HIV, Drug Injection, and Harm Reduction Trends in Eastern Europe and Central Asia: Implications for International and Domestic Policy

  • Katherine LaMonaca
  • Kostyantyn Dumchev
  • Sergii Dvoriak
  • Lyuba Azbel
  • Olga Morozova
  • Frederick L. AlticeEmail author
Substance Use and Related Disorders (F Levin and E Dakwar, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Substance Use and Related Disorders


Purpose of Review

Scaling up evidence-based HIV prevention strategies like opioid agonist therapies (OAT), syringe services programs (SSPs), and antiretroviral therapy (ART) to mitigate the harms of drug injection is crucial within Eastern Europe and Central Asia (EECA), the only region globally where HIV incidence and mortality are increasing.

Recent Findings

Though the proportion of new HIV cases directly attributable to drug injection has recently declined, it remains a critical driver of HIV, especially to sexual partners. Concurrently, scale-up of OAT, SSPs, and ART has remained low, contributing to a volatile HIV epidemic among people who inject drugs (PWID).


Despite evidence that drug injection contributes to an evolving HIV epidemic in EECA, coverage of evidence-based harm reduction programs remains substantially below needed targets. Due to a combination of punitive drug laws, ideological resistance to OAT among clinicians and policymakers, and inadequate domestic and international funding, limited progress has been observed in increasing the availability of these programs.


HIV prevention Drug injection Harm reduction Opioid agonist therapy Eastern Europe Central Asia 



The editors would like to thank Drs. Robert Friedel and Dwight Evans for taking the time to review this manuscript.

Compliance with Ethical Standards

Conflict of Interest

Kostyantyn Dumchev, Sergii Dvoriak, and Lyuba Azbel each declare no potential conflicts of interest. Katherine LaMonaca reports grants from NIH (awarded to Yale University). Olga Morozova reports grants from NIH (NIDA). Frederick L. Altice reports grants from Gilead, Merck, NIH, SAMHSA, and HRSA and personal fees from Gilead, Merck, and Practice Point Communications.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: •• Of major importance

  1. 1.
    Joint United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS data 2017.Google Scholar
  2. 2.
    Joint United Nations Programme on HIV/AIDS. Global AIDS update 2016.Google Scholar
  3. 3.
    Joint United Nations Programme on HIV/AIDS. Prevention gap report 2016.Google Scholar
  4. 4.
    •• Degenhardt L, Peacock A, Colledge S, Leung J, Grebely J, Vickerman P, et al. Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review. Lancet Glob Health. 2017. This review includes country-level data on injection drug use and infection disease prevalence from a variety of peer-reviewed, international, and government sources, using metaanalyses to create aggregate estimates. CrossRefGoogle Scholar
  5. 5.
    Joint United Nations Programme on HIV/AIDS (UNAIDS). Ending AIDS: progress towards the 90-90-90 targets 2017.Google Scholar
  6. 6.
    Low AJ, Mburu G, Welton NJ, May MT, Davies CF, French C, et al. Impact of opioid substitution therapy on antiretroviral therapy outcomes: a systematic review and meta-analysis. Clin Infect Dis. 2016;63(8):1094–104. Scholar
  7. 7.
    Altice FL, Kamarulzaman A, Soriano VV, Schechter M, Friedland GH. Treatment of medical, psychiatric, and substance-use comorbidities in people infected with HIV who use drugs. Lancet. 2010;376(9738):367–87. Scholar
  8. 8.
    Degenhardt L, Mathers B, Vickerman P, Rhodes T, Latkin C, Hickman M. Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed. Lancet. 2010;376(9737):285–301. Scholar
  9. 9.
    Hickman M, Vickerman P, Degenhardt L. The impact of opiate substitution therapy and highly active antiretroviral therapy on mortality risk among people who inject drugs. Clin Infect Dis. 2015;61:1166–8. Scholar
  10. 10.
    •• Larney S, Peacock A, Leung J, Colledge S, Hickman M, Vickerman P, et al. Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review. Lancet Glob Health. 2017. This review provides a detailed synthesis of harm reduction program availability for each EECA country, including data quality rankings and recency information. CrossRefGoogle Scholar
  11. 11.
    Alistar SS, Owens DK, Brandeau ML. Effectiveness and cost effectiveness of expanding harm reduction and antiretroviral therapy in a mixed HIV epidemic: a modeling analysis for Ukraine. PLoS Med. 2011;8(3):e1000423. Scholar
  12. 12.
    Abdul-Quader AS, Feelemyer J, Modi S, Stein ES, Briceno A, Semaan S, et al. Effectiveness of structural-level needle/syringe programs to reduce HCV and HIV infection among people who inject drugs: a systematic review. AIDS Behav. 2013;17(9):2878–92. Scholar
  13. 13.
    Elovich R, Drucker E. On drug treatment and social control: Russian narcology’s great leap backwards. Harm Reduct J. 2008;5:23. Scholar
  14. 14.
    East Europe and Central Asia Union of PLWH. Eastern Europe and Central Asia: let’s not lose track! 2016.Google Scholar
  15. 15.
    Zaller N, Mazhnaya A, Larney S, Islam Z, Shost A, Prokhorova T, et al. Geographic variability in HIV and injection drug use in Ukraine: implications for integration and expansion of drug treatment and HIV care. Int J Drug Policy. 2015;26(1):37–42. Scholar
  16. 16.
    Degenhardt L, Mathers BM, Wirtz AL, Wolfe D, Kamarulzaman A, Carrieri MP, et al. What has been achieved in HIV prevention, treatment and care for people who inject drugs, 2010-2012? A review of the six highest burden countries. Int J Drug Policy. 2014;25(1):53–60. Scholar
  17. 17.
    European Centre for Disease Prevention and Control, WHO Regional Office for Europe. HIV/AIDS surveillance in Europe 2018 – 2017 data. Copenhagen: WHO Regional Office for Europe; 2018.Google Scholar
  18. 18.
    European Centre for Disease Prevention and Control, WHO Regional Office for Europe. HIV/AIDS surveillance in Europe 2017 – 2016 data. Stokholm: ECCD; 2017.Google Scholar
  19. 19.
    Cakalo JI, Bozicevic I, Vitek C, Mandel JS, Salyuk T, Rutherford GW. Misclassification of men with reported HIV infection in Ukraine. AIDS Behav. 2015;19(10):1938–40. Scholar
  20. 20.
    Dumchev K, Varetska O, Kornilova M, Azarskova M. Improved ascertainment of modes of HIV transmission in Ukraine highlights importance of risk due to injecting and homosexual risk behavior among males. 16th European AIDS Conference; Milan, Italy: Abstract #PE23/33; 2017.Google Scholar
  21. 21.
  22. 22.
    Joint United Nations Programme on HIV/AIDS. Do no harm: health, human rights, and people who use drugs Geneva 2016.Google Scholar
  23. 23.
    United Nations Office on Drugs and Crime. World drug report 2017.Google Scholar
  24. 24.
    Berleva G, Dumchev K, Kasianchuk M, Nikolko M, Saliuk T, Shvab I, et al. Estimation of the size of populations most-at-risk for HIV infection in Ukraine. Kyiv; 2012.Google Scholar
  25. 25.
    Booth RE, Davis JM, Brewster JT, Lisovska O, Dvoryak S. Krokodile injectors in Ukraine: fueling the HIV epidemic? AIDS Behav. 2016;20(2):369–76. Scholar
  26. 26.
    Booth RE, Davis JM, Dvoryak S, Brewster JT, Lisovska O, Strathdee SA, et al. HIV incidence among people who inject drugs (PWIDs) in Ukraine: results from a clustered randomised trial. Lancet HIV. 2016;3(10):e482–9. Scholar
  27. 27.
    •• Altice FL, Azbel L, Stone J, Brooks-Pollock E, Smyrnov P, Dvoriak S, et al. The perfect storm: incarceration and the high-risk environment perpetuating transmission of HIV, hepatitis C virus, and tuberculosis in Eastern Europe and Central Asia. Lancet. 2016;388(10050):1228–48. This paper describes how increasing rates of opioid use disorder and harsh criminalization of drug use interact to drive ongoing infectious disease epidemics in Eastern Europe and Central Asia. CrossRefGoogle Scholar
  28. 28.
    Bemoni Public Union, Curatio International Foundation. Population size estimation of people who inject drugs in Georgia 2014 2015.Google Scholar
  29. 29.
    Maitieva V, Mambetov T, Akmatova Zh, Yanbukhtina L, Bayazbekova J, Jumalieva G, Ismailova A. National progress report on global actions to fight HIV in 2014 (available in Russian only) 2015.Google Scholar
  30. 30.
    European Monitoring Centre for Drugs and Drug Addiction. Latvia country drugs report 2017.Google Scholar
  31. 31.
    Union for HIV Prevention and Harm Reduction in Moldova, Eurasian Harm Reduction Network. National report: the Republic of Moldova “Harm reduction works. Making a case for funding” 2017.Google Scholar
  32. 32.
    Maistat L, Kravchenko N, Reddy A. Hepatitis C in Eastern Europe and Central Asia: a survey of epidemiology, treatment access and civil society activity in eleven countries. Hepatol Med Policy. 2017;2(1):9. Scholar
  33. 33.
    Donoghoe MC, Lazarus JV, Matic S. HIV/AIDS in the transitional countries of Eastern Europe and Central Asia. Clin Med (Lond). 2005;5(5):487–90.CrossRefGoogle Scholar
  34. 34.
    Ancker S, Rechel B. Policy responses to HIV/AIDS in Central Asia. Glob Public Health. 2015;10(7):817–33. Scholar
  35. 35.
    Rhodes T, Stimson GV, Crofts N, Ball A, Dehne K, Khodakevich L. Drug injecting, rapid HIV spread, and the ‘risk environment’: implications for assessment and response. AIDS. 1999;13(Suppl A):S259–69.PubMedGoogle Scholar
  36. 36.
    UNICEF. After the fall: the human impact of ten years of transition. Florence: International Child Development Centre1999.Google Scholar
  37. 37.
    Booth RE, Mikulich-Gilbertson SK, Brewster JT, Salomonsen-Sautel S, Semerik O. Predictors of self-reported HIV infection among drug injectors in Ukraine. J Acquir Immune Defic Syndr. 2004;35(1):82–8.CrossRefGoogle Scholar
  38. 38.
    Booth RE, Kwiatkowski CF, Brewster JT, Sinitsyna L, Dvoryak S. Predictors of HIV sero-status among drug injectors at three Ukraine sites. AIDS. 2006;20(17):2217–23. Scholar
  39. 39.
    European Centre for Drugs and Drug Addiction. European drug report 2017: trends and developments 2017.Google Scholar
  40. 40.
    Abdala N, Grund JP, Tolstov Y, Kozlov AP, Heimer R. Can home-made injectable opiates contribute to the HIV epidemic among injection drug users in the countries of the former Soviet Union? Addiction. 2006;101(5):731–7. Scholar
  41. 41.
    Alves EA, Grund J-PC, Afonso CM, Netto ADP, Carvalho F, Dinis-Oliveira RJ. The harmful chemistry behind krokodil (desomorphine) synthesis and mechanisms of toxicity. Forensic Sci Int. 2015;249:207–13. Scholar
  42. 42.
    Otiashvili D, Zabransky T, Kirtadze I, Piralishvili G, Chavchanidze M, Miovsky M. Why do the clients of Georgian needle exchange programmes inject buprenorphine? Eur Addict Res. 2010;16:1–8. Scholar
  43. 43.
    Grund JP, Latypov A, Harris M. Breaking worse: the emergence of krokodil and excessive injuries among people who inject drugs in Eurasia. Int J Drug Policy. 2013;24(4):265–74. Scholar
  44. 44.
    Azbel L, Dvoryak S, Altice FL. Krokodil and what a long strange trip it’s been. Int J Drug Policy. 2013;24(4):279–80. Scholar
  45. 45.
    Skowronek R, Celinski R, Chowaniec C. “Crocodile”--new dangerous designer drug of abuse from the East. Clin Toxicol (Phila). 2012;50(4):269. Scholar
  46. 46.
    Hearne E, Grund JP, Van Hout MC, McVeigh J. A scoping review of home-produced heroin and amphetamine-type stimulant substitutes: implications for prevention, treatment, and policy. Harm Reduct J. 2016;13:14. Scholar
  47. 47.
    Otiashvili D, Tabatadze M, Balanchivadze N, Kirtadze I. Policing, massive street drug testing and poly-substance use chaos in Georgia – a policy case study. Subst Abuse Treat Prev Policy. 2016;11(1):4. Scholar
  48. 48.
    Booth RE, Kennedy J, Brewster T, Semerik O. Drug injectors and dealers in Odessa, Ukraine. J Psychoactive Drugs. 2003;35(4):419–26. Scholar
  49. 49.
    Zule WA, Pande PG, Otiashvili D, Bobashev GV, Friedman SR, Gyarmathy VA, et al. Options for reducing HIV transmission related to the dead space in needles and syringes. Harm Reduct J. 2018;15:3. Scholar
  50. 50.
    Kozlov AP, Shaboltas AV, Toussova OV, Verevochkin SV, Masse BR, Perdue T, et al. HIV incidence and factors associated with HIV acquisition among injection drug users in St Petersburg, Russia. AIDS. 2006;20(6):901–6. Scholar
  51. 51.
    Tavitian-Exley I, Boily MC, Heimer R, Uuskula A, Levina O, Maheu-Giroux M. Polydrug use and heterogeneity in HIV risk among people who inject drugs in Estonia and Russia: a latent class analysis. AIDS Behav. 2017;22:1329–40. Scholar
  52. 52.
    Booth RE, Lehman WE, Kwiatkowski CF, Brewster JT, Sinitsyna L, Dvoryak S. Stimulant injectors in Ukraine: the next wave of the epidemic? AIDS Behav. 2008;12(4):652–61. Scholar
  53. 53.
    European Monitoring Centre for Drugs and Drug Addiction. Ukraine country overview. 2016. Accessed 12 Apr 2018.
  54. 54.
    Rosmarin A, Eastwood N. A quiet revolution: drug decriminalisation policies in practice across the globe. London; 2012.Google Scholar
  55. 55.
    European Monitoring Centre for Drugs and Drug Addiction. Estonia country drug report 2017.Google Scholar
  56. 56.
    Izenberg JM, Bachireddy C, Soule M, Kiriazova T, Dvoryak S, Altice FL. High rates of police detention among recently released HIV-infected prisoners in Ukraine: implications for health outcomes. Drug Alcohol Depend. 2013;133(1):154–60. Scholar
  57. 57.
    Polonsky M, Azbel L, Wegman MP, Izenberg JM, Bachireddy C, Wickersham JA, et al. Pre-incarceration police harassment, drug addiction and HIV risk behaviours among prisoners in Kyrgyzstan and Azerbaijan: results from a nationally representative cross-sectional study. J Int AIDS Soc. 2016;19(4 Suppl 3):20880. Scholar
  58. 58.
    Kutsa O, Marcus R, Bojko MJ, Zelenev A, Mazhnaya A, Dvoriak S, et al. Factors associated with physical and sexual violence by police among people who inject drugs in Ukraine: implications for retention on opioid agonist therapy. J Int AIDS Soc. 2016;19(4 Suppl 3):20897. Scholar
  59. 59.
    DeBeck K, Cheng T, Montaner JS, Beyrer C, Elliott R, Sherman S, et al. HIV and the criminalisation of drug use among people who inject drugs: a systematic review. Lancet HIV. 2017;4(8):e357–e74. Scholar
  60. 60.
    Lunze K, Raj A, Cheng DM, Quinn EK, Bridden C, Blokhina E, et al. Punitive policing and associated substance use risks among HIV-positive people in Russia who inject drugs. J Int AIDS Soc. 2014;17:19043. Scholar
  61. 61.
    Booth RE, Dvoryak S, Sung-Joon M, Brewster JT, Wendt WW, Corsi KF, et al. Law enforcement practices associated with HIV infection among injection drug users in Odessa, Ukraine. AIDS Behav. 2013;17(8):2604–14. Scholar
  62. 62.
    Beletsky L, Thomas R, Smelyanskaya M, Artamonova I, Shumskaya N, Dooronbekova A, et al. Policy reform to shift the health and human rights environment for vulnerable groups: the case of Kyrgyzstan’s instruction 417. Health Hum Rights. 2012;14(2):34–48.PubMedGoogle Scholar
  63. 63.
    Strathdee SA, Beletsky L, Kerr T. HIV, drugs and the legal environment. Int J Drug Policy. 2015;26(Suppl 1):S27–32. Scholar
  64. 64.
    World Health Organization, editor. Workshop report: how to scale‐up and implement opioid substitution treatment based on the experiences of selected EU Member States 2012 May 22-23; Vilnius, LithuaniaGoogle Scholar
  65. 65.
    Harm Reduction International. The global state of harm reduction 2016. London, United Kingdom 2016.Google Scholar
  66. 66.
    Khachatrian A. Uzbekistan: government discontinues pilot opiate substitution therapy program. HIV AIDS Policy Law Rev. 2009;14(2):26–7.PubMedGoogle Scholar
  67. 67.
    Eurasian Harm Reduction Association. Kazakhstan risks losing opioid maintenance therapy programs. 2018. Accessed 8 Feb 2018.
  68. 68.
    Latypov A. Opioid substitution therapy in Tajikistan: another perpetual pilot? Int J Drug Policy. 2010;21(5):407–10. Scholar
  69. 69.
    WHO, UNODC, UNAIDS. Technical guide for countries to set targets for universal access to HIV prevention, treatment, and care for injecting drug users Geneva 2009.Google Scholar
  70. 70.
    Stone K, Shirley-Beavan S. Global state of harm reduction 2018. London, United Kingdom 2018.Google Scholar
  71. 71.
    Azbel L, Polonsky M, Wegman M, Shumskaya N, Kurmanalieva A, Asanov A, et al. Intersecting epidemics of HIV, HCV, and syphilis among soon-to-be released prisoners in Kyrgyzstan: implications for prevention and treatment. Int J Drug Policy. 2016;37:9–20. Scholar
  72. 72.
    Izenberg JM, Bachireddy C, Wickersham JA, Soule M, Kiriazova T, Dvoriak S, et al. Within-prison drug injection among HIV-infected Ukrainian prisoners: prevalence and correlates of an extremely high-risk behaviour. Int J Drug Policy. 2014;25(5):845–52. Scholar
  73. 73.
    Joint United Nations Programme on HIV/AIDS. Global AIDS monitoring 2017: indicators for monitoring the 2016 United Nations political declaration on HIV and AIDS. 2017.Google Scholar
  74. 74.
    Vagenas P, Azbel L, Polonsky M, Kerimi N, Mamyrov M, Dvoryak S, et al. A review of medical and substance use co-morbidities in Central Asian prisons: implications for HIV prevention and treatment. Drug Alcohol Depend. 2013;132(Suppl 1):S25–31. Scholar
  75. 75.
    Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505. Scholar
  76. 76.
    Mazhnaya A, Marcus R, Bojko MJ, Zelenev A, Makarenko I, Pykalo I, et al. Opioid agonist treatment and improved outcomes at each stage of the HIV treatment cascade in people who inject drugs in Ukraine. J Acquir Immune Defic Syndr. 2018;79(3):288-95. Scholar
  77. 77.
    Bojko MJ, Mazhnaya A, Makarenko I, Marcus R, Dvoriak S, Islam Z, et al. “Bureaucracy & Beliefs”: assessing the barriers to accessing opioid substitution therapy by people who inject drugs in Ukraine. Drugs (Abingdon Engl). 2015;22(3):255–62. Scholar
  78. 78.
    Vranken MJM, Mantel-Teeuwisse AK, Junger S, Radbruch L, Scholten W, Lisman JA, et al. Barriers to access to opioid medicines for patients with opioid dependence: a review of legislation and regulations in eleven central and eastern European countries. Addiction. 2017;112(6):1069–76. Scholar
  79. 79.
    Madden L, Bojko MJ, Farnum S, Mazhnaya A, Fomenko T, Marcus R, et al. Using nominal group technique among clinical providers to identify barriers and prioritize solutions to scaling up opioid agonist therapies in Ukraine. Int J Drug Policy. 2017;49:48–53. Scholar
  80. 80.
    Wu Z, Shi CX, Detels R. Addressing injecting drug use in Asia and Eastern Europe. Curr HIV/AIDS Rep. 2013;10(2):187–93. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Katherine LaMonaca
    • 1
  • Kostyantyn Dumchev
    • 2
  • Sergii Dvoriak
    • 3
  • Lyuba Azbel
    • 4
  • Olga Morozova
    • 5
  • Frederick L. Altice
    • 1
    Email author
  1. 1.Department of Medicine, Section of Infectious Diseases, AIDS ProgramYale University School of MedicineNew HavenUSA
  2. 2.Ukrainian Institute on Public Health PolicyKyivUkraine
  3. 3.Academy of Labour, Social Relations and TourismKyivUkraine
  4. 4.London School of Hygiene & Tropical MedicineLondonUK
  5. 5.Department of BiostatisticsYale University School of Public HealthNew HavenUSA

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