One Year On: Success of Tajikistan’s innovative pilot project for marginalized drug users in
the fight against HIV
“Nothing was good when I used to inject drugs, 15 years of heroin. I divorced my
wife, did criminal work to get a dose… I was often in prison. Since I started the
OST, my life has changed and I no longer do such activities. ” Farrukh, Injecting
Drug User (IDU) living with HIV
“I have been on the programme since it opened. Before I had difficulties. Right
now life is better and I am now able to work in construction repairing houses.”
Alisher, IDU living with HIV
Opioid Substitution Therapy
(OST) is a new, important,
innovative but controversial
treatment for IDUs living
with HIV or at risk of
infection, where clients use
of opioids, in particular
heroin, is replaced with a
free, daily, oral dose of liquid
methadone.
A
UNDP
sponsored
OST
pilot
programme
started
in
Three clients of the pilot OST programme quoted.
Tajikistan in 2010, and a year
Real names are withheld.
on is a clear success. The
often marginalized clients, many with twin problems of living with HIV/AIDs and
drug addiction, are enthusiastic to say how much the programme has improved
their quality of life. Further, as injecting drug use with unsterile equipment is the
main route of HIV transmission in Tajikistan, it could be the key in stopping the
epidemic developing as it leads to less use of needles and infected equipment in
circulation.
As of 1 June 2011, 3,395 HIV cases had been officially registered in Tajikistan, while UNAIDS
estimates 10,000 people are living with HIV (PLHIV) of a population of approximately 7.5 million.
A further concern is that the HIV epidemic is growing quickly in Tajikistan, with cases significantly
up from the 429 officially registered in 2005 and 1,345 in 2008. HIV prevalence is highest among
at risk populations. Of particular concern is the high prevalence among IDUs, 17.3% in 2009, in
part as Tajikistan is one of the major smuggling routes for Afghan opiates, in particular heroin,
and unsafe drug use is high. Tajikistan is in the concentrated stage of an HIV epidemic where
prevalence is high among at-risk populations, but lower in the general population. There is a
grave risk of progressing to a generalized epidemic, where HIV is high across the whole
population. High prevalence rates among IDUs has made injection drug use the driving force of
the epidemic, and interventions aiming to arrest the epidemic’s development need to focus on
the needs of IDUs.
Preparing the dose of methadone and passing it securely to clients
As Principal Recipient in Tajikistan to Global Fund to Fight AIDS, Tuberculosis and Malaria
(GFATM) grants, UNDP Tajikistan disperses GFATM funds to sub-recipients and strongly supports
national HIV efforts. UNDP Tajikistan has been acutely aware of the importance of working with
at risk populations, and since 2008 has advocated for OST programmes for IDUs living with HIV or
at risk of infection, one of nine interventions to address injecting drug use and HIV endorsed by
the United Nations. It involves replacing client use of illegal opioid drugs with, under medical
supervision, a less euphoric and dangerous opioid, in Tajikistan methadone, and has been shown
to support improvements in clients’ physical and mental health. By slowly reducing the dosage of
methadone, clients can also reduce their drug addiction. Further, with particular significance to
Tajikistan, IDUs living with HIV are less likely to use and infect equipment that others may use.
IDUs on the programme not infected with HIV do not use injecting equipment, including HIV
infected needles, and are less at risk.
Following cross-organizational support, including from the Ministry of Health and UN agencies, in
February 2010 a pilot OST programme was launched at a site in Dushanbe, the capital of
Tajikistan, hosted at the Republican Narcology Centre of the Ministry of Health. This has been
managed by the Ministry of Health’s National Centre for Monitoring and Prevention of Drug
Addiction, with ongoing UNDP monitoring and support, and crucial funding from the UNDP,
covering the supply of methadone, prevention commodities, site repair work furniture
procurement and staffing costs. Each day, clients’ visits to the site are registered and a dose of
methadone is given, along with support from the medical staff, a social worker and a
psychologist. Irina Alexsevna, the OST pilot social worker, understands concerns over drug
replacement, but says “I wasn’t sure about the treatment initially. However over the last few
years my opinion has changed, and our doctors have concluded that methadone is the best way to
reduce risky behavior.” Further replacement therapies are used as a last resort for individuals who
have failed time and time again to abstain from drugs. Though many clients have HIV, the specific
requirements are that they have been IDUs for at least five years, trying to abstain for at least
two, and be referred by medical practitioners.
Two clients discussing the treatment with the programme social worker
The OST Dushanbe site has been a big success and as of the end of July 2011, is attended by 114
clients, of whom 59 have HIV. On 24 June 2011, clients, medical staff and representatives from
Spin Plus (an NGO working with IDUs) celebrated at the Narcology Centre the programme’s one
year anniversary. Clients one-by-one described the deep harm caused to their lives by drug
addiction and HIV, and what the treatment meant to them. Later clients discussed in depth how
their health had improved, how some had got jobs and their family life improved. “I had trauma
in my spine from a car crash. The doctors told me I needed surgery, then they saw I was HIV
positive and wouldn’t do it and ignored me. Once I came here and started the treatment, I got
better. I still have my walking stick but I don’t use it” says Farrukh, before Nazaraly an IDU living
with HIV, adds “Its not only him. Others have similar stories… For me and my brother who is also
an IDU, we stole things from home. Everyone was nervous… with the help of this program there is
no need to commit crimes. Right now at home all is well.” Irina Alexsevna stresses that
psychologically clients are much more peaceful, and more open, sociable and driven for the
future. Further, clients have been referred to integrated counseling and testing centers, and
others received further medical support for other illnesses diagnosed, such as tuberculosis, STIs
and Hepatitis B and C.
The OST site has also helped fight the spread of HIV in Tajikistan. As methadone is taken orally,
HIV infected individuals on the programme are no longer infecting equipment that others may
use, while those without HIV no longer have the risk of infection through infected equipment.
Malika Khakimova, UNDP Tajikistan Prevention and Scale Up HIV/AIDS Programme, states, “The
OST programme helps those infected with HIV, increasing access and adherence to ARV. Almost
half of OST clients in TJK are on ARV treatment. Further the programme has meant there are less
infected needles in circulation, addressing the epidemic at a key point. It has assisted in reducing
HIV prevalence and the risk of HIV transmission and infection, while also reducing the proportion
of users who inject drugs and the frequency of infection.”
While UNDP Tajikistan is looking at ways to improve the service, increase client numbers and
adherence to the treatment, the success of the site in Dushanbe has led to OST expansion in
Tajikistan. Staff from Khujand in the north of Tajikistan were trained on running OST by the
Dushanbe site staff, and opened a centre in March 2011 which currently has 52 clients. An OST
site in Khorog (east Tajikistan) was recently launched in June 2011 and already has 12 clients. In
the future, the OST programme in Tajikistan will be expanded to Khatlon region (south Tajikistan),
meaning there will be functioning OST sites throughout the country. Even more encouraging is
how involved clients are. After describing how the treatment has helped them, Farrukh describes
a methadone user society he is setting up and Nazahalee ends “I tell all my friends with the same
problems about OST to come. It works.”