I. SUMMARY

The government of Kazakhstan has a rare and limited-duration opportunity to contain a rapidly growing HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome) epidemic. So far the disease is largely confined to specific populations, in particular injection drug users and sex workers. But the severe human rights abuses these persons face impede their access to prevention and treatment programs, fueling the epidemic.

Human Rights Watch's research suggests that police arrest injection drug users and sex workers not for specific illicit acts, but primarily because of their status as drug users and sex workers. The resulting marginalization increases their vulnerability to HIV/AIDS. The police force, which is generally repressive and routinely violates the rights of detainees, is especially brutal with these stigmatized persons. Needle exchange-a health program whereby injection drug users exchange used syringes for sterile ones-is available in Kazakhstan and is a proven means of reducing HIV transmission among injection drug users. But the utilisation and effectiveness of needle exchange services is severely limited in part because drug users are aware that police in the past targeted needle exchange sites to harass drug users and continue to do so today, though less so than in the past. Furthermore, drug users, sex workers, and others who are marginalized in society are deeply suspicious of turning to state authorities for services. This distrust is a major obstacle in any state effort to control the epidemic's spread and effects. It is crucial that the government take immediate steps to curb abuses such as those detailed in this report and to expand preventive and treatment services to avoid a major AIDS epidemic.

Throughout the history of the HIV/AIDS epidemic, human rights abuses have both fueled the spread of HIV and been suffered disproportionately by people living with HIV/AIDS. The late Jonathan Mann, who headed the first major United Nations program on HIV/AIDS, was among those who recognized early in the epidemic the importance of protecting the human rights both of persons vulnerable to HIV infection-including sex workers, men who have sex with men, and injection drug users who were stigmatized even before AIDS came onto the scene-and of persons already infected.¹ Due largely to his influence, early policy statements on AIDS from U.N. agencies underlined the importance of a two pronged strategy to combat the epidemic. First, governments must eliminate all forms of discrimination in laws, policies, and practice. This includes discrimination based on gender, sexual orientation, ethnicity, race, social status, and disability. By ending discrimination, governments take a significant step toward ensuring that all people have access to the information that allows them to reduce their risk of exposure to the virus and to have some control over situations that might lead to exposure. Secondly, as a corollary, governments must ensure that HIV-infected persons are also protected from discrimination.

As the epidemic grew, national policies in the industrialized world came increasingly to include explicit provisions against discrimination based on HIV status, protections for vulnerable persons including confidentiality of HIV testing, and prohibitions of the use of mandatory testing by the state. Few such provisions are present in the law and policy of former Soviet states, however, which currently are home to the fastest growing AIDS epidemic in the world. Antiretroviral medicines, which in wealthy countries have been crucial to the containment of HIV/AIDS as well as of stigma associated with the disease, remain largely unavailable in Kazakhstan and other former Soviet states.

Current government estimates put the number of persons living with AIDS in Kazakhstan at more than 25,000, in excess of the combined total from official estimates in the four other Central Asian republics. The epidemic in Kazakhstan has thus far been largely contained among injection drug users; over 80 percent of HIV-positive persons are estimated to be drug users. Injecting drug use is a more efficient means than sex for transmitting HIV. Kazakh authorities reported that in 2001 alone the number of HIV infections rose by about 240 percent. A high prevalence of sexually transmitted infections (STIs) in the population also increases HIV transmission risk. Kazakhstan also bears the highest tuberculosis burden in Central Asia. Tuberculosis, suicide, and narcotics drug overdose are the largest contributors to mortality of persons with AIDS, according to experts in the country.

People at risk of infection and people living with AIDS face a triple threat. The Kazakhstan police are corrupt, abusive, and seemingly impervious to any oversight. The police routinely target injecting drug users and sex workers-more for their inability to shield themselves from extortion and then lack of credibility when they file complaints for abuse-than for any legitimate law enforcement purpose. This report shows that once injection drug users and sex workers are in custody, they are often forced to bribe arresting officers regardless of whether the arrest itself was legitimate or, in the case of sex workers, provide sexual "services" for the police. Those who are unwilling or unable to comply are routinely beaten, framed, and/or falsely charged with a crime.

These abuses occur in context of extremely harsh laws governing drug possession. Under the penal code, a person can be detained for as little as 0.5 grams of opiates.² In the face of enforcement of these draconian laws, set-ups by the police, and sentences tied to conviction for both drug charges and additional false changes, many drug users end up serving prison sentences.

But detention in a jail or prison is also risky. Ironically, in some cases, defendants are even given narcotic drugs by the police as a reward for confessing to a drug charge or another charge. Drugs are reportedly widely available in places of detention-but harm reduction services are limited or nonexistent in these facilities. As a result many injection drug users resort to unsafe injection practices behind bars. The practice of segregating HIV-positive inmates from other inmates fuels misinformation about HIV/AIDS and reinforces the stigma associated with being HIV- positive.

Finally, as a result of having been identified as an injection drug user or a sex worker, the very people who most need access to accurate information, testing, counseling, and other services are either denied access to services because of who they are or are subjected to abuse by the authorities. This is a recipe for disaster. Information and services are not reaching the people most in need; abusive practices by a multitude of state actors breeds distrust of all state actors; and risky behaviors that could be changed continue unabated.

This report documents how officials routinely harass and discriminate against injection drug users and sex workers, compounding their already marginalized status and reinforcing their reluctance to use AIDS-related health services, including needle exchange. While on the one hand, some state health facilities have attempted to reach out to drug users and other high-risk groups by offering prevention and care services, other state actors, in particular law enforcement agents, dissuade persons at risk from taking advantage of these services through repressive practices. Other vulnerable persons, including men who have sex with men, and those already living with AIDS, are similarly deeply stigmatized and marginalized.

Eighty percent of injection drug users interviewed by Human Rights Watch stated that they had served a prison sentence at one time or another during the span of their addiction. Mistrust of state HIV/AIDS-related services is prevalent among drug users, whose most frequent interaction with the government, as this report demonstrates, appears to be through the criminal justice system.

Sex workers, whose numbers have substantially increased in Kazakhstan since the fall of the Soviet Union, provide a crucial bridge to the general population in the spread of HIV. Members of this group overlap significantly with drug users as the latter sometimes turn to sex work to support their habit. Sex workers are also systematically detained and extorted by police because they frequently lack official registration documents which are required to obtain legal residence and city services. Police also rape and demand free and sometimes unprotected sex from sex workers in lieu of detention or money.

A discriminatory practice of isolating HIV-positive prisoners has in addition produced serious tensions in the prison population and between prisoners and prison personnel. The government adopted new testing guidelines in July 2002 which discontinue this practice, but at the time of this writing many HIV-positive prisoners continued to be isolated. Discrimination in employment, health, and housing is evidence of further stigma faced by persons living with HIV/AIDS and those at risk.

Because government HIV/AIDS services are based on policies that violate the right to confidentiality, they have so far failed overall to gain the trust of high-risk groups. Skin and venereal disease hospitals, which deal with detection and treatment of sexually transmitted infections (STIs), and narcological centers, mandated to deal with substance abuse, conduct compulsory testing and require patients to identify their sex partners to the authorities. These facilities register clients and their partners as injection drug users or STI carriers, information which becomes a part of clients' permanent identification status on record with authorities.

Harm reduction³ services, including needle exchange, condom distribution, and voluntary HIV and STI screening, are available throughout the country, but they are reaching target populations at a much lower level than is needed to counter the epidemic. According to the U.N., only 8 to 10 percent of high-risk persons in Kazakhstan have been covered so far by harm reduction services, and recent studies show that risky behavior is still widespread. The U.N. estimates that harm reduction programs have achieved a significant impact only when a minimum of 50 percent of injection drug users are reached.

The criminalization of drug users coupled with severely limited access to effective narcotics addiction and rehabilitation and treatment-including methadone maintenance or other substitution therapy-means that injection drug users are offered few genuine alternatives. Treatment at rehabilitation and drug centers is often ineffective, in part due to underfunding, and is in most cases applied in a repressive fashion. Deep-rooted stigma and discrimination along with the lack of effective rehabilitation and treatment have led to an overwhelming sense of hopelessness for injection drug users. Hope is a key ingredient to inspire drug users to take part in prevention and treatment programs.

The lack of combination antiretroviral (ARV) therapy in the country compounds the absence of effective treatment services for persons living with AIDS. A very short course of ARVs is available to HIV-positive pregnant women in much of the country, but access to long-term ARVs for people with AIDS is either severely limited or non-existent. Perhaps in part due to a lack of information on the effects and benefits of ARVs, many health professionals and persons living with AIDS interviewed by Human Rights Watch hold the view that ARV treatment is either too difficult to follow or ineffective, and several drug users stated that they refused ARV treatment on these grounds. The head of the National AIDS Program⁴ has nevertheless indicated that discussions have begun on the possibility of acquiring generic antiretroviral drugs for use in Kazakhstan.

The government of Kazakhstan has taken several positive steps in the past year. In July 2002 the government adopted measures to lift the long-standing national policy of mandatory HIV testing of a wide range of persons, including drug users and those in pretrial detention. The government has also announced an end to the discriminatory policy of segregating HIV-positive prisoners. A revision of HIV/AIDS-relevant regulations and laws is currently underway with the view of bringing them into compliance with international standards on HIV/AIDS and human rights. Two pilot methadone substitution therapy programs were promised by the end of the first trimester of 2003, and the president of Kazakhstan has commissioned a study to consider the legalization of cannabis and hashish and reduced penalties for drug users as part of "humanizing" their treatment. In addition, in 2001 the government developed a five-year interministerial plan to combat HIV/AIDS, involving eight ministries and agencies.

It is furthermore encouraging that senior Kazakh officials have in the recent past begun to make public comments which could elevate discussion about the epidemic to a more prominent level of national policy debate and even introduce a rights-based approach. Top-ranking health officials have in recent months warned of potential social and economic crises should the disease not be kept in check. In November 2002, the head of the National AIDS Program, Dr. Isidora Erasilova, announced that persecution of drug users discourages them from gaining access to prevention programs and makes them particularly vulnerable to contracting HIV.

¹ Jonathan M. Mann, "Human rights and AIDS: The future of the pandemic," in Jonathan M. Mann, Sofia Gruskin, Michael A. Grodin and George J. Annas, eds., Health and human rights: A reader (New York and London: Routledge, 1999), p. 217.

² This tiny amount, less than one fiftieth of an ounce, is plainly only enough for very limited personal use.

³ Harm reduction refers to programs and policies designed to diminish the individual and social harms associated with drug use, including the risk of HIV infection, without requiring the cessation of drug use. In practice, harm reduction programs include needle exchange, replacement therapy, health and drug education, HIV and sexually transmitted disease (STD) screening, psychological counseling, and medical referrals. For more information on harm reduction, see the website of the International Harm Reduction Development (IHRD) program of the Open Society Institute (OSI), www.soros.org/harm-reduction.

⁴ For the purposes of this report, the Republican AIDS Prevention and Control Center, as it is known in Kazakhstan, will be referred to as the National AIDS Program.