Tajikistan National Report. Summary HARM REDUCTION WORKS FUND IT! Arguments for strategic investment. Summary of National Report: Tajikistan

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1 HARM REDUCTION WORKS FUND IT! National Report Summary Arguments for strategic investment With the support of

2 The present document contains a summary of the key conclusions and recommendations provided in the National Report of the Republic of Harm Reduction Works: Arguments for Strategic Investment, which have to be taken into account when developing a plan for transition to the national funding of harm reduction programs in the country for the years Study methodology The recommendations and conclusions are based on the results of collaborative activity of s governmental and non-governmental organizations such as SPIN Plus, Volunteer and others within the framework of the regional program Harm Reduction Works Fund It!. With technical support from the Eurasian Harm Reduction Network (EHRN), the said organizations carried out joint monitoring of services and investment in harm reduction programs. The current study employed the following instruments: monitoring of expenses on harm reduction and assessment of the unit value of harm reduction programs, gaps in the funding of harm reduction programs, accessibility, priority ranking and quality of harm reduction services. All the mentioned instruments were developed by the Futures Group and EHRN. Focus groups for assessment included 246 representatives of the community of people who use drugs; questionnaires were answered by 674 respondents. HIV epidemic in In 2013, according to UNAIDS data, the prevalence of HIV in the Republic of, in relative terms, stood at 57.2 cases per 100,000 population. Meanwhile, according to the data of the State Sanitary and Epidemiological Surveillance Service of the Republic of, the HIV prevalence rate among people who inject drugs (PWID) does not exceed 13.5% (sentinel surveillance data for 2011). The problem of HIV prevention in the Republic of remains highly relevant. Aiming to prevent further spread of HIV-infection and ensure integrated and comprehensive approach to the implementation of proper medical and preventive measures, the Program for the Prevention and Response to the HIV/AIDS Epidemic for the Period of was approved by Government Regulation No 562 of October 30,

3 Harm reduction program In the recent five years, the harm reduction program in proved to be efficient: the growth in the HIV/AIDS epidemic among PWID has stabilised. According to the data of the National Centre for the Prevention and Response to AIDS, the number of new cases of HIV among PWID in the country has markedly decreased in recent years (24.2% in 2014, against 59.2% in 2010). This is against the background of a sharp increase in the coverage of voluntary counselling and testing for HIV among this target group. Another fact proving the reduction in prevalence of HIV among PWID is the results of sentinel surveillance, according to which the HIV prevalence rate stood at 12.9% in 2014 (against 16.3% in 2010). Figure 1: Proportion of PWID among new cases of HIV in the country, (sentinel surveillance data for , National Centre for the Prevention and Response to AIDS) Studies of the efficiency of opioid substitution therapy (OST) program in the Republic of revealed, that OST patients have significantly changed their injection behaviour as compared to their time before assisting in the program making it less risky in terms of HIV infection (see Figure 1). Harm reduction programs contribute to the improvement in the health status of the population in general and testify to the economic efficiency of such interventions, achieved through the reduction in the burden of disease (limitation in / loss of capacity for work) and number of new cases of HIV/AIDS in the Republic of. 3

4 Strategic objectives of the Program for the Prevention and Control of the HIV/AIDS Epidemic in the Republic of are as follows: Setup of a legal framework, contributing to the provision of universal access to prevention, treatment, care and support services; Implementation of HIV prevention program and provision of access to services for all population groups, especially for the most vulnerable ones; Delivery of antiretroviral therapy (ART), treatment of opportunistic diseases; Provision of palliative care for people living with HIV (PLWH); integration of antiretroviral therapy into primary healthcare; Reduction in the level of stigmatisation of PLWH and representatives of vulnerable population groups; Improvement of the system for epidemiological surveillance, monitoring and assessment of preventive measures. Further development of harm reduction programs is critical in to harness HIV epidemic. Harm reduction produces maximum effect from the perspective of combatting not only HIV but also Hepatitis С and other diseases. Efficiency of needle and syringe exchange programs (NSP) and opioid substitution therapy programs (OST) According to the results of an independent assessment of the cost-effectiveness of the needle and syringe exchange program in the Republic of for the period of , conducted in 2011 (UNAIDS Report 2011), the total funding for the program amounted to 2.83 million USD. The program allowed preventing 4,004 cases of HIV and 6,124 cases of hepatitis С among PWID. The value of one prevented case of infection is 279 USD. Figure 2: Injection drug use before and after entering the OST program, by site 4

5 By the end of 2014, the widest NSP coverage was achieved in the country throughout the entire period of the program activity. In 2014, NSP coverage stood at over 53% of the estimated number of PWID in the country, which is more than twice the levels of 2010 and 2011 and times higher than in Voluntary counselling and testing and ART among PWID is characterised by similar positive trend. It should be noted, however, that OST coverage of PWID in is still quite low, which does not allow making a significant impact on the epidemic. Figure 3: Structure of expenses on NSP in the Republic of (per cent of total expenses) Apart from low OST coverage, there are other additional barriers to the efficient implementation of harm reduction programs in the Republic of : Lack of psychological support for OST program clients; Compulsory registration of PWID wishing to get care of a drug abuse specialist or enter the OST program, which is a barrier to accessing drug dependency treatment; Absence of HIV rapid tests at the premises of NGOs and outreach workers; Absence of state registration of methadone and, as a consequence, thereof, non-inclusion in the list of essential medical drugs; Insufficient participation of PWID in the development, implementation and assessment of harm reduction programs; No access to treatment for hepatitis C for PWID despite the fact, that prevalence among vulnerable population groups is the highest. Apart from that, the level of screening for hepatitis В and С among PWID in the country is very low. 5

6 Figure 4: Gap between the actual and recommended coverage of NSP (60%) and OST (40%) programs in 2013 Recommendations for further improvement of harm reduction programs in the country: 1. To increase the coverage of services provided within the framework of the OST program from 4 to 20% of the estimated number of people who inject drugs (PWID), including, funds from the state budget. 2. To increase the participation of non-governmental organisations (NGOs) in the provision of harm reduction services; to approve schemes of allocation of public funds for NGOs activities. Necessary legal changes The following legal changes are meant to help to achieve the desired result: 1. Inclusion of funding of harm reduction (NSP and OST) program in the state budget, including a joint order of the Ministry of Finance, Ministry of Health and Social Protection of the Republic of on gradual transition of existing counselling sites to public funding. 2. At the moment the Ministry of Health and Social Protection of the Republic of is working to update the existing drug addiction treatment protocol, which would allow the use of methadone according to the intersectoral cooperation plan. This plan aims at further implementation of OST programs for drug addiction patients in the Republic of. 6

7 3. Provision of supplies for NGOs at the premises of state healthcare facilities (counselling services of NSP). 4. Development and implementation of an instrument for NGO funding by means of: а) public procurement of social services; b) grants for the provision of services through the National Fund for the Prevention and Response to HIV/AIDS. Funding transition In order to ensure the sustainability of harm reduction and OST programs while external funding is decreasing, there is a critical need for a smooth transition to state funding. Currently, public investment in direct expenses on harm reduction programs is limited to provision of premises and reimbursement of utility costs for OST and counselling services. At the moment, the planning of the budget and expenses on harm reduction programs is taking place in. As per requirements of the Global Fund for Low Income countries, the national contribution to direct expenses on such programs/interventions has to make up at least 5%. State commitment to allocate funding for the acquisition of syringes and wages of the NSP staff (6.3% of the total required amount by 2018) and acquisition of methadone and wages of the OST program staff (10% of the total required amount by 2018) from the state budget (under the Program for the Mid-Term Planning of Public Expenses for ) is currently under discussion. There is also a plan to include part of expenses related to the treatment of HIV in the national budget. 7