1. Legal and Policy Barriers to Effective Health Interventions among IDUs in Kaliningrad, Russia Inna Vyshemirskaya (1), Alexander Koss (2), Victoria Osipenko (1), Olga Burkhanova (3), Zita Lazzarini (4)(7), Scott Burris (5),(7), Patricia Case (6) (1) Kaliningrad NGO Young Leaders Army, Russia (2) Immanuel Kant’s University of Russia, (3) Kaliningrad NGO Help Now, Russia, (4) University of Connecticut Health Center, USA (5) Temple University Beasley School of Law, USA (6) Fenway Community Health Center, USA (7) Center for Law and the Public’s Health at Georgetown and Johns Hopkins Universities, USA NGO “YLA”, Kaliningrad Issue: Kaliningrad region and city have one of the highest HIV prevalence rates in Russia. Despite the fact that the main HIV transmission route in Kaliningrad is injection drug use, HIV prevention measures have not been targeted at IDUs. The local health authorities have not supported health care interventions for IDUs. The NGO sector generally has been too weak and unable to do so. Our research identified a set of interrelated legal, political, and social factors preventing effective health interventions among IDUs in Kaliningrad. 1. Dominance of law enforcement authorities over other policy actors Russian law effectively gives the State Drug Control authorities control over all activities dealing with IDUs. Russian law prohibits “propaganda” (Criminal code, art.230) or “encouragement" (Federal Law “On narcotic drugs and psychotropic substances”, art. 46) of drug use. These laws could be interpreted to apply to public health interventions aimed at IDUs. To avoid possible prosecution harm reduction programs for drug users must be authorized by the health authorities and the drug control authorities. In practice, the Kaliningrad State Drug Control representatives will not approve syringe exchange programs and take the position that any programs conducted without their approval are illegal and prohibited. Health authorities are unwilling to challenge the drug control agency. This legal environment deters the willing and capable NGOs from doing prevention work among IDUs. Methods: Using a community-based action research method called Rapid Policy Assessment and Response (RPAR), a research team guided by a Community Action Board collected written laws and policies, conducted 3 focus groups, interviews with key informants including health care providers, lawyers, law enforcement representatives, NGO staff (N=26) and injection drug users (N=14) to learn how the law, policies and their implementation influence health risks among IDUs. The Kaliningrad RPAR was begun in March 2006; research was completed in December 2006. “Harm reduction is impossible here as it’s considered to be drug use encouragement followed by criminal liability… there is a specific article on that … for syringe exchange. It can only be possible, if approved by the drug control service and local authorities” - Employee of the drug control service “The work with drug users should definitely be done, but it mustn’t encourage drug use. Syringe exchange program isn’t needed. … Our attitude to harm reduction programs is exclusively negative. It’s the standpoint of our service” - Employee of the drug control service “Best Practices” for HIV prevention among IDU and their availability in the Kaliningrad region Counseling and testing programs targeted especially to high risk groupsNone Street outreach education programsNone Harm reduction (NEP, etc.)None Detoxification programs Available – 20 free places Substitution therapy None Rehabilitation programs Available – 4 centers with 100 chargeable places “NA” or other 12-Step Groups Available – attended by very few people Number of IDUs in the Kaliningrad region (01.01.2006) 2,360 – officially registered IDUs 1,010 – IDUs, who have undergone anonymous treatment 23,000 – actual number of drug users including IDUs estimated by experts 2. Dominance of the abstinence model in health care and social welfare State-sponsored drug treatment is based on detoxification and abstinence. Methadone is illegal and harm minimization approaches are mistrusted or opposed by health authorities and the narcological establishment in Kaliningrad. Few NGOs work with IDUs and most of these focus on abstinence (targeted support to particular IDU/CSW or rehabilitation work aimed at complete abstinence). Despite the high level of HIV, neither state health authorities nor NGOs have any special HIV prevention programs for IDUs in Kaliningrad. The staff of public health and social welfare institutions serving IDUs (for drug treatment) are not entrusted with responsibility for IDUs’ overall health. The majority of health, social welfare and NGO specialists working with IDUs are not aware of, or ill-informed about, a harm reduction approach. They neither realize the need for, nor are capable of, working on health risk reduction. As a result, IDUs do not receive health risks reduction assistance. ”I work at the hospital for quite some years, and this is the first time for me to realize that we should carry out work on health risks. Until now we are concentrating on turning them to sobriety. These drug users here in the hospital, they come back here all the time … and we continue talking about sobriety to them…” – Staff member of the narcological facility 3. Stigma and scarce resources We found that stigma exacerbates the lack of services for IDUs in an environment in which p ublic health and social welfare programs of all kinds are underfunded. Informants repeatedly opined that it was wrong to spend money caring for IDUs or preventing diseases among them, when other “innocent” people do not receive the services they needed. The widespread social stereotype that drug use is incurable negatively impacts both the quality of services for IDUs and IDUs’ attitudes towards drug treatment. Staff of public health and social welfare institutions serving IDUs do not believe that drug users can recover and therefore they are discouraged. This negative stereotype and lack of positive role models of recovered IDUs leads other IDUs to feelings of futility and hopelessness and they stop trying to seek a way out of drug use. “In our country the treatment of many patients is not funded. Do we have any special programs for people with diabetes, cancer, etc.? First, normal people should be treated and helped and only after that those other ones” – Doctor from the emergency medical care “Show me one recovered drug user, just one. Why should we treat them? To spend money for them to resume drug use afterwards? …I was always saying, and I am saying again: there are no ex-drug users” – Junior doctor from the emergency medical care “…I am still pained when thinking: why I didn’t have this knowledge before…I stopped believing that it’s possible to get out of it. I thought that everything was lost. You know, you make couple attempts and you see that it’s hopeless, so you stop struggling and just go with the flow. … While using drugs every user needs to know, that there are people who managed to get out of it. They need to know positive examples” – Former IDU, now an NGO member working with IDUs and HIV+ people RESULTS Conclusions: The complete absence of effective interventions for IDUs in Kaliningrad leaves IDUs in despair and endangers public health. Prospects for improvement depend on: Developing actors able to challenge stigma and the abstinence model, and to advocate urgently for the drug control, health authorities, and NGOs to take prevention measures targeted at IDUs; Nurturing the ability of those actors to raise funds and empower grass-root activities aimed at vulnerable populations; Building cooperative relationships with authorities and staff of public health and social welfare institutions serving IDUs. Since a harm reduction approach (especially NEP) is rigorously opposed in Kaliningrad we strongly encourage donor organizations to support projects that include not only NEP but also other activities aimed at health interventions. This research was supported by NIDA/NIH Grant # 5 R01 DA17002-02 PI: LAZZARINI, ZITA. The findings and conclusions expressed are those of the authors and not necessarily of NIH, NIDA, or the US Government.