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IV. Background

HIV/AIDS in Ukraine

As many as 416,000 people—1.7 percent of the adult population age fifteen to forty-nine—were estimated to be living with HIV/AIDS in Ukraine in 2005.4  Ukraine had the highest HIV/AIDS prevalence rate in Europe in 2005, and was home to one of the fastest growing HIV/AIDS epidemics in the world.5  The spread of HIV/AIDS has been rapid and dramatic.  Before 1994, fewer than eighty cases were diagnosed annually, mostly among foreigners infected through sexual contact, but within a few years the number of newly reported cases rose dramatically.6  In March and April 1995, more than 1,000 drug users were diagnosed with HIV in the southern cities of Mykolaiv and Odessa.  By 1996, all twenty-five regional capitals reported HIV cases, and by 1997, Ukraine had more than 25,000 reported cases—more than one-half the cumulative total for Eastern Europe.7 

An estimated 70 percent of all cases registered by the government between 1987 and 2004 were injection drug users.8  Studies have reported HIV prevalence among injection drug users in several cities in Ukraine ranging from 14 to 74 percent, and have estimated that 8.5 to 9.6 percent of injection drug users nationwide are HIV-positive.9  High rates of HIV also have been reported among sex workers and prisoners.10 

Sex work in Ukraine increased with the social and economic upheaval resulting from the collapse of the Soviet Union, a phenomenon common throughout the region.  Many sex workers inject drugs, or have clients or sex partners who are injection drug users. Many drug users exchange sex for drugs or money to support their habit.  The overlap between sex work and injecting drugs heightens the risk of HIV transmission (through needle sharing as well as sexual transmission) and exposure to police violence and harassment.  As many as 80 percent of street sex workers in Mykolaiv were estimated to be injection drug users, according to a 2000 report commissioned by the Joint United Nations Program on HIV/AIDS (UNAIDS).11  In Odessa, HIV rates as high as 67 percent have been reported among sex workers who inject drugs, compared with 17 percent among non-injecting sex workers.12

According to official statistics, an increasing percentage of HIV cases in Ukraine is among women, and attributed to heterosexual transmission.13  Research by the Ukraine AIDS Centre and UNAIDS has found that these trends result from changed HIV testing practices.  Beginning in 1996, with the introduction of prevention of mother-to-child transmission programs, the number of pregnant women tested for HIV steadily increased, while with the cessation of mandatory testing14 of injection drug users in 1998, the number of injection drug users tested decreased.15  World Health Organization experts argue that to interpret an increase in heterosexual and mother-to-child transmission rates as evidence of a more generalized epidemic is premature, given that most heterosexual cases are among female partners of drug users, and that a substantial proportion of HIV-positive pregnant women are either partners of injectors, or injectors themselves.16  Some evidence also exists that cases of HIV transmission among men who have sex with men are underreported, and that there has been a recent marked increase in HIV cases in this population.17 

Ukraine has made important progress in the reduction of mother-to-child HIV transmission, with rates decreasing from 28 percent in 2001 to less than 10 percent in 2003, one of the lowest rates in Eastern Europe.18  Research suggests that HIV-positive women who inject drugs may not benefit equally from programs to prevent mother-to-child transmission, however.19

The rapid spread of HIV/AIDS in Ukraine has coincided with an explosion in tuberculosis (TB) rates.20  Because of their compromised immune systems, people living with HIV/AIDS are at increased risk of developing active tuberculosis.21  Tuberculosis is a leading cause of death for people living with HIV/AIDS.22  The situation is particularly critical in prisons: 7 percent (14,000) of Ukraine’s 200,000 inmates have active TB, and more than 40 percent of prison deaths are attributed to TB.23  Multi-drug resistant tuberculosis (MDR-TB), which can result from inconsistent or partial treatment of TB, is also a serious problem and a challenge for the health system, as it is more difficult and more expensive to treat, and much more likely to be fatal.24 

Widespread ignorance about the basic facts of HIV/AIDS is a serious problem in Ukraine, an issue that the government itself has acknowledged.  The government reported that in 2004, only 14 percent of young people had a comprehensive understanding of HIV/AIDS.25  According to a 2002 study by UNICEF and UNAIDS, only 9 percent of young women could identify three methods of HIV prevention, and 79 percent harbored at least one major misconception about the disease, such as that a healthy-looking person cannot have HIV.26 

Lack of knowledge also contributes to widespread stigma and discrimination faced by people living with HIV/AIDS.  A 2004 survey of 692 people living with HIV/AIDS in sixteen cities throughout Ukraine found that 42 percent of respondents reported violations of their rights related to employment, education, health care, or privacy because of their HIV status.  More than 10 percent of respondents said that they had lost a job because of HIV, and 9 percent had had to change jobs.  Seventy percent said that rights to confidentiality of HIV diagnosis had been violated, and more than one-third reported having been tested for HIV without their consent. Sixty percent of respondents reported that they were either unaware of their legal right to receive free medicines, or that this benefit was unavailable to them.27 

A 2004 study of forty previously pregnant HIV-positive women and fifteen health care providers found that nearly half of HIV-positive women said that they had been strongly encouraged to have an abortion by a health care provider; several women reported that they were not given a choice but told they must have an abortion.  More than one-third of women reported that they were treated worse than HIV-negative women in labor and delivery settings; and more than half reported that health care providers assumed that they were injection drug users because of their HIV status.28

Injection Drug Use and HIV/AIDS in Ukraine

It is estimated that there are 397,000 injection drug users (1.6 percent of the population between fifteen and forty-nine years old) in Ukraine.29  Nationally, the number of newly reported HIV cases among injection drug users continues to grow.  Most injectors are young males.  However, a significant proportion—23 percent—of injection drug users diagnosed with HIV in 2004 were females.30

Risky injection practices, including the sharing and reusing of needles and other drug paraphernalia; the sharing of drug solution from a common container; and front- and backloading (squirting drug solution from one syringe into another with the needle or plunger removed), are also widespread.31  The use of blood in the preparation of injected drugs also has been reported.32  Homemade preparations of liquid poppy straw—an injected opiate solution commonly know as shirka—is the main drug used, but methamphetamines, including a homemade preparation of ephedrine called vint,are also injected and have become increasingly popular among drug users.  Researchers report that the use of drugs in groups is common in Ukraine, and that a significant number of drug users acquire drugs through exchange of services, such as drug preparation, drug purchase and delivery, or sex.33  Research also suggests that women injection drug users are more likely than men to share injection equipment, inject drugs in a group, and exchange sex for drugs.34

Targeted interventions for injection drug users such as the provision of sterile injecting equipment and opiate substitution therapy have proved effective in preventing HIV transmission and other adverse consequences of drug use.  Often referred to as “harm reduction,” these approaches have been endorsed by the World Health Organization and UNAIDS as an integral part of HIV prevention and care strategies for drug users.35  Countries that have implemented harm reduction measures on a sufficiently large scale have successfully controlled large-scale HIV epidemics among injection drug users and in the non-injecting population.36  In Poland, for example, a strong national response, including syringe exchange and other targeted interventions for injection drug users, successfully contained the epidemic among injection drug users, and averted a more widespread epidemic in non-injecting populations.37

Public health authorities recommend that for people who cannot or will not stop injecting drugs, using a sterile syringe for each injection is the safest and most effective way to prevent HIV and other blood-borne viruses.38  Ukraine’s national AIDS law recognizes this fact, providing an explicit commitment to provide HIV prevention services for drug users, including by supporting the establishment of syringe exchange programs.39 

As of mid-2005, there were more than 250 NGO-run syringe exchange sites or points operating in Ukraine, reaching more than 70,000 injection drug users (almost a fifth of the estimated total of injection drug users in Ukraine).40  In addition to providing sterile syringes, many sites also provide counseling and information, condoms, and referrals to other health and social services for drug users.  There were also fifty-five government-run consultation points for injection drug users and other vulnerable groups, some of which also distribute syringes.41  Some sites also provide medical care for drug users.  Pharmacies, which can legally sell syringes to adults in unrestricted numbers, are also an important source of syringes for many drug users.

Access to effective drug addiction treatment is critical both to prevent HIV among injection drug users, and to support adherence to antiretroviral treatment for HIV-positive drug users.  But drug users in Ukraine have limited options for effective drug addiction treatment and encounter significant barriers in their attempts to obtain it.   

Substitution or replacement therapy, for example with methadone, is one of the most effective treatment options for opiate dependence.  It has been proved to reduce drug use as well as criminal activity, overdose deaths, and behaviors such as syringe sharing, and to improve uptake and adherence to antiretroviral treatment for HIV-positive opiate users.42  In light of this evidence, the World Health Organization (WHO), the United Nations Office on Drugs and Crime (UNODC), and UNAIDS have jointly recommended that substitution maintenance therapy, including with methadone and buprenorphine, be integrated into national HIV/AIDS programs, both as an HIV/AIDS prevention measure and to support adherence to antiretroviral treatment and medical follow up for opiate dependent drug users.43 

Ukraine’s national HIV/AIDS program has identified the implementation of a substitution therapy program linked with HIV prevention, care, and treatment programs as one of its main goals.44  The Ukrainian parliament also has recommended implementing substitution therapy to prevent and treat HIV/AIDS among drug users.45  But because of significant opposition in some parts of government—most notably, the Committee on Narcotic Drugs Control, Ministry of Interior, and the Security Services of Ukraine—substitution therapy is largely unavailable in Ukraine.46

Ukraine’s efforts to introduce substitution therapy with buprenorphine to 200 drug users by the end of 2005 have been criticized by the WHO, UNODC, and UNAIDS as grossly insufficient to address the needs of opiate-dependent drug users in Ukraine. These agencies recommended in a joint June 2005 report that Ukraine “do everything in its power to simplify the introduction and scale up” of substitution therapy with methadone and buprenorphine to between 60,000 and 238,000 people.47

Other factors inhibit access to drug treatment.  These include official registration requirements that expose drug users to police and undermine employment prospects; ineffectiveness of treatment that is provided; and poor attitudes of medical professionals toward drug users.48  Drug users and service providers interviewed for this report told Human Rights Watch that drug users avoided seeking drug treatment out of concern about registration with narcologists and by police.  They also said that drug users avoided seeking health care for injuries related to their drug use, such as abscesses, out of fear that health care workers would report their drug use to the police, or that their employers would fire them if they discovered that their injuries were related to drug use.49

The lack of effective drug treatment, coupled with health care provider discrimination against drug users, is also contributing to Ukraine’s tuberculosis epidemic, and to mortality among drug users living with TB and HIV.  A 2005 study of HIV/AIDS, tuberculosis, and drug addiction treatment in 13 regions of Ukraine found that 2,540 tuberculosis patients terminated treatment because they were expelled from the hospital due to drug use.  Of these, 420 patients were co-infected with TB and HIV.50 

A large percentage of drug users in Ukraine find themselves incarcerated in state custody at some point in their lives. Incarceration, in turn, is itself a critical risk factor for HIV.  Injection drug use is widespread in Ukrainian prisons, with many drug users continuing to inject while in prison, while access to HIV prevention and effective drug treatment services in prison is limited.51 HIV prevalence in prison has been reported to be several times that of the population at large: according to the WHO, in 2000, 7 percent of prisoners were HIV-positive.52  There is also increased risk of exposure in prison to other infectious diseases (such as tuberculosis), which heightens HIV and other health risks.53

Policing and HIV Risk

Police have a legitimate interest in controlling illicit drug possession and prostitution, to the extent that both are proscribed by Ukrainian law.  But Ukraine’s law enforcement practices are undermining government efforts to provide HIV information and services to drug users and sex workers, the very people whom the government has identified as at highest risk of HIV/AIDS.  Indeed, police practices drive people at risk away from services that prevent HIV/AIDS. 

Ill-treatment by police, sometimes reaching the level of torture, has been acknowledged as a widespread problem in Ukraine by domestic and international human rights bodies.54  The European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT), in December 2004 published its findings from a late-2002 visit to Ukraine, including that “persons deprived of their liberty by the Militia [Ukraine’s domestic law enforcement body] run a significant risk of being physically ill-treated at the time of their apprehension and/or while in custody of the Militia (particularly when being questioned), and that on occasion resort may be had to severe ill-treatment/torture.”55  According to a July 2005 report on human rights violations in Ukraine by Nina Karpachova, Ukraine’s parliamentary ombudsperson on human rights, the ombudsperson’s office received 1,518 reports of torture and ill-treatment by police in 2003, while the Ministry of Internal Affairs received 32,296 such reports in 2002 and 2003.56

There are a number of systemic reasons why police abuse continues unabated in Ukraine.  Police reportedly must fulfill periodic “work plans,” or arrest quotas.  The expectation that police will solve a high number of criminal cases, and that this is a measure of police success, encourages police to seek out easy targets for arrest.57  In its response to the CPT’s report, Ukraine acknowledged police detectives’ “wrong understanding of crime disclosure rate as the main criteria of the efficiency of their work,” as a factor in police abuse, stating that this “wrong understanding” was “why some officers try to achieve the high crime disclosure by any means.”58  In addition, the need to fulfill arrest quotas or achieve convictions may encourage police to engage in torture or other abusive tactics to extract confessions from criminal suspects.  The U.N. Committee against Torture has expressed concern about “the numerous convictions based on confessions” in Ukraine, as well as the fact that the “number of solved crimes” is among the “criteria for the promotion of investigators.”  According to the Committee, this “can lead to torture and ill-treatment of detainees or suspects to force them to ‘confess.’”59  Domestic and international human rights bodies have also expressed concern that Ukraine’s failure adequately to investigate, prosecute, or punish cases of police abuse created a climate of impunity that has permitted abusive policing practices to persist.60

As Human Rights Watch has documented in previous reports on Russia and Kazakhstan, drug users and sex workers make especially easy targets for arrest or ill-treatment by police needing to fulfill arrest quotas.61  In Ukraine, drug users can be arrested and convicted for possession of very small amounts of drugs, often less than one dose.62  Ukrainian law also provides that a person charged with the possession of illegal drugs can escape criminal responsibility if he or she “actively participates in the investigation of drug-related offenses”—a requirement that can lead police to take extreme measures to extract information from drug users.63  Drug users suffering from withdrawal may be especially vulnerable and thus more likely to submit to police pressure.  And since drug users and sex workers are widely regarded as socially undesirable, police face little risk of censure for their actions.

People interviewed by Human Rights Watch explained that police sometimes justified their arrest of drug users and sex workers by explaining that they were under pressure to fulfill a quota.  In one case, an outreach worker said that a police officer told her as she attempted to intervene to stop the arrest of a drug user suffering from a high fever: “Well, she’ll die soon anyway, and I have to fulfill the plan.  Well, what?  They’ll kick me out if I don’t close two cases this month.”64

Research on sex workers in Central and Eastern Europe and Central Asia has identified police abuse, including rape and other forms of physical violence, as a significant factor contributing to sex workers’ vulnerability to HIV/AIDS and other health risks.65  The practice of subbotnik, in which police demand free sexual services (often without condoms) as a condition of limiting police harassment or in lieu of arrest, has also been reported in several countries of the former Soviet Union.66

Research in several countries has established that criminal laws proscribing drug possession and associated policing practices targeting drug users increase the risk of HIV and other adverse health outcomes in both direct and indirect ways.67  The fear of arrest or police abuse creates a climate of fear for drug users, driving them away from lifesaving HIV prevention and other health services, and fostering risky practices.  In some countries, many injection drug users do not carry sterile syringes or other injection equipment, even though it is legal to do so, because possession of injection equipment can mark an individual as a drug user, and expose him or her to punishment on other grounds.68  Police presence at or near government sanctioned harm reduction programs (such as legal needle exchange sites) drives drug users away from these services out of fear of arrest or other punishment.69 

Many countries have taken measures to protect drug users’ right to the highest attainable standards of health by instituting structural changes in policing practices to ensure drug users’ access to HIV prevention and other health services.  In the United States, some jurisdictions have protected drug users’ access to harm reduction services through court orders barring police from arresting or punishing needle exchange participants for drug possession based on residue in used syringes, or through police department orders directing police not to patrol areas near syringe exchange sites.70  At least twenty-seven cities worldwide, including in Switzerland, Germany, Australia, and Canada, have established supervised injection sites that permit drug users to inject in a safe, hygienic environment without risk of arrest or prosecution for onsite possession of illegal drugs.71  As of this writing, Ukraine is finalizing plans to implement prison-based needle exchange programs,72 following the example of neighbors in both Western and Eastern Europe and Central Asia, including Belarus, Moldova and Kyrgyzstan.73 

Health Care Delivery in Ukraine

The structure of Ukraine’s health system has changed little since it became independent upon the demise of the Soviet Union in 1991.  Public health services are administratively centralized and vertically organized, with specialized and distinctly separate health services for HIV/AIDS, tuberculosis, sexually transmitted infections, and substance abuse treatment.  Each of these diseases has its own specialists, and patients are referred to different facilities for specialized care and treatment.  Prison health care is provided by a parallel health system under the State Department for the Penitentiary System.74  Inadequate coordination among parallel systems providing civilian public health services, and between civilian and prison health care services, mean that people in need of comprehensive health care services often fall between the gaps. 

The Ministry of Health of Ukraine is responsible for setting national health care policies, and for directly managing and funding certain health care institutions.  Each of Ukraine’s twenty-seven administrative units has its own health administration, which in turn owns and manages a range of health care facilities.  Primary health care facilities are owned by local governments.75

As of July 2005, there were twenty-five regional HIV/AIDS centers throughout Ukraine; HIV/AIDS centers in the cities of Kyiv and Sevastopol; and an additional five city HIV/AIDS centers in areas with high rates of HIV/AIDS.  Antiretroviral therapy was available at fifteen of the regional centers, while people living with HIV/AIDS outside of those regions have the option to seek antiretroviral therapy at the Gromashevskiy National Institute of Infectious Diseases Clinic (Lavra AIDS Clinic) in Kyiv.76 

Specialized HIV/AIDS centers do not provide comprehensive care, but rather a limited range of services for people living with HIV/AIDS.  People living with HIV/AIDS in need of other services should be provided care either at specialized clinics, where appropriate (such as for tuberculosis or substance abuse treatment, for example) or at neighborhood clinics on the same basis as other people.  Although their work often overlaps, AIDS specialists typically do not get involved in the work of narcologists, nor with that of tuberculosis specialists.

Ukraine’s constitution guarantees health care free of charge in state institutions.77  Ukraine’s post-independence economic crisis and the resulting decline in state income have led to a significant decline in state health care expenditures.  Budget shortfalls, in turn, have led government health care facilities to levy official fees for public health care services, sometimes disguised as “donations” or “voluntary cost recovery.”  It is not unusual for state health care providers also to demand “informal user fees” or bribes as a condition of receiving services.78 

In 2002, Ukraine’s Constitutional Court ruled that health care in state and community facilities should be provided “without preliminary, current or subsequent payments,” but stipulated that fees could be sought for health services considered beyond the limits of health care.  The government subsequently approved a list of health care services to be provided free of charge by state and community health care facilities, including emergency care and inpatient care for pregnant women and women in labor. Certain populations considered socially vulnerable (such as people with disabilities, children under six, and retired persons receiving minimum pension) are exempted from user charges, or are eligible for free or reduced cost medication or other services.79  People living with HIV/AIDS are guaranteed the right to free medication necessary to treat existing diseases, under Ukraine’s national HIV/AIDS law.80

The imposition of fees for health care services has created serious barriers to access to necessary care for many Ukrainians.  A 2002 survey of 9,478 households by the State Statistics Committee found that more than 25 percent of households were unable to obtain necessary medical care for any family members, the vast majority due to exceptionally high costs of drugs, homecare devices, and health services.  The study also found that a substantial number of patients were charged for services that the state health system was required by law to provide.81  A 2003 poll by Ukraine’s Social Monitoring Center and the Institute for Social Studies found that 78 percent of respondents believed that all or most government officials collected bribes, identifying Ukraine’s state health care services as the biggest bribe takers.  This figure is consistent with a 2002 survey by the Ukrainian NGO Partnership for a Transparent Society, which reported that more than half of respondents had paid a bribe to receive medical services.82


[4]  World Health Organization, “Ukraine: Estimations of HIV/AIDS Prevalence and Treatment Needs,” April 2005, [online] http://www.euro.who.int/aids/surveillance/20050419_1?PrinterFriendly=1&. (retrieved January 9, 2005).  As of September 2005, 83,326 HIV cases had been officially registered in Ukraine since the beginning of the epidemic, including 11,321 AIDS cases and 6,643 AIDS deaths.  World Health Organization, “HIV/AIDS Country Profiles for the WHO European Region,” [online] http://www.euro.who.int/eprise/main/WHO/Progs/SHA/surveillance/20051114_1 (retrieved November 15, 2005).  Official figures understate actual numbers, because they only include HIV infections among people who have been in direct contact with official testing facilities.

[5] UNAIDS/WHO, AIDS Epidemic Update: December 2005  (Geneva: UNAIDS, 2005), p. 48.  Ukraine also reports the highest number of annual AIDS deaths in the European region; in most cases, the decedents had no access to antiretroviral therapy.  World Health Organization Regional Office for Europe, “HIV/AIDS Country Profiles for the WHO European Region.”

[6] F. Hamers, “HIV Infection in Ukraine (1987-96),” Revue d’Epidemiologie et de Santé Publique, vol. 48 (supp. 1), 2002, pp. 1S3-15; Karl L. Dehne et al., “The HIV/AIDS epidemic in eastern Europe: recent patterns and trends and their implications for policy-making,” AIDS, vol. 13 (1999), pp. 741-749.

[7] Dehne et al., “The HIV/AIDS epidemic in eastern Europe,” p. 744.

[8] European Centre for the Epidemiological Monitoring of AIDS (EuroHIV) HIV/AIDS Surveillance in Europe. End-year report 2004 (Saint-Maurice: Institut de Veille Sanitaire, 2005), pp. 13, 15.

[9] UNAIDS, AIDS Epidemic Update, p. 50; Carmen Aceijas et al., “Global Overview of Injecting Drug Use and HIV Infection among Injecting Drug Users,” AIDS  vol. 18 (2004), pp. 2295-2303.

[10] UNAIDS, AIDS Epidemic Update, p. 50.

[11] Karl L. Dehne and Yuri Kobushche, “The HIV/AIDS Epidemic in Central and Eastern Europe.  Update 2000,” November 2000, p. 13.  A 2005 study of street sex workers in Vinnitsa found that 71 percent had injected drugs at least once, and 59 percent were regular injectors.  High rates of sharing syringes was also reported. See P. Kyrychenko and V. Polonets, “High HIV Risk Profile Among Female Commercial Sex Workers in Vinnitsa, Ukraine,” Sexually Transmitted Infections, vol. 81, (2005) pp. 187-88.

[12] UNAIDS, AIDS Epidemic Update, p. 50.

[13] According to official data, the percentage of injection drug users among newly diagnosed HIV cases has decreased significantly (from 84 percent in 1997 to 57 percent in 2004), while the corresponding percentage of cases attributed to heterosexual transmission has increased (from 11.2 percent in 1997 to 40 percent in 2004). EuroHIV, HIV/AIDS Surveillance in Europe. End-year report 2001 (Saint-Maurice: Institut de Veille Sanitaire, 2002), pp. 27, 29, 30; HIV/AIDS Surveillance in Europe. End-year report 2004, pp. 12, 13, 15, 16.  New cases among women have increased from 23 percent in 1996 to 42 percent in 2004. Alla Shcherbinskaya et al., “HIV/AIDS among children in Ukraine,” XVth International AIDS Conference, Bangkok, Thailand, July 2004, conference abstract C12116; UNAIDS, AIDS Epidemic Update, p. 50.

[14] Human Rights Watch opposes mandatory HIV testing as a threat to the rights to privacy and to health. Because of the environment of stigma, discrimination, and abuse surrounding HIV/AIDS, mandatory HIV testing risks driving individuals at high risk, or who believe themselves to be infected with HIV, "underground", or away from needed services which provide information on HIV prevention and care. Furthermore, testing without informed consent damages the credibility of health services, and injects distrust into the interaction between individuals and health care providers, jeopardizing the long-term relationship required for effective HIV therapy. WHO has recognized that "There are no benefits either to the individual or for public health arising from testing without informed consent that cannot be achieved by less intrusive means, such as voluntary testing and counselling”; and further that “public health experience demonstrates that programmes that do not respect the rights and dignity of individuals are not effective”.  World Health Organization, “Statement from the Consultation on Testing and Counselling for HIV Infection,” 1992.

[15] See Alla Shcherbinskaya et al., “Relation between the practice of HIV-testing and the officially registered HIV-cases,” XVth International AIDS Conference, Bangkok, Thailand, July 2004, conference abstract C12356; and World Health Organization, “HIV/AIDS Country Profiles for the WHO European Region.”  In 2004, 97 percent of all pregnant women were tested for HIV; 91.3 percent of 1,334 HIV-positive women who delivered in 2002 received antiretroviral drugs to prevent mother-to-child HIV transmission.  Mother-to-child transmission rates were reduced from 30 percent to 10 percent in 2004.  WHO Regional Office for Europe, “HIV/AIDS Country Profiles for the WHO European Region.”

[16]Martin C. Donoghoe, Srdan Matic, “HIV-1 in Eastern Europe,” The Lancet (letter), vol, 361, no. 9372, May 31, 2003, pp. 1910-11.  But see Murray Feshbach and Cristina M. Galvin, “HIV/AIDS in Ukraine.  An Analysis of Statistics,” January 2005, pp. 17-18 (arguing that the fact that Ukraine’s prevalence rates are higher than elsewhere in Europe indicates that the epidemic is broadening).

[17] Ministry of Health of Ukraine, “National Report on the Follow-up to the UNGASS Declaration of Commitment on HIV/AIDS,” February 2005, p. 5; UNAIDS, AIDS Epidemic Update, pp. 50-51. 

[18] UNAIDS, AIDS Epidemic Update, p. 50.

[19] See, e.g., N. Aryaev et al., “Drug Addiction and Mother-to-Child HIV Transmission Programs in the South Ukraine,” presentation at XVth International AIDS Conference, Bangkok, Thailand, July 2005 (finding that in medical institutions without specially designed programs for HIV-positive injection drug user pregnant women in Mykolaiv, Simferopol, and Odessa, HIV-positive active injection drug user pregnant women had a low usage rate of antiretroviral drugs to prevent mother-to-child transmission compared to non injection drug user HIV-positive counterparts).

[20] Tuberculosis incidence in Ukraine has almost tripled since independence, from 32.2 cases per 100,000 in 1991 to 91.3 per 100,000 in 2002. Valeria Lekhan et al., Health Care Systems in Transition. Ukraine (Copenhagen: WHO Regional Office for Europe on Behalf of the European Observatory on Health Systems and Policies, 2004), p. 9.

[21] HIV and TB form a lethal combination, each speeding the other’s progress.  People who are HIV-positive and infected with TB are up to 50 times more likely to progress to active TB disease from latent infection in a given year than those infected with TB who are HIV-negative.  Without proper treatment, about 90 percent of people living with HIV/AIDS die within months of contracting TB. See World Health Organization, Frequently asked questions about TB and HIV, [online] http://www.who.int/tb/hiv/faq/en/ (retrieved February 3, 2006).

[22] UNAIDS, “Eastern Europe and Central Asia Fact Sheet,” AIDS Epidemic Update: December 2004 (Geneva: UNAIDS, 2004).

[23] Valeria Lekhan et al., Health Care Systems in Transition: Ukraine, p. 9.

[24] See World Health Organization, Frequently asked questions about TB and HIV.  An estimated 10 to 15 percent of cases are multi-drug resistant. UNAIDS, “Eastern Europe and Central Asia Fact Sheet.”

[25] Ukraine, “National Report on the Follow-up to the UNGASS Declaration of Commitment on HIV/AIDS.  Reporting Period: 2003-2004,” February 2005, p. 3.

[26] UNICEF, UNAIDS, WHO, “Young People and HIV/AIDS: An Opportunity in Crisis,” Geneva, 2002, pp. 16-17.

[27] All-Ukrainian Network of People Living with HIV/AIDS and International HIV/AIDS Alliance, “Access to Rights and Services of People Living with HIV in Ukraine: Social Research Results,” 2004; see also Katerina Barcal et al., “A Situational Picture of HIV/AIDS and Injection Drug Use in Vinnitsya, Ukraine,” Harm Reduction Journal  vol. 2, no. 16, (September 15, 2005), pp. 1-11 (people living with HIV isolated in hospital and narcodispensary wards, and HIV-status not kept confidential; some health care workers reluctant to treat people living with HIV/AIDS).

[28] Ukrainian Institute for Social Research et al., “Analytical Report: Access of HIV-positive Women to Quality Reproductive Health and Maternity Services,” 2004, pp. 37, 49, 68.

[29] Carmen Aceijas et al., “Global Overview of Injecting Drug Use and HIV Infection among Injecting Drug Users,” AIDS vol. 18, (2004), pp. 2295-2303 (low-estimate of injection drug user population at 200,000; mid-range, 397,000; high range, 595,000.  There were 83,868 officially registered drug users (cases of drug addiction) by end 2002.  Katerina Barcal et al., “A Situational Picture of HIV/AIDS and Injection Drug Use in Vinnitsya, Ukraine,” (citing Ukrainian Center for AIDS Prevention/Ministry of Health of Ukraine, “The Problem of HIV Infection, Drug Addiction, and Sexually Transmitted Diseases,” Informational Bulletin, Kyiv2003).

[30] UNAIDS, AIDS Epidemic Update, p. 50 (citing Ukrainian AIDS Centre, 2005).

[31] See, e.g., Don C. Des Jarlais et al., “HIV Risk Behaviour Among Participants of Syringe Exchange Programmes in Central/Eastern Europe and Russia,” International Journal of Drug Policy, vol. 13 (2002), pp. 165-174; Robert E. Booth et al., “Predictors of Self-Reported HIV Infection among Drug Users in Ukraine,” Journal of Acquired Immune Deficiency Syndrome, vol. 35, no. 1 (January 1, 2004), pp. 82-88; Ministry of Health of Ukraine, “National Report on the Follow-up to the UNGASS Declaration of Commitment on HIV/AIDS,” February 2005, pp. 3, 22, 39.  Reusing syringes leads to bruising and scarring, and contaminates other drug paraphernalia and shared drug solute.  Stephen Koester, “Following the Blood: Syringe Reuse Leads to Blood-Borne Virus Transmission Among Injection Drug Users,” Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, vol. 18 (1998), Suppl. 1, p. S139.

[32] Blood is used in the preparation of the opiate solution shirka to assist in filtering the drug solution, usually after the use of anhydride.  During the last stage of preparation, a few drops of blood are added to the shirka mixture and warmed up.  The blood coagulates and absorbs particles of dirt.  The solution is then filtered, and the clear solution is ready for use.  Because the shirka solution usually is not boiled, HIV-positive blood in the solution can remain infectious.  Some drug users use albumen from eggs instead of blood to assist in the filtering process.  E-mail communication from Leonid Vlasenko, narcologist, research division, All-Ukrainian Narcological Association, to Human Rights Watch, December 16, 2005.

[33] WHO, The Practices and Context of Pharmacotherapy of Opioid Dependence in Central and Eastern Europe, pp. 108-109; E-mail communication from Konstantin Lezhentsev, M.D., program officer, International Harm Reduction Development Program, to Human Rights Watch, January 19, 2006.

[34] P. Kyriychenko, “Predictors of Sharing Injection Paraphernalia Among Users of the Syringe Exchange Program: Implications for HIV Intervention,” XVth International AIDS Conference, Bangkok, Thailand, July 2004, conference abstract Thailand AIDS Conference Abstract No. WePeC5983.

[35] See also “WHO, Evidence for Action for HIV Prevention, Treatment and Care among Injection Drug Users,” International Journal of Drug Policy, vol 16, S1 (December 2005), pp. 1-76.

[36] Martin Donoghoe, “Injecting Drug Use, Harm Reduction, and HIV/AIDS,” in HIV/AIDS in Europe, pp. 43-66 (reviewing evidence).

[37] Ibid., p. 60.  Well-designed national programs in the Czech Republic, Slovakia, and Slovenia have also been credited with contributing to low HIV prevalence among injection drug users and low incidence among noninjecting populations.

[38] See, e.g. United States Public Health Service, “HIV Prevention Bulletin: Medical Advice for Persons Who Inject Illicit Drugs,” May 9, 1997, [online] http://www.cdc.gov/idu/pubs/hiv_prev.htm (retrieved October 16, 2005).

[39] Law of Ukraine on Prevention of Acquired Immune Deficiency Syndrome (AIDS) and Social Protection of the Population (Vedomosti Verkhovnoy Rady of Ukraine, 1992, No. 11, Art. 152; 1998, No. 35, Art. 235; 2002,  No. 6, Art.41), article 4.

[40] Two hundred and fifty-six syringe exchange points were established in Ukraine with Global Fund money, and  4,284,665 syringes were distributed between April 1, 2004, and June 30, 2005.  E-mail communication from Pavel Skala, major of police (in reserve since November 2004) and policy and advocacy manager, International HIV/AIDS Alliance, Ukraine, to Human Rights Watch, October 4, 2005; International HIV/AIDS Alliance, Information Bulletin, December 2005.  

[41] These consultation points were established by the Ministry of Youth, Family, and Sport.  In 2004 these points distributed 105,509 syringes.  E-mail communication from Pavel Skala to Human Rights Watch, October 6, 2005, and chart from Ministry of Youth, Family, and Sport. 

[42] See WHO, UNAIDS, UNODC, “Joint WHO/UNAIDS/UNODC Mission on Opioid Substitution Therapy in Ukraine,” pp. 11, 14-20; WHO, UNODC, UNAIDS, “Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention: Position paper,” p. 2; Thomas Kerr et al., “Opioid Substitution and HIV/AIDS Treatment and Prevention,” The Lancet, vol. 364 (November 27, 2004), pp. 1918-19.

[43] WHO, UNODC, UNAIDS, “Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention: Position paper,” p. 2 (noting that “substitution maintenance therapy is one of the most effective treatment options for opioid dependence,” and a “critical element of community-based approaches in the management of opioid dependence and the prevention of HIV infection among injecting drug users.”).

[44] See “National Program to Ensure HIV Prevention, Care, and Treatment for HIV-infected and AIDS Patients for 2004-2008,” and “Strategy Concept of the Government Actions Aimed at Preventing the Spread of HIV/AIDS up to Year 2011,” both approved by Resolution of the Cabinet of Ministers of Ukraine, March 4, 2004, No. 264.

[45] Decree of Verkhovna Rada of Ukraine No. 1426, “On the Recommendations of parliament hearings on the subject of Socio-economic problems of HIV/AIDS, drug use and alcoholism in Ukraine and ways to overcome them,” March 2, 2004.

[46] See “Preliminary conclusions of Security Service of Ukraine (SBU) on methadone substitution therapy.  Methadone Cons and Pros;” Statement of Vladislav Bukhrahyev, deputy head of service to combat international drug trafficking, Central Directorate to Fight Corruption and Organized Crime, in Minutes of the Working Meeting on Substitution Therapy in Ukraine, April 16, 2004; WHO, UNAIDS, UNODC, “Joint WHO/UNAIDS/UNODC Mission on Opioid Substitution Therapy in Ukraine,” pp. 46-47; Alena Voskresenskaia, “Methadone: Panacea or Ruin,” Kievljanin, no. 22 (140), 2004, p. 4.; Vera Valerko, “Poison for Free,” Kievskie Vedomosti, May 28, 2004.

[47] WHO, UNAIDS, UNODC, “Joint WHO/UNAIDS/UNODC Mission on Opioid Substitution Therapy in Ukraine,” p. 7. See also Sophie Pachoud and Martin C. Donoghue, “Opioid Substitution Therapy Scaling Up Plan for Ukraine,” WHO Regional Office for Europe, January 2006.

[48] See, e.g., Katerina Barcal et al., “A Situational Picture of HIV/AIDS and Injection Drug Use in Vinnitsya, Ukraine,” Harm Reduction Journal, vol. 2, no. 16 (September 15, 2005); World Health Organization, The Practices and Context of Pharmacotherapy of Opioid Dependence in Central And Eastern Europe, (Geneva: WHO, 2004), p. 115.

[49] Human Rights Watch interview with Viktor M., Dnipropetrovsk, July 12, 2005; Human Rights Watch interview with Elena Kuleshova, Way Home, Odessa, July 4, 2005.

[50] Artur Ovsepyan, All-Ukrainian Network of People Living with HIV/AIDS, Assessment of TB and HIV/AIDS Service Infrastructure, 2005.

[51] See Ukraine Helsinki Human Rights Union, “Human Rights in Ukraine – 2004.  Human Rights Organizations’ Report,” 2005, pp. 286-287.  The State Department for the Execution of Punishments, recognizing that unsafe injection use takes place in prison, has taken steps to launch pilot needle exchange programs in two prison colonies in 2006; and the Ministry of Health has also issued an order permitting the distribution of antiretroviral drugs to thirty patients in a Kherson prison.  Presentation by Andriy Klepikov, executive director, International HIV/AIDS Alliance in Ukraine, at stakeholders meeting, Kyiv, February 14, 2006.

[52] WHO, “HIV/AIDS in Prisons,” [online] http://www.euro.who.int/aids/prevention/20040115_2 (retrieved November 16, 2005).  By end 2004, approximately 12,700 prisoners had been diagnosed with HIV, of whom more than 3,500 were still incarcerated.  UNAIDS/WHO, AIDS Epidemic Update,  p. 50.

[53] Significant outbreaks of HIV and multidrug resistant TB have been reported in prisons in Ukraine and Russia.  See Burris et al., “Addressing the ‘Risk Environment’ for Injection Drug Users” p. 132 (citing studies).  Huge increases in HIV prevalence in Thailand in the 1980s have been attributed to drug users moving in and out of prisons.  See Paola Bollini, ed., HIV in Prisons: A Reader with Particular Relevance to Newly Independent States (Geneva: WHO, 2001), p. 24. 

[54] See European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT), “Report to the Ukrainian Government on the Visit to the Ukraine Carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment from 24 November to 6 December 2002,” December 2004, paras. 18-20. The CPT, a body of independent experts established under the European Convention for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment, is empowered to visit places of detention to examine the treatment of detainees and to recommend necessary improvements to States. See also Amnesty International, “Ukraine: Time for Action: Torture and Ill-Treatment in Police Detention” (AI Index: EUR 50/004/2005), September 2005. 

[55] CPT, “Report to the Ukrainian Government on the Visit to the Ukraine Carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment from 24 November to 6 December 2002,” para. 20.  Generally, CPT reports of country visits are published only with the agreement of the State concerned, and accompanied by the State’s response.

[56] See Amnesty International, “Ukraine: Time for Action: Torture and Ill-Treatment in Police Detention.”  In July 2006, Karpachova reported to parliament that a poll of senior members of Ukraine’s criminal investigations bureaus found that “about 97 percent of those polled confirmed that torture is used either frequently or periodically in Ukraine.”  See "On the situation regarding observance of human rights and freedoms in Ukraine," July 6, 2005, [online] http://www.ombudsman.kiev.ua/pres/releases/rel_05_07_06.htm (Ukrainian); http://www.ombudsman.kiev.ua/pres/releases/rel_05_07_07.htm (Russian) (retrieved January 11, 2006)

[57] See United Nations Committee Against Torture, Conclusions and Recommendations: Ukraine, 25/09/2002, A/57/44, paras. 54-58. 

[58] Response of the Ukrainian Government to the report of the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment on its first visit to Ukraine from 24 November to 6 December 2002, p. 7.

[59] United Nations Committee Against Torture, Conclusions and Recommendations: Ukraine, 25/09/2002, A/57/44, paras. 54-58.

[60] See, e.g.,  CPT, “Report to the Ukrainian Government on the Visit to the Ukraine Carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment from 24 November to 6 December 2002,” paras. 22, 23; U.S. Department of State, Country Report on Human Rights Practices: Ukraine 2004 (February 2004); Amnesty International, “Ukraine. Time for Action: Torture and Ill-Treatment in Police Detention.”

[61] Human Rights Watch, “Lessons Not Learned: Human Rights Abuses and HIV/AIDS in the Russian Federation,” A Human Rights Watch Report,  Vol. 16, No. 5(D), April 2004; Human Rights Watch, “Fanning the Flames: How Human Rights Abuses Are Fueling the AIDS Epidemic in Kazakhstan,” A Human Rights Watch Report, Vol. 15, No. 4(D), June 2003.

[62] Article 309, para. 1 of the Criminal Code of Ukraine imposes penalties for drug possession. Individuals possessing any amount of heroin up to 1 gram; 0.15-1.5 grams of amphetamine or MDMA; or 0.1-10 grams of acteylated opium are subject to three years in prison. See "Table of Small, Large and Especially Large Amounts of Narcotic Drugs in Illegal Circulation," [online] http://zakon.rada.gov.ua/cgi-bin/laws/main.cgi?nreg=z0512-00; "Table of Small, Large and Especially Large Amounts of Psychotropic Substances in Illegal Circulation," http://zakon.rada.gov.ua/cgi-bin/laws/main.cgi?nreg=z0513-00. A typical dose of shirka varies from 0.1 gram to 0.5 grams. E-mail communication from Konstantin Lezhentsev, M.D., program officer, International Harm Reduction Development Program, January 20, 2006.

[63] Criminal Code, art. 307, para. 4.  In certain circumstances, such as for first time drug offenses for small amounts of drugs, a person can also escape criminal responsibility if he or she voluntarily starts drug treatment.  Criminal Code, art. 309, para. 4.

[64] Human Rights Watch interview with Larissa Borisenko, social worker, Dnipropetrovsk, July 11, 2005.

[65] See Central and Eastern European Harm Reduction Network (CEEHRN), Sex Work, HIV/AIDS, and Human Rights (Vilnius, Lithuania: CEEHRN, 2005), pp. 41-45, and studies cited therein.

[66] Ibid., pp. 22, 43; Human Rights Watch, “Fanning the Flames,” pp. 21, 25.  During the Soviet period, a subbotnik, from subbota (Saturday), was unpaid community service work.  As now colloquially applied to sex workers, it means providing free sex.  

[67] See Scott Burris et al., “Addressing the ‘Risk Environment’ for Injection Drug Users: The Mysterious Case of the Missing Cop,” The Milbank Quarterly, vol. 82, no. 1 (2004), pp. 131-35 (reviewing studies).

[68] A survey of drug users in five Russian cities found that 40 percent routinely did not carry injection equipment, in part out of fear of attracting police attention.  Jean-Paul C. Grund, “Central and Eastern Europe,” in HIV and AIDS: A Global View, Karen McElrath, editor (Westport, Connecticut: Greenwood Press, 2002), pp. 41-67.  See also studies cited in Burris et al., “Addressing the ‘Risk Environment’ for Injection Drug Users,” pp. 131-35; Human Rights Watch, “Lessons Not Learned”; Human Rights Watch,” Fanning the Flames”; and Human Rights Watch, “Not Enough Graves: The War on Drugs, HIV/AIDS, and Violations of Human Rights,” A Human Rights Watch Report, Vol. 16, No. 8(C) (June 2004).

[69] Ibid. See also Human Rights Watch ”Injecting Reason: Human Rights and HIV Prevention for Injection Drug Users; California: A Case Study,” A Human Rights Watch Report, Vol. 15, No. 2(G), September 2003.  The case of Thailand is also illustrative: Studies reported a significant decline in the number of drug users seeking substance abuse treatment during Thailand’s 2003 “war on drugs,” and that a significant percentage of drug users who had formerly attended drug treatment centers went into hiding, in some cases sharing syringes because sterile syringes were difficult to obtain.  Human Rights Watch, “Not Enough Graves,” pp. 36-37; and E-mail communication from Swarap Sarkar, regional director, UNAIDS-South Asia to Human Rights Watch, May 18, 2004.  Researchers have also found that the government crackdown on drug users was likely to discourage drug users from obtaining HIV testing and other medical services.  Tassanai Vongchak et al., “The influence of Thailand’s 2003 ‘war on drugs’ policy on self-reported drug use among injection drug users in Chiang Mai, Thailand,” International Journal of Drug Policy, No. 16 (2005), pp. 115–121.

[70] See, for example, Roe v. City of New York, 232 F. Supp.2d 240 (U.S. DCt, SDNY, 2002); Doe v. Bridgeport Police Department, 198 F.R.D. 325 (U.S. DCt., SDCT, 2001); Los Angeles County Police Order (directing police to refrain from targeting or conducting observation in syringe exchange locations to identify, detain, or arrest persons for narcotics-related offenses).

[71] In Vancouver, Canada, for example, drug users are covered by a provision of the federal Controlled Drugs and Substances Act that exempts any person or class of persons from the application of the Act if, in the opinion of the Minister of Health, “the exemption is necessary for a medical or scientific purpose or is otherwise in the public interest.”  Controlled Drugs and Substances Act, Section 56.  For further information on safe injection sites, see Richard Elliott et al., Establishing Safe Injection Facilities in Canada: Legal and Ethical Issues (Canadian HIV/AIDS Legal Network, 2002), [online] http://www.aidslaw.ca/Maincontent/issues/druglaws/safeinjectionfacilities/safeinjectionfacilities.pdf; and City of Vancouver, “Supervised Injection Sites (SISs): Frequently Asked Questions,” [online] www.city.vancouver.bc.ca/fourpillars (retrieved January 4, 2006).

[72] The State Department for the Execution of Punishments, with the support of the International HIV/AIDS Alliance in Ukraine, has taken steps to launch pilot needle exchange programs in prison colonies in Lviv and Mykolaiv, planned to begin in 2006.  Presentation by Andriy Klepikov, executive director, International HIV/AIDS Alliance in Ukraine, at stakeholders meeting, Kyiv, February 14, 2006.

[73] See Glenn Betteridge, “Prisoners’ Health and Human Rights in the HIV/AIDS Epidemic,” draft background paper for “Human Rights at the Margins: HIV/AIDS, Prisoners, Drug Users, and the Law.  Satellite of the XVth International AIDS Conference, Bangkok, Thailand,” June 2004, pp. 11-12.

[74] Valeria Lekhan et al., Health Care Systems in Transition: Ukraine, pp. 17-19.

[75] Ibid.

[76] Human Rights Watch interview with Alla Scherbinska, director, Ukraine National AIDS Centre, July 18, 2005.

[77] Constitution of Ukraine, article 49 (“The State creates conditions for effective medical service accessible to all citizens. State and communal health protection institutions provide medical care free of charge; the existing network of such institutions shall not be reduced.”).

[78] Valeria Lekhan et al., Health Care Systems in Transition. Ukraine, p. 41; Rebecca Weaver, “RFE/RL Profiles Ukraine’s Fight against Corruption,” East West Institute News, January 20, 2003.

[79] Valeria Lekhan et al., Health Care Systems in Transition. Ukraine, p. 34-40.

[80] Law of Ukraine on Prevention of Acquired Immune Deficiency Syndrome (AIDS) and Social Protection of the Population, article 4 (guaranteeing “free-of-charge supply of medicines necessary for treatment of disease, means of personal prevention and psycho-social support” to people living with HIV/AIDS).

[81] Valeria Lekhan et al., Health Care Systems in Transition. Ukraine, p. 37.

[82] Rebecca Weaver, “RFE/RL Profiles Ukraine’s Fight against Corruption.”


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