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

https://doi.org/10.1016/j.drugpo.2014.09.011Get rights and content

Highlights

  • We conducted 12 focus group discussions in Kulob and Khorog and analysed available literature.

  • In Kulob and Khorog, almost all people who inject drugs use heroin.

  • Scaling-up both OST and ART coverage is the top priority for reducing HIV prevalence and incidence in Tajikistan.

  • Drug treatment and harm reduction services for women, as well as naloxone distribution programmes need to be expanded.

Abstract

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We conducted 12 focus group discussions in Kulob and Khorog and analysed peer-reviewed literature, published and unpublished programme and country reports and other publications that focused on substance use and/or HIV/AIDS in Tajikistan and included the Khatlon and Gorno-Badakhshan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.

Introduction

The Republic of Tajikistan, the smallest and the poorest of the Central Asian Republics, continues to face intertwined epidemics of substance use and HIV. Political and civil unrest following the fall of the Soviet Union in 1991, poor socio-economic conditions, and its location on the main heroin trafficking route from Afghanistan have all contributed to the availability of cheap heroin and high rates of injecting drug use in the country. Among the Central Asian states, Tajikistan shares the longest border with Afghanistan (1344 km).

Economic development has been slowly improving, however a significant proportion of its 8 million inhabitants live below the poverty level with per capita gross domestic product (GDP) estimates as low as 872.3 USD (World Bank, 2013). It is estimated that more than 1 million Tajik people work as migrant labourers, primarily in Russia and Kazakhstan, and about half of the country's GDP comes from migrants’ remittances (National Coordination Committee to Combat HIV/AIDS, 2013, World Bank, 2013). According to recent World Bank estimates for Central Asian republics for the year 2011, Tajikistan's health expenditures per capita in purchasing power parity (constant 2005 international) were the lowest among all five countries of the region (World Bank, 2013). Total health expenditures per capita (current USD) were 54.9 USD in 2012, ranking Tajikistan as the lowest in the European region (European average – 2349 USD) (UNDP, 2014).

Similar to other Central Asian countries, research on substance use and HIV/AIDS has been scarce in Tajikistan. Moreover, most of the research on these topics that is available has been conducted in the capital, Dushanbe (Vickerman et al., 2014, Beyrer et al., 2009, Stachowiak et al., 2006). The data on substance use and HIV in Tajikistan that are available locally as unpublished or grey literature vary widely in quality due to methodological differences that affect their reliability and validity. To address these gaps in our knowledge on situations beyond the national capital of Tajikistan, the present paper aims to analyse data on substance use and related problems in two regional (oblast) capital cities situated on major drug trafficking routes, and severely affected by both drug injection and HIV epidemics: the city of Kulob (Khatlon Oblast), with a population of 98,500 people, located about 70 km north from the Afghan border, and the city of Khorog with about 28,600 inhabitants (Gorno-Badakhshan Autonomous Oblast (GBAO) in the Pamir mountains) (Tajik Presidential Statistics Agency, 2013). Khorog is situated on the Panj River, which represents a natural border with the Badakhshan region of Afghanistan. The paper will review and synthesize substance use and HIV/AIDS related information available for these cities and supplement it with data from focus group discussions.

Section snippets

Literature review

We searched the peer-reviewed and gray literature for information regarding injecting drug use and HIV in Kulob and Khorog. A PubMed search of publications in the previous 10 years that included the search terms, Tajikistan AND (hiv OR idu OR pwid OR heroin), returned 34 publications. However, when the search was limited to publications that included Khorog or Kulob, the search returned zero results. We searched the Web of Science databases for Khorog or Kulob. That search only returned one

Problem drug use prevalence estimates

In the Central Asian republics, including Tajikistan, problem drug use is generally defined and understood as “injecting opiate use” (Zabransky, Mravcik, Talu, & Jasaitis, 2014). The calibrated estimate (using calibration multiplier) of the size of the population of people who inject drugs in the city of Kulob was calculated in 2009 and is 1100 PWID. For Khorog, the calibrated estimate was 2100 PWID (APMG, 2009). These appear to be the only estimates made specifically for these two cities,

Discussion

Our comparative analysis of drug scenes, drug use and drug-related infectious diseases in Kulob and Khorog reveals both similarities and differences in these two Tajik cities – the regional capitals of Khatlon and Gorno-Badakhshan Oblasts – situated along the opiate trafficking routes from Afghanistan. Furthermore, this analysis raises a number of issues critical to our interpretation and understanding of available data as well as the situations both in these two cities and in the country in

Concluding remarks

In conclusion, our analysis suggests that ‘going beyond the surface’ of the national aggregated data and examining drug scenes, drug use and related health consequences and responses at the regional level in two Tajik cities of Kulob and Khorog may not only elucidate insightful site-specific patterns and trends, but also serve as a powerful lens through which to explore ‘a bigger picture’ and to uncover issues with serious implications for the entire country. These issues include serious

Acknowledgments

The authors would like to thank local partners in Tajikistan, NGO “Jovidon”, NGO “Volunteer” and NGO “Apeyron”, for their help and support in organising focus group discussions and conducting research in Kulob and Khorog cities. This research was supported by NIH grant number R34DA035094 from the National Institute on Drug Abuse (PI Zule, W.).

Conflict of interest: None.

References (39)

  • O.S. Ashley et al.

    Effectiveness of substance abuse treatment programming for women: A review. [Research Support, U.S. Gov’t P.H.S. Review]

    The American Journal of Drug and Alcohol Abuse

    (2003)
  • J. Ataiants et al.

    Drug overdose: A review of the situation and responses in 12 Eastern European and Central Asian countries

    (2011)
  • C. Beyrer et al.

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

    AIDS Research and Human Retroviruses

    (2009)
  • DCA

    Report on the drug situation in the Republic of Tajikistan for 2009

    (2010)
  • DCA

    Report on the drug situation in the Republic of Tajikistan for 2010

    (2011)
  • DCA

    Report on the drug situation in the Republic of Tajikistan for 2011

    (2012)
  • DCA

    Report on the drug situation in the Republic of Tajikistan for 2012

    (2013)
  • DCA

    Report on the drug situation in the Republic of Tajikistan for 2013

    (2014)
  • F. De Danieli

    Silk Road mafias: The political economy of drugs and state-building in post-Soviet Tajikistan

    (2010)
  • Cited by (14)

    • More than saving lives: Qualitative findings of the UNODC/WHO Stop Overdose Safely (S-O-S) project

      2022, International Journal of Drug Policy
      Citation Excerpt :

      Treatment of opioid use disorders with long-acting opioid agonists can reduce the risk of non-accidental fatal overdoses by almost 90% (World Health Organization, 2009, 2014). Although Opioid Agonist Maintencance Treatment (OAMT) is available in most Eastern European and Central Asian countries, eligibility restrictions mean access is insufficient to meet needs (Bojko et al., 2015; Kan et al., 2014; LaMonaca et al., 2019; Latypov, Otiashvili & Zule, 2014). Existing drug laws and stigmatising policies also limit access.

    • Sexual behavior experience of former injecting drug users infected with HIV in Bali, Indonesia

      2020, Enfermeria Clinica
      Citation Excerpt :

      P2, Male, 46). Re-using of non-sterile syringes among IDUs had a risk for HIV transmission.5,10 This could point out that blood is an intermediary media to transmit HIV from one person to another person.

    View all citing articles on Scopus
    View full text