Editorial
Illicit drugs in Central Asia: What we know, what we don’t know, and what we need to know

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Introduction

In 2013, two special issues with focus on health and drugs in Central Asia were published in Drug and Alcohol Dependence and Central Asian Survey journals (El-Bassel et al., 2013a, Latypov, 2013, Latypov, 2014). In this third special issue published by the International Journal of Drug Policy, the authors of ten research papers and commentaries seek to provide additional knowledge on a range of issues related to illicit drugs in the region, including the epidemiology of drug use and drug-related infectious diseases and other consequences, drug treatment and harm reduction programmes, the Central Asian drug markets and actors, drug economies and the state-crime nexus.

What informs these most recent papers and what questions, critical for our understanding and interpretation of on-going challenges in Central Asia, do they raise? In this editorial we highlight eleven core aspects of the intensely disquieting public health situation in Central Asia, discussed in these papers. We also point at two further, less exposed aspects – tuberculosis and the region's prison systems.

HIV, HCV, tuberculosis and sexually transmitted infections (STIs); injecting drug use, imprisonment, poverty and stigma; drug business, state corruption, criminalisation and extortion; impoverished health services and poorly educated and motivated health professionals, unable to cope with the rising tide. These are the interlocking biological and social ingredients of the region's mounting syndemic (Singer & Clair, 2003). We finally draw together this amalgam of profiteering, corruption, addiction and disease, illustrating how its vicious synergy fosters disease and seriously jeopardises the well-intended efforts to modernise the region's response to the disease burden discussed in this special issue.

Section snippets

Drug situation in Central Asia

The special issue offers a summary of the drug situation in four of the five post-Soviet Central Asian republics (Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan) using the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)-developed system of key indicators of drug epidemiology. In their paper, Zabransky, Mravcik, Talu, and Jasaitis (2014) cover drug use in general population, problem drug use as defined in Central Asia, demand for drug treatment, drug-related infectious

HIV and HCV prevalence among people who inject drugs (PWID)

One of the key trends reported by Zabransky et al. (2014) is the declining HIV and HCV prevalence among PWID in Tajikistan and Uzbekistan. According to the authors, this “represents an unprecedented development and still needs further explanation and research.” Data from Kazakhstan, on the other hand, suggest a relatively low and stable HIV prevalence against the backdrop of the highest HCV seroprevalence compared to other counties. Latypov, Otiashvili, and Zule (2014) also discuss significant

HIV counselling and testing

Globally, research shows that HIV testing and counselling is a central strategy to receiving care and treatment among HIV-infected individuals and therefore plays an important role in HIV prevention for both infected and uninfected persons. Knowing one's HIV status can promote declines in sexual and drug risk behaviours (Denison, O’Reilly, Schmid, Kennedy, & Sweat, 2008). Although HIV testing has been extensively encouraged and supported globally for PWID, many drug users in Central Asia face

Combination HIV prevention for PWID

There is no complete and reliable data on the coverage of antiretroviral therapy (ART) among HIV-infected PWID in Central Asian republics. Many PWID have been lost to follow-up and some have not been assessed for ART eligibility (McNairy, Deryabina, Hoos, & El-Sadr, 2013). In 2010, the overall coverage of ART in Eastern Europe and Central Asia is estimated to be 35%, which is well below the global level of 60% (Donoghoe & Stengaard, 2010). Although Kazakhstan (163 needles and syringes per

Advocating for OST in Central Asia

The Vickerman et al., 2014 paper also underscores the critical need for legal and policy changes to enable the development of proven-to-be-effective combination HIV prevention interventions and the importance of political will and governments’ support of scaling up these prevention approaches. In Central Asia, where the majority of PWID inject opiates, this is particularly critical for OST, as coverage is below 1% (Latypov et al., 2014, Zabransky et al., 2014). Furthermore, OST programmes

Mortality of drug users and drug overdoses

As four papers (Kan et al., 2014, Latypov et al., 2014, Mravcik et al., 2014, Zabransky et al., 2014) in this special issue emphasise, overdose mortality appears to be significantly underestimated in Central Asia. While official data point to a decrease in reported fatal overdoses across the region, these reports are unreliable for a number of cultural, religious, policy and other reasons (Zabransky et al., 2014, Ataiants et al., 2011). In their study of the mortality of drug users in Central

Females who inject drugs and non-IDU female sex partners of men who inject drugs

In recent years, a steady rise has occurred in the incidence of sexual transmission of HIV among two key populations: females who inject drugs (FWID) and non-IDU female sex partners of men who inject drugs (MWID) (UNAIDS, 2012). Despite this emerging trend, the true number of FWID and non-IDU female sex partners of MWID in Central Asia remains unknown and research about these two key affected populations in the region is limited (El-Bassel et al., 2014a, El-Bassel et al., 2014b).

A number of

Drug offences and arrests of people who use drugs for possession of minor quantities

Another important aspect underscored in this special issue concerns drug-related criminal offences reported by Kazakh, Kyrgyz, Tajik and Uzbek law enforcement agencies. While only data from Kazakhstan point explicitly to drug users often being the main target for the police, who arrest them for possession of minor quantities for personal consumption (less than 1 g of heroin, as was the case in Kazakhstan) (Zabransky et al., 2014), this is a significant problem in the region. Thus, as 1128

Police corruption and state-crime nexus

In Central Asia, policing drug users is heavily linked with high levels of corruption running through the ranks of law enforcement. In Tajikistan, police officers are often involved in directly facilitating the distribution and street-level sales of narcotic drugs, providing heroin to favoured dealers, arresting or blackmailing competing dealers and exploiting drug users in various ways for the sake of information, money or sexual favours, or in order to fulfil arrest quotas (Latypov, 2011a,

“Hashish as cash” and the significance of drugs in an agricultural semi-subsistence economy

As De Danieli and Kupatadze reveal, narcotic drugs in Central Asia serve primarily to enrich the deeply intertwined upperworld and underworld networks. However, the fascinating research by Botoeva (2014) seeks to shift away from the upperworld–underworld paradigm and to investigate the contexts and conditions, whereby narcotic drugs also function as a vital commodity incorporated in local economic and social transactions. Indeed, Botoeva describes how drugs serve as a symbolic form of cash in

From emerging epidemics to syndemics

As pointed out by many papers in this special issue, Central Asia represents a global HIV “hotspot” (Thorne et al., 2010), facing “the perfect storm” of high risk drug use, various blood borne infectious diseases (El-Bassel, Strathdee, et al., 2013) and other drug related harms, such as fatal overdoses (Kan et al., 2014, Mravcik et al., 2014). Such events of “disease clustering” (Knox, 1989) or “syndemics” (Singer & Clair, 2003) are more than just biological occurrences, but part of a process

Tuberculosis and co-infection issues in Central Asia

Tuberculosis is widespread in Central Asia. TB rates are reportedly “extremely high,” with alarmingly high rates of multidrug-resistant tuberculosis (MDR-TB) (Cox et al., 2004, Schluger et al., 2013). Co-occurring rising rates of HIV infection among people who inject drugs (PWID), their sex partners, men who have sex with men, female sex workers and migrant workers raise acute concerns over a “potentially devastating co-epidemic of TB/HIV and MDR-TB/HIV” (El-Bassel et al., 2013a, Schluger et

Central Asian prison systems

The antiquated prison systems in Central Asia are a key vector in the spread of infectious diseases, development of MDR-TB and an important obstacle to developing patient-centred care approaches for the affected populations. Although the prison population has been reduced in almost all Central Asian countries over the last 20 years, the total number of prisoners is still high (in all five countries together approximately 127,000). The number of prisoners per 100,000 ranges from 121 (Tajikistan)

The missing links

However, the interaction of the cocktail of infectious diseases and inadequate public health responses discussed above is only part of the syndemic equation. Indeed, the response of public health authorities – in and outside of the prison walls – is shaped by further social-political contingencies, and we will try to illustrate this with an example from Kyrgyzstan, where one of the authors of this editorial paper recently assessed the response to MDR-TB in the prison system (Grund et al., 2012).

Concluding remarks

This editorial and the ten research papers and commentaries in this special issue discuss several of the Known Knowns, Known Unknowns and Unknown Unknowns (Rumsfeld, 2002) of the syndemic emergency that is developing in Central Asia around the use of illicit drugs. The known knowns are clear: high rates of injecting opiate use and rapid diffusion of several blood-borne viruses are merging into a context of outdated health services, prohibition, unstable political economies and corruption. An

Conflict of interest statement

None declared.

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