“Legal” Obstructions to HIV Prevention in Odessa, Ukraine Robert E. Booth, Ph.D.

Eastern Europe

The HIV Epidemic in Ukraine In 1995, the WHO characterized Ukraine as a low prevalence country. By 1996, all 25 regional capitals in Ukraine reported HIV, primarily among drug injectors. In some cities, rates of HIV among IDUs rose from nearly zero in 1994 to more than 50% two years later. Today, Ukraine is the most HIV-affected country in Europe and Central Asia, with an estimated 440,000 infected between the ages of , or 1.63% of the population in this age range.

Why the rapid increase in HIV?

1) The social and economic disintegration that followed the collapse of the Soviet Union in With the withdrawal of the Soviet Union in December 1991: Police controls became ineffective, drugs more readily available and corruption uncontrolled. Locally produced opiates and amphetamines proliferated. Registered drug users increased from 30,000 to 63,000 between 1990 and ) The injecting practices of IDUs in Ukraine. Opiates, (liquefied poppy straw) purchased from dealers, who are typically injectors, are obtained by extracting the solution from a common container with the user’s needle/syringe, or with the dealer’s needle/syringe, and front or backloading into the user’s syringe. Pseudo-ephedrine, purchased through pharmacies, is usually prepared by groups of users and drawn from shared drug mixing containers.

Why is the epidemic continuing to escalate?

HIV Prevalence Rates in the Cities We Have Worked In HIV HIV HIV HIV HIV HIV CityPopulationBaseline 6 months Total Kiev2,765,500 34% 2% 36% Odessa 1,080,000 53% 12% 65% Donetsk/ 1,500,000 20% 8% 28% Makeyevka Simferopol 340,600 19% 15% 34% Nikolayev505,900 55% 14% 69%

The stigma of drug use and HIV infection, resulting not only in discrimination but in the denial of critical services and outright brutality, is responsible for the epidemics’ continued escalation. The result: Drug injectors in Ukraine are afraid to carry clean syringes and practice safer needle hygiene, leading to hurried injections and risky needle practices. Users biggest fear is withdrawal. Their 2nd biggest fear is the police.

Purpose 1.To gain an understanding of the attitudes and policies in which IDUs and HIV-infected IDUs are regarded and treated in Odessa using in-depth semi-structured interviews with officials. 2.To assess IDUs’ experiences with various officials, particularly law enforcement, through focus groups with HIV-infected and non-infected IDUs and female IDU sex workers. 3.Using survey methods, a) measure the frequency to which IDUs encounter barriers and discrimination related to HIV and drug use; b) assess the extent to which having HIV is related to experiencing these barriers.

Law Enforcement N = 10 Legal Establishment N = 9 Methods Semi-structured interviews were conducted by teams of two, a Ukrainian and an American, and led by the Ukrainian. Tape recordings were not allowed. While questions varied by group, everyone was asked a series of 5 “core questions”. Those interviewed included:

Focus groups were led by Bob Booth & Tom Brewster and tape-recorded. Groups included: HIV infected womenN = 7 HIV infected menN = 8 HIV negative womenN = 7 HIV negative menN = 8 HIV infected couplesN = 6 Female sex workersN = 6 Total N = 42

Findings What is your opinion about providing treatment to IDUs with HIV or at risk of HIV, including maintenance medications such as methadone? Police: “I do not sympathize with the drug user. Everyone can make a choice in their life to use or not to use drugs. I had a choice to use marijuana but chose not to.” When asked about ST in prisons: “Drug users/dealers lose their rights in prison. Officially there are no drug users in prison because there cannot be drug use in prison, so there is no ST in prison because there are no drug users.” “Drug users/dealers lose their rights in prison. Officially there are no drug users in prison because there cannot be drug use in prison, so there is no ST in prison because there are no drug users.”

Users: “Police will oppose it because they will lose their source of income money provided by us. This is why the police are against it.”

Some drug users have stated that they have been beaten by police because they are drug users. Have you heard of this happening? Some drug users have stated that they have been beaten by police because they are drug users. Have you heard of this happening?Police: “Drug users will invent a story for 100 hryvnia. Addicts are liars. There are no sadistic people working in the militia who want to beat up addicts.” “The facts are that police beatings are greatly exaggerated. Police never beat a person for using drugs. In the process of arresting a drug user if they fight back or attempt to get away, the police will use force to hold them; this may be interpreted as a beating.”

Legal: “The police treat IDUs the same as everyone else, but they are hated a little bit more. IDUs exaggerate the level of police brutality. There are some arrest quotas, but there are limits on them. I have heard that police take money from IDUs then return drugs to the users. Police do have a room where those who are apprehended are interrogated. IDUs don’t have to be tortured, just take their drugs from them and they will confess. Police do use electrical shock and a gas mask and withhold air as part of their interrogation tactics.”

Users: “Yes, the police took my hands and taped them together. They beat me with a stick so bad I had blood in my urine. They did this because I would not talk about another drug user”. “I know someone who died from the police. After the police killed him at the station they put him in a car with a syringe in his hand to make it look like an O.D.”

Do drug users know that they can complain about being beaten to the authorities and there will be an investigation? User: “This legislation does not work; it makes it worse if you complain about being beaten. Police officials pass on that you complained to street police and you get beaten much worse so drug users do not report this”.

Have you ever been forced to have sex by the police? Have you ever been forced to have sex by the police? 13/20 females - 65% - said “yes” and 100% had heard of it 13/20 females - 65% - said “yes” and 100% had heard of it “Police violate our human rights. They do not treat users as people. Police are not afraid of getting HIV when they have sex with users.”

Do you see any barriers that prevent IDUs with HIV or at risk of HIV from getting medical services and accessing HIV prevention programs? Police: “I don’t see any barriers. These people (drug users with HIV) don’t want services and that is why they don’t get them.” Legal: “ There are no such barriers.”

Users: “The dealers are in collusion with the police; the dealer tells the police when and where they will make a sale so the police are waiting when the IDU buys the drugs and police arrest them, take the drugs, threaten the IDU and sell the drugs back to them.” “The dealers are in collusion with the police; the dealer tells the police when and where they will make a sale so the police are waiting when the IDU buys the drugs and police arrest them, take the drugs, threaten the IDU and sell the drugs back to them.” “The police hang around pharmacies and wait for users to buy needles. After the addict purchases the needles the police follow them and take their needles, requiring that they be paid in order to get them back. This is how they make money. The police also work near the drug sale points.

Users: “If they find new syringes they force the drug user to pay 20 hrynia to keep the new syringes. It happens if you have drugs too – you can pay to keep the drugs.” “It is impossible to defend your rights. Police often beat up drug users at the police station. I knew two people who were killed by police”. “We don’t want to steal, but we have to pay the police.”

Quantitative Research Findings

20% 4% 15% 7%

24% 9% 15% 7%

85% 22% 78% 51%

41% 20% 25% 10%

32% 13%

Multiple Logistic Regression of Factors Associated with HIV Serostatus, using Past 30 Day Drug Risk Behavior Variables (n=200) Step Variable Added Adjusted OR for Final Model 95% CI for Adjusted OR P-value for Final Model 1 Ever rushed injection due to police presence – 33.9 < Gotten drug solution from pre- loaded syringe – 19.3 < Working at least occasionally or seasonally – 0.5 < Front/backloaded with a dealer – 11.1 <.002

Summary Clearly, the drug using practices of IDUs in Odessa contributes to their high rates of HIV infection. Clearly, the drug using practices of IDUs in Odessa contributes to their high rates of HIV infection. However, police enforcement practices also are responsible for these rates: However, police enforcement practices also are responsible for these rates: 24% reported being beaten/tortured by police 24% reported being beaten/tortured by police 24% avoided carrying clean syringes for fear of police 24% avoided carrying clean syringes for fear of police 17% avoided pharmacies due to fear of the police 17% avoided pharmacies due to fear of the police 57% hurried injections due to fear of the police 57% hurried injections due to fear of the police The ‘risk environment’ drug users in Odessa face must change if the epidemic is to be controlled. The ‘risk environment’ drug users in Odessa face must change if the epidemic is to be controlled.