Appendix C
Country Case Examples

This appendix provides a series of case studies from individual countries selected from the regions that are the focus of this report. The cases demonstrate the wide range of policies and programs that are being implemented in an effort to control IDU-driven HIV epidemics. The purpose of this section is not to evaluate or compare performance or effectiveness, but rather to provide readers with a wide-angle view of the rich diversity of policies and programs being implemented worldwide. These case studies are not intended to be comprehensive, rather they represent summaries and expansion upon material provided to the Committee about individual national experiences that have helped to inform observations and recommendations about the complexities of implementing new programs.

The case studies of Iran, Malaysia, and China illustrate how countries with burgeoning HIV epidemics among IDUs have forged a compromise between a criminal justice approach and a public health approach to the dual epidemics of drug dependence and HIV among drug users. These experiences particularly informed the Committee’s recommendation regarding the value of creating broad cross-sector consensus processes which permit those with conflicting perspectives to find the “common ground.”

The fourth and fifth case studies, on Russia and Ukraine, show the impact of the legal and cultural context on policy, and the ability of a country to review and modify its policies on the basis of evolving lessons learned. They underscore the impact of stigma and the need to document and consider the unintended consequences of policy positions.



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Appendix C Country Case Examples This appendix provides a series of case studies from individual countries selected from the regions that are the focus of this report. The cases demonstrate the wide range of policies and programs that are being implemented in an effort to control IDU-driven HIV epidemics. The purpose of this section is not to evaluate or compare performance or effectiveness, but rather to provide readers with a wide-angle view of the rich diversity of policies and programs being implemented worldwide. These case studies are not intended to be comprehensive, rather they represent summaries and expansion upon material provided to the Committee about individual national experiences that have helped to inform observations and recommendations about the complexities of implementing new programs. The case studies of Iran, Malaysia, and China illustrate how countries with burgeoning HIV epidemics among IDUs have forged a compromise between a criminal justice approach and a public health approach to the dual epidemics of drug dependence and HIV among drug users. These experiences particularly informed the Committee’s recommendation regarding the value of creating broad cross-sector consensus processes which permit those with conflicting perspectives to find the “common ground.” The fourth and fifth case studies, on Russia and Ukraine, show the impact of the legal and cultural context on policy, and the ability of a country to review and modify its policies on the basis of evolving lessons learned. They underscore the impact of stigma and the need to document and consider the unintended consequences of policy positions.

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Likewise, finally, the case study on Thailand shows how a country modifies its policies and approaches as it addresses the changing drivers of its HIV epidemic. IRAN Iran sits directly on a key drug transit route running from Afghanistan to markets in the Persian Gulf, Turkey, Russia, and Europe (Nissaramanesh et al., 2005). Although non-injecting use of opium is more prevalent than injecting drug use, the country has an estimated 112,000 to 300,000 IDUs. HIV prevalence among IDUs ranges from 0.5 to 13.0 percent (Aceijas et al., 2004), and 60 to 70 percent of HIV transmission is IDU-related (Mokri, 2002). After the 1979 Islamic Revolution, the country embarked on a tough anti-drug campaign that emphasized strict enforcement of new drug laws, the closure of treatment and detoxification programs, and the opening of compulsory rehabilitation camps (Nissaramanesh et al., 2005). Over the past 20 years, some 1.7 million Iranians have been imprisoned for drug offenses (State Welfare Organization, 2000, as cited in Nissaramanesh et al., 2005). However, in the 1990s, the policy changed to reflect the recognition that drug dependence is also a medical problem. Drug users who access treatment are now exempt from penal punishment and the country reopened short detoxification programs and created narcotics anonymous support groups and abstinence-based therapeutic communities (Nissaramanesh et al., 2005). By the end of the 1990s, it became clear that these efforts were insufficient. The Iranian government encouraged its medical and public health experts to talk with drug treatment experts from other countries. This dialogue and several other factors led to a more comprehensive approach to reducing HIV transmission among drug users, including psychosocial services, opioid agonist maintenance therapy, drug-free treatment, and access to sterile needles and syringes (Nissaramanesh et al., 2005). Other factors leading to Iran’s policy changes included the advocacy role of nongovernmental organizations and civil society, the cooperation between the Ministry of Health, the prison department health authorities, and other stakeholders on drug treatment and HIV/AIDS, and the education of senior policymakers regarding HIV prevention for IDUs (Razzaghi et al., 2006). In 2000, Iran began its first pilot methadone project in a psychiatric hospital, and in 2002 a major outpatient methadone maintenance program opened in Tehran. Other maintenance treatment programs have since started in other parts of the country, although buprenorphine is not yet widely available outside of special research and demonstration programs. The Ministry of Health has expressed satisfaction with these projects and is

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drafting national guidelines for methadone maintenance treatment (Nissaramanesh et al., 2005). The Welfare Organization and Ministry of Health have supported private centers directed by general practitioners that offer methadone and buprenorphine maintenance treatment along with detoxification and abstinence-based interventions. More than 600 private centers now operate nationwide, and up to 600 more centers have been recommended. Narcotics Anonymous, an abstinence-based 12-step program, is also widely used in Iran, with some 20,000 participants (Personal communication, A. Mokri, May 4, 2006). Drug users and IDUs account for a significant proportion of the Iranian prison population. In 2003, prison authorities initiated an HIV prevention program, and some 40 prison clinics now provide drug treatment, including methadone maintenance therapy, and HIV prevention services (Nissaramanesh et al., 2005). Iran has recently initiated a network of some 60 community-based drop-in centers that provide basic health care as well as information on HIV risk, condoms, and, in some cases, clean needles and syringes (Nissaramanesh et al., 2005). A growing number of nongovernmental organizations also offer counseling, other abstinence-based treatments, family education, and even inpatient care. Clean needles and syringes are provided through drop-in centers, although the number of IDUs using this service is unclear. The Iranian government expressed support for needle and syringe exchange in an executive order in January 2005 (Nissaramanesh et al., 2005). Overall, although Iran still sees drug dependence as a crime, the broad range of HIV prevention services targeting drug users reflects a shift from a strictly punitive approach to one that includes drug treatment and HIV prevention. MALAYSIA Malaysia has some of the world’s harshest drug laws and enforcement practices. According to the Dangerous Drug Act of 1952—revised in 1983 (Treatment and Rehabilitation Act)—any person who is guilty of consuming or administering certain amounts of a long list of drugs is subject to mandatory 2-year treatment and rehabilitation. The same law makes carrying injecting equipment without a prescription illegal (Kamarulzaman, 2005). Malaysia’s self-declared goal is to become a “drug-free society by 2015,” and in 2003 the government launched a campaign, which identified IDUs as a principal target (Reid et al., 2005). The country initially viewed needle exchange and opioid agonist maintenance programs as undermining this strong drug control policy and its goal of becoming drug-free (Reid et

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al., 2005). However, a major policy shift has occurred over the past 2 years, as Malaysia’s response to its IDU-driven HIV epidemic has evolved from a primarily criminal justice model to one that includes public health interventions. Key factors driving the transition include: An awareness of the escalating HIV crisis. Malaysia reported some 65,000 HIV cases at the end of 2004—up from near zero in 1990—and about 75 percent of all cases are attributable to IDUs (Reid et al., 2005).1 Malaysia’s commitment to achieving all eight of the United Nation’s Millennium Development Goals—one of which is reducing the incidence of HIV/AIDS (Kamarulzaman, 2005). An evaluation of the country’s mandatory 2-year detention for drug use, which showed high relapse rates among drug users after release from detention (Reid et al., 2005).2 A provision in Islam, the major religion in Malaysia, that tolerates individual harm (such as the provision of clean needles and opioid agonist maintenance treatment to IDUs) to prevent harm to a population (an HIV epidemic) and that tolerates a lesser harm in order to eliminate a greater harm (Kamarulzaman, 2005). In October 2005, the government launched a free pilot methadone maintenance project for 1,200 patients. In January 2006, Malaysia also initiated a pilot government-sponsored needle exchange and outreach program (Kamarulzaman, 2005). The country began allowing the use of buprenorphine for opioid maintenance therapy in 2001, and private general practitioners now administer the treatment to about 20,000 heroin users. However, imports of buprenorphine are limited to 12 kilograms per year (Personal communication, M. Mahmud, May 8, 2006). Thus Malaysia represents a nation learning from its experience in balancing policies to combat drug abuse and the spread of HIV among IDUs. CHINA China’s HIV epidemic has been concentrated among injecting drug users, except in several central provinces where blood selling was the driving force. All 31 provinces and autonomous regions have reported HIV 1 However, that could be an overestimate because the recording of arrested and incarcerated IDUs is mandatory. Other than pregnant women and blood donors, who are routinely screened, there is no surveillance of any other HIV-infected population (such as sex workers). 2 Officially, Malaysia has some 900,000 illicit drug users, including both IDUs and non-IDUs. The country has 28 drug rehabilitation centers, with HIV rates of 16–18 percent. The centers house between 10,000 and 14,000 drug users each year.

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infection among IDUs. Although HIV prevalence is difficult to estimate because the IDU population is often hidden, it exceeds 50 percent among IDUs in some areas of Xinjiang, Yunnan, and Sichuan (Ministry of Health PRC et al., 2006). Sexual transmission has also risen substantially in the past few years, and emerging evidence shows that HIV has begun spreading to the general population. Opiate abuse has existed in China since the 16th century. According to one estimate, some 200 million persons were opium abusers before the founding of the People’s Republic of China (PRC) in 1949 (China UN Theme Group on HIV/AIDS and Ministry of Health PRC, 1997). In 1950, the Chinese government launched an extensive campaign against drug abuse and drug trafficking, and nearly wiped out opium abuse within 3 years. However, when China began to open its borders and change its economic structure in 1980, opium and heroin began to enter the country from the Golden Triangle region. While the government is still committed to eradicating drug abuse, the country is home to about 2 million IDUs (China UN Theme Group on HIV/AIDS and Ministry of Health PRC, 1997). Rapid changes in methods for administering heroin—from smoking or inhaling to injecting—have greatly increased the likelihood that HIV, hepatitis, and other infectious diseases will spread. Although a powerful and well-funded policy emphasizes the arrest and confinement of IDUs, the rise of HIV among IDUs convinced the Chinese government to permit pilot needle and syringe exchange (NSE) programs. The government currently funds 91 such programs, and international donors have funded others (Office of the State Council Working Committee on AIDS in China, 2005). Since 2004, the China State Council has issued official statements supporting needle and syringe exchange, methadone maintenance treatment, and other community-based HIV prevention strategies. The Council’s HIV/AIDS Working Committee has also coordinated interagency efforts—including between public health authorities and police—to prevent HIV transmission among IDUs, and made such work a high priority. Also in 2004, after strong advocacy by key scientists at the China Centers for Disease Control, the government launched an ambitious methadone maintenance program. By the end of 2005, 128 government-supported methadone maintenance treatment sites were serving more than 8,000 clients (Office of the State Council Working Committee on AIDS in China, 2005). The program aims to establish 1,000 to 1,500 sites serving 200,000 to 300,000 clients by 2008. Government funding is available for methadone maintenance treatment programs in urban areas, and for needle and syringe exchange in rural areas. Despite these encouraging signs, there are tensions and inconsistencies between criminal justice and public health policies that have operational

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implications. For example, in southern Guangxi Province, police—as directed by provincial and local authorities—have supported a cross-border HIV prevention project that provides peer education and NSE. Yet police have also intensified crackdowns on drug users, committing growing numbers to detoxification centers and labor camps and driving many others underground. These activities have had a chilling effect on the willingness of IDUs to meet with peer educators and receive sterile injecting equipment: the average number of needles/syringes the cross-border project provides each month dropped from 12,000 in 2003 to 8,000 in 2005 (Personal communication, T. Hammett, Abt Associates, June 30, 2006). IDUs who receive fewer sterile needles/syringes are more likely to share equipment and put themselves and others at higher risk for HIV. These tensions may gradually subside, given that Chinese policies for preventing and controlling HIV transmission have become much more pragmatic. Methadone maintenance treatment and NSE—almost unimaginable several years ago—are expanding across the country. This trend may accelerate as the Chinese economy continues to integrate with international markets, but the country still recognizes the need to balance and, to the extent possible, harmonize the policy environment. RUSSIA HIV prevalence in Russia remained low until the mid-1990s, when HIV entered the IDU population. The epidemic has since expanded, with outbreaks in 82 of the 89 oblasts (regions) over the past decade. Official Russian data show about 350,000 people living with HIV/AIDS as of the end of 2005 (Ladnaya, 2005 as cited in UNAIDS, 2006).3 However, the latest estimates from UNAIDS say that as many as 560,000 to 1,600,000 people are now living with HIV (UNAIDS, 2006). Increasingly, HIV is spreading from IDUs to their non-injecting sexual partners and beyond, suggesting that the HIV epidemic—once concentrated among IDUs—is becoming more generalized (UNAIDS, 2006). After the Soviet Union dissolved in 1991, Russia adopted strict criminal codes on the use of illicit drugs in the face of rapidly escalating numbers of IDUs (Klein et al., 2004). The Russian Ministry of Health estimates that there are between 0.5 and 1.5 million drug users in Russia, with as many as 6 million people reporting drug use at some point in their lifetime.4 Laws passed in 1998 and 2001 incorporated the three United Nations drug con- 3 Data also available in Russian at http:/hivrussia.org/stat [accessed August 23, 2006]. 4 Data online (in Russian). Available at: http://www.medlinks.ru [accessed August 23, 2006].

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trol conventions5 and contained several articles on narcotics. These laws set very low thresholds for possession of illicit drugs punishable by mandatory imprisonment. For example, purchases of 0.005 grams of heroin—one-hundredth of an average daily dose—were punishable by 5 to 7 years in prison. As a result, today about one-third of prisoners in the country’s penal system are serving time for drug charges. However, legislative changes since 2003 have reshaped the policy context for IDUs. Compulsory drug treatment is prohibited, and penalties for small-scale drug possession have been relaxed. In May 2004, Russia amended the Criminal Code so that possession of up to 10 times the “average single dose” (equivalent to 1.0 grams) is no longer a criminal offense, and possession of 10 to 15 times the average single dose is punishable by a fine and community service. Punishment for drug sales is harsher than in the past, reflecting a trend toward imposing stricter penalties on drug dealers as opposed to drug users. In 2005, because of lobbying by the Federal Drug Control Service, the legislation was again revised to amend the “average single dose.” The 1998 and 2001 legislation forbade the use of opioid agonist maintenance treatment for drug dependence, including methadone and other long-term pharmacotherapy programs. This reflects the position of Russian professional narcotics community, which does not accept opioid agonist maintenance as treatment (Personal communication, V.N. Krasnov, Russian Society of Psychiatrists, June 16, 2006). As a result, the traditional drug treatment system in Russia is abstinence oriented. In the face of the tensions between the law enforcement approach and the public health approach, progress has been made. A peer-outreach counseling program (without needle exchange) in Moscow funded by Médecins Sans Frontières distributed leaflets and condoms to some 10,000 IDUs in 1997—a figure that grew by 50 to 250 per month during the following 2 years. However, referrals to drug treatment and HIV testing facilities were low, as IDUs did not want to become registered as drug users because of potential consequences regarding employment and housing status (Platt et al., 2004). Nonetheless, the program became a model for other HIV prevention programs aimed at IDUs, and received broad attention from the Ministry of Health and the Russian media (UNAIDS and UNDCP, 2001) Other HIV prevention activities include a peer-driven intervention in Yaroslavl, a mobile syringe exchange project in Moscow, and a mobile education and syringe project in St. Petersburg (Rhodes et al., 2004; Sergeyev et al., 1999; UNAIDS and UNDCP, 2001). 5 UN drug control conventions available at: http://www.unodc.org/unodc/drug_and_crime_conventions.html.

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As of February 2003, nearly all of the estimated 75 documented HIV prevention programs for IDUs included needle and syringe exchange, and one study found that more than half the projects surveyed operated mobile outreach services. However, coverage remains restricted: results from another survey suggest that 65 percent of the needle and syringe exchanges in Russia reach less than 1 percent of the local IDU population, and that fewer than 5 percent of NSEs reach more than 5 percent of their local IDU population (Burrows, 2001). Thus Russia continues to balance the tradeoffs between ensuring quality of individual programs and dissemination for public health impact. UKRAINE Ukraine has one of the most significant HIV/AIDS epidemics in Europe, with a mean estimated HIV prevalence in excess of 1 percent among people aged 15 to 49 years (Bernitz and Rechel, 2006). Ukraine is home to an estimated 560,000 IDUs (Nikolaevich et al., 2003)—8.5 percent to 9.6 percent of whom are thought to be HIV-seropositive (Aceijas et al., 2004). Sentinel surveillance data suggest HIV-prevalence rates among IDUs range from 12 percent to 38 percent in Ukrainian cities (Bernitz and Rechel, 2006). As a result of high rates of sex workers who are also IDUs, sexual transmission of HIV is closely tied with transmission through shared injecting equipment (Dehne and Kobushche, 2000; Kyrychenko and Polonets, 2005). HIV transmission is also common among Ukrainian prison populations (Bollini, 2001). IDUs in Ukraine mainly inject liquid poppy straw and liquid amphetamine, typically purchased as pre-loaded syringes from drug dealers (Booth et al., 2006). Heroin use has also been observed, given that Ukraine lies on the drug route from Afghanistan into Western Europe (U.S. Department of State, 2001). Although Ukraine, much like Russia, previously emphasized criminalization of drug use, it has emphasized a greater commitment to HIV prevention in recent years. Legislation on HIV/AIDS guarantees the right to information on HIV, and the country has abandoned mandatory testing for some groups (e.g., sex workers and IDUs) in favor of voluntary testing. State commitment to HIV prevention programs includes needle and syringe exchange and opioid agonist maintenance using buprenorphine which was identified as an important objective by the National AIDS Program (Human Rights Watch, 2006). Needle and syringe exchange is not illegal, nor are needle possession and purchase, and needles can be readily purchased from pharmacies (Human Rights Watch, 2006). Despite the legislative steps, implementation of actual programs has tended to be slow, except for needle and syringe exchange and a related

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package of interventions. Some 300 exchange points—mainly operated by nongovernmental organizations and funded by international agencies such as the Global Fund—now reach about 70,000 IDUs (Human Rights Watch, 2006). NSE sites typically also provide information, counseling, and referrals to other services. Government-run clinics use injectable buprenorphine on a small scale for detoxification and 6-month opioid agonist maintenance treatment serving an estimated 650 patients. In 2004, sublingual buprenorphine was introduced on a pilot basis in government facilities in two cities. In September 2005 sublingual buprenorphine was expanded further, with Global Fund support, to 200 patients in seven cities. However, opposition to opioid agonist therapy from law enforcement agencies and agencies involved with narcotic drugs seems to be significant (Human Rights Watch, 2006). The scale of opposition is particularly serious for methadone, which is not currently in use by treatment programs in Ukraine. Efforts to learn from evolving experiences and implement new policies across sectors continue. THAILAND Thailand is one of the few countries in the world to have successfully reversed its heterosexual HIV epidemic, after having launched a massive education and condom campaign aimed at sex workers and their clients (Phoolcharoen et al., 1998). The country’s “100% condom use campaign” is lauded as a model effort to control HIV through collaboration among government agencies, law enforcement officials, public health authorities, and private groups (Perngmark et al., 2003). Thailand is also one of the first developing or transitional countries to have implemented an effective perinatal HIV prevention campaign, by scaling up use of the antiretroviral drug AZT (Amornwichet et al., 2002). Although HIV prevalence has dropped as much as four-fold across Thailand, injecting drug use has emerged as a major risk factor for HIV transmission. For example, even as HIV prevalence among 21-year-old male military conscripts fell from 11.4–11.9 percent in 1991–1993 to 2.4 percent in 1998, the percentage of HIV-seropositive men with a history of drug use rose from 1 percent in 1991 to 25.8 percent in 1998 (Nelson et al., 2002). Over the past several years, national surveys have reported HIV prevalence rates among IDUs of 30 and 50 percent. Southern Thailand—which has minimal HIV prevention services for IDUs—has reported the highest rates (Perngmark et al., 2003). Within the emerging IDU-driven HIV epidemic, incarceration has been shown to be an independent risk factor for HIV seroconversion: that is, incarcerated IDUs are more likely to become infected than non-incarcerated

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IDUs (Choopanya et al., 2002; Dolan et al., 2003). This trend is not unique to Thailand (Rahbar et al., 2004), but no reported HIV prevention programs in Thailand target incarcerated IDUs (Rahbar et al., 2004). Thailand is known for its strict enforcement of drug laws, and its 2003 crackdown on illicit drug use—which led to the death of more than 2,000 people—attracted international attention. A rapid expansion of the use of “yaba,” as amphetamines in tablet form are known in Thailand, prompted the crackdown. (Kulsudjarit, 2004; Beyrer et al., 2004). Sources showed obvious declines in the use of both methamphetamine and heroin in rural areas after the drug war (Vongchak et al., 2005; Poshyachinda et al., 2005). In the face of these aggressive policies against drugs, HIV prevention strategies for IDUs in Thailand have evolved to varying degrees. Outreach and education have the longest history, as the Ministry of Public Health has been using media campaigns to disseminate information on HIV transmission through needle sharing since the early 1990s (Perngmark et al., 2003). Needle exchange and bleach distribution have begun on a pilot basis in Bangkok and some areas of northern Thailand (Gray, 1995; Vanichseni et al., 2004). In southern Thailand, while no needle and syringe exchange exist, IDUs can purchase equipment legally and at very low cost from area pharmacies (Perngmark et al., 2003). District hospitals nationwide offer short-term, tapered methadone treatment, although many addicts eventually resume drug use and return to the clinic (Saelim et al., 1998). Few clinics, most of which are in Bangkok, offer long-term maintenance therapy (Choopanya et al., 2003). The recently unveiled national HIV/AIDS plan for Thailand noted that HIV prevention interventions for IDUs including needle and syringe exchange, opioid agonist maintenance, and outreach, will be expanded and made accessible throughout the country (Thailand Ministry of Public Health, 2006). REFERENCES Aceijas C, Stimson GV, Hickman M, Rhodes T. 2004. Global overview of injecting drug use and HIV infection among injecting drug users. AIDS. 18(17):2295–2303. Amornwichet P, Teeraratkul A, Simonds RJ, Naiwatanakul T, Chantharojwong N, Culnane M, Tappero JW, Kanshana S. 2002. Preventing mother-to-child HIV transmission: The first year in Thailand’s national program. Journal of the American Medical Association. 288:245–248. Bernitz B, Rechel B. 2006. HIV data in central and Eastern Europe: Fact or fiction? In Matic S, Lazarus J, Donoghoe M, eds. HIV/AIDS in Europe: Moving from Death Sentence to Chronic Disease Management. Copenhagen, Denmark: WHO Regional Office for Europe. Pp. 232–242.

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