Training and support for 'Harm Reduction' programmes in Russia
6 June 2001
BACKGROUND After a situation assessment in 1995-97, MSF, together with the Russian Ministry of Health, determined that effective HIV prevention among injecting drug users would require three key developments.:
the training of several hundred Russian doctors, government officials, NGO staff, and ex-drug users in the HIV prevention methods which have proven successful in other countries
the establishment of prevention interventions in cities and regions throughout the nation
the political support of the government for these prevention measures.
MSF worked with several national and international organizations to develop activities to meet these needs. The Ministry of Health of the Russian Federation, through its Infectious Diseases and Narcology Departments, offered significant, practical advice and support in setting up the training program and selecting the participants. In order for prevention activities that would emerge from the training program to be sustainable, MSF formed a strategic alliance - called the Russian AIDS Prevention Initiative-Drugs (RAPID) - with the international organizations The Lindesmith Center (TLC), Open Society Institute-Russia (OSI-R) and Médecins du Monde.
Under the RAPID program, participants who successfully completed a Rapid Situation Assessment (RSA) in their city or region were invited to apply for technical assistance (from international advisors) and for the funding of harm reduction programs (from OSI-R).
MSF and UNAIDS worked together on the development of Russian educational material prior to the training course. Staff from the Trimbos Institute participated in the design and delivery of the first three training courses.
The objective of the program was to provide training and support to 200 health professionals from 60 Russian cities (plus cities in other countries of the CIS) that would enable these professionals to set up and/or improve HIV/AIDS prevention programs among injecting drug users in their own place of origin.
Teams from the cities usually consisted of three representatives, to ensure that each of the following sectors were represented: government AIDS centres; narcological clinics and dispensaries (government structures used for the treatment of alcoholism and drug addiction); and non-governmental organizations.
As part of the training, participants were asked to carry out a rapid situation assessment (RSA) in their city or region as a major step towards designing and implementing an effective program to prevent HIV transmission among IDUs.
COMPREHENSIVE TRAINING PROGRAM
The main resource materials on which the training was based were the WHO Rapid Assessment and Response Guide on Injecting Drug Use, and the European Peer Support Manual. The training course covered the following topics: the prevention of HIV and sexually-transmitted infections; harm reduction; the methodology for rapid assessments; the dissemination of assessment findings; the development of outreach and community-based activities; recruiting and managing staff; planning and budgeting; writing grant applications; and ways to provide continued training.
Each training cycle took place over a period of four months. It began with an Initial Training Course (11-12 days) in Moscow. The participants then returned to their cities and, during the next 12 weeks, worked on assembling a team and carrying out a rapid situation assessment (with technical support and city visits from MSF staff and consultants, where requested and possible).
The cycle concluded with a Return Training Course (5-6 days) in Moscow: participants having completed an RSA or attempted to carry one out discussed their results with the training staff and their ideas for HIV prevention programs. They were assisted in developing goals and objectives and encouraged to apply for further assistance under the RAPID program and funding from the Open Society Institute.
The training courses were scheduled to overlap with one another, so that the participants in the Initial Training Course spent their last day listening to the results of RSAs carried out by participants of the Return Training Course.
OUTPUT AND OUTCOME
The training courses allowed the participants to perceive the need for rapid assessments of HIV prevalence and of drug use, in light of the worsening epidemic. The participants acquired the necessary skills and work methods to undertake RSAs.
By January 2000, participants from more than 60 cities (61 from Russia, 4 from other CIS countries) had been trained, and 63 RSAs had consequently been completed.
Conducting a comprehensive training program and integrating it into a structure that allows for further capacity development and funding has had a great impact. The beneficial effects of such a program surpass those obtained by short training courses on harm reduction and HIV prevention which have been offered in Eastern Europe and elsewhere.
The opportunity for participants to show that funding had been established for harm reduction initiatives in Russia was a powerful incentive for city administration officials to support both the RSAs and future programs. This is the great benefit of a strategic approach in which training, funding, technical assistance and advocacy each have their place.
As of November 2000, the Open Society Institute - Russia has approved 36 applications, thus filling the available grant slots to 100%. The harm reduction programs appeared all over Russia from Kalinigrad to Yuzhno Sakhalinsk. The programs include a mix of fixed and mobile needle exchange outlets; outreach and group education for intravenous drug users (IDUs); preparation and distribution of educational materials for IDUs; referrals and the provision of other, mainly medical, services. The grants were provided for one year with possible renewal for a further two years.
As there were only 4 HIV prevention interventions among IDUs in Russia at the beginning of 1998 and there are now 36 programs funded by OSI and at least 4 funded by other sources, the number of harm reduction programs in Russia increased 10 times within about three years.
The new Russian harm reduction programs will receive advanced technical assistance to further improve their performance and effectiveness: the training cycle which MSF and OSI/IHRD began in June 2000 - "Training on HIV/AIDS Prevention Strategies among Injecting Drug Users in Russia" - is ongoing.
MSF observed that this type of training approach appears to influence the attitudes and behavior of participants as well as to pass on knowledge and skills. The training program has stimulated collaboration between various players: health, law enforcement, and administrative agencies at the city and regional level, the Ministry of Health at the federal level, international governmental and non-governmental organizations, etc.
It has also increased inter-departmental collaboration both within cities and nationwide:
A major, political benefit of carrying out local RSAs lies in raising the issue of HIV among decision makers and the general community, and of gaining support for prevention programs targeting IDUs. The RSA was a practical step that the participants, with the help of some coaching, felt capable of undertaking. It was also a non-committal step: by conducting an RSA, the participants were seeking information on a topic for which they had some responsibility in their cities, rather than starting off simply talking about needle exchange or other contentious issues. While seeking support for the RSA, and during city visits by training staff, controversial topics were raised in the context of research data. The figures showed rapidly rising drug use and high levels of behaviours risks for HIV transmission.
By seeking support and information from various agencies in the city, an education process occurred in which important decision makers from several sectors were shown the dimensions of the problems and were introduced to strategies that which could be used to combat these problems.
When the RSA results were used to design programs, all of the important decision makers were at least aware of the rationale for the proposed program.
The training took into account the specific circumstances of the Russian Federation: a high level of education among professionals; limited access to international experience due to 70 years of isolation; the collapse of old structures and the transitory phase to new ones; booming medical needs at a time when most other international organizations were strikingly absent.
The training was cost-efficient. Repeated internal auditions and evaluations confirmed that available human and financial resources were used with maximum efficiency.
The knowledge and experience acquired from the training will be preserved. After the program was terminated in early 2000, all gathered written materials were handed over to the Medical Academy for Post-Graduate Studies of the Russian Federation. Henceforward, the entire training will be part of the curriculum for narcologists in Russia.
The training serves as a model for further international assistance.
The structure of the program - that is, the placement of the training within a strategic framework which also includes technical assistance and funding - serves, to a considerable degree, as a model for a World Bank loan being currently negotiated with the Russian government. As a timely, comprehensive, early model of intervention, the training program will contribute to the development of a national strategy to contain the epidemic of HIV.