2. Terms of Reference for the Evaluation That Has Been Carried Out

REPORT

DESCRIPTION AND EVALUATION OF MEDICAL, PSYCHOLOGICAL AND SOCIAL SERVICES FOR INJECTED DRUGS USERS IN TMR

Evaluation of services for IDUs that live in Transnistria, carried out between September 15 and October 5, 2009, was ordered by CARLUX organisation.

S.V. DVORIAC

Contents

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1. Abbreviations.

2. Terms of reference for the evaluation that has been carried out.

3. Acknowledgements.

4. Author of the report.

5. Brief justification of evaluation.

6. Legislation of Transnistria, related to assistance in case of drug addiction.

7. Status of narcological assistance in Transnistria.

8. Treatment of opioid addiction and HIV prevention in Transnistria.

9. Bases of the need to implement replacement therapy.

10. Consclusion.

11. Recommendations.

12. Reference.

1. Abbreviations

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1. <}0{>Terms of reference for the evaluation that has been carried out<0}

The evaluation has been ordered by Carlux social organization.The goal was to identify the problems of organizing response to the HIV epidemics in Transnistria and to propose recommendations for prevention of blood-borne infections among IDUs.

The following objectives were set:

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-<}0{>Evaluation of the existing system of services for IDUs in the eastern part of Moldova (Transnistria region) in the civil sector;<0}

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-Evaluation of the existing system of services for IDUs in the eastern part of Moldova (Transnistria region) in penitentiaries;

-Visits to the institutions providing assistance to IDUs on the territory of Transnistria;

-Technical assistance in developing a mechanism of the pilot project of implementation of methadone supportive therapy in the eastern region;

-Recommendations for involved partners(Republican Narcological dispensary in Tirapol, Ministry of Healthcare of Transnistria, Centre of HIV/AIDS Prevention and Tackling) regarding the implementation of project of methadone replacement therapy;

-Providing partners with conclusions of the evaluation, made during the round-table discussion.

1. Acknowledgements.

Our work has been carried out thanks to the financial support of the Carlux public organization and personal involvement of its director Lilian Severin and of its employees Petru Sara and Vitalie Morosan.

We express special gratitude to the deputy minister of health care of Transnistria Mrs.Svetlana Arkadyeva Ivanovna.

As well as to the head of the Republican Narcological Dispensary Andrei IvanovichiRotari, to the narcologist Oxana Borisovna Dovgopol, to the head of the Department of HIV treatment of the Republican Clinical Hospital Tatiana Petrovna Alexeyenko, to the edipemiologist Petru Ivanovichi Olievsky, deputy chief doctor of the Central Ribnita District Hospital Ghenadi Nikiforovichi Negruta, to the narcologist Anatoli Dmitrievichi Boiko, deputy head of the Psychiatry Department of the Republican Clinical Hospital Andrei Vladimirovichi Panasiuc, to the deputy head of the State Punishment Execution Service, head of the CMP V.A. Pozdneakov, head of the public organization "Healthy Future” in Tiraspol Alina Takmelova and her collegues Natalia Palamari and Ludmila Andropova.

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1. <}0{>Author of the Report<0}

Dvoriac Serghey Vasilyevich – psychiatrist and narcologist, PhD in medicine, director of the Ukrainian Institute of Rearch in Social Health, temporary WHO expert on the issues of drug dependents' treatment and care, UNODC consultant, lecturer at the Department of Narcology of Kharkov Medical Academy of Post-University Education, member of the National Council for Drug Addiction Prevention of the Ministry of Interior of the Ukraine, author of numerous scientific articles about various issues in narcology and HIV/AIDS prevention, member of the editorial board of several scientific magazines in Europe and the USA, member of EUROPAD board of directors.

During the last 5 years Mr. Dvoriac has been running the project “Scientific and methodological assistance for implementation of replacement therapy programs in Ukraine». He also developed national plans of implementation of replacement therapy in Kazakhstan, Azerbaijan, Tadjikistan, Turkmenistan, contracted by UNODC. He is also the scientific advisor of a number of research projects, funded by WHO and NIDA. He is the co-director of the International seminar «Efficient treatment of opioid dependence» in Salzburg (funded by the Open Society Institute).

1. Brief justification of evaluation.

Just as in the majority of the former USSR countries, the number of HIV-positive people in Moldova has grown quite significantly over the last two decades.According to the National AIDS Centre, there were 4131 HIV-positive people at the end of 2007. A significant part of them come from the left bank of Moldova – Transnistria. The most alarming factor is the increased number of HIV-positive among IDUs in this region(see Table 1).

If in 2005 there were identified 111 infected, then in the following year - 129, in 2007 – 131. In general, the HIV incidence among IDUs in Moldova constituted in 2007 21 %, and the general HIV incidence – 0.4% (UNAIDS).It is evident that the situation in Transnistria nowadays is not better, since close neighbourhood with Moldova and Ukraine leads to the fact that the problem of injected drugs use and HIV spread is as acute as in those countries.

Table 1.

It is quite well known that in Moldova, as well as in Ukraine, Russian Federation and other former USSR countries, injected drug use is the main way of propagation of HIV, even though for the last few years the sexual way predominates, still up to 45% of the new cases of HIV are related to IDU.Thus, this vulnerable group must be tackled actively.Firstly, those that use injected drugs must be identified, efficiently treated and involved into various harm reduction programs.

1. The legislation of Transnistria, related to drug addiction assistance.<0}

Assistance and medical, psychological and social services for the drug addicts and IDUs, as well as measures to prevent drug consumption and drug addiction are origanised in compliance with the following legislation:

- The Constitution of Transnistria

- The law on social rehabilitation of patients suffering from chronic alcoholism, drug and substance addiction;

- The law on licensing certain types of activities

- The Criminal code of Transnistria

- The code of administrative offence of Transnistria

The constitution of Transnistria abolishes the laws of Moldova on the territory of Transnistria. In general, the legislation of Transnistria is oriented towards the Russian one.According to the information, received during the meetings with the representatives of the state institutions (Ministry of Health Care, Ministry of Justice), the legislation of Transnistria must be harmonized with the legislation of the Russian Federation.

Medical assistance, according to the Constitution of Transnistria, is free of charge.Article 39. «The citizens of the TransnistrianMoldovanRepublic are guaranteed the right for health care, including free medical service and treatment in state medical institutions.»

The peculiarities of Trasnistrian legislation related to drug consumption, compared to the other former USSR countries, are the followings:

First, the use of drugs is considered an administrative offence and is punished with a fine according to the Code of administrative offence.[art.44 – Illegal purchase or storage of drugs or psychotropic substances in small quantities, or consumption of drugs or psychotropic substances without prescription of a doctor.Illegal purchase or storage without the intention of further sale of drugs or psychotropic substances in small quantities, as well as consumption of drugs or psychotropic substances without prescription of a doctor shall lead to a fine in the amount between 7 (seven) and 300 (three hundred) minimum salaries or administrative arrest for up to 15 (fifteen) days].

Second, illegal purchase and storage of drugs without the intention of further sale (no matter what the volume or weight is) is punished according to art.226 of the Criminal Code with up to 3 years of imprisonment.(In many other countries such measures are taken only against those to whom storage of large and very large quantities, or storage for further sale is incriminated).

In this case, it is very important to note that with such strict norms of control of consumption by law enforcement agencies it is very difficult to implement harm reduction programs and take measures for treatment of drug addiction and HIV prevention because IDUs are fully criminalized, go "into the dark”, turn into an extremely closed and, thus, hardly accessible vulnerable group.

1. The status of narcological assistance in Transnistria.

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In Transnistria, just as in other countries of the former USSR, there is an institution of narcological assistance, provided in the health care system by narcologists and nurses.The institution of social workers is practically absent.There are no psychologists in narcological institutions.Medical assistance is provided in narcological dispensaries, offices for substance abuse counselors and psychiatry hospitals.There is just the Republican Narcological Dispensary (Tiraspol) in Transnistria, which is a ward of the RepublicanClinicalHospital.The same hospital has a psychiatry ward, where 10 beds have been reserved for narcology patients.They are mostly occupied by patients with alcohol addiction and psychosis.There is also a narcological ward of 60 beds (20 of them for patients with drug addiction) in the RepublicanPsychiatryHospital located in the country, inVyhvatintsyVillage, Rybnitsa District.At the time of the visit, there were no patients with drug addiction in the ward and all beds were taken by patients with alcohol addiction.

The structure of narcological assistance is shown in Fig. 1.

Fig. 1

The structure of narcological service in Transnistria

Narcological medical assistance in the Republic

1

According to the narcologists, for the last 3 years the number of IDUs in Transnistria has significantly decreased, which is explained first of all by active measures taken by the police, which "closed all access channels for drugs".At the same time, (September 2009) there are 1886 people registered now.Many of them were registered for prevention, without any signs of dependence, but not all of them use injected drugs.According to the information, received from the doctors of the Republican narcological dispensary, 50% of this number, i.t. 9450 people suffer from dependence.About the same number of people use injected opiates.

One of the peculiarities of evidence of people suffering from substance addiction in Transnistria is the fact that they are normally registered after the expertise for drug intoxication. Since cannabis is the most widespread drug, the majority of the registered users are consumers of cannabis.Thus, the percentage of HIV-infected people is calculated to among IDUs only, but among all drug users, many of them being most likely not addicted.

Mention must be made that no surveys have been carried out in Transnistria and thus the information about the number of IDUs is based upon the number of applications of patients or arrests.Since there is severe punishment for storage and purchase of drugs and the police is actively using repressions against IDUs, the latter prefer not to apply for help and thus, the group remains out of the reach of professional helpers.

The information about registered drug users is shown in the tables.

Table 2

Statistic indexes of the drug addicts and drug users that live in various districts of Transnistria.

1

If one should calculate the percentage of HIV-infected among the IDUs only, then one would get more realistic figures of the epidemic, closer to the ones, registered in other countries, for example in the Ukraine. According to the information on registered drug users, there are 945 IDUs in Transnistria, 302 of them being HIV-positive.Thus, the percentage of affected in this group is 32%, not 11.3% as the narcologists of Transnistria propose to consider.Besides that, one must remember that only 50% of IDUs were tested for HIV.Thus, if the coverage of testing increases, then the percentage will also increase.It is not excluded that more than 50% of IDUs are HIV-positive.With such a level of incidence, it is clear that decisive special measures are necessary to control the epidemic in this vulnerable group.

According to the information of the narcological service of Transnistria, the incidence of substance addiction can be presented in the following way.

Table 3

Nosologic distribution of drug consumers in various regions of the Republic:

TIRASPOL

BENDER

SLOBOZIA

1

Fig.2

Registered drug consumers

Consumers Consumers

Dependent onthat are not

drugsdependent on drugs

Table 4[1]

One must take into account the fact that the majority of those who consume more than one drug are normally dependent on opioids and one or several other drugs. Thus, they may be considered patients requiring treatment of addiction to opioids.Thus implies that the addiction to opioids is the most important problem related to drug consumption.Judging by the available data we may conclude that about 800 people require therapy of opioid dependence.(The number of patients, diagnosed with addiction to opiates and several substances is summed up.)

According to the WHO recommendations the need of ORT with high provision of this kind of treatment makes over 40% of the IDUs, identified during surveys[2].In many former USSR countries the correlation between registered IDUs and their reference number is 1 to 4 or 5. One may conclude that with 978 officially registered drug addicts, there are in fact 4-5 thousand of them in Transnistria.In other words, if we base the calculations on the estimated number of drug consumers and the WHO recommended indexes of driving 20 to 40% of that number to the ORT, we will see that between 800 and 200 people require ORT.

Table 5

Ways of transmission in the registered cases of HIV/AIDS in Transnistria [3]

1. Sexual

Taking into account the fact that IDUs normally tend to conceal their behaviour, it is quite probable that a large number of people with non-identified dependencies may very well be using injected drugs.

Thus, there is no doubt about the fact that the problem of consumption of injected drugs in Transnistria is still actual.At the same time, the analysis of the existing prevention and treatment programs for IDUs shows that the Republic does not use the experience of the majority of developed countries in tackling the HIV epidemic among IDUs effectively.The program of ORT for opioid addict IDUs is still not implemented, though WHO, UNAIDS and UNODC recommend this method as the most efficient one for countries where HIV/AIDS spreads because of injected drug use[4]. Harm reduction strategies are not used efficiently.

It is necessary to broaden the opportunities of the ORT and provide more access to this kind of therapy to the IDUs that require it. The international experience shows that the coverage of ORT must constitute about 20-40% of the opioid addicts in order for prevention to be efficient.

1. Treatment of opioid substance dependence and HIV prevention in Transnistria.

Treatment of behaviour and psychological disorders, caused by intake of opioids with symptoms of dependence, is carried out in Transnistria according to the methodology, proposed in Soviet time.The narcologists said that there are no official standard, confirmed by Health Care Ministry, of treatment of drug dependence or clinical protocols that describe therapy of this illness, approved by the Ministry of Health of Transnistria.The doctors of the narcological dispensary have attended professional development courses, organized by the department of psychiatry and narcology of DnepropetrovskMedicalAcademy and the department of psychotherapy of KharkovMedicalAcademy of post-university level.It is quite well known that the approaches to treatment of drug dependence, used in the above-mentioned institutions, are based on old concepts, mostly preserving the principles, formed during the Soviet period, i.e. are based on a repressive approach and do not correspond to the latest standards, described in the last CDC, WHO guidelines[5].