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