37918 HIV/AIDS - Getting Results These reports describe activities, challenges and lessons learned during the World Bank Global World Bank's HI/AIDS work with countries and other partners. HIV/AIDS Program Preventing HIV infection in Russia: best practices in harm reduction programs A new assessment of best practices in HIV/AIDS harm reduction programs in the Russian Federation was done for the World Bank by the Open Health Institute in 2006. "Harm Reduction Programs in the Civilian and Prison Sectors of the Russian Federation: Assessment of Best Practices", provides insights into factors contributing to successful harm reduction programs. These programs are vital in helping to control the HIV epidemic in Russia, where injecting drug users account for 70% of all HIV cases. Context ­ HIV in Russia Countries of the former Soviet Union have some of the sharpest increases in HIV incidence ever observed. In 1995, the Russian Federation had a cumulative total of one thousand registered HIV cases; by April 2006, over 352,000 cases had been recorded (Figure 1). With 70% of HIV cases in Russia in 2004-2005 connected with Injecting Drug Users (IDUs), and estimates of the Figure 1: Number of new cases and total number of number of IDUs in the country ranging from 2 ­ 4 million, cases in the Russian Federation, 1996-2005 the situation is critical. Projections are difficult, but predictions of 1,250,000 HIV cases in Russia (up to 50% 350000 of IDUs infected) by 2008 are relatively modest, compared New cases with the US National Intelligence Council's estimate of 3 ­ 300000 Cumulative cases 8 million cases by 2010. Indeed, although this may simply 250000 be the result of lower testing coverage from 2002 ­ 2004, there is some evidence of the beginning of an upsurge in 200000 the epidemic. Even optimistic predictions of HIV trends and their economic impact by 2010 expect a decrease in 150000 GNP by 4.15% and in investments by 5.5%. 100000 Since the HIV epidemic in the Russian Federation is driven largely by intravenous drug users (in prisons and in the 50000 civilian population) sharing contaminated needles, effective programs to prevent new infections must focus on 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 these groups, and their sexual partners. "We are at a turning point," says Patricio Marquez, lead Source: National AIDS Center, 2006 health specialist and Team Leader of a World Bank- financed Russia Tuberculosis and HIV/AIDS control The actual number of HIV cases is most likely several project. There is some evidence that Russia, like its times higher, because many people with the greatest neighbor Ukraine, is already experiencing the epidemic's risk of infection do not have routine access to health "second wave," when the virus breaks out of a care services and so have a much smaller chance of concentrated high risk group. There is an urgent need to being tested. UNAIDS estimates the number at 860,000; reach all high risk drug-injecting people with effective other estimates range from 420,000 to 1,400,000. programs, to stop the virus spreading to the general population through a "bridge" group of their partners, participate in the program pass on needles and syringes to wives and girlfriends. others not in the program), and insufficiently control for confounding factors. So although debate about the Anti-drug policies that prohibit and criminalize drug use effectiveness of HR continues, a mounting body of have proved unsuccessful, and increase IDU risk of HIV. evidence ­ including hard data from Australia and Canada Numerous studies in a number of countries have shown ­ suggests that harm reduction programs are a necessary high failure rates among IDUs who try to stop drug use and cost-effective tool in stopping the spread of HIV in (92% in one St Petersburg sample); other policies are countries where drug use is an important "driver" of the needed to prevent the spread of HIV among and beyond epidemic. Studies record significant success in reducing the IDU population. risky behavior and HIV prevalence among IDUs in cities with different levels of HR activity, and among HR Harm Reduction participants and non-participants. All studies in Russia and elsewhere have shown HR to be cost-effective compared Harm reduction (HR) policies and programs aim to with other life-saving interventions. reduce the adverse health, social and economic consequences of drug use. Needle exchange programs Harm reduction in Russia (NEP) are one component of HR, and prevent the transmission of HIV (and other infections) that comes The first pilot HR project in Russia began in 1996, and in from sharing non-sterile injection equipment and drug 1997, there were 5 needle exchange and peer education preparations. HR programs often also include other programs operating in Moscow, St Petersburg and other medical and social services to improve the health of areas. The Russian Federal Ministry of Health then worked IDUs. with local and international NGOs in a coordinated effort to expand program coverage, offering training, and facilitating Worldwide, HR began in 1984 in the Netherlands. Harm rapid situation assessments and grants from the Open reduction programs have gained widening acceptance in Society Institute in Russia (OSI-Russia). By the end of the last five years and exist in all 25 members of the 2000, OSI was supporting 36 needle exchange projects in European Union, in many countries of Eastern Europe 32 regions. The number of HR projects in Russia has and the Former Soviet Union, and many countries in continued to increase, with 63 projects underway in mid- Asia including China and India (see map in Figure 2). 2006, funded by DFID, international NGOs, and the Global They are supported by major international agencies, Fund. However, coverage is still low. including WHO, UNAIDS, UNICEF, UNODC, and the World Bank. Given Russia's HIV incidence and trends, the number of IDUs and the huge size of the country, a comprehensive Figure 2: Harm Reduction Programs in 2003 national strategy and an urgent scale-up of HR for IDUs is necessary, including additional funding from federal and regional governments. "While NGO, Government, and donor efforts are ramping up, only a tiny fraction of Russia's injecting drug users are getting help ­ funding and capacity building must rise exponentially if real progress is to be made in stemming the epidemic," stresses Marquez. The Bank-financed $286 million Russia Tuberculosis and HIV/AIDS control project offers an opportunity to consolidate HR programs to make them sustainable and increase their scale and coverage. "We need to create a consensus at the federal and regional levels that harm reduction programs are effective and that criminalization of drug usage in the context of an HIV/AIDS epidemic is not the solution. Increased enforcement does not lead to a drop in drug consumption but increases HIV infections Source: Wodak A. 2000 (http://www.ihra.net/) among drug users." says Marquez. Studies on the effectiveness of HR seldom report If programs are to be expanded, and considerably more biological outcomes, often disregard alternate sources of resources invested in HR, then it is important to syringes and "secondary exchange" (in which IDUs who understand how to design and operate HR programs that 2 are most effective in preventing HIV infection, and most criteria most often cited spontaneously by the respondents cost-effective. as relevant in comparing projects. These criteria (none of which was shown to have overwhelming importance for Best Practice in Harm Reduction in Russia evaluating HR projects) were then subjected to further analysis to measure the influence of the criteria categories In 2001, a study carried out for the World Bank on "Best selected by the respondents on their evaluation of Practice in Harm Reduction in the Community and in projects. The distance between the ratings given to Prisons in the Russian Federation" identified factors that particular (actual) projects and to hypothetical best and contribute to good practice and program success: worst projects permitted conclusions about the relative importance of success criteria. ¡ Attitude of HR programs staff toHR strategies (activism, enthusiasm, etc); Results ¡ Support from local authorities and institutions; ¡ International funding and technical support; Where HR was initially viewed negatively, attitudes ¡ Use of rapid situation assessments; became more favorable after exposure to the programs. Opinion was divided as to whether the aim of HR was to ¡ Support for peer education and secondary prevent HIV transmission within the IDU community or to exchange. keep the HIV epidemic within this community. Many respondents viewed narrow programs confined to needle Much has been done and learned about HR in Russia exchange to be one step in the evolution of HR to a since 2001, so a new study was done to update the early general "health oriented" strategy involving a assessment in the context of a more mature HR program comprehensive range of services, including medical care, in Russia. It looks at best practice in relation to process social support and legal aid, premised on the drug user as (staff, evaluation system, use of resources, etc), and a human being in need of complex care. This attitude was outcome indicators (incidence of HIV, STI and seen to be in contrast to the perceived official government overdoses). It also considers the extent to which the position, in which IDUs are lumped together with the label context of HR programs is determined or modifiable. of potential or present criminal. It also diverged widely from the reality of HR in Russia today, which is focused on Best practice in harm reduction is defined as programs needle exchange. Although some respondents believed that achieve good results (even in a hostile that substitution therapy (banned in the USSR in the environment), that improve modifiable context 1970's) is a necessary element of HR, attitudes of state characteristics and achieve objectives of effectiveness, representatives and prison officials ranged from cautious multi-sector collaboration and sustainability. to negative. On the whole, respondents believe that HR is successful, and were optimistic about the future. Methodology Success Indicators Following a review of the literature on harm reduction, 57 anonymous, semi-structured interviews of 40 minutes HR programs are seen to be successful in that they: were recorded with managers and providers of HR ¡ Control the HIV/AIDS epidemic, with lower incidence services, users of these services (IDUs and inmates) rates in areas with HR programs (there was only and regional policy-makers in six regions of the Russian anecdotal data to support this, a caution noted by Federation. These included the two regions most some respondents, but the belief was widespread). successful in implementing HR civilian and prison programs. In addition, seven pilot interviews and a "Before, 70-80% of HIV [infection] was among further seven interviews with federal decision-makers IDUs, now it is only 20%." were carried out. ¡ Provide greater access to an otherwise increasingly Of the 71 people interviewed, 41 also filled out "repertory closed target group. The possibility that even a small grids" which were then analyzed. Repertory grids are a number of HR clients might quit was also seen as a way to elicit the personal constructs by which people great advantage, and HR was the most successful organize events and experiences. The open-ended means of reaching them. structure of this technique, which invites respondents to ¡ Increase safe injecting practices (again often there choose their own factors for evaluating HR projects was anecdotal but no hard data to confirm this belief). (either three existing projects known to them or one project in the past, present and future, together with an "In 2000 72% of users were sharing equipment, ideal project and a bad project) provided a way to presently it is 18% only." compare the importance given to different criteria in the interviews. Analysis of the repertory grids identified the 3 ¡ Increase or sustain political support for HR. The third most important criterion which emerged from the ¡ Increase collaboration with law enforcement bodies. repertory grid analysis was the breadth of services This was seen to be hard-won and still often fraught. provided by the HR project. Respondents emphasized the Regular training for law enforcement staff was need for a holistic approach to HR, not limited to needle recommended, given the high turnover rates among exchange, but including a variety of medical and social junior officers, who are often hostile to IDUs and support services, including testing and counseling. This outreach workers. The absence of hostility from the breadth of services was seen to attract clients and State Drug Control Service was seen to be critical to motivate staff. It is relevant that in identifying the benefits success. It should be noted that in some regions the of HR programs, IDUs themselves mentioned not only the Drug Control Service refused to participate in this syringes and condoms supplied, but also the benefits of study in order to avoid expressing their attitude. information, social support and access to medical services. ¡ Increase links across the health Outreach, rather than the location of the HR project, is care system. Animosity between important for successful HR programs. Adaptability to the HR projects and the health care fluid, increasingly hidden and isolated narcotics scene was system greatly hampers harm viewed as critical. Support for secondary exchange, and reduction projects, and the extent an open hours program were also highlighted. Involvement to which this was overcome was of former and current IDUs, although problematic, can help an important factor in success. in the recruitment and maintenance of clients, and was Attitudes of IDUs to HR programs more important than mobile exchange sites. This is were positive, although only HR users reflected in the fourth repertory grid criterion ­ knowledge were interviewed for this study. of the HR program among members of the target groups. How is success achieved? In terms of organization, most respondents expressed The repertory grids reinforced the findings of the preference for projects for which there was overall NGO interviews, highlighting factors critical to the success of responsibility, in partnership with state institutions, which HR programs. Despite the belief that outcomes were were viewed as unduly rigid. Flexibility of approach was affected by HR, respondents used process indicators -- considered essential both as regards funding and the not outcome indicators-- to judge the effectiveness of HR content of the program. programs. In summary, a best practices project should invest Internal variables accounted for 78% of all criteria listed resources in improvi ng societal perceptions of HR. It by respondents. Nevertheless, the dominant criterion should have a well-planned recruiting and retention cited was the external variable, societal environment ­ strategy for staff, and should provide a wide range of public and administrative opinion of HR. Negative services to IDUs, including medical care and information. public and media attention was seen to be highly It should ensure that IDUs are informed about these detrimental to the success of an HR program. services. Government support and financing were judged to be slightly less important than societal environment, HIV prevention in the Russian penal system perhaps because most of the projects considered already had fairly long-term financing. Sufficient funding, Russia's imprisonment rate (670/100,000 population in which remains precarious for many HR projects in 2003) is amongst the highest in the world. As in Eastern Russia, was viewed as fundamental to the sustainability European countries, HIV rates among prisoners in Russia of HR projects. Respondents said that ideally, funding are higher (4% in 2002) than in the general population. should come from both regional and national IDUs are often over-represented in prison populations, and governments and from external donors. usually continue to use drugs while incarcerated. Human resources were ranked in both interviews and HR programs began to a limited extent in Russian prisons repertory grids as the second most important criterion for in 1990. WHO guidelines issued in 1993 recommended successful HR projects. Strong leadership and good that HR should be as available in prisons as in civil management were cited in the interviews, but the communities, and literature from other countries shows repertory grids focused primarily on the necessity for that needle exchange programs are feasible and beneficial professional, enthusiastic employees. It was in prison populations. However, Russian law forbids recommended that attention be given to the high burnout syringe exchange in prisons, so programs are limited to rate of outreach workers, that their salaries be increased HIV education for staff and prisoners, peer education, and and their professional profile be formalized. provision of disinfectants and condoms (although condoms 4 are not available to the same degree as in civilian HR References, further information programs). A Russian study comparing two prisons ­ ¡ Open Health Institute. 2006. Harm Reduction one with an HR program and with one without ­ found Programs in the Civilian and Prison Sectors of the that prisoners with access to HR knew more about HIV, Russian Federation: Assessment of Best Practices, reported less risky behavior, and no more drug use, than On line at: www.worldbank.org/aids > Publications prisoners with no HR program (Bobrik, 2004). ¡ Russia Tuberculosis and HIV/AIDS control project This perception was echoed in the assessment although, From www.worldbank.org, search for project P064237 as with the civilian programs, no epidemiological data ¡ Wodak, A. 2006. "Controlling HIV among injecting drug were cited to substantiate this. Eleven interviews with users: current status of harm reduction", Presentation peer educators, leaders of prison projects and heads of at International AIDS Conference, Toronto, August prison medical departments discussed prison HR 2006. projects. Five experts completed repertory grids. In http://www.ihra.net/pdf/AWodak2006Torontoslides.pdf addition to preventing HIV transmission, increased knowledge of HIV among both inmates and prison staff ¡ Bobrik A. 2004. Assessment of prevalence of HIV, and improved socialization of prisoners were cited as syphilis and risk factors of its transmission in penal jurisdiction. Medico-social problems of socially achievements of HR programs. conditioned diseases. Scientific works, Ministry of Health, Central Public Health Research Institute, In the repertory grids, as for the civilian programs, the Russia, Moscow. experts focused on process rather than outcome criteria. External factors were less relevant than for civil projects, ¡ Burrows D. 2001. A Best Practice Model of Harm given the closed nature of the institutions, however the Reduction in the Community and in Prisons in Russian influence of the prison administration and the Federal Federation. The World Bank, Washington, DC. Penitentiary Service was critical. The dominant factors ¡ WHO Guidelines on HIV infection and AIDS in prisons. for successful prison HR projects were: (1) wide access WHO Global Programme on AIDS. 1993: 9 to services and (2) a wide range of services. The availability of peer education, education of both prison staff and administration, training sessions and the presence of professional psychologists were all cited, as was the availability of condoms. The third factor, also stressed during the interviews, was the need for continuity of care after inmates were released from prison, through links with other organizations. The absence of this social support was seen to be the major failing of the present system. Moving forward Barriers and limitations aside, best practice efforts are emerging. A multi-year program for Russia's prison system, under way since 1999, set up HIV prevention and health promotion efforts in the prisons of four For more information: regions. A Harm Reduction Bridging Project as well as Patricio Marquez, Lead Health Specialist, World an initiative called `GLOBUS' are further expanding Bank, Europe and Central Asia Region. these types of programs, both inside and outside pmarquez@worldbank.org. prisons. A Russian Harm Reduction Network is expanding its activities around the country as part of these scaling-up efforts. In every instance the involvement of local non-governmental organizations "HIV/AIDS - Getting Results" series editor: with first-hand knowledge of the IDU community are Joy de Beyer, World Bank Global HIV/AIDS Program critical to success. Government support is also critical. jdebeyer@worldbank.org September 2006 5