Lack of access to substitution therapy now forms the biggest barrier preventing access to antiretroviral therapy in Eastern Europe and Central Asia, the first Eastern European and Central Asian AIDS Conference heard last week in Moscow.
Substitution therapy consists of either methadone or buprenorphine, but most countries in the region do not offer either form of substitution therapy. Albania, Armenia, Azerbaijan, Belarus, Kazakhstan, Russia, Tajikistan, Turkmenistan and Uzbekistan do not offer substitution therapy. According to the Canadian HIV/AIDS Legal Network, more than 80% of HIV-posiitive people in the region who inject drugs live in countries where substitution therapy is not available.
In Ukraine substitution is restricted to buprenorphine, the more expensive alternative. Buprenorphine registration is due to lapse in June and while Ukraine already has capacity to provide substitution therapy to 1200 people, according to Pavlo Smyrnov. Field Programmes director for AIDS Alliance Ukraine, only 300 people are currently able to receive buprenorphine. The use of the cheaper alternative, methadone, was blocked by the national drug control authority due to fears of diversion of methadone supplies from clinics and pharmacies.
But in Kyrgyzstan legislators took the view that AIDS was a sufficient threat to national security and health to require national legislation specifically permitting substitution therapy, said Urban Weber, the Global Fund’s portfolio manager in Eastern Europe.
Why does such suspicion of substitution therapy exist in Eastern Europe and Central Asia? Russian Minister of Internal Affairs Boris Gryzlov said in 2003 that Russia’s drug policies were “not the government’s own initiative…but rather the result of our responsibility to implement the UN drug conventions of 1961, 1971, and 1988.”
But Richard Pearshouse, senior policy analyst at the Canadian HIV/AIDS Legal Network, said this position is derived at least in part from an inaccurate reading of UN agreements. He told the conference: “It is categorically untrue that the UN Conventions on Drug Control prohibit the use of buprenorphine or methadone.”
Article 38 of the 1961 convention obliges signatories to take all practicable measures to provide treatment for drug dependence, and there are provisions in the 1961 and 1971 conventions to require prescription of methadone, not outright prohibition. Indeed, said Richard Pearshouse, UNODC has explicitly stated that substitution therapy could hardly be perceived as contrary to the text of the treaty, a position supported by the International Narcotics Control Board in 2003.
Yet resistance to substitution therapy remains strong in the health ministries of the region, who declare that substitution therapy merely perpetuates drug dependency, does not promote abstinence from opioids, does not prevent continued illicit drug use alongside methadone and does not remove drug users from a criminal milieu.
Challenging these beliefs in a plenary session presentation, Martin Donoghoe of WHO’s European office reminded delegates that WHO’s own review of the evidence has shown that substitution therapy:
- reduces illicit drug use and crime
- reduces syringe sharing, so preventing HIV infection
- retains drug users in treatment more effectively than detoxification
- does not trap people in a cycle of drug dependency
- improves IDU access to antiretroviral treatment
WHO recommends substitution therapy as an essential component of harm reduction programmes for injecting drug users, but this guidance continues to be ignored throughout the region, effectively placing HIV treatment beyond the reach of hundreds of thousands of injecting drug users who form the core group of the HIV epidemic throughout Eastern Europe and Central Asia.
In the face of such resistance to the scientific evidence, some advocates argue that human rights law needs to be utilised, despite the sometimes arbitrary interpretation of democratic rights in the Confederation of Independent States (CIS). Richard Pearshouse highlighted several possible avenues for legal challenge under the UN Covenant on Economic, Social and Cultural Rights:
- the right to the highest attainable standard of health
- the principle of non-discrimination
However Denes Banos, director of the Hungarian Civil Liberties Union, pointed out that the legal system in Russia is based on a civil code rather than the common law system that prevails in the English-speaking world. Under common law it can take only one judgement to change the interpretation of the law throughout the whole legal system, since judges are bound to follow the precedent of their colleagues. However, under civil law systems judges are not bound to take precedent into account, leaving less scope for legal activism.
The other avenue for action, says Pearshouse, is to step up pressure on UNODC to move methadone and buprenorphine from Schedule I to Schedule II or III of the Convention on Psychotropic Substances. Schedule I substances include cocaine, heroin and LSD, drugs with high potential for destructive abuse, but also includes methadone. Schedule III covers drugs with significant potential for abuse which nevertheless offer therapeutic value. Movement of methadone from Schedule I, argues Pearshouse, may give health ministries greater backing to argue for reform of national drug laws in order to allow substitution therapy, because it would undermine the argument that methadone substitution contravenes UN conventions.
Although movement from Schedule I occurs on the basis of expert advice from WHO, it is ultimately a political decision that is made by the Commission on Narcotic Drugs, the central drug policy-making body within the UN system. The United States has repeatedly blocked attempts by the Commission to liberalise statements on needle exchange, claiming that needle exchange does nothing to reduce demand for drugs, but has remained silent on substitution therapy and its proven potential to reduce the demand for drugs.
But even where substitution therapy programmes do exist, entry criteria and practices affect the ability of drug users to access treatment. Any illicit drug use alongside substitution therapy may result in termination of the therapy, and patients often have no control over the methadone doses they receive, which can be particularly problematic in those receiving efavirenz-based antiretroviral therapy, Konstantin Lezhentsev of the International Harm Reduction Programme told the conference. Since efavirenz reduces methadone levels by 50%, drug users can begin to experience withdrawal symptoms within a few days of beginning efavirenz treatment. “Methadone doses should be determined in consultation with the patient and in accordance with medical best practice, and dosage should never be used as a reward or punishment for people receiving substitution therapy,” said Richard Pearshouse.
Duration of substitution therapy also needs to be adequate to ensure treatment effectiveness; programmes that give only six months of methadone inevitably perpetuate a cycle of drug dependence because they don’t give drug users long enough to address the psychosocial factors that encourage drug use.