The Republic of Uzbekistan
The formation of Uzbekistan’s drug policy started in 1994, when the State Commission for Drug Control was established and its overall trend has not changed since then. It is based on prohibition, and restrictive measures are central to the national anti-drug strategy which emphasizes combating illicit drug trafficking and drug use.
To date, there are 48,000 of people who use drugs in the country and HIV transmission due to unsafe injecting is still relevant. The estimated number of people living with HIV is 54,000. Injecting drug use accounts for 18.2% out of the 3,983 HIV cases registered in 2018.
Needle and syringe programs
In 2000 to prevent the spread of HIV “Trust points” were established at the health care facilities. Their objective was to ensure free access to harm reduction services for people who use drugs. In 2001, there were three such points and only in Tashkent. Today there are more than 230 of them. Nowadays, Trust points provide counseling, needle and syringe exchange, and distribute individual protection equipment. Due to the COVID-19 pandemic, prevention kits contain additional materials such as protective masks and disinfectants.
Since the Trust points are located in public health care facilities, they are not convenient for clients to receive harm reduction services. When clients visit them, they fear the possibility of being recognized by neighbors or being caught by the police.
In addition to a doctor, these points also have outreach workers from representatives of the community of people who use drugs. Two years ago, the programs switched to partial government funding which significantly limited the participation of peer consultants in these activities. 60–70% of so-called peer consultants are physicians and nurses of those institutions where Trust points are located. Those people do not have experience and have never faced the issues and problems of drug use.
The decrease in the number of peer consultants is due to the state standards that require social workers to have a higher education. This construed a barrier for many community representatives, so healthcare professionals replaced them. How the community of people who use drugs will be involved in Trust points’ activities when they switch to budget funding is unclear.
Changes in drug scene
Operating in health care facilities and not having a flexible structure, the needle exchange points failed to adapt their activities to the recent changes in the drug scene. New psychoactive substances (NPS) and pharmacy medications have replaced traditional Uzbekistan drugs, such as opium and heroin, at the illicit drug market. NPS are usually purchased in Darknet or via Telegram and e-wallets. Additionally, injecting drug use among people who use drugs decreased. Changes in patterns of buying and using drugs occurred because of the lockdown restrictions due to the COVID-19 pandemic. This situation requires the development of a new package of harm reduction services.
Opioid substitution program and drug dependence treatment
The shortage of traditional substances, widespread distribution of synthetic and pharmaceutical drugs, increase in their cost, and other factors influenced the increase in the demand for drug treatment in Uzbekistan. Nevertheless, there is a limited number of methods applied in drug dependence treatment, and they do not always meet the international standards and principles of humane drug policy.
Until now, detoxification and treatment of withdrawal syndrome are the main therapeutic methods used in the country. In Uzbekistan, substance abuse treatment relies on the concept of drug addiction from the Soviet times. It implies the widespread application of compulsory court-ordered treatment, along with voluntary treatment. Mandatory treatment is provided in specialized medical institutions. Its duration is unclear and depends upon the treatment facility in which the person is held.
One of the examples of non-compliance with international standards is the absence of opioid substitution therapy (OST) programs and state-supported, effective drug dependence treatment, which are not limited to detoxification, and are supplemented with efficient rehabilitation programs. A pilot OST program was launched in Uzbekistan in 2006. It provided OST with methadone and buprenorphine. According to WHO assessment, the program demonstrated high effectiveness. Despite this, the Government of Uzbekistan in 2009 decided not to continue the OST program due to its inexpediency. At the time of the closure, there were approximately 140-150 clients in the program.
Overdose prevention
Naloxone for opioid overdose prevention was not on the List of Essential Medicines for a long time, and the state did not purchase it. In 2009, Naloxone was included in the List, so it became possible to start procuring and using it for opioid overdose treatment in health care facilities. However, this did not solve the problem with the access to Naloxone. It is still not available at the Trust points.
Harm reduction and drug treatment in penitentiary facilities
Within the penitentiary system, there is the widespread practice of compulsory treatment of people who use drugs. It is based on a court decision and takes place in specialized penal institutions. However, such institutions are not much different from other detention places. And various forms of punishment typically are used there as treatment. Neither needle and syringe nor opioid substitution programs are available inside the penitentiary facilities.
Drug user registry
In case of arrest or seeking treatment people, who use drugs, are automatically registered as drug addicts. Registration is valid for a period of up to 3 years and causes significant restriction of rights. It can be a reason for dismissal from work, deprivation of parental rights, refusal to obtain a driver’s license, etc. Moreover, both men and women have to provide a certificate from the drug addiction center and a paper on HIV status to the civil registry office as a prerequisite to register a marriage. All this information is available to the relatives of people who plan to get married.
Services for women who use drugs
In Uzbekistan, clients of harm reduction and drug dependence treatment programs are predominantly male. The existing services do not provide any special services for women and do not have separate premises or scheduled times to work with them.
The perception of women who use drugs reflects the predominant societal understanding of their traditional role compounded by negative attitudes towards drug users. This attitude is widespread in the country and significantly increases their vulnerability and risks to their health and life.
COVID-19
COVID-19 pandemic lead to decreased availability of harm reduction and drug treatment services in Uzbekistan. The situation is due to the lockdown measures. They include travel restrictions, re-profiling patient capacity in drug addiction clinics, and changes in the work of health facilities where needle exchange points are located. In some cities, services are mainly provided online.
Due to the current crisis in harm reduction in Uzbekistan, there is a need to ensure the maximum possible continuity of adequate access to effective health and social services for people, who use drugs, and the necessary community-based services. Including low-threshold services, psychosocial care, pharmacological treatment in various facilities, and immediate reinstatement of OST program.