The annexation of Crimea by Russia this week is likely to have far-reaching consequences for an already much marginalized group within society. There are an estimated 14,000 people who inject drugs living on the Crimean peninsula and, in one fell swoop, their access to life-saving medical and HIV prevention services has been severely compromised.
The Russian Federation has extremely repressive drug laws and the annexation potentially puts at risk the lives of drug users benefiting from HIV prevention services such as the distribution of clean needles. The Russian government does not itself support any efficient programs for preventing HIV and hepatitis C among people who use drugs and the government refuses to help its own 1.8 million injecting drug users. Needle exchanges and opioid substitution therapy (OST) are illegal in Russia.
The present political situation is particularly alarming for some 800 patients currently receiving OST in Crimea as stocks of methadone and buprenorphine -- which replace an opioid like heroin and are taken under medical supervision -- are only expected to last a matter of weeks. With the blocking of highways that connect Crimea to the mainland, getting medical supplies through is challenging. In Sevastopol substitution therapy sites have already been compelled to start decreasing patients' dosage. There is a very strong likelihood that these OST patients will go into withdrawal and potentially revert to illegal drugs, which in turn puts them at much greater risk of contracting HIV through dirty needles.
From an HIV perspective, there are two main causes for concern. Firstly, people who have stopped or reduced injecting drugs will start or increase again, leading to a rise in transmission of HIV if people don't have access to clean injecting equipment. Secondly, there's an increased threat that people with HIV who are on both antiretroviral therapy and methadone will become more vulnerable. This also applies to TB treatment.
One of the key things about methadone treatment, in addition to its physiological effects of making people feel well or 'normal,' is that it's also an effective way to encourage sick and marginalized people to engage in services. At the methadone clinics in Crimea for example, people were also receiving TB and HIV care, together with the support of a peer group or counselor. Closing down their OST supply means closing down a whole gateway to services and support for people who otherwise don't or can't get help from mainstream services.
So what needs to happen to ensure continuity of services? The International HIV/AIDS Alliance in Ukraine has approached the de facto Crimean authorities and offered to act as an intermediary between the authorized bodies there and in Ukraine in order to provide an urgent humanitarian supply of medicines to cover substitution therapy needs for the next six months. They have yet to receive a response to their proposal.
Additionally the International Network of People who Use Drugs has called on UN organizations to support the continuation of existing harm reduction interventions in Crimea and asked the government of the Russian Federation to cease any attempts to close down these lifesaving programs.
A harm reduction approach works in Ukraine
Ukraine has been a regional leader in the provision of needle exchange and substitution therapy programs which prevent HIV among people who use drugs, so called harm reduction programs. The largest HIV prevention program in the Eastern Europe and Central Asia region is implemented by the International HIV/AIDS Alliance in Ukraine with the support of the Global Fund to Fight AIDS, Tuberculosis and Malaria and has been providing substitution therapy, needle exchanges, condom distribution, rapid HIV and STI testing and counseling.
Such an approach has resulted in a continuous decrease of HIV transmission among people who inject drugs. In 2012, for the first time since 1999, the overall number of newly registered HIV cases in Ukraine decreased by two percent. The number of new cases registered among people who inject drugs fell by nine percent compared with the previous year.
Any interruption to harm reduction programming is likely to prove a disaster for health, human rights and the HIV epidemic in Crimea and the region more generally. Territorial politicking should not come before the public health of citizens.