Restrictive policies that can sometimes prevent people from keeping their jobs could be compromising the effectiveness of Global Fund-supported opioid substitution therapy programs across Eastern Europe and Central Asia, civil society representatives from around the region told Aidspan.
Without improvements to the quality and effectiveness of these programs, they risk driving away the very people who are most in need of the services -- and could undermine the sustainability of these programs once ownership transitions to national governments.
"We want to start talking about OST program challenges, which are not only coverage and finances that are mainly discussed by the donors and NGOs, but also the effectiveness and quality of these programs,” said Andrey Yarovoi, board member for Association of Substitution Treatment Advocates of Ukraine (ASTAU). They consider the fact that OST programs are still pilot, vertical programs that have yet to be integrated into the national health service one of the biggest impediments to their success.
Most doctors who work with people who inject drugs consider OST to be the same drug with different packaging, whereas drug users see it as medical treatment. This disconnect means that program participants are not often treated as patients, and are discriminated against by medical professionals.
Regionally, similar problems with OST therapy have been identified: those enrolled are restricted in their movements due to the need to check in daily to receive their dosage. This means they have a hard time getting or staying in jobs, due to the rigors of being part of the program.
"The overarching problem is that methadone (and buprenorphine where it is available), despite being medicines, are delivered in a framework that prioritizes patient control. While Western European countries (as well as Australia and the US) all provide stable patients with take home doses, these are unavailable for methadone patients," said Daniel Wolfe, the director of the international harm reduction development program for Open Society Foundations. "Rigid requirements keep patients "locked" to clinics, and unable to enjoy the social participation that we say we want to return to them (travelling for family functions, taking a few days off, etc), and understandably mistrustful of systems that seem more concerned with control than with care."
Stigma against so-called narcomen is also pervasive; stereotypes about the untrustworthiness of drug users means that even those who are trying to kick their habits by enrolling in OST are viewed suspiciously, and the OST centers are a visible manifestation of that suspicion.
Around the region, there are other country-specific challenges being confronted. In Ukraine, although legislation has been approved by parliament to allow individuals to go home with a 10-day dosage, most centers do not follow this rule. Furthermore, there is no enforcement mechanism in place.
For people who inject drugs in Moldova, the barriers to access are so large that they prove insurmountable to many. "The program does not give a choice as the only medication available in the country is methadone," said Vitali Rabinciuc, who leads the PWID advocacy group Puls. "Plus, measures taken against drug users are often quite humiliating and discriminatory."
Oksana Ibragimova, an advocacy specialist with the Kazakh Union of People Living with HIV, said that bonding participants to particular sites has replaced collaboration, coordination and cooperation within the network of people who inject drugs. So by restricting participants from moving around, they are losing the social component of recovery that is so important to keep people in the program. And if they fail, she adds, they will wind up in prison -- where there are no OST programs in place.
OST programs were first launched in EECA in 1989, in an effort to respond to the burgeoning crisis of injected drug use that is now the primary driver of HIV infections across the region. According to statistics compiled by the UN reference group on HIV and injected drug use, there are around 3.7 million PWID in EECA region: the highest prevalence globally. One in four of these drug users are thought to be living with HIV.
Now 25 of the 28 countries in the region -- barring Uzbekistan, Russia and Turkmenistan -- have some degree of OST enshrined as part of the national HIV response. OST programs in most of these countries are paid for in whole or in part by the Global Fund, and run by local medical institutions. The threat of the Fund's departure from many of these countries due to its new allocations methodology that is prioritizing low income countries with high disease burdens means that many of these programs are vulnerable.
To ensure they remain in place, and funded by national governments, a Global Fund-supported regional campaign run by Eurasian Harm Reduction Network, 'Harm Reduction WorksFund It!' is providing community activists with communications, outreach and campaigning tools they hope will help with advocacy on behalf of OST and other harm reduction activities. Another major component of the initiative is program assessment to develop evidence-based recommendations for improving existing programs and helping to prioritize interventions. Strengthening of community systems for people who use drugs, including those living with HIV, is a critical area of focus within this program, said Olga Belyaeva, information and technical support program officer of EHRN.