The Harm Reduction Program in Moscow
6 June 2001
BACKGROUND The Harm Reduction Program in Moscow has been run and funded by MSF since 1996. It was handed over to the Russian NGO "Return to Life" in April 2001, but continues to receive technical and financial support from MSF. The concept of the program was developed in partnership with Mainline (an experienced Amsterdam-based harm reduction organization), and with the Trimbos Institute (a Dutch institute specialized in mental health and addiction). The overall purpose of the program is to increase knowledge about modes of HIV transmission and to help prevent the spread of infectious diseases among young, injecting drug users in Moscow. With its focus on HIV prevention among intravenous drug users (IDUs), the program was one of the first of its kind in Russia. It also introduced the principle of peer support - that is, that education on HIV prevention is best provided by ex drug users who are trained and experienced in outreach work. From the beginning, this principle has shaped and driven the program. Peer education and outreach work were also the only options suitable for Russia in 1996, since needle exchange programs and methadone for drug users were considered a violation of narcotics laws and were officially prohibited. SPECIFIC OBJECTIVES The specific objectives of the Harm Reduction Program are: 1. to reach young, injecting drug users of Moscow through outreach work conducted by peers. 2. to disseminate information and educational materials among this group. 3. to raise awareness of HIV and other adverse consequences of drug use on one's health and social life, and to stimulate safer behaviour through peer education. MAIN ACTIVITIES Outreach work Recruited ex drug users were first trained using the European Peer Support Manual. In 1997, outreach work started in the Lubyanka area - the centre of Moscow and, at that time, of drug-related activities. In 1997, the program's first year, the 10 MSF outreach workers reacted to the urgent need to provide objective information on HIV/AIDS to as many drug users as possible: logbooks indicate they reached 10,000 IDUs and distributed 20,000 "Protect Yourself" leaflets and condoms. The leaflets cover the topics of HIV, Hepatitis B and C, vein care, overdoses, detoxification, drug treatment, and legal issues. In 1998, outreach work was expanded to two of the country's largest narcological hospitals: Moscow's Hospital ##17 and ##19. As drug use continues within the hospital walls, it is necessary to give patients information on HIV prevention and increase their awareness of the virus. It is anticipated that the program will further expand to hospitals for infectious diseases. Since 1999, a team of trained peer educators has also been conducting outreach work among drug-using sex workers in Moscow. The team offers verbal counselling and distributes condoms and leaflets. Training, counselling, and other activities Since 1998, a team of peer educators has been offering regular training - both indoors and outdoors - on IDU and related health risks. This "training of trainers" created a snowball effect and increased the number of drug users reached. The number of new IDUs reached in 1998 and 1999 varied between 50 and 250 per month. Peers and the program psychologist also provide counselling for HIV-positive drug users. The program staff also advocate for the human rights of intravenous drug users, share their knowledge and findings with officials, decision-makers, and journalists, and closely monitor drug trends. The latter activity involves documenting the number of drug users contacted and of publications distributed, keeping track of the problematic cases encountered and questions asked by IDUs, and writing down field observations in daily and weekly reports. A POSITIVE MODEL The Harm Reduction Program has received broad attention from the Ministry of Health and the Russian mass media, and has stimulated awareness and discussion on the subject of HIV among injecting drugs users, health professionals, and the general public. It has become a model for harm reduction activities nationwide. MSF staff provide practical training for numerous exchange programs which have been recently set up cities throughout Russia. The "Protect Yourself" leaflets have been extensively copied, reproduced, and distributed by other programs in the country. Internally, the program has been evaluated by MSF on a regular basis. These evaluations have concluded that the program is effective in HIV prevention among injecting drug users in Moscow. MSF has also benefited from the help of expert advice from health professionals in Moscow, notably for the creation of educational materials, which were tested among focus groups to ensure that the messages were appropriate for the target population. Regular support and on-site project monitoring were also offered by the consultant-organization Mainline. Though an MSF survey conducted in 1998 confirmed that a large percentage of IDUs share injecting equipment, outreach workers have more recently observed a change towards safer behaviour, perhaps due to a growing perception among drug users that sharing is "shameful". The latest MSF survey indicates IDUs are aware of HIV and they are reporting less sharing than before. It would be useful to conduct a new survey to monitor behavioural changes and determine to which extent these can be attributed to the work of the Harm Reduction Program. LESSONS LEARNED
The most important lesson learned is that without the involvement of drug users themselves, there can be no effective HIV prevention and no ongoing behavioural changes within the high-risk group. It is crucial to implement harm reduction activities on the basis of the peer-support principle, involving people from the drug-using community.
It is crucial to link and incorporate harm reduction activities into the existing health care structures by means of regular informational exchanges between GOs and NGOs.
The program realized the importance of maintaining regular informational exchange between harm reduction programs operating within Moscow, in different cities in Russia, and even in different countries of the world. To this end, information officers should be assigned to each program.
Given the rare knowledge within the Russian society about the drug using population, the harm reduction movement should be engaged in advocacy for reform. This includes informing the wider society about developments in harm reduction, protecting the human rights of drug users, and combating the stigmatisation of this social group.
By providing HIV/AIDS education through peers and by stimulating safer behaviour, the program aims to help curb the epidemic among IDUs in Moscow. However, as there are only two such programs in a city of 10 million inhabitants, its impact is clearly limited.
The program is still dependent on international funding. Efforts to have local health and social security agencies take over and pursue the program have so far not been successful. The reasons for this range from lack of financial resources to lack of political support for a preventive approach.
The large-scale implementation of a comprehensive HIV prevention program, including peer support outreach, is urgently needed in Moscow and in Russia in general.