Elsevier

Health Policy

Volume 85, Issue 2, February 2008, Pages 162-171
Health Policy

Prevention of HIV/AIDS among injecting drug users in Russia: Opportunities and barriers to scaling-up of harm reduction programmes

https://doi.org/10.1016/j.healthpol.2007.07.005Get rights and content

Abstract

Objectives

to examine attitudes of Russian policy-makers and HIV stakeholders towards harm reduction (HR) scale up, focusing on the factors constraining the scale-up process.

Methods

Semi-structured interviews with representatives of 58 government and non-governmental organisations involved in HIV policies and programmes in Volgograd Region, Russian Federation.

Results

We found a considerable diversity of opinion on HR scale-up and suggest that Russia is experiencing the situation of power parity between HR supporters and opponents with many stakeholders being indecisive or cautious to express their views. We identified six main factors which constrain policy decisions in favour of HR scale-up: insufficient financial resources; lack of information on HR effectiveness; perception of HR as being culturally unacceptable; reluctance of IDUs to use the services; opposition from law enforcement agencies and the Russian Church; and unclear legal regulations. We demonstrate a complex interplay between these factors, policy-makers’ attitudes and their choices on HR scale-up.

Conclusions

A number of actions are needed to achieve a successful scale-up of HR programmes in Russia and similar political contexts: (i) a strategic approach to HR advocacy, targeting neutral and indecisive stakeholders; (ii) more systematic evidence on HR effectiveness and cost-effectiveness in the local context; (iii) HR advocacy targeting law enforcement agencies and the Russian Church; and (iv) aligning best international HR practices with the objectives of local policy-makers, practitioners and service-users.

Introduction

Harm reduction among injecting drug users (IDUs) is a prevention strategy aimed at reducing the adverse health, social and economic impact of drug use without requiring abstinence from drugs [1]. HR interventions include education about injecting risks, needle and syringe exchange (NSE) and opioid substitution therapy [2], [3]. HR has been successfully applied in many settings [4], [5], [6], [7] and is recommended as a priority prevention strategy in countries with rapidly developing HIV epidemics driven by IDUs [8], [9], [10], [11], [12], [13], [14], [15]. HR has been particularly effective when introduced in the early stages of the HIV epidemic and at substantial scale [8], [9]. Although there is no consensus on the scale and/or scope of services needed to contain the spread of HIV/AIDS, the United Nation Joint Programme on HIV/AIDS (UNAIDS) recommends reaching at least 60% of IDUs in a given geographical location [10], [11]. HR scale-up is commonly interpreted as reaching larger numbers of IDUs in a given place; coverage of a larger geographical area; increasing the scope and volume of services for IDUs; and reaching other high-risk groups, such as IDU sex workers (SWs) and prisoners [9], [12], [13].

In Russia, HR interventions began in the mid 1990 s in response to the rapidly growing number of IDUs and a series of explosive outbreaks of HIV among IDUs and IDU SWs [16], [17], [18]. Within a decade, over 80 pilot projects were established throughout the country with the support of the Russian Ministry of Health and funding from international donors [12], [19], [20]. Although a number of local and international studies have shown the effectiveness of these projects in reducing HIV risks among the IDUs they targeted [21], [22], [23] HR has neither been formally integrated into the national framework of HIV response nor scaled-up to a level sufficient for significant epidemiological impact [19], [20], [24], [25]. Indeed, a rapid assessment of HR coverage conducted in 15 Russian cities in 2004 found only two sites where 60% of IDUs or more were in contact with HR services. One third of the projects surveyed had reached no more than 10% of IDUs [26]. Similarly, the 2005 analysis of 20 HR sites funded by the Russian Harm Reduction Network found that the average project coverage was 12.5% [27]. Furthermore, although the Russian Ministry of Health nominally supports HR [28], [29], the National AIDS Programme for 2002–2006 provided no reference to HR and identified no resources to support such activities. Most HR projects have been for years dependent on non-governmental funding, with 70% of resources provided by international donors [19], [24]. Also, there are controversies around provision of NSE and opioid substitution therapy [30], [31], [32]. Projects, which provide clean needles and syringes to IDUs do so only at the discretion of local authorities and police forces, and have frequently faced threats of closure [24], [31], [32]. Opioid substitution therapy is prohibited under the Russian legislation and has not been formally established, in spite of methadone and buprenorphine being on the WHO Essential Medicines List [33].

The reluctance of the Russian Government to mainstream HR activities within the national HIV response has been questioned by international donors and local non-governmental organisations (NGOs) [20], [24], [32], [34], [35]. However, the reasons behind such apparent resistance to expand the services, which have proven to be effective at small pilot scale, have not been systematically explored.

In this paper we examine the attitudes of Russian policy-makers and HIV stakeholders towards HR scale-up. In particular, the study explores the perceptions of local decision-makers of the factors, which impede the scale-up process. The influence of contextual factors on the policy process has been discussed in policy analysis literature [36], [37], [38] and in HIV/AIDS [39], [40], [41]. By examining this issue in the Russian context, we aim to identify challenges that may be specific to the post-communist transitional environments; challenges that need to be addressed before programmes targeting high-risk populations can be successfully scaled-up in these contexts.

Section snippets

Study area

The study was conducted in Volgograd region, which is situated in the south-west of Russia and has a population of 2.7 million, of whom 75% live in urban areas. The region covers a territory of 113,000 square kilometres and is administratively divided into 39 municipalities [42].

The first HIV case in the region was registered in 1987. Cumulative notification rates in 2004 were 157 per 100,000, (22nd highest among 89 Russian regions) [43]. The first and the only HR project in the region was set

Attitudes towards scaling-up

About half of the policy-makers interviewed supported HR scale-up, with one third being against it; and another fifth being undecided (Table 1). The majority of the supporters were ICA members. In other stakeholder groups opinions were equally divided with two fifths for and against and one fifth undecided. Five of the 13 local NGOs were “strongly against HR scale-up”; while many neutral stakeholders were among government organisations.

Perception of barriers to scaling-up

The perceived barriers to scaling-up HR were grouped into

Discussion

HIV/AIDS continues to be a major public health issue in Russia [50]. By May 2007 the Russian authorities had reported 386,141 officially registered HIV cases [51] but the actual figure may be as high as 1.5 million [35], [52]. The majority of infections are among IDUs [19], [35], [51], whose numbers are estimated at 1.5–3.5 million [35]. Needle-sharing practices are widespread, ranging from 36 to 82% depending on the location [53]; and in some cities HIV prevalence amongst IDUs reaches 60% or

Acknowledgements

This work was carried out as part of the Programme “Knowledge for Action in HIV/AIDS in the Russian Federation” funded by the UK Department for International Development (DFID). We would like to thank DFID for the support provided. DFID however is not responsible for the views expressed. We would like also to thank the regional administration, health department, HIV/AIDS centre and medical school in Volgograd for their support in conducting this study; our special thanks are to Dr. Alexander

References (88)

  • World Health Organisation. Biregional Strategy for Harm Reduction 2005–2009. HIV and Injecting Drug Use. Geneva;...
  • D.R. Gibson et al.

    Effectiveness of syringe exchange programmes in reducing HIV risk behaviour and HIV seroconversion among injecting drug users

    AIDS

    (2001)
  • T. Azim et al.

    Effectiveness of harm reduction programmes for injecting drug users in Dhaka city

    Harm Reduction Journal

    (2005)
  • World Health Organisation, United Nations Office for Drugs and Crime, United Nations Joint Programme on HIV/AIDS....
  • J.A. DeJong

    Question of scale: the challenges of expanding the impact of non-governmental organisations’ HIV/AIDS efforts in developing countries

    (2001)
  • United Nations Joint Programme on HIV/AIDS. Preventing the Transmission of HIV among Drug Abusers. A Position Paper of...
  • International Harm Reduction Development Programme Harm Reduction Developments 2005. New York: Open Society Institute;...
  • Burrows D. Strategies for Scaling-up HIV Prevention in Russian Federation. Working Paper;...
  • United Nations Joint Programme on HIV/AIDS. Intensifying HIV Prevention. Position Paper. Geneva;...
  • World Bank. The World Bank's HIV/AIDS Program of Action. Washington;...
  • World Health Organisation/United Nations Office on Drugs and Crime/United Nations Joint Programme on HIV/AIDS....
  • T. Rhodes et al.

    HIV infection associated with drug injecting in the newly independent states, eastern Europe: the social and economic context of epidemics

    Addiction

    (1999)
  • J.A. Kelly et al.

    The newest epidemic: a review of HIV/AIDS in central and eastern Europe

    International Journal of STD & AIDS

    (2003)
  • Central and Eastern European Harm Reduction Network. Injecting Drug Users, HIV/AIDS Treatment and Primary Care in...
  • I. Ivanov

    The research in Tver (Russia) on injecting drug users’ sexual behavior

  • L. Hide

    Entering the community of injecting drug users: secondary needle exchange in the Far East of Russia

    Outreach

    (2004)
  • G.F. Moshkovich

    Implementation of the harm reduction programme in Nizhny Novgorod

    Krugly Stol (Round Table)

    (2001)
  • Donoghoe MC. Injecting drug use, harm reduction and HIV/AIDS. In Martic S., Lazarus JV, Donoghoe MC, editors. HIV/AIDS...
  • M.C. Donoghoe et al.

    HIV/AIDS in the transitional countries of eastern Europe and central Asia

    Clinical Medicine

    (2005)
  • Open Health Institute. Rapid Assessment of Harm Reduction Coverage in 15 Russian Cities (unpublished report);...
  • Russian Harm Reduction Network. Annual Report 2005. Moscow;...
  • Sanitary and Epidemiology Service Ministry of Health. Decree of the Chief Sanitary Doctor of the Russian Federation on...
  • Federal Service for control of consumer rights and wellbeing Ministry of Health. Decree of the Chief Sanitary Doctor of...
  • Badrieva L. Harm reduction projects under the policy of elimination of drug abuse: peculiarities of work in Kazan....
  • Butler WE. HIV/AIDS and drug misuse in Russia: harm reduction programmes and the Russian legal system. London;...
  • S. Oleynik

    Defence of harm reduction programmes in courts

    Harm Reduction in Russia

    (2006)
  • World Health Organisation. WHO Model List of Essential Medicines. 14th ed.; March...
  • United Nations Joint Programme on HIV/AIDS. 2004 Report on the Global HIV/AIDS Epidemic: 4th Global Report. Geneva;...
  • United Nations Development Programme. HIV/AIDS in Eastern Europe and the Commonwealth of Independent States: Reversing...
  • G. Walt

    Health policy. An introduction to process and power

    (1994)
  • W. Parsons

    Public policy. An introduction to the theory and practice of policy analysis

    (1995)
  • C. Hay

    Political analysis. A critical introduction.

    (2002)
  • T. Barnett et al.

    AIDS in the twenty-first century: disease and globalisation

    (2002)
  • Cited by (39)

    • The evidence does not speak for itself: The role of research evidence in shaping policy change for the implementation of publicly funded syringe exchange programs in three US cities

      2015, International Journal of Drug Policy
      Citation Excerpt :

      In these scenarios, research evidence may be used by advocates to convince appointed policymakers that harm reduction services, such as SEPs, are not only something the community desires but are public health interventions that make fiscal sense via prevention of infectious diseases, such as HIV and Hepatitis. This is of particular importance in countries such as Russia, where policy decisions pertaining to the scale up of harm reduction services are constrained by financial resources, lack of information about harm reduction efficacy, and the cultural acceptability of harm reduction services (Tkatchenko-Schmidt, Renton, Gevorgyan, Davydenko, & Atun, 2008). In scenarios such as these, research evidence may be used to educate policymakers about the public health and fiscal utility of SEPs and to guide policy reform in ways that align with data-driven public health practice.

    • A tale of two cities: Stigma and health outcomes among people with HIV who inject drugs in St. Petersburg, Russia and Kohtla-Järve, Estonia

      2015, Social Science and Medicine
      Citation Excerpt :

      However, they have developed divergent political approaches and social responses to HIV and injection drug use. For example, the Estonian government is much more supportive of harm reduction programs than the Russian government is (Jon Cohen, 2010; Csete et al., 2004; EMCDDA, 2014; Tkatchenko-Schmidt et al., 2008; Wolfe et al., 2010). Our samples at both locations began with seeds from existing harm reduction programs, but the program in Kohtla-Järve has a single stable location whereas the programs in St. Petersburg operate out of vans that are sometimes targeted by police.

    • How complexity science can inform scale-up and spread in health care: Understanding the role of self-organization in variation across local contexts

      2013, Social Science and Medicine
      Citation Excerpt :

      USAID Conference on Research & Evaluation Methods for Scaling Up Evidence-Based Interventions, June 1–2, 2010, U.S. Agency for International Development, Washington D.C.; Institute for Healthcare Improvement Conference to Advance the Science and Practice on Scale-up and Spread of Effective Health Programs, June 25–26, 2010, Washington D.C.). SUS failures are often attributed to a lack of consideration for the variation among different health care settings (Laher et al., 2011; McCannon, Schall, Perla, & Barker, 2011; Paina & Peters, 2011; Tkatchenko-Schmidt, Renton, Gevorgyan, Davydenko, & Atun, 2008). The designs of SUS initiatives tend to focus on reproducing interventions with total fidelity, overlooking the unique attributes of local contexts.

    • The quest for multi-sectoral HIV/AIDS prevention in Central and Eastern Europe and why it matters

      2011, HIV and AIDS Review
      Citation Excerpt :

      In CEE with higher HIV prevalence among IDUs governments are often least accountable and human rights and legal frameworks remain non existence and politicians are uncommitted in decriminalization of proven treatment modalities such as opioid substitution therapy, clean needle and syringe exchange program [38–40]. Additional obstacle is the often mistrustful relationships that exist between civil society and often corrupt and inefficient governments hindering health and prevention programs particularly connected to HIV/AIDS, TB initiatives [41]. A number of EU declarations with respect to a need for standardizations of prisons and health and human rights guarantees have been adapted.

    • Sex, drugs and economic behaviour in Russia: A study of socio-economic characteristics of high risk populations

      2011, International Journal of Drug Policy
      Citation Excerpt :

      Drug control policies have largely focused on strict punitive measures and a tendency to isolate IDUs from the rest of the population (Rhodes et al., 2004; UNDP, 2004). Needle and syringe programmes face multiple challenges, receive no funding from the Russian Government and cover about 7% of IDUs as against the recommended level of 60% (Mathers et al., 2010; Tkatchenko-Schmidt, Renton, Gevorgyan, Davydenko, & Atun, 2008; WHO, UNODC, & UNAIDS, 2009). Drug treatment services are of poor quality and methadone-based substitution therapy remains illegal (Bobrova et al., 2006; Butler, 2003).

    View all citing articles on Scopus
    View full text