"What have drug users got to do with you anyway?"
Anya Sarang
Médecins Sans Frontières (MSF) Russia
anya.sarang@

When they first arrived in Russia, MSF carried out a field survey and informed the Russian Federation's Ministry of Health how serious the HIV epidemic was going to be for years to come. MSF also made it known that it was necessary to work with the drug users and to train physicians in dealing with this population. Anya Sarang talks about the reasons for personal involvement.

My name is Anya Sarang and I have been working for MSF since 1998. 1 am a senior trainer in harm reduction* for MSF's Russian Harm Reduction Initiative.
We are running harm reduction training sessions in the framework of regional harm reduction programmes. In 1998-2000, these sessions catered mainly for health service workers -specialists in the fields of drugs, infectious diseases and those who work with drug users- and members of NGOs. The aim was to transmit the knowledge gained from experience in Europe and to teach rapid assessment methods for use on local situations. Representatives of 60 regions attended these sessions. After this, we organized anew training course designed with a view to getting something more concrete done. This made the participants attending eligible to obtain funding from the Otkrytoe Obshestvo (Open Society - Soros Fund) to implement local programmes. By now there are 36 projects being completely funded in this way, and 10 others are supported partly by this fund and partly by federal or local subsidies.
The rapid assessment procedures involved making immediate contact with drug users and rating their awareness of HIV/AIDS. In exchange, thanks to these methods (based on surveys, interviews, focus groups, etc.), the users quickly gained some knowledge about risky practices and learned how risks can be avoided. Statistical information was collected during a period of two months on the number of cases of HIV and the number of registered addicts, the number of drug seizures by the police, and so on.
One of the most difficult problems is how to make contact with drug users on the streets. There are several possible approaches, but this was mainly done via users who are in touch with the public health system. When they are about to leave hospital, for instance, we persuade them to work with us, which incidentally isn't always easy. Now things have changed. We have outreach experience, meaning peer contact. If we succeed in persuading a single user to work with us as an outreach worker, he will then persuade five others to become volunteers and so it continues.

"So where are the hidden video cameras? Aren't you going to take our names? What are you going to do with this information afterwards."

We quickly realised that users had quite a high level of theoretical knowledge about HIV/AIDS, but that these same users were highly unaware of the risks they were often taking. It should also be pointed out that the virus had not yet spread very extensively at that time. In the regions where HIV was spreading at faster rates, the work was easier because people were aware of the issues involved.

The first steps are always the hardest. This is due to the attendants' suspicions. From their point of view, any contact with the medical establishment, at whatever level, was thought to constitute a potential risk, as it showed them up as drug users, and if the session was being recorded, they might become known to the police and have to deal with all the problems that can entail. The questions are most frequently asked are "So where are the hidden cameras? Aren't you going to take our names? What are you going to do with this information afterwards?" And when they realise that nothing unpleasant is going to happen, they ask "What's all this about if you're not going to lock us up?"

In Novorossisk, the programme had been running for a long time, but only three people on average were coming each week to exchange their syringes!

One of the conditions for obtaining funding from Otkrytoe Obshestvo (Open Society) is to submit a letter of support from the local branch of the Ministry of the Interior (UVD). These programmes obviously wish to avoid interference from the militia and experience has proved that this is the most effective solution. There were problems at Laroslav and St Petersburg, but these were the first two programmes launched and we hao not conducted our rapid assessments or discussed matters with h, who lined up beside the bus and stamped on the sterile syringes we had brought. Of course, there have been various difficulties pretty much everywhere. We've had patrols giving chase to a drug user they spotted near one of our centres and so on. But by contacting the higher ranks, we were able to solve the problem. In addition, we give those who attend membership cards, on which the aims of the project are listed and that means they don't get into trouble with the militia.

A perfect example of how it works is what happened in Novorossisk. We had a programme down there for a long time but only three people a week on average were coming to exchange their syringes! However, we had the support of the local council who asked the militia not to interfere. One day, when a drug user was stopped with syringes on him, he showed his card proving membership of the programme and the militiaman saluted him and let him go. The news spread -information gets around fast in user circles- and the exchange point suddenly became a lot busier. It's only in Moscow that the local authorities refuse to listen, which means it is the only town where SEPs are still unable to operate. There have even been problems there when our project workers have been stopped in the street themselves.

One of the main weaknesses of these programmes is that their scope is fairly narrow. They operate from hospital annexes, which are not necessarily places where drug users tend to congregate. This failing is somewhat compensated for by mobile services using buses and minibuses, which circulate in towns such as Volgograd, Nijni Novgorod, Saint Petersburg and Kazan, where the users tend to assemble out of doors. But in many other towns, the trafficking and sale of drugs take place inside people's flats. We have to find ways of getting g brochures and condoms and so on delivered to these places. That is where outreach workers take over, going from one sales point to another with bagsful of stuff. But as there are relatively few of these workers, it is difficult to really cover these areas. One method is to use volunteers who have lots of contacts among drug users, such as drug dealers, as syringe exchange workers.

"You mean you are going to give free syringes to those anti-social individuals?"

Lately, the only negative media coverage we have received has been about the idea of introducing methadone* main- tenance programmes, which in any case are non-existent so far. In 1998, the media were horrified: "What? You're going to give free syringes to those antisocial individuals? When our hospitals are short of syringes, and our old folk have no medicines?" By now syringe exchange has acquired quite a favourable reputation. But the fact that the exchange of syringes has become almost synonymous with harm reduction during the last two years is not at all satisfactory. Now I think it is time to introduce new strategies, especially for informing people. Many regions would like to receive our brochures (1), but they do not have the necessary funds for reprinting them, and they are really delighted if we can send them ten copies of the Mozg magazine for the population of a whole town to read.

When we began our work, we had more funds, and we had a psychologist and even a lawyer at every user contact point The possibility of consulting professionals like these is often important for users. If we had more money, we would be able to strengthen our teams by hiring more social workers, setting up more centres and providing more syringes and more condoms etc.

But all these programmes are hampered by a lack of financial means. You cannot do everything. Some groups choose to work with opium addicts, others wih Vint* injectors, and so on. In Moscow, the lasen association decided to start by working among the students, who are fairly easy to approach. In Pskov, there was a girl who had close connections with the gypsy community, which is involved in the sale as well as the consumption of drugs. Thanks to her, we were able to gain access to this group. Currently we are concentrating on women working in the sex industry, as many of them are drug users as well as prostitutes, and the risks they run are therefore twofold.

Looking back, you cannot say that we have laboured in vain. At the very least, we have reached a stage where people are not completely taken aback when we mention the need to replace used needles. That has become standard practice by now. The fact remains, however, that we have been unable to stop the spread of the HIV virus in many places. This is not really surprising when you consider the actual scale of our projects, in which only 1000 people are involved per city of 1.5 million inhabitants on average. The main disappointment is the weakness of State action, particularly the lack of co-ordination between the Ministry of Health departments and those of the Ministry of the Interior. It's because the position of the Ministry of the Interior is, how can /put it ... Locally, we feel we have gained their support, but the positions adopted at Federal level are inscrutable. And the Federal Spid-Tsent (AIDS centres) and the Ministry of Health have played very little part in our activities. They have contented themselves with giving us tacit support and attending our training sessions. In this country today, apart from our project workers and those with whom they come into contact, few people know that the HIV epidemic is developing at a speed which is matched nowhere else in the world.

l have never wondered why I am doing this job. I have tried unsuccessfully on a few occasions to put it into words. Everybody has his or her own reasons, I suppose. A woman from Kazan once described her own motives for being involved in very strong terms. When asked, "What has all this drugs stuff got  to do with you, anyway?", she answered "We live in a society where the rights of any individual cannot only be swept away at any instant, but carry no weight. r   And as far as that goes I am no different from a drug addict. We are all citizens of the same country and in those terms, we all in the same boat. By defending the rights of drug addicts from the medical point of view, I am also asserting my own rights".

1 The newsletter published by the Moscow branch of MSI is available at the following website:

THE RAPID ASSESSMENT METHOD

The Rapid Assesment method is a tool which can be used for mobilisation and survey purposes. It provides a fast diagnosis of epidemiological situations, the practices involved and the services available by compiling reports, qualitative information, published data and other documents with a view to defining appropriate interventions. It takes less than one month to apply and is thought to constitute a valid alternative to the methods classically used to assess public health requirements. This method is sponsored by international organizations (UNAIDS and WHO), and is particularly useful in countries and regions where no interventions have been carried out so far in the field of drugs and/or HIV Infection. It enables those working on the field to define their objectives and orient their interventions as accurately as possible.

The Rapid Assessment method can be downloaded from the following site:

SAINT PETERSBURG: A BUS FOR EXCHANGES...

Several NGOs, including Médecins Sans Frontières (MSF) and Médecins Du Monde (MDM), are actively involved in Russia, where they are initiating and implementing many harm reduction projects. The syringe exchange programmes include the Bus programme launched jointly by Médecins du Monde and the "Return" Foundation on January 1, 1997 in Saint Petersburg. During the first two years, 6,500 drug abusers with a mean age of 21.7 years benefited regularly from the services available on this bus. A total number of 80,000 visits were recorded at the 5 points of call: 170,000 syringes were exchanged, and 3,500 medical and psychological consultations were given by the members of the crew. By now, approximately 2,500 people a year are applying to the bus to undergo HIV screening tests. The example of this Bus shows that it is possible to set up links with the drug users' community in Russia. The programme for 2001 also reflects the need expressed by many NGOs to reinforce partnerships with municipal and national institutions, in order to anchor the mission of the Bus to local structures, and in view of the successful results obtained, to apply interventions on similar lines in other regions where there are high rates of HIV infection.