No opiate substitutes for the masses of IDUs.

C R E D IT : M A L C O L M L IN T O N KYIV, ODESSA, AND DNIPROPETROVSK, UKRAINE; MOSCOW AND ST. PETERSBURG, RUSSIA—On Easter Sunday, Sergey Nenov, along with hordes of other people in Odessa, took a basket fi lled with sprinkle-covered frosted cake, cookies, and other offerings to a gold-domed Orthodox church and lit candles in prayer. But when Nenov came to a gilded painting of the Madonna and Child, he separated himself from the crowd by pressing his lips to glass that protected the Christian icon. Nenov had reason to be grateful this year. He is one of 4300 opiate addicts in the country to receive methadone, a substitution treatment that has freed him from his dependency, allowing him to stop having run-ins with the law and, at long last, begin to tackle his dual infections with HIV and tuberculosis (TB). Nenov, who lives at a TB hospital in the city that dispenses his daily dose of methadol—a pill form of methadone— started injecting chernaya, an opiate made from liquid poppy straw (see p. 161), in 1988. He is astonished that he survived long enough to see the substitute opiate come to Ukraine; importing it was illegal until December 2007. “Before, we would watch TV reports about these Dutch substitution treatment programs and say, ‘It will never happen in our country,’ ” says Nenov. Opiate substitutes are one component of harm reduction, an international movement that promotes treatment rather than arrest and incarceration of injecting drug users (IDUs). The harm-reduction “package,” which aims to protect IDUs from infections and other health risks, also includes clean needles, counseling, HIV testing, and education. In a 2005 position paper, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the World Health Organization, and the United Nations Offi ce on Drugs and Crime explicitly backed opiate substitutes to prevent HIV’s spread. An expert committee convened by the U.S. Institute of Medicine in 2007 cited “strong evidence” that methadone and another popular substitute, buprenorphine—now used by only 800 others in Ukraine—reduced illicit drug use and HIV-risk behaviors such as sharing injecting equipment. It recommended that they “be made widely available, where feasible.” Although Ukraine, Russia, and other countries in the former Soviet Union have IDU-driven HIV/AIDS epidemics that are increasingly spreading into the broader population through sex, harm reduction remains spotty throughout the region. Even the Ukrainian government has not fully embraced harm reduction, which is largely delivered by nongovernmental organizations (NGOs) that receive support from the Global Fund to Fight AIDS, Tuberculosis and Malaria. Ukraine’s 2010 HIV/AIDS progress report to the United Nations, endorsed by the minister of health, acknowledges the short comings: “The scope, scale, quality and intensity of HIV prevention activities among the most vulnerable population groups remain insuffi cient to stop HIV spreading in these groups and limit the potential spread of HIV among the general population.”