HIV, Drug Injection, and Harm Reduction Trends in Eastern Europe and Central Asia: Implications for International and Domestic Policy
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.
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.
KeywordsHIV 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.Joint United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS data 2017.Google Scholar
- 2.Joint United Nations Programme on HIV/AIDS. Global AIDS update 2016.Google Scholar
- 3.Joint United Nations Programme on HIV/AIDS. Prevention gap report 2016.Google Scholar
- 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. https://doi.org/10.1016/S2214-109X(17)30375-3. 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.Joint United Nations Programme on HIV/AIDS (UNAIDS). Ending AIDS: progress towards the 90-90-90 targets 2017.Google Scholar
- 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. https://doi.org/10.1016/S2214-109X(17)30373-X. 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.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. https://doi.org/10.1371/journal.pmed.1000423.CrossRefPubMedPubMedCentralGoogle Scholar
- 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. https://doi.org/10.1007/s10461-013-0593-y.CrossRefPubMedPubMedCentralGoogle Scholar
- 14.East Europe and Central Asia Union of PLWH. Eastern Europe and Central Asia: let’s not lose track! 2016.Google Scholar
- 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. https://doi.org/10.1016/j.drugpo.2014.09.004.CrossRefPubMedGoogle Scholar
- 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. https://doi.org/10.1016/j.drugpo.2013.08.004.CrossRefPubMedGoogle Scholar
- 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.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
- 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.World Health Organization. People who inject drugs (PWID). 2018. http://www.euro.who.int/en/health-topics/communicable-diseases/hivaids/policy/policy-guidance-for-key-populations-most-at-risk2/people-who-inject-drugs-pwid.
- 22.Joint United Nations Programme on HIV/AIDS. Do no harm: health, human rights, and people who use drugs Geneva 2016.Google Scholar
- 23.United Nations Office on Drugs and Crime. World drug report 2017.Google Scholar
- 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
- 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. https://doi.org/10.1016/s2352-3018(16)30040-6.CrossRefPubMedPubMedCentralGoogle Scholar
- 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.Bemoni Public Union, Curatio International Foundation. Population size estimation of people who inject drugs in Georgia 2014 2015.Google Scholar
- 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.European Monitoring Centre for Drugs and Drug Addiction. Latvia country drugs report 2017.Google Scholar
- 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
- 36.UNICEF. After the fall: the human impact of ten years of transition. Florence: International Child Development Centre1999.Google Scholar
- 39.European Centre for Drugs and Drug Addiction. European drug report 2017: trends and developments 2017.Google Scholar
- 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. https://doi.org/10.1097/01.aids.0000218555.36661.9c.CrossRefPubMedGoogle Scholar
- 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. https://doi.org/10.1007/s10461-017-1836-0.CrossRefPubMedCentralGoogle Scholar
- 53.European Monitoring Centre for Drugs and Drug Addiction. Ukraine country overview. 2016. http://www.emcdda.europa.eu/countries/ukraine_en#laws. Accessed 12 Apr 2018.
- 54.Rosmarin A, Eastwood N. A quiet revolution: drug decriminalisation policies in practice across the globe. London; 2012.Google Scholar
- 55.European Monitoring Centre for Drugs and Drug Addiction. Estonia country drug report 2017.Google Scholar
- 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. https://doi.org/10.1016/j.drugalcdep.2013.05.018.CrossRefPubMedPubMedCentralGoogle Scholar
- 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. https://doi.org/10.7448/ias.19.4.20880.CrossRefPubMedPubMedCentralGoogle Scholar
- 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. https://doi.org/10.7448/IAS.19.4.20897.CrossRefPubMedPubMedCentralGoogle Scholar
- 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.Harm Reduction International. The global state of harm reduction 2016. London, United Kingdom 2016.Google Scholar
- 67.Eurasian Harm Reduction Association. Kazakhstan risks losing opioid maintenance therapy programs. 2018. http://harmreductioneurasia.org/kazakhstan-risks-losing-opioid-maintenance-therapy-programs/. Accessed 8 Feb 2018.
- 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.Stone K, Shirley-Beavan S. Global state of harm reduction 2018. London, United Kingdom 2018.Google Scholar
- 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. https://doi.org/10.1016/j.drugpo.2016.06.007.CrossRefPubMedPubMedCentralGoogle Scholar
- 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. https://doi.org/10.1016/j.drugpo.2014.02.010.CrossRefPubMedPubMedCentralGoogle Scholar
- 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.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. https://doi.org/10.1016/j.drugalcdep.2013.07.010.CrossRefPubMedGoogle Scholar
- 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. https://doi.org/10.1097/qai.0000000000001827.CrossRefGoogle Scholar
- 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. https://doi.org/10.3109/09687637.2015.1016397.CrossRefGoogle Scholar
- 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. https://doi.org/10.1111/add.13755.CrossRefPubMedGoogle Scholar
- 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. https://doi.org/10.1016/j.drugpo.2017.07.025.CrossRefPubMedGoogle Scholar