Government health services related to the fight against HIV/AIDS continue to a troubling degree to embody the Soviet legacy of controlling and repressive policies. Relevant services are divided among AIDS centers, narcotics rehabilitation and addiction centers, and skin and venereal hospitals (charged with detection and treatment of sexually transmitted infections). Human Rights Watch's observations indicated that some of the AIDS centers are beginning to overcome this legacy by emphasizing voluntary counseling and testing and by offering a range of services under one roof. Persons in high-risk groups are nonetheless fearful that their status as HIV-positive or STI-infected persons, or their being labeled injection drug users, sex workers, or men who have sex with men will become known and used against them if they use government facilities. In addition, many health professionals seemed to have little appreciation for the link between stigma and abuse of persons affected by or at high risk of HIV on the one hand and the spread of the AIDS epidemic on the other. It is thus not surprising that many observers said services at all these institutions are underutilized. In Shymkent, the director of the Shymkent skin and venereal hospital indicated that during the course of the past year just 250-300 clients had come for STI screening, and that of those only 20 percent sought HIV tests.159 The mistrust of government health services among injection drug users is of particular concern given that HIV prevalence among them is the highest in the high-risk groups. Their most frequent interaction with the government is often through the criminal justice system, as demonstrated by the research in this report.
Officials nonetheless assert positive results of the AIDS centers' prevention efforts in Karaganda and Pavlodar provinces. According to the director of the Karaganda AIDS Center, Dr. Nikolai Kuznetsov, the use of prevention services has resulted in a steady decline of the rate of new HIV infections in Karaganda province since 1998.160 UNAIDS indicated that two thirds of injection drug users in Temirtau were covered by prevention services.161 In Pavlodar, the head of the AIDS Center, Dr. Fedor F. Fesenko, said 30 to 35 percent of injection drug users in Pavlodar province have access to trust points, and that the HIV infection rate has in 2002 leveled off due to prevention programs.162 Notably, IDUs and sex workers encountered in Karaganda and Pavlodar indicated to Human Rights Watch that people with AIDS were treated humanely and helped with their clinical problems at the AIDS centers in those two cities, and the center staff reached out particularly to sex workers and drug users in respectful ways, perhaps providing some explanation of reports of the success of preventive efforts.
The government-run AIDS centers espouse confidentiality and anonymity, but certain practices would appear to contradict this policy, and certainly among persons at high risk of HIV the overall perception of lack of confidentiality prevails. For example, the National AIDS Program allegedly retains a database with names of all registered HIV-persons in the country.163 Officially registered HIV-positive persons are required to register with the local AIDS Center if they change their place of permanent residence. In one province, the AIDS Center is said to require that blood samples submitted to them by venereal and skin disease hospitals be identified by name and address of the donor, creating a significant risk of breach of confidentiality. The AIDS Center has also been accused by some parties in the recent past of providing police with personal information on injection drug users who have come for anonymous testing, resulting in their arrest and conviction.164
Harm reduction services
Drug users recounted that although trust points were a welcome and necessary prevention service, generalized fear, discrimination, and an atmosphere of criminalization continues to prevent their widespread use. Twenty-seven-year-old Baljan K. in Pavlodar stated that fear outweighed the incentive of receiving free syringes:
The fear of being identified as an injection drug user and the accompanying stigma are also prevalent, according to twenty-one-year-old Vitaly Bumakov in Almaty: ". . . In any case, drug users are scared, and not only scared, they just don't state that they use drugs. They hide this, and don't go to the needle exchange point, rather, they buy needles in the drugstore. They have money for drugs, so they'll find money for the syringe."170 Parents of injection drug users recounted that their children were reluctant to approach needle exchange services due to the stigma surrounding drug use. "Our children don't go to the needle exchange points because they're either afraid, or ashamed, or simply because it's easier to buy in the drugstore."171
`Injection drug users' generally low level of confidence in trust points can be attributed in part to their perception that they will be met with an insensitive reception. AIDS center staff and harm reduction workers told Human Rights Watch that there was a need to make trust points more welcoming by rendering them less official-that is by staffing them with personable and approachable people and providing a comfortable atmosphere. Vasily S., a harm reduction volunteer in Pavlodar, related: "If we could create a homelike atmosphere in our trust points . . . they [the IDUs] are always hungry. You need to sit down with a person, chat, offer a cup of tea, some bread, not just `Here's a needle, okay, need anything else?' . . . They don't need a lot. . . . In short, a person will be more inclined to come [if it's like this]."172 The approach of some harm reduction workers, however, betrays a lack of appropriate training and propels stigma. As an example, Vitaly Bumakov explained that a recent visit to a trust point located in an Almaty polyclinic had put him on the defensive and made him reluctant to return. Unable at first to locate the needle exchange point, he had asked for directions at the reception area. The receptionist asked why he needed to go there:
Police interference with harm reduction services
The head of the AIDS Center in Pavlodar, Dr. Fesenko, also said police interference with trust points was a continuing problem: "The police can pounce on [IDUs] at the trust and needle exchange points, and put them under surveillance. . . . just recently one of my volunteers, Mikhail Nizhnik, was detained while carrying two boxes of empty syringes. When I found out I called up the police station and only that way got him out."175 Twenty-year-old Sasha O. and twenty-two-year-old Sagat A., both inmates in Colony 162/2176 in Pavlodar, told of the case of a fellow prisoner arrested and convicted on drug possession grounds at a drug dealing location while carrying on his person an anonymous treatment card from the Pavlodar AIDS Center.177 They asserted that he was kept in the prison for four months until a judicial review of his case concluded that the arrest was unfounded.178
The testimony of injection drug users accessing trust points did not suggest regular police surveillance of these sites. But in Pavlodar and Almaty several persons said police conducted regular surveillance of drugstores in order to identify drug users who buy disinfection material or syringes, sometimes stopping them for questioning or body searches as they exit from the drugstores. Some IDUs said they had had to resort to using dirty needles instead of exposing themselves to police monitoring, as Vitaly Bumakov in Almaty:
General fear of police in practical terms also obstructs harm reduction activity. In Shymkent, for example, harm reduction workers claimed that when police conduct "raids" to fill an arrest quota, numbers of clients frequenting trust points fall significantly and the effectiveness of mobile trust points is also diminished in consequence.180 The police's widespread targeting of trust points to identify, harass, and arrest injection drug users, common in some locations up until one to two years ago, appears to have dropped in intensity thanks to increased understanding by the police of the role of the trust points and ongoing educational efforts with law enforcement agents.181 Nonetheless, problems remain. A 2002 injection drug user survey that covered nine cities in Kazakhstan found 43 percent of respondents pointed to fear of police as a factor limiting their access to disposable syringes available either at trust points or in pharmacies.182 In Karaganda, for example, police continued to trail a mobile trust point, and in Shymkent, a trust point was closed down in 2002 because of police interference, including harassment and arrests.183 Evgenia V., a thirty-four-year-old harm reduction volunteer in Shymkent, stated that police often without explanation seize condoms from peer educators.184 "Quite often the police grab condoms from the volunteers, when they're conducting raids . . . . they need them for themselves, they just take them, no explanation given."185 In Almaty, workers who offer harm reduction services to sex workers in a mobile trust point told Human Rights Watch that police who regularly harass sex workers absent themselves on the evenings when the mobile trust point makes its rounds but reappear when it has gone.186
A high turnover rate in the police force means that constant HIV/AIDS and harm reduction training must be conducted to help prevent police harassment at trust points, but several officials claimed that under funding of governmental HIV/AIDS programs prevents this.187 Government officials, harm reduction personnel, and health workers interviewed by Human Rights Watch in Kazakhstan indicated that police training and sensitization were among the top priorities for making harm reduction and HIV prevention services more effective.
Inna Zvereva, twenty-nine-year-old sex worker and IDU, Temirtau, August 18, 2002
Helping injection drug users get to the point where they no longer depend on injected drugs is a singularly important HIV prevention strategy. In Kazakhstan, the criminalization of drug users coupled with severely limited access to effective rehabilitation and narcotics addiction treatment means that IDUs are not offered genuine alternatives. Treatment in rehabilitation and narcotics addiction (narcology) centers is often limited and ineffective, in part due to underfunding. Furthermore, rehabilitation programs are often harsh and repressive. Police are frequently present inside the narcology centers, leading to their description as "prison-like," and some witnesses alleged that police conduct surveillance of outpatients, as in the narcology center in Almaty.188 Thirty-four-year-old Vika S. from Temirtau told Human Rights Watch:
All injection drug users consulted by Human Rights Watch who had received treatment in narcology centers said they too had returned to drug use almost immediately following the course of treatment. A common complaint was that although detoxification was initially successful, the lack of psychological and moral support, accompanied by an oppressive and restrictive atmosphere, had prevented an effective cure. Thirty-year-old Alexander Kniazikov's experience in Pavlodar mirrored that of Vika S. in Temirtau: "`Rostovskaya 50' - that's a prison-like regime, it's just not effective. They throw people in cells, they waste away there without any medication, without any moral support, they simply suffer through the physical break. . . . it's really hard . . . I went back on drugs soon afterwards."190
Witnesses said private drug treatment clinics often do not offer sufficient psychological or moral support. Baljan N., twenty-seven years old, underwent unsuccessful treatment in a private drug treatment clinic in Pavlodar: "I had paid treatment, I paid U.S.$100, and the medication cured my addiction. But after the physical dependency was eliminated, I didn't get any moral support. There, you just get treatment so that you're not in pain. After some time I fell back into drug use, it just wasn't effective."191
Interviewees also alleged that corruption plays a role in reducing the effectiveness of the treatment centers. An epidemiologist in Pavlodar stated that if a client could not pay the required fee, narcology center staff would deliberately prescribe reduced medication, thus ensuring a failed treatment.192 Another drug user alleged that during his stay in a narcology center in Pavlodar in 2001, drugs could be bought from center personnel.193 These claims ring true in light of the comments of a U.N. official in Kazakhstan, who said some staff of narcology centers make extra income for themselves by under-the-table sales of medicines they take from the centers.194 An exception to the rule of underfunded narcology centers is the new ultra-modern National Scientific-Practical Center of Medico-Social Problems of Addiction in Pavlodar, the national narcology center. It includes a research and experimental drug rehabilitation center which offers a U.S.$750 two-month program for a maximum of 100 patients.195
Methadone substitution therapy for approximately eighty persons in Karaganda and Pavlodar is due to be offered in the first trimester of 2003.196 Implementation of these projects has been delayed because of strong resistance from narcology center personnel, a number of whom support only those treatment strategies that do not rely on any chemical dependency,197 while others reportedly fear that illegal revenues gained from providing under-the-table detoxification treatment will be lost should substitution methadone therapy be legalized.198 The director of the National AIDS Program, Dr. Isidora Erasilova, has nonetheless supported the methadone pilots and also proposed the introduction of substitution methadone therapy in prisons.199
Lack of access to effective treatment and substitution therapies for drug users, coupled with long-standing stigma and discrimination policies, has led to an overwhelming sense of hopelessness among injection drug users. As twenty-four-year-old Beksod S. from Pavlodar stated, "Here we say, `The road for drug users leads either to prison or the cemetery."200 Experience from other settings shows that hope is a central ingredient to inspire injection drug users to take an active part in the fight against HIV/AIDS.
Lack of antiretroviral treatment
Many persons living with AIDS, possibly because they have been given incomplete or erroneous information by health professionals on the benefits of ARVs, believe that ARVs are unnecessary for persons who do not have serious symptoms of AIDS, or too much trouble to try, particularly if they are injection drug users. The large majority of HIV-positive prisoners interviewed by Human Rights Watch had either not heard of ARVs or were unaware of their benefits, and the same was true for many other persons living with AIDS.202 One former drug user said he spoke for many when he asserted that general opinion holds that persons living with AIDS do not deserve costly antiretroviral treatment as they will die anyway.203
Medical personnel throughout the country attribute the lack of ARV medicine to grossly insufficient state funds. Kazakhstan's five-year interministerial plan to combat HIV/AIDS from 2001-2005 does not make the provision of antiretroviral treatment a high priority, and only recently have national officials begun to note the lack of ARVs and consequent lack of access for persons living with AIDS to essential treatment.204 The head of the National AIDS Program indicated that discussions have begun on the possibility of acquiring generic antiretroviral drugs for use in Kazakhstan.205
Many medical practitioners apparently hold the view that the treatment is too difficult for injection drug users to follow. In Karaganda, for example, AIDS Center staff required IDUs to demonstrate that they have stopped taking narcotic drugs for at least six months before they "merit" ARV therapy.206 The majority of medical staff interviewed at a male penal colony housing persons living with AIDS in Karaganda province were also of the view that ARVs are in general too difficult to administer.207 In an AIDS epidemic where over 80 percent of those infected are injection drug users, discrimination appears to be shutting out from treatment the population that needs it most. It is possible that part of the overall lack of confidence in AIDS centers and harm reduction programs is due to the perception among persons living with AIDS and other high-risk groups that these institutions do not offer effective clinical care that will significantly contribute to saving their lives.208 There is no shortage of desperation among injection drug users affected by AIDS. Drug users, medical personnel, and AIDS experts told Human Rights Watch that drug overdose and suicide, followed by tuberculosis, were leading causes of death of persons living with AIDS in Kazakhstan.
159 Human Rights Watch interview with Dr. Tatiana Rodina, Shymkent, August 22, 2002. The STI hospital estimates that there are close to 1,000 sex workers in Shymkent, while the Public Opinion Research Centre's 2002 survey on IDUs shows that 40 percent of IDUs turned to selling sex in the previous six months to finance their habit. Public Opinion Research Center, "Behavioral Surveillance Among Injecting Drug Users...," p. 17.
160 Human Rights Watch interview with Dr. Nikolai P. Kuznetsov, head doctor, Karaganda AIDS Center, August 17, 2002.
161 Ibid.; and Human Rights Watch interview Alexander Kossukhin, UNAIDS, Almaty, August 15, 2002.
162 There are an estimated 10,000-14,000 IDUs in Pavlodar province, according to the Pavlodar AIDS Center. Human Rights Watch interview with Fedor F. Fesenko, head doctor, Pavlodar AIDS Center, August 29, 2002.
163 Human Rights Watch interview with Alexander Kossukhin, UNAIDS, Almaty, August 15, 2002.
164 To satisfy this requirement, doctors and nurses explain that they have to date supplied false names and addresses. Human Rights Watch interview with doctors and nurses and harm reduction NGO representatives, identities and location withheld, August 2002.
165 A review of research on needle exchange even by a traditionally very skeptical U.S. government confirmed the effectiveness of this intervention with respect to HIV transmission. See, e.g. the U.S. Department of Health and Human Services public statement on this subject of April 20, 1998 [online] at
166 U.N., "Support to National Strategic Plan Against HIV/AIDS, STIs and Injecting Drug Use," p. 3; Public Opinion Research Centre, "Behavioral Surveillance Among Injecting Drug Users in Nine Cities of Kazakhstan..." The government's national strategic plan to combat HIV/AIDS aims by 2005 to reduce needle and syringe sharing to under 5 percent of IDUs and to have prevention programs cover at least 50 percent of sex workers. U.N., "Support to National Strategic Plan Against HIV/AIDS, STIs and Injecting Drug Use," p. 3.
167 Almaty has a population of approximately 1.3 million. Dr. Gulsara Suleimanova estimates the numbers of IDUs in Almaty at 20-25,000. Human Rights Watch interview with Dr. Gulsara R. Suleimanova, deputy director, Almaty AIDS Center, September 12, 2002.
168 Human Rights Watch interviews with Nurali Amanzholov, Vika S., Alex Pasko, and others, Temirtau, August 18, 2002; and Valentina Kniazova, Almaty, August 14, 2002. In addition, high-risk practices among IDUs in 2002 were still common and overall not significantly different from those in other cities. "Behavioral Surveillance Among Injecting Drug Users in Nine Cities of Kazakhstan...," p. 15.
169 Human Rights Watch interview with Baldjan K., Pavlodar, September 2, 2002.
170 Human Rights Watch interview with Vitaly Bumakov, Almaty, September 11, 2002.
171 Human Rights Watch interviews with Vera T. and Lola N., August 30, 2002.
172 Human Rights Watch interview with Vasily S., Turan, Pavlodar, August 31, 2002.
173 Human Rights Watch interview with Vitaly Bumakov, Almaty, September 11, 2002.
175 Human Rights Watch interview with Fedor F. Fesenko, August 29, 2002.
176 "Colony" means prison in Russian. Inmates serve labor sentences in colonies, that is, work, while inmates in prisons do not serve labor sentences.
177 Many AIDS centers provide clients with anonymous treatment cards, ensuring confidential treatment at AIDS centers, venereal hospitals, and for dermatological and gynecological care.
178 Human Rights Watch interviews with Sasha O. and Sagat A., Colony 162/2, Pavlodar, September 2, 2002.
179 Human Rights Watch interview with Vitaly Bukanov, Almaty, September 11, 2002.
180 Human Rights Watch interview with Valentina Skriabina, and other harm reduction workers, Shymkent, August 23, 2002.
181 Specialists throughout the country told of widespread problems with the police when the trust points first began to function. Police harassed and arrested IDUs directly at the trust points.
182 Public Opinion Research Centre, "Behavioral Surveillance Among Injecting Drug Users in Nine Cities of Kazakhstan..." p. 20.
183 Human Rights Watch interviews with Dr. Nikolai P. Kuznetzov, head doctor, Karaganda AIDS Center; Dr. Nadezhda V. Kozachenko, State Medical Academy, Dr. Vagif Aliev, United Nations Development Programme (UNDP) and Andrey Schmidt, director, Zhemchuzhina (Pearl), all in Karaganda, August 17, 2002; and Dr. Tatiana Rodina, Shymkent, August 22, 2002.
184 In the HIV/AIDS and harm reduction spheres, peer educators are drug users working with drug users, sex workers working with sex workers, or men who have sex with men working with other men who have sex with men, for example.
185 Human Rights Watch interviews with Evgenia V. and Zhanna S., Senim, Shymkent, August 22, 2002.
186 Human Rights Watch interviews with driver and doctor of Almaty AIDS Center mobile trust point, Almaty, September 11, 2002.
187 Human Rights Watch interviews with Dr. Ryskulbek S. Baikharashev, director, and Dr. Dauletbek D. Dzhumagaliev, deputy director, Shymkent AIDS Center, Shymkent, August 23, 2002; and Fedor F. Fesenko, August 29, 2002.
188 Human Rights Watch interview with Valeria Gourevich, director, International Harm Reduction, Soros Foundation Kazakhstan, Almaty, August 15, 2002.
189 Human Rights Watch interview with Vika S., Temirtau, August 18, 2002.
190 "Rostovskaya 50" is a narcology center in Pavlodar. Human Rights Watch interview with Alexander Kniazikov, HIV ward, Colony 159/18, Karaganda province, September 7, 2002.
191 Human Rights Watch interview with Baljan N., Pavlodar, September 2, 2002.
192 Human Rights Watch interview with Natalia Babina, epidemiologist, Pavlodar AIDS Center, Pavlodar, September 2, 2002.
193 Human Rights Watch interview with Alexander Kniazikov, HIV ward, Colony 159/18, Karaganda province, September 7, 2002.
194 Human Rights Watch electronic mail communication with U.N. official in Almaty, January 17, 2003.
195 At the time of Human Rights Watch's visit to the Center in August 2002, sixty-five patients were undergoing treatment. The detoxification regime is seen by many to be strict, with clients required to sign a contract that forbids even the smoking of cigarettes, however, there are significant psychological, educational and physical training facilities.
196 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.
197 Human Rights Watch electronic mail communication with U.N. official in Almaty, January 17, 2003.
199 Human Rights Watch interview with Dr. Isidora Erasilova, Almaty, September 9, 2002.
200 Human Rights Watch interview with Beksod S., Republic Scientific-Practical Center of Medico-Social Problems of Addiction, Pavlodar, August 29, 2002.
201 Among the AIDS centers which offer this treatment are Karaganda, Temirtau, and Almaty.
202 Human Rights Watch interviews with persons living with AIDS at Colony 159/17, Karaganda province, September 6, 2002.
203 Human Rights Watch interview with Nurali Amanzholov, Temirtau, August 18, 2002. A 2002 study of IDUs by the Central and Eastern European Harm Reduction Network (CEEHRN) in the former Soviet bloc region also found the view among survey respondents that as IDUs do not respect life they do not deserve live-saving medication. CEEHRN, p. 12.
204 Dr. Isadora Erasilova, the head of the National Aids Program, noted in November 2002 that persons living with AIDS do not have access to ARVs and must wait for symptoms of HIV/AIDS to develop. Interfax, November 28, 2002.
205 Human Rights Watch interview with Dr. Isidora Erasilova, Almaty, September 9, 2002, and remarks, "Health Security in Central Asia: Drug Use, HIV and AIDS" conference, Dushanbe, October 15, 2002.
206 Interview with Dr. Nikolai P. Kuznetsov, Karaganda, August 17, 2002.
207 Human Rights Watch interviews with prison medical staff and at Colony 159/17, Karaganda province, September 6, 2002.
208 Public health experts, among them over 100 Harvard University professors who work on HIV/AIDS, have argued that HIV/AIDS preventive efforts will fail if treatment access is not expanded. Gregor Adams et al., Consensus Statement on Anitretroviral Treatment for AIDS in Poor Countries, March 2001, [online],