International Journal of Drug Policy 25 (2014) 1153

Contents lists available at ScienceDirect

International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo

Foreword: Illicit drugs in Central Asia

The focus of this issue of the International Journal of Drug Policy on Central Asia is, no doubt, both relevant and timely. It is estimated that close to 1% of adults in the region inject drugs. This number may exceed 10% in areas located along major drug trafficking routes, representing one of the highest rates of injection drug use in the world. One of the papers in this volume tells us that in parts of Tajikistan, a dose of heroin costs less than a bottle of vodka! This has tremendous public health implications. People who inject drugs (PWID) account for over half of new HIV infections in the region and are at major risk of contracting other diseases such as hepatitis C (with prevalence rocketing as high as 75% in some countries) and Tuberculosis (TB), which are leading causes of death among people living with HIV. Female partners of PWID are also at greater risk. The international counter-narcotics policy in Central Asia, largely supported by international donors, has focused on a security approach aimed at reducing drug supply by securing borders and strengthening police capacity to enforce repression of traffickers and drug users. These efforts and the resources invested, have, however, clearly failed to reduce the flow of narcotics and to tackle drug-related public health issues in the region. Eastern Europe and Central Asia is still home to the fastest growing HIV/AIDS epidemic in the world, largely fueled by drug use. It is alarming that there are nearly 100,000 AIDS deaths each year in the region, a figure that has increased by more than 25% since 2005, compared to decreasing levels globally. Even more concerning is that treatment coverage remains unacceptably low. It is estimated to be now at around 35% – versus 61% globally. Yet we know what works. There is ample evidence that the spread of HIV can be prevented among people who inject drugs with the distribution of sterile needles and syringes, substitution of illicit drug use with opioid therapy, testing/counseling for HIV, and antiretroviral therapy. TB prevention, diagnosis and treatment are also included in the Comprehensive Package of Harm Reduction recommended by WHO, UNODC and UNAIDS. These interventions can have high impact provided that they are delivered as a comprehensive and quality package and at the needed scale. However, in Central Asia, only 11% of all HIVprevention investments focus on populations at higher risk. Only one third of people who inject drugs are reached by needle and syringe programs and just 1% access opioid substitution therapy. Most countries of the region also have inadequate legal and human rights frameworks that allow for aggressive law enforcement and policing practices. Between 40 and 70% of incarcerations in the region are for minor drug offences, including use and possession. Because prisons themselves constitute a risk environment http://dx.doi.org/10.1016/j.drugpo.2014.09.006 0955-3959/© 2014 Elsevier B.V. All rights reserved.

for the acquisition of HIV, we see a vicious circle of minor drug use, incarceration and HIV/HCV/TB infection. Fear of police and arrest is also one of the greatest factors for needle sharing and HIV risks. If the trend goes on, countries in the region are facing a looming tragedy. This issue of the International Journal of Drug Policy offers possible explanation of why the region is so late on implementing the evidenced-based policies and strategies that have become standard in many other parts of the world. Despite some progress, there is a sheer lack of political will to change approaches, reform drug policies and effectively scale up evidence-based HIV prevention, especially when it comes to the implementation of opioid substitution therapy. One possible explanation that is supported by several articles in this special issue could be the intertwined interests of both drug traffickers and state authorities – resulting in a strong resistance to change the statusquo, especially in lower income countries. Another explanation is that drug monitoring and care systems are still based on “narcology” inherited from Soviet times, resulting in poor reliability of data. This must be added to strong stigma around drug users and other “key-affected populations” such as sex workers and men who have sex with men, which also results in biased data. Most interventions therefore fail to target key affected populations and do not impact the overall course of the epidemic. In every country in Central Asia, I have witnessed tremendous efforts by local NGOs to address PWID’s needs in the region. But I have also seen huge challenges in having governments recognize that work and find structural ways of cooperation between the governmental and non-governmental sectors. There is an urgent need to switch focus and move away from a security approach to drug policies, to a health-centred approach based on scientific evidence. More attention is to be given to research and data collection that would allow countries to tailor prevention and treatment services to the real needs of their populations. As a member of the Global Commission on Drug Policy, I have been involved in a global move to rethink drug policies. The international community will have the opportunity to discuss an alternative model at the next UNGASS in 2016 – one that is based on science, human rights and efficiency. I strongly hope the world will take this chance and that Central Asian countries will actively participate in the debate. Michel Kazatchkine UN Secretary General Special Envoy on HIV/AIDS in Eastern Europe and Central Asia, Switzerland

Foreword: illicit drugs in Central Asia.

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