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HIV/AIDS in the former Soviet Union
Until the mid-1990s, it was widely thought that the former Soviet Union had been spared a significant HIV/AIDS epidemic. In stark contrast, the United Nations system's annual reports on the state of the global HIV/AIDS epidemic in both 2001 and 2002 estimated that Eastern Europe and Central Asia-the United Nations region that includes the former Soviet Union (FSU)-has the fastest growing epidemic in the world.6 Official U.N. estimates put the number of persons living with AIDS in this region in late 2002 at 1.2 million, but it is widely recognized, including by U.N. officials, that these figures are a gross underestimate.7 The U.N. figure of 250,000 new infections in 2002, although it represents a 25 percent annual rate of increase, probably is a significant undercount.

The epidemic is growing so fast in the former Soviet Union at least partly because injecting drug use, the most prevalent means of HIV transmission in the region, is much more efficient than sexual transmission. In addition, experts have noted that especially risky injecting practices, including sharing of needles and other drug paraphernalia and use of blood in preparation of injected drugs, are widespread.8 The United Nations estimates that about one out of 100 persons in Eastern Europe and Central Asia is an active injection drug user,9 a very high percentage by global standards. Many analysts have traced the meteoric rise in use of injected heroin since the fall of the Soviet Union to economic collapse and attendant rises in unemployment, poverty and desperation, and to increased availability of cheap heroin trafficked through Central Asia and across the FSU.10 Some experts have suggested that the aftermath of the events of September 11, 2001 in Afghanistan and Central Asia has done nothing to stem the flow of heroin through the region and may even exacerbate it in the long run.11 There is no indication that the epidemic of injecting drug use in the region is abating.

In the countries of Central Asia, Russia, Moldova, Belarus, Ukraine and the Baltic states, at least 60 percent of registered HIV/AIDS cases are injection drug users.12 In Russia the figure is 93 percent. In Ukraine, which has the worst HIV/AIDS epidemic in the region in terms of HIV prevalence in the adult population-about 1 percent-the percentage of IDUs among new HIV cases has declined from over 80 percent in 1997 to about 60 percent in 2001 as the growing epidemic is increasingly spread through sexual transmission in the general population.13

The HIV/AIDS epidemic in Russia was highlighted in the widely cited 2002 report of the U.S. National Intelligence Council, an affiliate of the U.S. Central Intelligence Agency, on the "next wave" of global AIDS. The Council's analysis suggested that there could be as many as 8 million persons living with HIV/AIDS in Russia alone by 2010,14 a figure well in excess of extrapolations from current U.N. estimates. This report suggests that with injecting drug use "rampant and rising," a deteriorated health system, and the government's "limited capability to respond" to the epidemic, the adult HIV prevalence rate by 2010 could be as high as 11 percent, a disastrous situation.15

Although the absolute numbers of persons living with the disease in Central Asia are small in comparison with those of Russia, HIV/AIDS in the five Central Asian countries has the potential to be a major calamity. The most recent U.N. report on the epidemic characterizes the growth of HIV/AIDS in Uzbekistan, for example, as "explosive," noting that there were as many new HIV infections in the first half of 2002 as in the previous ten years.16 UNAIDS also highlights Tajikistan as being on the brink of a major epidemic in view of recent increases in heroin use.

In any AIDS epidemic where injecting drug use is so central in driving the spread of the disease, societal, legal and judicial attitudes and practices toward drug users are important determinants of the capacity of a country to mount an effective response to HIV/AIDS. Unfortunately, with few exceptions, drug users in the FSU are socially marginalized and stigmatized, drug laws are draconian, and abuses of due process in handling of narcotics offenses abound. In addition, by global standards, a very high percentage of drug users in the FSU find themselves in prison or in state detention at some time in their lives. Prisoners throughout the region are at high risk of contracting HIV/AIDS in prison because harm reduction services and access to condoms in prisons are so limited. The HIV prevalence in prisons in Russia, for example, is estimated to be much higher than that of the general population,17 and Russia is probably not alone in this regard.

Beginning in about 1987, countries throughout the Soviet Union, including those in Central Asia, began establishing AIDS centers. Unfortunately, the mission of these centers does not seem to have been to provide information and preventive services to the population but rather to carry out a massive program of mandatory testing and official registration of persons with AIDS.18 Recommendations from international public health bodies generally condemn mandatory HIV testing, instead encouraging voluntary testing with counseling to help HIV-positive persons minimize further spread of the disease and HIV-negative persons to remain that way (though widespread anonymous HIV testing for surveillance of the epidemic has been conducted in many countries.)19 Widespread testing in Russia was neither voluntary nor apparently for epidemic surveillance. It is estimated that from 1987 to 1993 the Russian government conducted over 120 million HIV tests, largely on an involuntary basis, of "high-risk" persons, including drug users, gay and bisexual men, persons diagnosed with other sexually transmitted diseases, persons who had traveled abroad, and the sex partners of persons in these categories.20 Virtually none of these persons received counseling about HIV testing or HIV/AIDS.

Similar practices were carried out throughout the Soviet Union and lingered past its demise. Mandatory testing of anyone arrested by the police on any charge was also established in most countries and exists to this day, and those who test positive are still isolated from other prisoners or detainees in much of the FSU.21 There is no tradition of respecting the confidentiality of any medical testing in or outside of prisons.
There have been a few signs of change in recent years. In 1998, Ukraine adopted a law abolishing the practice of mandatory testing of detainees and isolation of HIV-positive prisoners.22 Thanks to the work of a number of pioneering organizations, including the Open Society Institute, some needle exchange services are available in virtually all countries of the FSU though in most countries they reach a very small percentage of those who need them.23 Substitution therapy such as methadone maintenance therapy, which has been widely credited with controlling HIV transmission among injection drug users in Western Europe and North America, is available in a few countries but was illegal in nine countries of Central and Eastern Europe and the FSU as of mid-2002.24 The Central and Eastern Europe Harm Reduction Network reported that more than 80 percent of all HIV-positive injection drug users lived in these nine countries.25 Throughout the FSU, drug rehabilitation and detoxification programs are unavailable to the vast majority of users and when available are usually highly punitive.26

Commercial sex work in the region has become much more widespread since the fall of the Soviet Union. As in many parts of the world, in the FSU the exchange of sex for drugs and the use of sex work to support drug habits provide important links between injection drug use and commercial sex.27 Sex workers obviously represent an important population in the course of the epidemic because of their sexual interaction with the general population. Figures on condom use among sex workers are difficult to come by, but surveys show that rates of condom use in the general population are low in the region. For example, a recent study of condom use in Ukraine showed that among sexually active young men 28 percent said they always use a condom, 27 percent said they use condoms often, 34 percent reported rare use, and 11 percent said they never use condoms. For young women reporting on condom use of their sex partners, the corresponding figures were 17 percent, 23 percent, 41 percent and 19 percent.28 Surveys reveal a worrying deficit of detailed knowledge of the epidemic in the region among both young people and adults. While in Ukraine virtually all girls and young women aged fifteen to nineteen surveyed in recent studies had heard of HIV/AIDS, only 10 percent of the same population knew three ways of avoiding infection.29 In Uzbekistan, less than 60 percent of this age group had even heard of HIV/AIDS, and less than 10 percent knew how to protect themselves.30 In Tajikistan, only about 10 percent of girls had heard of HIV/AIDS.

There is very little access to antiretroviral treatment for persons with HIV/AIDS in the FSU, and there is even more limited access for injection drug users than for the rest of the population.31 In Ukraine in 2002, for example, although 70 percent of persons with HIV/AIDS were estimated to be drug users, only 20 percent of persons getting antiretroviral therapy were drug users.32 In Russia, where about 90 percent of persons with HIV/AIDS were estimated to be drug users, about 50 percent of ARV treatment was among IDUs.
The rapid spread of HIV/AIDS in the region is facilitated by a catastrophic explosion in levels of other STIs since the fall of the Soviet Union, and AIDS mortality is facilitated by an underlying tuberculosis epidemic that has not received adequate attention.33 Kazakhstan, for example, had a syphilis incidence of 640 cases per 100,000 population in 2000, a 500-fold increase from the early 1990s.34 The STI treatment strategy in much of the former Soviet Union has been to hospitalize patients for diseases that are treated in most countries of the world on an outpatient basis and to require patients to identify their sexual partners and to be registered as STI carriers.35 Drug users and sex workers are understandably not eager to seek treatment under these conditions.

Tuberculosis is a long-standing problem of epidemic proportion in the region. In 2000, the countries of Western Europe had thirteen cases of tuberculosis per 100,000 population while the fifteen countries of the FSU had ninety-two per 100,000.36 With the deterioration of health services in the region in the 1990s, mortality due to tuberculosis grew to forty-seven deaths per 100,000 population in 1998 from fourteen in 1991.37 The growing use of directly observed treatment of tuberculosis-where patients take their medicines in the presence of health workers-seems to have slowed mortality in some countries.38 Prisons remain heavily affected by tuberculosis because of overcrowding and poor hygiene and nutrition.

HIV/AIDS in Kazakhstan
In 2002, the government of Kazakhstan estimated that some 25,000 persons were living with HIV/AIDS in the country (population 16 million), though the number of "registered" cases is much smaller.39 Kazakhstan is estimated to have more than double the number of persons with HIV/AIDS of the other four Central Asian countries combined. The first cases of HIV emerged in the one-company town of Temirtau near the city of Karaganda where the closing of the town's smelting plant in the early 1990s threw much of the population into unemployment and poverty. By the late 1990s, the United Nations estimated that about 2000 of the 32,000 persons aged fifteen to twenty-nine in Temirtau were injection drug users.

The first HIV-positive persons were registered in Temirtau in 1996,40 and the town was estimated in early 2002 to be home to over half of the registered cases in Kazakhstan.41 More recently the government has said that no region of the country is without some persons with AIDS.42 Nationwide, about 85 percent of HIV transmission is estimated to be due to injecting drug use.43 In late 2001, a high-level government official noted that of the 3,000 drug users registered in the preceding eighteen months, 87 percent were HIV-positive, indicating a frighteningly widespread problem among injection drug users.44 The second most highly affected group, as in Russia and Ukraine, is probably sex workers, though numbers are difficult to come by. Sex workers, as elsewhere in the FSU, provide a crucial bridge to the general population in the spread of HIV. Men who have sex with men, normally also highly vulnerable to HIV infection, are marginalized and hidden except in the biggest cities, and the degree to which they have been affected by the epidemic is unknown.

As the Temirtau case illustrates, the rapid spread of HIV/AIDS in Kazakhstan has come hand in hand with increased poverty and unemployment since the fall of the Soviet Union. Although the Kazakh economy enjoyed 13.5 percent growth in 2001 due mostly to higher oil prices and increased oil and gas production in the country, the 1990s was a period of steep economic decline.45 The Asian Development Bank estimated that the real unemployment rate in 2001 was 10.4 percent, an improvement over the levels of the previous several years,46 but the U.S. Agency for International Development (USAID) estimated in 2002 that the real unemployment rate might be as high as 30 percent.47 Though certain sectors are experiencing economic growth, "the economy remains dominated by oligarchic interests,"48 and the economic decline of the 1990s left over 30 percent of the population living in poverty by late in the decade.49 Educational opportunities for young people are much more limited than during the Soviet period. The U.N. Children's Fund (UNICEF) reported in 2002, for example, that in Almaty only 10 percent of secondary school graduates were able to benefit from higher education, and about 7 percent joined the army (following their obligatory military service), but the vast majority were without further training and were very unlikely to get decent jobs.50

Economic decline and the serious deterioration of social services experienced across the former Soviet Union have in Kazakhstan as elsewhere gone hand in hand with an explosion in injecting drug use. At first serving as a transit area for the trafficking of opiates from Afghanistan, Kazakhstan became a market for heroin in the 1990s. In some parts of the country, the price of a dose of heroin is not much greater than that of a small bottle of vodka.51 UNICEF's recent report on the situation of young people in Kazakhstan said there was a fourfold increase in the young people registered as narcotics drug users by the government from 1999 to 2002,52 and those registered very likely represent a small percentage of the actual population. Some 19 percent of children aged twelve to fourteen years and 40 percent of children fifteen to eighteen years old reported in 2002 that they had consumed alcohol.53

Although nearly all young people and adults in Kazakhstan have been shown in various surveys to have some awareness of HIV/AIDS and much more awareness of HIV/AIDS than of other STIs, young people's understanding of HIV transmission is wanting. UNICEF's recent survey of 1028 teenagers (aged thirteen to eighteen) around the country showed that 26 percent believed HIV was transmitted by sharing dishes or spoons, by insects, by kissing or by casual contact, and 20 percent thought "repressive and punitive actions" against persons with AIDS were necessary to contain the epidemic.54 Only 15 percent of the children said they had received information on safer sex in school.55 The need to conduct broader campaigns among young people is vividly clear: in Pavlodar alone, about 80 percent of HIV cases are reported to be among fifteen- to twenty-nine-year-olds. In 2002 thirteen schoolchildren (ranging in age up to seventeen years) in the area were registered with HIV.56
Young people's expression of the need for repressive measures against persons with AIDS reflects both wider social opinion and government policy. Persons living with HIV/AIDS in Kazakhstan face deep stigma, social ostracization, and sometimes abandonment by their families. This stigma reflects the strong association in the public mind between HIV/AIDS and injecting drug use; injection drug users are deeply stigmatized. One U.N. official said this stigma is sometimes reinforced by government campaigns that "blur the difference between drug addiction and drug trafficking."57 Mandatory HIV testing of a wide range of persons considered to be at risk, including drug users and all persons in pre-trial detention, was national policy up until July 2002, and those who were convicted of a crime and who test positive for HIV are isolated in a special prison colony for persons with HIV/AIDS. In August 2002, the director of the National AIDS Program in Almaty announced that this practice would be discontinued, but the implementation of this policy was incomplete as of this writing.58

The government has permitted the establishment of needle exchange programs-services where injection drug users can exchange their used syringes for sterile ones, reducing the HIV transmission risk associated with reuse or sharing of syringes. Many such services exist at health facilities and in mobile units under both public and private auspices in the country. Substitution therapy59 has so far been illegal, but the government recently said it would authorize two pilot projects using methadone.60 Detoxification therapy-where toxic levels of an addictive drug are eliminated from an addict's body, usually gradually-is unavailable to the vast majority of drug users. The president of Kazakhstan recently commissioned a study to consider the legalization of cannabis and hashish and reduced penalties for drug users as part of an effort to "humanize" their treatment.61

There are government AIDS centers, health facilities charged with HIV prevention and AIDS care, in all fourteen provinces of the country. They offer HIV tests and register HIV-positive persons. As in much of the rest of the former Soviet Union, they are not integrated with tuberculosis, STI, or narcology centers. The AIDS centers in Karaganda, Temirtau, and Almaty have offered combination antiretroviral therapy to a small number of persons living with the disease, but drug users in Karaganda have been excluded unless they show themselves to be drug-free for at least six months.62 As one AIDS activist noted, both drug users and former drug users are deeply suspicious of government health services. Some former drug users have refused antiretroviral treatment because they do not trust the government services and believe that the medicines may be toxic.63 Antiretroviral treatment in other parts of the country appears to be severely limited.

Kazakhstan established a five-year interministerial plan to combat HIV/AIDS for 2001-2005 focusing largely on prevention and epidemiologic surveillance. Implementation of the plan is estimated to cost about U.S.$150 million, of which the government is seeking about U.S.$147 million from outside sources.64 A proposal was recently made to the Global Fund for HIV/AIDS, Tuberculosis and Malaria toward this end. The plan includes "social protection" of groups vulnerable to HIV infection, lowering "risky conduct," "upgrading the state policy on attracting the social organizations to solve HIV/AIDS problem," information and education programs on "a healthy way of life," upgrading medical services related to HIV prevention, and improving the coordination of prevention programs.65

AIDS mortality in Kazakhstan is fueled by a severe tuberculosis problem, and HIV transmission in Kazakhstan is facilitated by high rates of STIs in the population. Kazakhstan has the highest tuberculosis burden in Central Asia.66 Although the introduction of "directly observed" treatment, including in some prisons with the support of the international organization Prison Reform International, has reduced tuberculosis mortality in recent years,67 thousands remain untreated. Tuberculosis contributes greatly to AIDS mortality in Kazakhstan, as in other countries where there is a great deal of untreated tuberculosis. Kazakhstan is estimated to have the highest incidence of syphilis of all countries in the Europe region of the World Health Organization.68 Alarmingly, while national surveys have shown that adults are aware of HIV/AIDS as a sexually transmitted infection, 36 percent of women and 16 percent of men in 1999 had not heard of STIs other than HIV/AIDS.69 At the same time, 22 percent of unmarried men reported having multiple sex partners, and condom use was reportedly very low.70 A 1999 survey of university students in Almaty indicated that up to 30 percent had at some point contracted a sexually transmitted infection.71

It is difficult to judge the success of government efforts to address the epidemic so far. The government's AIDS program is extremely underfunded. Planning and targeting of activities are handicapped by the lack of reliable figures on new and existing cases. The long tradition of using health facilities for mandatory testing for HIV and other infections and the lack of confidentiality of testing and other services make user-friendly services for drug users, sex workers, and people with AIDS the exception rather than the rule. The incomplete implementation of the decision to eliminate mandatory testing of persons in state detention may contribute to a lack of confidence on the part of drug users and others in government AIDS services.

The government has taken the progressive step of ordering a full review of existing laws and regulations with respect to international standards on HIV/AIDS and human rights. The Ministries of Justice, Health and the Interior as well as United Nations agencies are involved in this effort, and at least one human rights NGO has been invited to participate. Dr. Isidora Erasilova, the new director of the National AIDS Program, recently publicly recognized the degree to which stigmatization of drug users has impeded an effective AIDS response, noting that "lack of understanding of the problem [of AIDS] and persecution of drug-takers discourage them from taking part in prevention programs and make them especially vulnerable to contracting HIV."72

6 UNAIDS/WHO, AIDS Epidemic Update (UNAIDS/02.58E), December 2002, p.12, and UNAIDS/WHO, AIDS Epidemic Update (UNAIDS/01.74E), December 2001, p. 6.

7 AIDS Epidemic Update, December 2002, p. 12.

8 "Central Asia Faces `Explosive Growth' of HIV/AIDS Cases," Eurasia Recaps, January 1, 2001, [online], (retrieved January 25, 2003); .
Jean-Paul Grund, UNAIDS, presentation at "Health Security in Central Asia: Drug Use, HIV and AIDS" conference, Dushanbe, October 14, 2002.

9 Report on the Global AIDS Epidemic, June 2002, p. 34.

10 See, e.g., Karl L. Dehne, Jean-Paul C. Grund, Lev Khodakevich, and Yuri Kobyshcha, The HIV/AIDS Epidemic among Drug Injectors in Eastern Europe: Patterns, Trends and Determinants, Journal of Drug Issues 29 (4), 1999; Julie Stachowiak and Chris Beyrer, John Hopkins Bloomberg School of Public Health, "HIV Follows Heroin Trafficking Routes," October 14, 2002 [online] (retrieved January 25, 2003).

11 Nancy Lubin, Alex Klaits and Igor Barsegian, "Narcotics interdiction in Afghanistan and Central Asia: Challenges for international assistance" (A report to the Open Society Institute), 2002.

12 Central and Eastern European Harm Reduction Network (CEEHRN), "Injecting Drug Users, HIV/AIDS Treatment and Primary Care in Central and Eastern Europe and the Former Soviet Union" (report of a survey), July 2002, p. 6.

13 AIDS Epidemic Update, December 2002, p. 13.

14 National Intelligence Council, "The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China," September 2002.

15 Ibid., pp. 10-12.

16 AIDS Epidemic Update, December 2002, p. 13. Some 620 new cases were officially registered in the first six months of 2002.

17 Mark Schoofs, "Jailed Drug Users Are at Epicenter Of Russia's Growing AIDS Scourge," Wall Street Journal, June 25, 2002 at A1. This article reports that in 2002, at Kresty prison in St. Petersburg, for example, about 1000 of 7800 inmates are HIV-positive.

18 Julie Stachowiak, "Systematic-forced-testing in Russia," Women Alive, Summer 1996. Available at, (retrieved December 10, 2002).

19 See, e.g., Joint United Nations Programme on HIV/AIDS and United Nations Office of the High Commissioner or Human Rights, HIV/AIDS and Human Rights: International Guidelines (HR/PUB/98/1), 1998, paragraphs 28(b) and 30(c).

20 Kevin J. Gardner (AESOP Center), "HIV Testing and the Law in Russia," 1995-96, [online],, (retrieved January 25, 2003); Stachowiak, "Systematic-Forced-HIV Testing in Russia." By 1996, official statistics held that there were only 1150 HIV/AIDS cases.

21 Joana Godinho, Hiwote Tadesse, Anatoly Vinokur, Mattias Lundberg, Eluned Roberts-Schweitzer, Saodat Bazarova, Natalya Beisenova, Dinara Djodosheva, Dilnara Isamiddinova and Guljahan Kurbanova, "Study Concept Note: Central Asia HIV/AIDS, STIs and TB," The World Bank (ECSHD/ECC08), June 2002, p. 7. The testing of detainees in the former Soviet Union, conducted generally without consent of the person tested and without provision of counseling, is in violation of international norms as stated, for instance, in the U.N. "HIV/AIDS and Human Rights: International Guidelines," which notes that the seriousness of HIV testing demands that counseling be provided (paragraph 28.c). In addition, disclosing an individual's HIV status to others but not to the individual is clearly in violation of both public health and right to privacy norms.

22 United Nations Office on Drug Control and Crime Prevention, Drug Abuse and HIV/AIDS: Lessons Learned (E/01/XI/15), p. 90. Also available at

23 See, e.g., Open Society Institute, "Drugs, AIDS and Harm Reduction: How to Slow the HIV Epidemic in Eastern Europe and the Former Soviet Union," 2001.

24 CEEHRN, p. 24.

25 Ibid. This calculation includes Kazakhstan, which, as noted below, has announced plans for two pilot methadone programs.

26 Henning Mikkelsen (UNAIDS-Geneva), "Building expanded responses to HIV/AIDS and injecting drug use in Central Asia," Eurasia Policy Forum, March 1, 2001 [online],, (retrieved January 25, 2003).

27 Godinho et al., p. 3.

28 British Council, EC-US HIV/AIDS Prevention and Awareness Programme forUkraine, Condom Use and Availability (consultant report), 2002, [online],, (retrieved January 25, 2003).

29 John Novak (USAID), "The HIV/AIDS Epidemic in Eastern Europe and Eurasia and USAID's Response," presentation to the HIV/AIDS Committee, American Bar Association,, November 1, 2002, Washington, DC

30 Ibid.

31 CEEHRN, p.3.

32 Ibid., p. 13.

33 It is well demonstrated clinically that having other STIs, including syphilis, increases an individual's risk of HIV transmission. See, e.g., United States Centers for Disease Control and Prevention, Fact Sheet: Prevention and Treatment of Sexually Transmitted Diseases as an HIV Prevention Strategy [online], (retrieved March 14, 2003).

34 Ali Buzurukov, "HIV/AIDS epidemic: Time is running out for Central Asia," Central Asia/Caucasus Analyst, April 10, 2002 [online], (retrieved January 25, 2003).

35 Ibid.

36 Godinho et al., p.3.

37 Ibid.

38 Kazakhstan is cited by some donors as having enjoyed some success in DOTS implementation. See USAID, "Central Asian Republics (Europe and Eurasia): Tuberculosis Control" at Retrieved December 27, 2002.

39 "Number of HIV-positive people exceeds 25,000 in Kazakhstan-expert," Interfax-Kazakhstan news agency, November 28, 2002.

40 Douglas Frantz, "Drug Use Begetting AIDS in Central Asia," New York Times, August 5, 2001, p. A8.

41 Buzukurov, "HIV/AIDS epidemic: Time is running out for Central Asia."

42 "Kazakh Official Number of HIV Sufferers 2,780," Interfax-Kazakhstan news agency, May 21, 2002.

43 UNAIDS, National Response Brief-Kazakhstan. Available at nationalresponse/result.asp (retrieved December 4, 2002).

44 "Kazakh deputy health minister sounds alarm over rise in HIV cases in country," Interfax-Kazakstan, November 27, 2001.

45 Asian Development Bank, Kazakhstan Country Report 2001 [online] at (retrieved December 11, 2002).

46 Ibid.

47 United States Agency for International Development (USAID), Kazakhstan country summary from the Fiscal Year 2003 Congressional Budget Justification of USAID [online] country/ee/kz/ (retrieved December 13, 2002).

48 Ibid.

49 Asian Development Bank, Kazakhstan Country Report, 2001.

50 United Nations Children's Fund (UNICEF)-Almaty, United Nations Educational, Scientific and Cultural Organization (UNESCO), "Young People of Kazakhstan: Along the Path to a Health Lifestyle," p. 11.

51 See Godinho et al., p.6.

52 UNICEF and UNESCO., p. 9.

53 Ibid.

54 Ibid., pp. 87 and 88.

55 Ibid, p. 85.

56 "Most of HIV Sufferers in Northern Kazakh Region Aged Between 15 and 29," Kazakhstan Today news agency web site, Almaty, in Russian 0435 gmt 29 Nov 02, reprinted in BBC Monitoring.

57 Mikkelsen, "Building Expanded Responses to HIV/AIDS."

58 Human Rights Watch attended the government press conference announcing the rescinding of the mandatory testing policy in Almaty on August 15, 2002. As of publication date, several officials from multilateral and bilateral organizations as well as government health practitioners on the ground confirmed that the long-standing practice of HIV testing of all persons in pretrial detention has not been fully discontinued. See also "Health Services" section below.

59 Substitution or maintenance therapies provide narcotics drug users with access to legal drugs that can substitute for drugs that are illegal or are obtained through illegal means. As the Drug Policy Alliance notes, these programs seek to assist drug users in switching from illicit drugs of unknown quality, purity and potency to legal drugs obtained from health services or other legal channels, thus reducing the risk of overdose and other medical complications, as well as the need to commit crimes to obtain drugs. For heroin addiction, methadone is a "substitution" drug of proven effectiveness. See Drug Policy Alliance, "Reducing Harm: Treatment and Beyond" [online], maintenancet/ (retrieved March 6, 2003).

60 The methadone programs were originally scheduled to start up in October-November 2002. Human Rights Watch interview with Dr. Sagat A. Altynbekov, director, Republic Scientific-Practical Center of Medico-Social Problems of Addiction, Pavlodar, August 29, 2002.

61 Zamira Eshanova, "Kazakhstan: President Orders Study On Effects Of Decriminalizing 'Soft' Drugs", Radio Free Europe/Radio Liberty, October 7, 2002, [online],, (retrieved January 20, 2003).

62 Human Rights Watch interview with Dr. Nikolai P. Kuznetsov, director, Karaganda AIDS Center, August 17, 2002, Karaganda.

63 Human Rights Watch interview with Nurali Amanzholov, president, Shapagat (NGO supporting HIV/AIDS-affected persons), August 18, 2002, Temirtau.

64 UNAIDS National Response Brief.

65 Government of Kazakhstan, Programme on Counteracting the AIDS Epidemic in the Republic of Kazakhstan for 2001-2005, Almaty, 2001, pp. 118-119.

66 Godinho et al. See also USAID, "Central Asian Republics (Europe and Eurasia): Tuberculosis Control."

67 USAID, "Tuberculosis Control".

68 Godinho et al., p.6. The prevalence of STIs among sex workers is also reported to be high. A study of selected sex workers conducted in the past two years showed that 60 to 70 percent suffer from STIs at any one time. And in Almaty, an AIDS Center doctor told Human Rights Watch that of female sex workers tested for HIV/AIDS and STIs, there was up to 60 percent syphilis prevalence and up to 80 percent chlamydia prevalence. U.N., "Support to National Strategic Plan Against HIV/AIDS, STIs and Injecting Drug Use," Almaty, June 12, 2002, p. 2; Human Rights Watch interview with doctor on duty at Almaty AIDS Center mobile trust point, Almaty, September 11, 2002.

69 Academy of Preventive Medicine of Kazakhstan, Demographic and Health Survey 1999 (Calverton, MD: Macro International, 2000).

70 Ibid.

71 Baurzhan Zhusupov, "HIV/AIDS in Kazakhstan," December 2001, [online],, (retrieved January 23, 2003).

72 Dr. Isadora Erasilova quoted in "Number of HIV-positive people...," Interfax, November 28, 2002.

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