EditorialIllicit drugs in Central Asia: What we know, what we don’t know, and what we need to know
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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Decisional considerations for methadone uptake in Kyrgyz prisons: The importance of understanding context and providing accurate information
2021, International Journal of Drug PolicyCitation Excerpt :Here, we determine context-specific factors that must be considered when designing a decision aid for the Kyrgyz prison context. Prison settings in many countries of the former Soviet Union share history, similarly organized criminal subcultures, and beliefs surrounding addiction and addiction treatment; government responses to drug use and criminal organization in prisons have also been similar in these countries (Bryuhnov, Kutyakin, & Napkhanenko, 2019; Latypov et al., 2014; Polonsky et al., 2016a,b; Ledeneva, 2018). Due to these similarities, a future decision aid may be exportable to countries elsewhere in the region, increasing the uptake of the most effective infection-prevention strategy among people who inject drugs and curtailing the spread of HIV in a region where HIV incidence is increasing (Joint United Nations Programme on HIV/AIDS, 2020).
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The perfect storm: incarceration and the high-risk environment perpetuating transmission of HIV, hepatitis C virus, and tuberculosis in Eastern Europe and Central Asia
2016, The LancetCitation Excerpt :This mass incarceration is the result of several intersecting factors, which have converged to result in some of the highest general-population prevalences of HIV,54 hepatitis C virus,55 and tuberculosis (including multidrug-resistant tuberculosis [MDR-TB])12 in the world,49,51 concentrated further within prisons where rates are substantially higher. After 1991, injectable opioid use increased substantially due to changes in drug routes from Afghanistan and the contribution of economic collapse to a new drug economy.8,56 Consequently, volatile opioid injection and HIV epidemics followed.10
Public health and international drug policy
2016, The LancetCitation Excerpt :EECA bear a heavy burden from the neglect of harm-reduction measures. Harsh anti-drug policies and moral judgments against people who use drugs contribute to making health services for this population a low political priority.87 In the first decade of its work, financial support from the Global Fund to Fight AIDS, Tuberculosis and Malaria helped to overcome these difficult political environments and supported the expansion of harm-reduction services, especially NSPs and OST, in several EECA countries and in east and southeast Asia.105
Managing drugs in the prisoner society: heroin and social order in Kyrgyzstan’s prisons
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