Opiates and the Emerging HIVEpidemicsof Eurasia

Chris Beyr-erMD, MPHDepartments of Epidemiologyand

InternationalHealth, Johns HopkinsBloombergSchool of Public Health

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DRIVERS OF SPREAD

1. Geographic proximity to overland drugtrafficking routes

2. Limited access to HIV preventive anddrug treatment services for IOU's

3. Punitive policies and criminalization of riskbehaviors

HIV/AIDS Cases among IDUs

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0 < '''' HIV/A'DS,nu ._"" 'OU.. 10- HIV/AIDS~ '. IOU.. "'" HIV/AIDS " moo."""

States (N= 26) with at least one site withHIVprevalence> 20% in IOU in 2005. Belarus. Estonia. Kazakhstan. Russia. Ukraine. Iran

. Burma. China

. India

. Indonesia

. Malaysia

. Nepal

. Thailand. Vietnam. Italy. Nethertands. Portugal. Serbia & Montenegro. Spain

. Argentina. Brazil

. Canada

. Uruguay

. Puerto Rico. USA. Libya

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HIV and HeroinTrafficking

Geographic proximity to overlanddrug trafficking routes

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Results: N= 489 IOU in Dushanbe

. HIVprevalence

. HCV

. Syphilis

12.0%

61.2%15.4%

. Ethnic Tajiks were 6 times as likely as others to have HIVinfectionHIV:Tajiks19.2%,Russians3.4%

. HIV rates were about half among IDU reporting ever havingused a NEP

OR: 0.52 (95'10CI 0.29, 0.96)

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The Emerging Epidemic in Tajikistan-Context for Spread

Poorest country of FSUGDP per capita 178 USD in 2000

On~~;;'~~I heroin trafficking route out of Afghanistanto Russia-E.

30-50% of all economic activity linkedto drug trade (Parfitt, Lancet2003 362(9391)

Estimated numberof IDUs in Tajikistan43,000 to 135,000 (Aceijas,etal AIDS, 2004)

2001 IOU prevalence in Dushanbe,was 3.85 % In 2001. Aimost 95%of IOU report sharing needlesand syringes

No substitution therapy currentiy available, no public sector ARVs

Emerging Epidemic: Iran.2-4 million drug users

. To date "'10,000 cases of HIV/AIDS reported to Iranian MOH

. HIV-1 prevalence: 15.2% among male IDU's attending drugtreatment in Tehran in 2005

. HIV-1 strongly associated with a history of shared druginjection in prison rather than sharing outside prison

zamani. Saman (200S)Prevaience of and Factors Associated woh HIV 1 Infection among OrugUsers Vi..in" Treatment Centers in Tehran. Iran. Harm Reduction Conference. SeWast.

2

HIV/AIDS Transmission Routes inIran

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Zamani,. S.ama~ (200S)Pr".valence of- a~d Factors Associ~ted with HIV 1 Infection among Drug

Economic Rationale for PoppyCultivation

Figure 28. Gross income of opium poppy and wheat per hectare in 2003 and 2004

1'.000

12.000

12.700

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3 8,0005.000

4.000

2.000

2004

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So~" UNODC."'>WFP

Afohanistan ODium Survev, 2004, UNODC

"One military officer who has served inAfghanistan gave a more pointed assessment:'What will be history's judgment on our nation-building mission in Afghanistan if the nation weleave behind is Colombia" of the 1990's?"

'We know the military is not the best tool forfighting drugs," said one senior Pentagonofficial. "We have the best troops in the world,We did in days what the Soviets could not do ina decade, But this is not about burning cropsor destroying labs, Eventually it is aboutfinding a better option for Afghans who haveto feed their families,"

Source: Shanker,T.(2005, March 25). Pentagon Sees AggressiveAntidrug Effort in Afghanistan. The New York Times Online.

Afghan Opium Production (metric tons)1980-2004

Afghanistan: Opium pFC>duction from 1980 to 2004 (metric .ons)

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What does this mean for HIV?Both the Bush and Karzai Governments agree that control in

Afghanistan will take years to decades

The last 4 regimes over 25 years have tried supply reduction-none have succeeded

Drug treatment and HIV prevention have to implemented nowand everywhere heroin is flowing

Licit cultivation (Australia is largest licit poppy grower) couldhelp, but will be difficult in current political context

Feasibility Study on Opium Licensing inAfghanistan for the Production of Morphine andOther Essential Medicines: The Senlis Council

In response to the urgent need to significantly reduce Afghanistan's illegal opium trade-the key issue in the reconstruction of the country - The Senlis Council launched a

~~c'Ir ~sn.:,':,~;~~b~'~ g:,~:ii~::?~~&f~um for the production of medicines

The first Phase of academic investigation has now been successfully conduded, wilh

~~~~~~s~~x~nng d~~~~~~~~8.';'~k1AW~~~~ g~ar~e:~1" toolresponse to the globaP shortage in opiate-based me8icines. The findings of Phase Iwere released on 26 Sepiemrer 2005, at The Kabullntemational Symposium.

Phase 2 of the Study is now undelWay and will explore a wkle-range ofrecommendations and areas for further investigation. It will examine how the resultsof Phase 1 may be practically applied, providing insight into the methods andimpiications of implementing a licensing system.

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Hungary '0-")

Azerbaijan '0°")Uzbekistan '0-"")

Conclusions

Drug use and drug policies are drivingemerging HIVepidemics across Eurasia

Drug users must be offered HIVtreatment andprevention wherever drugs are moving

Now is not the time to limit use of anyintervention with evidence for efficacy

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