervention policies and strategies, this collection of case studies shows the different adaptations that take place in response to local concerns.
Chapter I focuses on fieldwork projects, illustrating in 10 case studies how the main HIV preventive interventions targeting injecting drug users were put into practice, and how hidden target populations were reached. Experiences from outreach projects, peer education and low-threshold services show how supportive local conditions and clear strategy frameworks for community mobilization can contribute to the success of HIV prevention efforts. Further, the chapter gives examples of the work undertaken with specific target groups (sex workers and ethnic minorities) and highlights the practice of local cooperation between health and law-enforcement services, and state and non-governmental agencies. One example shows how the primary public health-care system can become a partner in the provision of substitution treatment to drug users, and thus contribute to reducing their stigmatization.
The case studies describe how interventions have been technically implemented by the various projects and, even more important, how a broad, community-based response to HIV/AIDS among injecting drug users was achieved. It was learned that interventions must be both early and comprehensive, and services user-friendly and responsive to individual needs.
Chapter II contains case studies that illustrate the process of political mobilization and national strategy development. Addressed, among others, are such questions as how all stakeholders can become actively involved in HIV/AIDS prevention among injecting drug users and the roles that a supportive legal framework and intersectoral cooperation can play. Five case studies are presented in the chapter. The case studies from Belarus, Kazakhstan and Ukraine document the process of shaping a new national approach to drug users, and also describe the various difficulties experienced and how they were overcome. The case studies of Hungary and Poland provide examples of the development of policies and programmes for HIV prevention among injecting drug users within the context of low HIV prevalence.
While bringing out regional diversity as well as similarity, the case studies give an up-to-date picture of the challenges commonly confronted in the development of strategies for HIV prevention among injecting drug users:
(a) Legal basis. A national strategy must build upon legal frameworks adapted to allow a comprehensive response;
(b) Awareness. A low level of awareness about the problems of drug use and HIV/AIDS among the general public, and inadequate knowledge about measures of prevention, often leads to prejudices against drug users;
(c) The understanding of drug use as a social phenomenon, and not purely a medical problem, must be fostered, and consensus on HIV/AIDS prevention must be reached among the general population as well as among professionals from various disciplines;
(d) Multisectoral approach. There must be cooperation among all sectors in order to prevent HIV/AIDS infection among drug users. This major public health objective can be tackled using a multidisciplinary approach, which can be a new concept for most professionals. Constructive collaboration is particularly important between the health and law-enforcement sectors;
(e) Local responsibilities. In the light of the experience of the case studies, more responsibilities in terms of decision-making powers and funding should be delegated and decentralized to the local level;
(f) Assessment. The extent of drug use and of behaviour that puts a person at risk of HIV/AIDS is, in many cases, largely unknown. There is a need to carry out research studies to assess and monitor the evolution of risk behaviour in order to inform national strategy development over time.
Chapter III provides five examples of training and networking projects, which play a major role as effective and cost-efficient contributions to information sharing, capacity-building and resource mobilization at the regional and national levels.
In order to design and establish new services, the capacities of the existing health-care system must be reoriented so as to meet the needs of a comprehensive drug abuse and HIV preventive strategy. Professionals need up-to-date information and training in providing diversified services to drug users and in HIV/AIDS preventive interventions in order to enable the effective delivery of services to the target population. Two examples of training projects highlight the steps taken to expand rapidly and systematically the coverage of HIV prevention efforts among injecting drug users, based upon a systematic assessment of local needs.
Networking among providers of HIV preventive services to exchange experience and lessons learned, and making up-to-date information about contemporary responses to the HIV epidemic available to a wider target audience, are both important contributions to the promotion of an effective response to HIV in the region. To illustrate the progress that has been made in this field over the past few years, examples are provided of networking activities at the national, subregional and regional levels.
Chapter IV provides a summary of the lessons learned and specific challenges with which HIV preventive projects among injecting drug users in the region had to cope. The chapter also draws on discussions held among representatives of projects at a meeting convened by UNDCP at Minsk, from 13 to 15 July 2000, as part of the preparation of the present booklet. Those discussions indicated high awareness among project implementers that a comprehensive strategy for HIV preventive intervention requires, as is the case in other fields of health promotion, an integrated approach towards encouraging individual, community and political action.
In the mid-1990s, the situation in Central and Eastern Europe and the Central Asian States presented particular circumstances that are worth noting: limited experience with drug abuse and associated problems; predominance of interdiction approaches; societies in transition with the accompanying social problems; and rapid dissemination of injecting drug use, high-risk behaviour and potential for HIV transmission.
Given this situation, several countries, supported in many cases by international organizations, responded to the urgent need to act to prevent HIV among injecting drug users. This meant the development of new, in some cases controversial, approaches, and work towards their legitimization. As a first step, measures aimed at avoiding HIV transmission were assigned priority. In this process, important challenges were encountered. Progressively, the need to diversify services for drug users and to offer a wider range of approaches was recognized. The need to develop comprehensive drug demand reduction programmes, a component of which is the prevention of the health and social consequences of drug abuse, in particular HIV prevention among injecting drug users, was also well understood.
In the course of the discussions held at Minsk, policy makers and project implementers noted that common challenges at the policy level were:
(a) Awareness raising and advocacy;
(b) Strategic planning of a multisectoral response;
(c) Design of implementation policies that are able systematically to broaden and diversify existing treatment and care approaches, including reduction of the health and social consequences of drug abuse;
(d) Situation analysis of available resources and needs assessment;
(e) Sustainability of interventions.
The experts considered the involvement of non-governmental organizations and the target population as vital in the implementation of preventive interventions, and viewed as a major challenge the establishment of broad local alliances and constructive partnerships with all stakeholders. These included the local administration, the police and providers of health care from the state and non-governmental sector, as well as representatives of the target populations. To improve services on the basis of local assessments and to tailor them towards the target population was viewed as another challenge.
The following joint statement, summarizing key principles of effective HIV/AIDS prevention, was elaborated by the participants in the meeting convened at Minsk: *
* The statement was developed by a subgroup of participants,
circulated to all participants for comment and finalized after the
Key components of effective prevention of HIV/AIDS
(1) A national strategy, policy and action plan, focused on effective interventions and targeted at groups in most risk of HIV/AIDS, has to be elaborated, agreed and implemented in every country in close cooperation with, and with the participation of, all relevant parties, organizations and individuals (e.g. representatives of the governmental, private, non-governmental, expert and local sectors). The plan should include general and short-term objectives, concrete tasks and expected results, and should clarify responsibilities, concrete interventions and evaluation procedures.
Effective and targeted interventions, focused on the reduction of specific harm and on specific preventive activities, have to be identified and implemented in every place, environment, community or region in which, risk behaviour, environment or conditions are reported, occur or are predicted. The principles for these interventions have been identified in the WHO publication, Principles for Preventing HIV Infection among Drug Users.a
a WHO Regional Office for Europe (Copenhagen, 1998).
The following elements are crucial to effective action and success:
(a) The involvement of all sectors of society, including individuals, the family and the community;
(b) The involvement of all professionals from all relevant agencies (social, health, law-enforcement and criminal justice), as well as those who are affected by or at risk of HIV/AIDS;
(c) Activities and interventions must be focused on knowledge and awareness, changing skills, attitudes and behaviour;
(d) To be effective, interventions must be locally oriented, focused on individual needs and periodically revised and changed according to the actual situation.