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VII. Barriers to Drug Treatment and Antiretroviral Therapy for Injection Drug Users

In 2005 Ukraine made important progress in its efforts to provide substitution therapy for drug users, and antiretroviral therapy for people living with HIV/AIDS.  Human Rights Watch research found, however, that significant obstacles remain that threaten to impede the implementation of substitution therapy and antiretroviral treatment programs. 

Barriers to Substitution Therapy

Without [substitution] therapy, the only things waiting for drug users are overdose, prison, HIV, other diseases, homelessness and the grave.
— Volodomyr D., participant in substitution therapy program, Kherson, July 9, 2005

Since 2001, the government has issued a number of official government documents (including parliamentary hearing recommendations, Cabinet of Ministers resolutions, and Ministry of Health orders) recommending the introduction of substitution therapy programs as part of national efforts to treat drug dependency and to control the spread of HIV/AIDS.¹⁹⁹  But opposition by drug and law enforcement agencies, particularly to methadone, has created significant barriers to the implementation of these programs.

Ukraine is party to U.N. drug control conventions obliging it to establish rehabilitation and social reintegration services for drug users according to international standards, and to make provisions for treatment systems.²⁰⁰  U.N. bodies monitoring these treaties have made clear that methadone substitution therapy does not breach these conventions.²⁰¹  Ukrainian officials have wrongly cited these conventions to oppose methadone, while ignoring the substantial body of evidence establishing methadone substitution as an effective treatment for opiate addiction.

Maj. Gen. Anatoliy Naumenko, the chief of the drug enforcement department of the Ministry of Interior from September 2003 to July 2005, vigorously opposed the use of methadone on several grounds, asserting that Ukrainian and Russian studies had proved methadone to be ineffective in treating opiate addiction, and that its use contravened United Nations drug conventions.  Naumenko also expressed concern about the illegal sale of methadone by underpaid health professionals and drug users.²⁰²  The Security Service of Ukraine has similarly opposed methadone, dismissing its use in HIV prevention as “propaganda,” and claiming that it did not address opiate drug addiction, but instead created a new form of drug addiction (“methadone mania”) as well as demand for the illegal manufacture and marketing of methadone.²⁰³ 

In mid-2005, the Cabinet of Ministers proposed to ban methadone altogether.²⁰⁴  In November 2005, following significant protest by domestic and international human rights, HIV/AIDS, and harm reduction advocates, Ukraine agreed to partner with the Clinton Foundation HIV/AIDS Initiative to “pilot and then scale up methadone-based drug substitution therapy.”²⁰⁵  At this writing, methadone remains unavailable, and the government has not announced plans for its use in substitution therapy programs.

Injectable buprenorphine has been used to treat opiate addiction in Ukraine for some years, both in drug detoxification, and on a more limited basis, for short-term substitution therapy.²⁰⁶  In 2004, pilot programs with sublingual buprenorphine were begun in Kyiv and Kherson, initially designed to treat thirty patients in Kherson and one hundred in Kyiv for six months.²⁰⁷  In September 2005, with support from the Global Fund to Fight AIDS, Tuberculosis and Malaria, Ukraine began to implement a pilot substitution therapy program with sublingual buprenorphine, with the goal of providing treatment to 200 drug users in seven cities by the end of the year.²⁰⁸  Methadone is significantly less expensive than buprenorphine, and at least as effective.  But the NGO the International HIV/AIDS Alliance in Ukraine, which is charged with implementing Ukraine’s substitution therapy program, chose to use buprenorphine for substitution therapy in part because of law enforcement opposition to methadone.²⁰⁹ 

Narcologists interviewed by Human Rights Watch were encouraged by Ukraine’s efforts to provide substitution therapy with buprenorphine, but some worried that state drug and law enforcement services would interfere with these programs.  A narcologist who had used buprenorphine to treat drug users in 2002 and 2003 expressed serious concern that state drug control authorities’ interference with the buprenorphine substitution therapy program would drive people away from services and might force health care workers to stop providing buprenorpine altogether. 

The narcologist told Human Rights Watch that in the program he ran in 2002-2003, regional authorities “created conditions under which it was impossible for me to work.  They inspected me every week.  My name was discussed at meetings.  They said that I was giving out drugs to drug users. . . .  [The] Department for Combating Illegal Drug Circulation told me not to play tricks.  They said if they had found any violations, they would have put me in jail.”  The narcologist said that a representative from the Committee for Inspection of Narcotic Drug Control had interrogated patients receiving buprenorphine about their treatment by him, driving several of them away from treatment altogether and forcing the program to shut down.  The narcologist told Human Rights Watch, “After being questioned by the Committee, several patients quit buprenorphine treatment.  Some returned to opiate use.” 

Although this narcologist has agreed to provide buprenorphine as part of the new government program, he remains concerned about interference by state drug control authorities, fearing that “it is inevitable that they will come.”  “I’m very concerned that law enforcement bodies will interfere with buprenorphine,” he said.  “I don’t know how, but there’s an article in the criminal code about distribution of illegal drugs, and if on the government level, they don’t approve of substitution therapy, they can incriminate me.”²¹⁰

Ukraine’s buprenorphine programs are also being implemented in ways that threaten the privacy of HIV-positive drug users.  Under Ministry of Health guidelines, only people who are HIV-positive are eligible to receive buprenorphine, which means that participation in the program itself advertises a person’s HIV status.²¹¹  As of January 2006, enrollment in substitution therapy programs was limited to individuals who have been registered and listed as drug users with narcology clinics;²¹² in most cases, narcology clinics officially register drug users who seek assistance from them.²¹³  Anatoliy Viyevskiy, head narcologist at Ukraine’s Ministry of Health, expressed concern that procedures were inadequate to ensure that this information remained protected both within and between medical institutions participating in substitution therapy programs, and from police.  Viyevskiy said that many narcology hospitals and clinics routinely shared information with police about registered drug users, and where this was the case, police would have ready access to confidential information about drug users on substitution therapy.  According to Viyevskiy, “It would be easy for police to say [to the narcology hospital] ‘we want this information,’ and they’ll hand it over.”²¹⁴

Given that, as noted above, many drug users reportedly do not seek treatment at narcology clinics out of concern with registration requirements and their consequences,²¹⁵ the same concerns may also deter drug users from enrolling in the substitution therapy program.  Viktor M., who told Human Rights Watch that he would not go to the narcology clinic because of the registration requirement and for fear that his employer would consequently find out and he would lose his job, recommended a solution to this dilemma: ensuring anonymous drug treatment.²¹⁶ This recommendation has been made by the World Health Organization in its January 2006 report on substitution therapy in Ukraine as an important factor to be considered to facilitate rapid scale up of Ukraine’s substitution therapy programs, and to ensure the confidentiality of patient information for drug users enrolled in the programs.²¹⁷ 

Restricting buprenorphine to HIV-positive drug users also fails to take into account guidance by Ukraine’s national HIV/AIDS strategy, as well as recommendations of international health organizations, which recognize the critical importance of substitution therapy in preventing HIV infection among drug users.²¹⁸  It also fails to take into account Ukraine’s own recent successful experience with substitution therapy.  According to Irina Blizhevskaya, the director of the buprenorphine substitution program at Kherson regional narcology center, of fifty people who had attended Kherson’s substitution therapy program, only five or six had returned to drugs; and fifteen of nineteen patients remaining in Kherson’s substitution therapy program in July 2005 were working.  Blizhevskaya noted that this was a “big accomplishment, particularly considering that some of these people spent a large portion of their lives in and out of prison,” and never before held a steady job.  And, as Blizhevskaya pointed out, only five of the nineteen patients in the Kherson pilot buprenorphine program were HIV-positive.²¹⁹

Narcologists interviewed by Human Rights Watch also expressed concern that government efforts to provide substitution therapy were insufficient to address the needs of opiate-dependent drug users in Ukraine.  In Dnipropetrovsk city, for example, according to official statistics, in June 2005 more than 4,000 registered drug users were classified as opiate addicted.²²⁰  A narcologist at the Dnipropetrovsk city narcodispensary told Human Rights Watch that there were only thirty slots for substitution therapy patients, which was plainly inadequate to treat those who needed it.²²¹  According to international drug control and health organizations, 30 to 40 percent of the opiate-addicted drug users in a given population should have access to substitution therapy on a daily basis to have an impact on drug dependency and HIV/AIDS.²²²  For Ukraine, with an estimated 200,000 to 590,000 drug users, this would mean providing between 60,000 and 238,000 treatment slots.²²³

Some narcologists also raised practical problems with coordinating substitution therapy with doctors from AIDS centers.  A narcologist at the Dnipropetrovsk city narcodispensary told Human Rights Watch, “Substitution therapy is a very politicized thing in our country.  AIDS doctors will take part in the substitution therapy but they refuse to have it on their premises.  There are lots of technical questions—storage, transportation, licensing—and they don’t want to deal with it.”²²⁴ 

In Kherson, Ukraine, the first participants in the buprenorphine substitution treatment program founded an NGO, “Awake!”, to educate people about substitution therapy and rally support for the program.  In its first year, Kherson’s buprenorphine program, one of two such pilot projects in Ukraine, was successful in helping long-term drug users quit street drugs and to find jobs, some for the first time in their lives.  Awake! members became peer educators to support other drug users seeking substitution therapy and traveled nationwide to speak publicly about its benefits.  Government officials visited Kherson’s program, looking to it as a model.  Kherson’s buprenorphine program experienced a crisis in the summer of 2005.  The program’s sponsor, the United Nations Development Programme, announced that by September it would have no more medicine to provide.  Doctors were forced to sharply cut doses to patients, and expressed concern that their patients would return to injecting drugs if the program ended.  Awake! members launched a concerted campaign to secure support for the program.  Awake! enlisted international HIV/AIDS and harm reduction advocates, including the European AIDS Treatment Group, the International HIV/AIDS Alliance in Ukraine, and the International Harm Reduction Development Program, to join the fight.  Awake!’s efforts helped ensure that the Kherson program would be supported by Ukraine’s Global Fund grant and could therefore continue offering services.  Awake! members and other patients in Kherson’s program experienced no interruption in their buprenorphine treatment.  Dozens more opiate-dependent people and their family members have contacted Awake! to learn more about how to get treatment with buprenorphine.²²⁵

Barriers to Antiretroviral Therapy

The World Health Organization in April 2005 estimated that 17,300 people in Ukraine were in immediate need of antiretroviral therapy.²²⁶  Between April 2004 and November 2005, 2,644 people living with HIV/AIDS were enrolled in antiretroviral treatment programs, a significant increase from the 255 people under treatment as of April 2004.²²⁷ 

In January 2004, the Global Fund to Fight AIDS, Tuberculosis, and Malaria suspended payments of U.S.$25 million to three HIV/AIDS programs in Ukraine, citing concerns with the slow progress of implementation of HIV/AIDS prevention and treatment programs, and management and governance problems.²²⁸  A spokesman for the Global Fund charged that the Ministry of Health’s failure to increase the number of people on antiretroviral treatment from about one hundred was “completely unacceptable.”²²⁹  In February 2004, the Global Fund handed over the administration of the grant to the International HIV/AIDS Alliance in Ukraine, which had been involved in the Ukraine HIV/AIDS program.²³⁰ 

In June 2005, the Global Fund to Fight AIDS, Tuberculosis, and Malaria raised the concern that “IDUs (injection drug users) remain a group of people significantly unable to access treatment in Ukraine.” ²³¹  Alla Shcherbinska, director of the Ukraine National AIDS Center, said that 46 percent of the 2,200 people receiving antiretroviral treatment as of July 2005 were drug users.²³²  This percentage was low given that according to Ukraine government statistics, as of July 2005, injection drug users represented 68 percent of all people living with HIV/AIDS.²³³  Moreover, Shcherbinska cautioned that these statistics likely underestimated the actual number of HIV-positive drug users, because official government statistics included only HIV infections among people who have been in direct contact with testing facilities, and many injection drug users avoided getting tested.  Shcherbinska acknowledged that “[m]any drug users are not getting tested for HIV because they are afraid that their status as a drug user would be disclosed.”²³⁴ 

Human Rights Watch’s research suggests that many drug users living with HIV/AIDS who were eligible for antiretroviral therapy may not have been receiving it for many of the same reasons that keep them from receiving HIV/AIDS information and support, and other health services more generally.  Many people living with HIV/AIDS learn about antiretroviral therapy from their regular doctors, and regularly visiting a doctor is sometimes an informal criterion for eligibility for antiretroviral therapy.  With many drug users facing the kind of discriminatory treatment by doctors and health workers described above, and thus being unlikely to seek any health care except in extreme emergencies, they are likely being deprived of information as well as access to antiretroviral therapy.  As Alla Shcherbinska recognized, it was “very difficult” for drug users to come to the health system.²³⁵

Ukraine’s policy is to provide antiretroviral therapy to people living with AIDS according to clinical criteria.²³⁶  In practice, the application of informal and highly subjective criteria, such as patient “commitment” or “motivation,” can serve to exclude active drug users from enrolling in some antiretroviral therapy programs.  Antonina Dyadik, head of the inpatient department, Dnipropetrovsk regional AIDS center, told Human Rights Watch, “We have no active drug users in our program.  We’re taking patients that are committed.  There is no commitment from drug users to antiretroviral therapy. . . . When given the choice between taking antiretroviral therapy and taking drugs, they choose drugs.”²³⁷  Irina Petrovskaya and Ludmila Ostrovskaya, doctors at Mykolaiv regional AIDS Center, told Human Rights Watch that they had not enrolled active drug users in the antiretroviral therapy program because active drug users were not “motivated for life,” and therefore unable to adhere to treatment.²³⁸  These practices contradict World Health Organization principles of antiretroviral treatment delivery, reflected in Ukrainian national clinical standards, which state:

Access to HIV treatment should not be artificially restricted due to political or social constraints.

Specifically there should be no categorical exclusion of injection drug users from any level of care. All patients who meet eligibility criteria and want treatment should receive it, including ID-users, sex-business workers and other populations.²³⁹

They also contradict the experience of active drug users in Ukraine, many of whom have successfully enrolled in antiretroviral treatment programs in Ukraine, as well as in other parts of the world.²⁴⁰

When asked how doctors measured “patient commitment,” Alla Shcherbinska, head of Ukraine’s national AIDS centers, told Human Rights Watch, “Before the doctor prescribes antiretroviral therapy, the doctor sees that person for three years.  The doctor has information on how that person follows instruction.  The doctor has an opinion of that person.”²⁴¹  As described above, invitations to start treatment are only extended to those patients who are “committed.”  This requirement appears to impede many drug users’ access to antiretroviral therapy: even if a drug user goes against the widespread inclination to shun health care services because of abusive treatment, and presents for treatment, it suggests that many doctors are likely to believe that as a drug user, he or she would have no commitment to treatment. 

Sergei Soltyk, head of medical services at Odessa regional AIDS center, expressed his interest in establishing a clear policy denying antiretroviral therapy for active drug users, following what he understood to be the law in Russia: “Unfortunately, until now we provide antiretroviral therapy to current drug users.  I think we should stop it soon, as it happened in Russia.  If a person still takes drugs, he shouldn’t get therapy.”²⁴² 

Elena Goryacheva, the director of the NGO Exit in Mykolaiv, told Human Rights Watch:

There are no official documents stating that active drug users can’t get antiretroviral drugs.  It’s just the conviction of doctors that drug users can’t adhere to treatment and the myth that drug users are just searching for drugs. . . . I’ve spoken with doctors at the AIDS center about active drug users and antiretroviral drugs.  Doctors say that active drug users can’t adhere to treatment.  They may not say this openly but somehow there’s these really expensive medications and why waste them.²⁴³

Aspects of the government’s punitive approach to drug addiction also interfere with antiretroviral treatment.  Drug users and outreach workers told Human Rights Watch that police had confiscated antiretroviral drugs from people living with HIV/AIDS in Dnipropetrovsk, Odessa, and Mykolaiv.  In early 2005, Odessa police stopped Vitaliy M., thirty-eight, and questioned him about drug possession.  Vitaliy said that after he showed police his antiretroviral drugs, and explained that they had been prescribed by the doctor, “They [police] detained me right away. They didn’t give me the possibility to explain.  They put me in a cell and they sent the medicines for analysis.  They didn’t believe me at all when I told them that I needed these medicines.  They thought it was ‘ecstasy.’”  The director of the NGO Time for Life, which works with people living with HIV/AIDS in Mykolaiv, said that police had confiscated antiretroviral drugs from people living with HIV/AIDS in Mykolaiv.²⁴⁴  To address this problem, Time for Life had developed cards with pictures and information about antiretroviral drugs for people to show police in case of arrest.

Government failure adequately to coordinate links among drug treatment, HIV/AIDS, tuberculosis, and outreach services to people living with and at high risk of HIV/AIDS, also creates significant barriers to obtaining information about, and in turn, access to, antiretroviral drugs.  HIV-positive drug users, for example, may receive little or no information about antiretroviral therapy from clinics where they receive drug addiction treatment.  Yuriy Chumachenko, narcologist at the Ilyochovsk narcology center, said that not all narcologists discussed antiretroviral therapy with their patients, and that narcologists in Ilyochovsk had “recently stopped asking questions about HIV status,” believing that they were “not allowed to ask such questions.”²⁴⁵  When Human Rights Watch interviewed Anatoliy B., nineteen, he was an outpatient at the Odessa narcology center for the second time in 2005.  Anatoliy told Human Rights Watch that he had found out in 2004 that he was HIV-positive.  He said, “I can probably get treatment for this, but I don’t know.  I don’t know where to get care or what the treatment is.”²⁴⁶

Svitlana Antoniak, chief doctor at Lavra AIDS Clinic in Kyiv, said that the lack of information among people living with HIV/AIDS about antiretroviral therapy, and the shortage of people trained to provide it, posed major barriers to obtaining it.²⁴⁷  The NGO Exit surveyed drug users in Mykolaiv, and found that only one (of twenty-five) had any knowledge of antiretroviral drugs.  Olga Sokolova of Exit said that drug users interested in seeking HIV testing often lacked information about where to get it: “And they know that medical workers have negative attitudes toward drug users and don’t want to go to them.”²⁴⁸  To address this lack of knowledge, Exit has developed materials for injection drug users on antiretroviral drugs and other HIV/AIDS-related services for distribution to injection drug users in Mykolaiv.