Perceived quality of HIV care and client satisfaction across different service providers in Ukraine.

BACKGROUND: Prior studies have shown that high client satisfaction and quality of services are important drivers of uptake and retention in human immunodeficiency virus (HIV) care. Study objectives were to assess the perceived quality of HIV services, satisfaction and associated factors across different types of health facilities in Ukraine. METHODS: We conducted a cross-sectional study among 649 individuals receiving HIV services across 47 health facilities in three regions of Ukraine. Primary outcomes were satisfaction and perceived quality of services measured along five dimensions: accessibility, user-friendliness, privacy and confidentiality, comprehensiveness (separately for testing and treatment services). Quality dimensions were constructed by confirmatory factor analysis. Links between quality dimensions, satisfaction and related factors were measured by structural equation modelling. RESULTS: Median scores for accessibility, user-friendliness, privacy and confidentiality, comprehensiveness of services and overall satisfaction ranged from 0.75 to 1 out of 1. User-friendliness was the main determinant associated with satisfaction (total effect: ß = 0.515, P < 0.001). Satisfaction was higher at primary healthcare centres (direct effect: ß = 0.145, P < 0.001; indirect effect through accessibility: ß = 0.060, P < 0.001), narcological/tuberculosis dispensaries (direct effect: ß = 0.105, P = 0.006; indirect effect through accessibility: ß = 0.060, P < 0.001) and hospitals (indirect effects through user-friendliness and accessibility: ß = 0.180, P < 0.001) when compared to acquired immune deficiency syndrome centres. CONCLUSIONS: User-friendliness is a key driver of client satisfaction with HIV services in Ukraine. Decentralization of services, together with improved training and supervision for provider-client interactions may provide important levers to improve client satisfaction with HIV services and enrolment and retention in the cascade of HIV services.

Optimal allocation of HIV resources among geographical regions.

BACKGROUND: Health resources are limited, which means spending should be focused on the people, places and programs that matter most. Choosing the mix of programs to maximize a health outcome is termed allocative efficiency. Here, we extend the methodology of allocative efficiency to answer the question of how resources should be distributed among different geographic regions. METHODS: We describe a novel geographical optimization algorithm, which has been implemented as an extension to the Optima HIV model. This algorithm identifies an optimal funding of services and programs across regions, such as multiple countries or multiple districts within a country. The algorithm consists of three steps: (1) calibrating the model to each region, (2) determining the optimal allocation for each region across a range of different budget levels, and (3) finding the budget level in each region that minimizes the outcome (such as reducing new HIV infections and/or HIV-related deaths), subject to the constraint of fixed total budget across all regions. As a case study, we applied this method to determine an illustrative allocation of HIV program funding across three representative oblasts (regions) in Ukraine (Mykolayiv, Poltava, and Zhytomyr) to minimize the number of new HIV infections. RESULTS: Geographical optimization was found to identify solutions with better outcomes than would be possible by considering region-specific allocations alone. In the case of Ukraine, prior to optimization (i.e. with status quo spending), a total of 244,000 HIV-related disability-adjusted life years (DALYs) were estimated to occur from 2016 to 2030 across the three oblasts. With optimization within (but not between) oblasts, this was estimated to be reduced to 181,000. With geographical optimization (i.e., allowing reallocation of funds between oblasts), this was estimated to be further reduced to 173,000. CONCLUSIONS: With the increasing availability of region- and even facility-level data, geographical optimization is likely to play an increasingly important role in health economic decision making. Although the largest gains are typically due to reallocating resources to the most effective interventions, especially treatment, further gains can be achieved by optimally reallocating resources between regions. Finally, the methods described here are not restricted to geographical optimization, and can be applied to other problems where competing resources need to be allocated with constraints, such as between diseases.

Feasibility of needle and syringe programs in Tajikistan distributing low dead space needles.

BACKGROUND: In 2012, the World Health Organization recommended that needle and syringe programs offer their clients low dead space insulin syringes with permanently attached needles. However, in many countries, these syringes are not acceptable to a majority of people who inject drugs. This study assessed the feasibility of working with needle and syringe programs to implement the WHO recommendation using low dead space detachable needles. The study also assessed the acceptability of the needles. METHODS: Two needle and syringe programs in Tajikistan-one in Kulob and one in Khudjand-received 25,000 low dead space detachable needles each. The programs distributed low dead space detachable needles and a marketing flyer that emphasized the relative advantages of the needles. Each program also enrolled 100 participants, and each participant completed a baseline interview and a 2-month follow-up interview. RESULTS: At follow-up, 100% of participants reported trying the low dead space detachable needles, and 96% reported that they liked using the needles. Both needle and syringe programs distributed all their needles within the first 60 days of the project indicating use of the needles, even among clients who did not participate in the study. CONCLUSIONS: This project demonstrates that it is feasible for needle and syringe programs to offer and promote low dead space needles to their clients. The findings indicate that low dead space needles are acceptable to needle and syringe program clients in these Tajikistan cities. To reduce HIV and hepatitis C virus transmission, needle and syringe programs should offer low dead space needles, low dead space insulin syringes in addition to standard needles, and syringes to their clients.

Drug preparation, injection, and sharing practices in Tajikistan: a qualitative study in Kulob and Khorog.

BACKGROUND: Sharing injection equipment remains an important rout of transmission of HIV and HCV infections in the region of Eastern Europe and Central Asia. Tajikistan is one of the most affected countries with high rates of injection drug use and related epidemics.The aim of this qualitative study was to describe drug use practices and related behaviors in two Tajik cities - Kulob and Khorog. METHODS: Twelve focus group discussions (6 per city) with 100 people who inject drugs recruited through needle and syringe program (NSP) outreach in May 2014. Topics covered included specific drugs injected, drug prices and purity, access to sterile equipment, safe injection practices and types of syringes and needles used. Qualitative thematic analysis was performed using NVivo 10 software. RESULTS: All participants were male and ranged in age from 20 to 78 years. Thematic analysis showed that cheap Afghan heroin, often adulterated by dealers with other admixtures, was the only drug injected. Drug injectors often added Dimedrol (Diphenhydramine) to increase the potency of "low quality" heroin. NSPs were a major source of sterile equipment. Very few participants report direct sharing of needles and syringes. Conversely, many participants reported preparing drugs jointly and sharing injection paraphernalia. Using drugs in an outdoor setting and experiencing withdrawal were major contributors to sharing equipment, using non-sterile water, not boiling and not filtering the drug solution. CONCLUSION: Qualitative research can provide insights into risk behaviors that may be missed in quantitative studies. These finding have important implications for planning risk reduction interventions in Tajikistan. Prevention should specifically focus on indirect sharing practices.

Factors that influence the characteristics of needles and syringes used by people who inject drugs in Tajikistan.

BACKGROUND: "Low dead space" syringes with permanently attached needles retain less fluid, blood, and HIV after use than standard "high dead space" syringes. This reduces the probability of HIV transmission if they are shared by people who inject drugs (PWID). The World Health Organization recently recommended that needle and syringe programs (NSP) offer clients low dead space syringes. The success of this recommendation will depend on PWID switching to low dead space needles and syringes. This paper examines the needles and syringes that PWID in Tajikistan use and factors that influence their choices. METHODS: In May 2014, we conducted six focus groups in Kulob and six in Khorog, Tajikistan, with a total of 100 participants. NSP staff members recruited participants. Focus group topics included the needles and syringes used and factors that influence choice of needles and syringes. Focus groups were conducted in Russian and Tajik, audio recorded, transcribed, and translated into English. The translated files were imported into NVivo 10 for coding and analysis. RESULTS: All participants in both cities were male and reported injecting heroin. Everyone also reported using syringes with detachable needles almost exclusively. The most popular syringe sizes were 2 and 5 ml. Needles ranged in gauge from 25 to 21 g. Needle gauge was influenced by the size of the vein, the viscosity of drug solution to be injected, and problems with blood clotting. Needles ranged in length from 12 to 38 mm, with 25 and 32 mm being the most popular. Needle length was influenced by the depth of the vein being used. Many PWID inject volumes of fluid greater than 1 ml into deep veins that require needles at least 25 mm long and 25 g in diameter. CONCLUSION: Most low dead space syringes are 1-ml insulin syringes with 12 mm 28 g permanently attached needles. Findings from this project suggest that these will not be acceptable to PWID who need larger syringes and longer and thicker needles that are detachable. Low dead space detachable needles appear to be an acceptable option that could overcome barriers to the widespread use of low dead space equipment for reducing HIV and HCV transmission.

Controlling HIV among people who inject drugs in Eastern Europe and Central Asia: insights from modeling.

BACKGROUND: Although there is evidence of the effectiveness of needle and syringe programme (NSP), opioid substitution therapy (OST) and antiretroviral therapy (ART) in reducing HIV prevalence, most Central and Eastern European sub-regions still have low or no coverage of most or all of these interventions. METHODS: We conducted a modelling analysis to consider the potential impact on HIV incidence and prevalence of OST, NSP and ART in three illustrative epidemic scenarios: Russia (St. Petersburg); Estonia (Tallinn) and Tajikistan (Dushanbe). For each intervention, we consider the coverage needed of each intervention separately or in combination to: (1) achieve a 30% or 50% relative reduction in HIV incidence or prevalence over 10 years; and (2) reduce HIV incidence to below 1% or HIV prevalence below 10% after 20 years. A sensitivity analysis for St. Petersburg considered the implications of greater on no risk heterogeneity, none or more sexual HIV transmission, like-with-like mixing, different injecting cessation rates and assuming a lower HIV acute phase cofactor. RESULTS: For St. Petersburg, when OST, NSP and ART are combined, only 14% coverage of each intervention is required to achieve a 30% reduction in HIV incidence over 10 years. Similar findings are obtained for Tallinn and Dushanbe. In order to achieve the same reductions in HIV prevalence over 10 years, over double the coverage level is required relative to what was needed to achieve the same reduction in HIV incidence in that setting. To either reduce HIV incidence to less than 1% or HIV prevalence to less than 10% over 20 years, with all interventions combined, projections suggest that very high coverage levels of 74­85% are generally required for the higher prevalence settings of Tallinn and St. Petersburg, whereas lower coverage levels (23­34%) are needed in Dushanbe. Coverage requirements are robust to increased sexual HIV transmission, risk heterogeneity and like-with-like mixing, as well as to assuming a lower HIV acute phase cofactor or different injecting cessation rate. CONCLUSION: The projections suggest that high but achievable coverage levels of NSP can result in large decreases (30%) in HIV incidence in settings with high HIV prevalence among PWID. Required coverage levels are much lower when interventions are combined or in lower prevalence settings. However, even when all three interventions are combined, the targets of reducing HIV incidence to less than 1% or prevalence to less than 10% in 20 years may be hard to achieve except in lower prevalence settings.

Drug scene, drug use and drug-related health consequences and responses in Kulob and Khorog, Tajikistan.

BACKGROUND: Tajikistan and other Central Asian republics are facing intertwined epidemics of injecting drug use and HIV. This paper aims to examine drug scene, drug use, drug-related infectious diseases, drug treatment and other responses to health consequences of drug injecting in two Tajik cities of Kulob (Khatlon Region) and Khorog (Gorno-Badakhshan Autonomous Oblast). METHODS: We conducted 12 focus group discussions in Kulob and Khorog and analysed peer-reviewed literature, published and unpublished programme and country reports and other publications that focused on substance use and/or HIV/AIDS in Tajikistan and included the Khatlon and Gorno-Badakhshan regions. RESULTS: In both Kulob and Khorog, heroin is used by the overwhelming majority of people who inject drugs (PWID), with one dose of heroin in Khorog costing less than a bottle of vodka. Opioid overdose among PWID in Tajikistan is a serious issue that appears to be substantially underestimated and inadequately addressed at the policy and practice levels. In integrated bio-behavioural surveys (IBBS), HIV and HCV prevalence in both Kulob and Khorog varied widely over a short period of time, raising questions over the quality and reliability of these data. Access to opioid substitution therapy (OST) and antiretroviral therapy (ART) by PWID is either lacking or inadequate. Very few women who inject drugs access needle and syringe programmes in Kulob and Khorog. HCV treatment cannot be afforded by the overwhelming majority of PWID due to high costs. CONCLUSION: Tajikistan IBBS data point to the potential problems in using composite national prevalence as an adequate reflection of the HIV epidemic among PWID in the country and highlight the importance of examining site-specific prevalence rates for better understanding of the dynamics of the epidemic over time as well as potential problems related to the reliability of data. Furthermore, our analysis highlights that in a country where almost all PWID inject opiates, agonist treatment should be an intervention of choice. Scaling-up both OST and ART coverage must be seen as the top priority for reducing HIV prevalence and incidence in Tajikistan. Naloxone distribution programmes need to be expanded and drug treatment, harm reduction and HIV services that meet the specific needs of female injecting drug users should be put in place.

Effective use of naloxone among people who inject drugs in Kyrgyzstan and Tajikistan using pharmacy- and community-based distribution approaches.

BACKGROUND: Opioid overdose (OD) is a major cause of mortality among people who inject drugs (PWID) in Central Asia, and distribution of naloxone, an opioid antagonist, can effectively prevent these deaths. However, little is known about the use and wastage of distributed naloxone ampoules. Having reliable data on wastage rates is critical for accurately calculating the health impact of naloxone distribution projects targeting PWID. METHODS: In 2011, Population Services International (PSI) launched two pilot naloxone distribution programs in Kyrgyzstan (pharmacy-based approach) and Tajikistan (community-based approach). PWID were trained on OD prevention and naloxone use. Upon returning for more ampoules, the PWID completed a brief survey on their OD experience and naloxone use. 158 respondents in Kyrgyzstan and 59 in Tajikistan completed the questionnaire. Usage and wastage rates were calculated based on responses. A four-year model wastage rate that takes into account the shelf life of naloxone for both countries was then calculated. RESULTS: 51.3% of respondents in Kyrgyzstan and 91.5% in Tajikistan reported having ever experienced an OD. 82.9% of respondents in Kyrgyzstan and all respondents in Tajikistan had ever witnessed an OD. Out of these PWID who experienced or witnessed OD, 81.5% in Kyrgyzstan and 59.3% in Tajikistan reported having been injected with naloxone, and 83.2% in Kyrgyzstan and 50.9% in Tajikistan reported injecting another individual with naloxone. Of ampoules received, 46.5% in Kyrgyzstan and 78.1% in Tajikistan were used. In both countries, 3.1% of these ampoules were wasted. The four-year model wastage rates for Kyrgyzstan and Tajikistan were found to be 13.8% and 3.9% respectively. CONCLUSION: Findings indicate that a high proportion of naloxone distributed to PWID is used in actual OD incidents, with low wastage rates in both countries. Expanding these distribution models can potentially create more positive health outcomes for PWID in Central Asia.

Factors mediating HIV risk among female sex workers in Europe: a systematic review and ecological analysis.

OBJECTIVES: We reviewed the epidemiology of HIV and selected sexually transmitted infections (STIs) among female sex workers (FSWs) in WHO-defined Europe. There were three objectives: (1) to assess the prevalence of HIV and STIs (chlamydia, syphilis and gonorrhoea); (2) to describe structural and individual-level risk factors associated with prevalence and (3) to examine the relationship between structural-level factors and national estimates of HIV prevalence among FSWs. DESIGN: A systematic search of published and unpublished literature measuring HIV/STIs and risk factors among FSWs, identified through electronic databases published since 2005. 'Best' estimates of HIV prevalence were calculated from the systematic review to provide national level estimates of HIV. Associations between HIV prevalence and selected structural-level indicators were assessed using linear regression models. STUDIES REVIEWED: Of the 1993 papers identified in the search, 73 peer-reviewed and grey literature documents were identified as meeting our criteria of which 63 papers provided unique estimates of HIV and STI prevalence and nine reported multivariate risk factors for HIV/STI among FSWs. RESULTS: HIV in Europe remains low among FSWs who do not inject drugs (<1%), but STIs are high, particularly syphilis in the East and gonorrhoea. FSWs experience high levels of violence and structural risk factors associated with HIV, including lack of access to services and working on the street. Linear regression models showed HIV among FSWs to link with injecting drug use and imprisonment. CONCLUSIONS: Findings show that HIV prevention interventions should be nested inside strategies that address the social welfare of sex workers, highlighting in turn the need to target the social determinants of health and inequality, including regarding access to services, experience of violence and migration. Future epidemiological and intervention studies of HIV among vulnerable populations need to better systematically delineate how microenvironmental and macroenvironmental factors combine to increase or reduce HIV/STI risk.

Breaking worse: the emergence of krokodil and excessive injuries among people who inject drugs in Eurasia.

BACKGROUND: Krokodil, a homemade injectable opioid, gained its moniker from the excessive harms associated with its use, such as ulcerations, amputations and discolored scale-like skin. While a relatively new phenomenon, krokodil use is prevalent in Russia and the Ukraine, with at least 100,000 and around 20,000 people respectively estimated to have injected the drug in 2011. In this paper we review the existing information on the production and use of krokodil, within the context of the region's recent social history. METHODS: We searched PubMed, Google Advanced Search, Google Scholar, YouTube and the media search engine www.Mool.com for peer reviewed or media reports, grey literature and video reports. Survey data from HIV prevention and treatment NGOs was consulted, as well as regional experts and NGO representatives. FINDINGS: Krokodil production emerged in an atypical homemade drug production and injecting risk environment that predates the fall of communism. Made from codeine, the active ingredient is reportedly desomorphine, but - given the rudimentary 'laboratory' conditions - the solution injected may include various opioid alkaloids as well as high concentrations of processing chemicals, responsible for the localized and systemic injuries reported here. Links between health care and law enforcement, stigma and maltreatment by medical providers are likely to thwart users seeking timely medical help. CONCLUSION: A comprehensive response to the emergence of krokodil and associated harms should focus both on the substance itself and its rudimentary production methods, as well as on its micro and macro risk environments - that of the on-going syndemic of drug injecting, HIV, HCV, TB and STIs in the region and the recent upheaval in local and international heroin supply. The feasibility of harm reduction strategies for people who inject krokodil may depend more on political will than on the practical implementation of interventions. The legal status of opioid substitution treatment in Russia is a point in case.

HIV among people who inject drugs in Central and Eastern Europe and Central Asia: a systematic review with implications for policy.

BACKGROUND AND OBJECTIVES: HIV among people who inject drugs (PWID) is a major public health concern in Eastern and Central Europe and Central Asia. HIV transmission in this group is growing and over 27 000 HIV cases were diagnosed among PWID in 2010 alone. The objective of this systematic review was to examine risk factors associated with HIV prevalence among PWID in Central and Eastern Europe and Central Asia and to describe the response to HIV in this population and the policy environments in which they live. DESIGN: A systematic review of peer-reviewed and grey literature addressing HIV prevalence and risk factors for HIV prevalence among PWID and a synthesis of key resources describing the response to HIV in this population. We used a comprehensive search strategy across multiple electronic databases to collect original research papers addressing HIV prevalence and risk factors among PWID since 2005. We summarised the extent of key harm reduction interventions, and using a simple index of 'enabling' environment described the policy environments in which they are implemented. STUDIES REVIEWED: Of the 5644 research papers identified from electronic databases and 40 documents collected from our grey literature search, 70 documents provided unique estimates of HIV and 14 provided multivariate risk factors for HIV among PWID. RESULTS: HIV prevalence varies widely, with generally low or medium (<5%) prevalence in Central Europe and high (>10%) prevalence in Eastern Europe. We found evidence for a number of structural factors associated with HIV including gender, socio-economic position and contact with law enforcement agencies. CONCLUSIONS: The HIV epidemic among PWID in the region is varied, with the greatest burden generally in Eastern Europe. Data suggest that the current response to HIV among PWID is insufficient, and hindered by multiple environmental barriers including restricted access to services and unsupportive policy or social environments.

The Soviet doctor and the treatment of drug addiction: "A difficult and most ungracious task".

This paper reviews the development of early Soviet drug treatment approaches by focusing on the struggle for disciplinary power between leading social and mental hygienists and clinical psychiatrists as a defining moment for Soviet drug treatment speciality that became known as "narcology." From this vantage point, I engage in the examination of the rise and fall of various treatment methods and conceptualizations of addiction in Russian metropolitan centres and look at how they were imported (or not) to other Soviet republics. As clinical psychiatrists appeared as undisputed victors from the battle with social and mental hygienists, the entire narcological arsenal was subdued in order to serve the needs of mainstream psychiatry. However, what that 'mainstream' would be, was not entirely clear. When, in 1934, Aleksandr Rapoport insisted on the need for re-working narcological knowledge in line with the Marxist approach, he could only raise questions and recognise that there were almost no "dialectically illuminated scientific data" to address these questions. The maintenance treatment of opiate users, which emerged as the most effective one based on the results of a six-year study published in 1936, was definitely not attuned to the political and ideological environment of the late 1930s. Maintenance was rather considered as a temporary solution, in the absence of radical therapeutic measures to free Soviet society from "narkomania." As the Great Terror swept across the Soviet Union, Stalin's regime achieved its objective of eliminating drug addiction from the surface of public life by driving opiate users deep underground and incarcerating many of them in prisons and the Gulag camps. In the final section, I briefly discuss the changing perceptions of drug use during the World War II and outline subsequent transformations in Soviet responses to the post-war opiate addiction [Additional file 1].

Healers and psychiatrists: the transformation of mental health care in tajikistan.

This article examines the transformation of mental health care in Tajikistan from the time of Russian colonization of Central Asia until the most recent years of post-independence. It incorporates a review of published literature into the analysis of locally available reports, focus group discussions, interviews and oral histories collected between 2005 and 2008. Traditional healers play a significant role in contemporary Tajikistan, where mental health care provision is influenced by the legacy of Soviet psychiatry. Tajik mental health care may now be in a "dormant" phase, characterized by a widespread neglect of people with mental illnesses.

Opioid substitution therapy in Tajikistan: Another perpetual pilot?

BACKGROUND: Opioid substitution therapy (OST) continues to face strong resistance in the former Soviet Central Asian republics. OST was discontinued by the Uzbek government in 2009. In Kyrgyzstan, with about 950 people currently receiving OST, the programme was about to be suspended in 2009. In Kazakhstan, a small pilot project serves 50 clients. Turkmenistan may introduce OST in 2010, while the Tajik Ministry of Health approved the introduction of an OST pilot in summer 2009. METHODS: This paper draws upon the analysis of interests of the OST-affected groups in Tajikistan as a case study to understand the roots of resistance to OST. RESULTS: In Tajikistan, OST may be contrary to the interests of some narcologists, law enforcement officers and drug dealers. People who use drugs do not play any role in national drug-policy making. The HIV prevention community within the Tajik executive bodies receives major financial support from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) to respond to an IDU driven epidemic, and yet it is the only group which has nothing to gain from the absence of OST. CONCLUSION: The Tajik government agreed to introduce OST in order not to jeopardize its future funding from GFATM. If the interests of the OST-affected groups are ignored, there is a high chance that OST in Tajikistan may remain a perpetual pilot project even despite all the necessary resources would come from GFATM and other donors. Putting "narcology on pilot" may prove helpful in both tackling the OST "perpetual pilots" and shifting the focus of public attention towards major inadequacies of the existing state-funded drug treatment systems in the region.

Characterization of the emerging HIV type 1 and HCV epidemics among injecting drug users in Dushanbe, Tajikistan.

This study aimed to determine HIV, HCV, and syphilis prevalence and correlates, and to characterize the molecular epidemiology of HIV-1 among injecting drug users (IDUs) in Dushanbe, Tajikistan. A cross-sectional study assessing risk factors for HIV and HCV through an interview administered survey was conducted. A total of 491 active adult IDUs were recruited from May to November 2004 in Dushanbe, Tajikistan. HIV-1 antibody status was determined with rapid testing and confirmed with ELISA. HCV antibody testing was conducted using a BIOELISA HCV kit. HIV-1 subtyping was done on a subset with full-length sequencing. Correlates of HIV and HCV infection were assessed using logistic regression. Overall prevalence of HIV was 12.1%, HCV was 61.3%, and syphilis was 15.7%. In a multivariate logistic regression model controlling for gender and ethnicity, daily injection of narcotics [odds ratio (OR) OR 3.22] and Tajik nationality (OR 7.06) were significantly associated with HIV status. Tajik nationality (OR 1.91), history of arrest (OR 2.37), living/working outside Tajikistan in the past 10 years (OR 2.43), and daily injection of narcotics (OR 3.26) were significantly associated with HCV infection whereas being female (OR 0.53) and always using a sterile needle (OR 0.47) were inversely associated with HCV infection. Among 20 HIV-1-positive IDU with specimens available for typing, 10 were subtype A, 9 were CRF02_AG, and one was an A-CRF02_AG recombinant. Epidemics of HIV-1, HCV, and drug use are underway in Dushanbe. The molecular epidemiology is distinctive, with West African variants accounting for roughly 50% of prevalent infections. Targeted prevention programs offering both needle exchange programs and opiate substitution therapies are urgently called for to prevent the further spread of HIV and HCV in Tajikistan.

Understanding post 9/11 drug control policy and politics in Central Asia.

This paper exposes contemporary drug policy challenges in Central Asia by focusing on a single point in the history of drug control, in a single region of the global war against drugs and terrorism, and on one agency whose mission is to help make the world safer from crime, drugs and terrorism. By looking closely at the post 9/11 security-oriented donor priorities, I conclude that, in Central Asia, the rhetoric of the taking a more 'balanced approach' to drug policy is bankrupt. When enacted by the national law enforcement agencies in the Central Asian republics, the 'Drug Free' aspirational goal is driving the HIV epidemic among IDUs. The face-saving 'containment' thesis does not reflect the drug situation in this region but rather the failure to adopt an evidence-based approach. The harm reduction agenda continues to face many challenges including resistance to substitution treatment, the harm from drug treatment, from poorly designed drug prevention programmes and from repressive counter-narcotics policies and practices.

Marked ethnic differences in HIV prevalence and risk behaviors among injection drug users in Dushanbe, Tajikistan, 2004.

OBJECTIVE: To examine differences by ethnicity of HIV prevalence and correlates among injection drug users (IDUs) in Dushanbe, Tajikistan. METHODS: The researchers enrolled 489 active adult IDUs in a cross-sectional risk factor study of HIV infection. Participants were provided HIV pre-and posttest counseling and risk reduction counseling and answered an interviewer-administered questionnaire. HIV-1 status was determined with rapid tests and confirmed with ELISA. RESULTS: Participants included four ethnicities: 204 Tajiks (49.1%), 145 Russians (29.7%), 58 Uzbeks (11.9%), and 46 participants of other nationalities (9.4%). Overall prevalence of HIV-1 infection was 12% and varied significantly by ethnicity: it was highest among ethnic Tajiks, at 19.2%; lowest among Russians and Uzbeks, at 3.4%; and 13% among other nationalities. Ethnic groups differed significantly in years injecting, receiving a needle from a needle exchange program (NEP), injecting in groups, having undergone drug treatment, reported condom use, and arrest history. Among Tajiks, HIV infection was significantly associated with daily injecting (OR 2.16); reporting that narcotics were very easy to obtain (OR 2.46); having undergone drug treatment (OR 2.75), and injecting "alone" (OR 3.12). CONCLUSIONS: Ethnic differences were strongly associated with HIV prevalence and risk behaviors in this multiethnic study, and prevention efforts might need to be targeted by ethnicity.