At the time of the interview Liudmila Тrukhan is Country Coordination Mechanism Secretary in charge of liaison with the Global Fund, member of the Eurasian Harm Reduction Network Steering Committee (Belarus). As a trained epidemiologist she was involved into the development and implementation of the first harm reduction program in the Republic of Belarus in 1997. Since 2005 she has also been involved in the design and implementation of syringe exchange programs in Belarus funded by the Global Fund grants. Since 2002 she has managed a harm reduction program in Soligorsk, which USAID considers one of the best programs in terms of coverage of injection drug users by prevention services. At present Liudmila is a consultant for the UN Department on Drugs and Crime.
At the time of the interview Leonid Vlasenko is Senior Program Manager at the Clinton Health Access Initiative (Ukraine). He is a trained psychiatrist with over 30 years of experience in assisting people with various addictions. Leonid worked as a doctor at the detox and psychotherapy ward of a drug addiction treatment clinic, then as deputy head of a regional drug addiction treatment clinic in charge of clinical practice. He has written and co-authored a number of research papers and projects on drug addiction and substitution therapy. For the last 10 years he has been actively cooperating with national and international NGOs working to incorporate harm reduction strategies into the national health care system and with those pushing for drug policy reforms.
- Liudmila, Leonid, how did harm reduction programs first start in the Ukraine and Belarus?
Liudmila: - In 1996 there was an outbreak of HIV infection among injection drug users in the city of Svetlogorsk. At one point as many as 800 HIV-positive patients were registered. Many international experts came then to the city and the local government decided to launch an NGO called „Parents for our Children´s Future”. The chair of this organization Yekaterina Fisyuk joined forces with an addiction specialist Vladimir Romantzov and in 1997 they opened the first “trust point” for PUD in the country, started to exchange syringes and counsel drug users, the first outreach workers were recruited then.
The first harm reduction programs were supported by the USAID office in Belarus (Roman Gailevich opened first harm reduction programs in Belarus: in Svetlogorsk, Mogilev, Vitebsk, Minsk, in 2000 – in Soligorsk and Pinsk) and by the Open Society Foundations (OSF). Starting from 2003 the harm reduction programs were coordinated by the civil association Positive Movement and the UN Development Programme, in 2004 they received funding from the Global Fund.
Belarus is unique in the way that from the very beginning our syringe exchange programs were run both by community and health care organizations. In 2000 a syringe exchange point in the form of an anonymous counseling room was opened in the Soligorsk district hygiene and epidemiology center where I was working at the time. It was listed by UNAIDS as one of the best practice sites in terms of drug user coverage by prevention programs.
In 2002-2003 EHRN helped to recruit the first team of outreach workers in Minsk and train outreach workers in other cities. The first steps in advocacy in the form of legal aid to outreach workers were made. Thanks to EHRN the first training visits to Poland were organized for law enforcement agency representatives, governmental officials and civic organization activists, so they could see how harm reduction programs and substitution therapy worked. In fact, what we saw there for the first time was the continuum of care. We also visited Ukraine, the city of Poltava. Raminta Stuikyte (the first Executive Director of EHRN Secretariat, EHRN) used to bring us many experts from Lithuania. They evaluated the existing and helped launch new programs.
Methadone substitution therapy programs have been run in Belarus since September 2007. The first substitution therapy programs were supervised by Vladimir Maximchuk, former Chief Addiction Officer at the Ministry of Health. The whole thing started with one pilot project in Gomel run at the Gomel Regional Drug Addiction Treatment Clinic. Dr Vitold Tumilevich, who was at the time managing the clinic as Head Doctor, cooperated with Liudmila Shabalina, psychologist and clinic ward manager, and the staff of the methadone substitution therapy room to create a comprehensive system of medical, social and psychological care for OST clients, funded by the Global Fund. Now there are nineteen OST programs in the country and another four will be launched soon.
As there is a limited number of donors working in Belarus, the Global Fund is the only source of funding for harm reduction programs. We used to have up to fifty five harm reduction programs but then we had to cut down their numbers, because their cost-effectiveness in smaller towns is very low.
Leonid: - Harm reduction came to the Ukraine at around the same time (mid 90s, EHRN). In 1994 – 1995 we had an HIV outbreak too, in Odessa and Nikolaevo regions. The government started opening AIDS Centers, which were mainly engaged in testing, notification and lectures about HIV for general population. No one was talking about prevention in vulnerable populations, of course. The very first harm reduction programs were introduced in the Ukraine by the Open Society Foundation. There is an OSF office in the Ukraine, a fund named “Vidrozhdennja” (“Resurrection”, EHRN), if I remember right, it was Vyacheslav Kushakov, future organizer of the Alliance against HIV/AIDS, who was in charge of their public health department then. The first syringe exchange programs were launched in several bigger cities: Odessa, Poltava, Livov, Donetsk.
At that time the drug scene was rather transparent, one could organize this kind of activities very well, everything was running smoothly and visibly good results were indeed achieved. The Vidrozhdennja Fund was financing the purchase of syringes; the Alliance got a grant to pay for social counseling and cover expenses for personnel´s salaries.
Kushakov then left for the Alliance and all the harm reduction programs went into the hands of Dennis Poltavetz (trained psychiatrist, between 2000 and 2005 he was Program Manager in the Public Health Initiative Program run by the International Vidrozhdennja Fund, EHRN), and this same man started managing all the issues of substitution therapy. Another person I would like to mention here is Lena Kucheruk, who worked at the national department of public health and with Slava Kushakov and Dennis Polzavetz, she is still working at the Fund.
The advancement of OST started in late 1990 – early 2000, when Emilis Subata (Director of the Vilnius Centre for Addictive Disorders and one of EHRN co-founders, EHRN) paid us a visit.
Liudmila: - Emilis visited us as well, he was a consultant on substitution therapy in Belarus when the Global Fund came to the country.
Leonid: - Emilis did presentations, showed us films about methadone, methadone in prisons, methadone in Gipsy campsites – EHRN was engaged in this kind of advocacy then.
The most powerful impulse for harm reduction in the Ukraine came from the Global Fund. Even then sustainability was rather high on the agenda – OSF could not possibly provide any long term support to the programs, it was not their job. However, since the arrival of the Global Fund harm reduction programs started to be part of the national response to HIV epidemic. The government allocated no funding but did support the projects run by NGOs.
As for substitution therapy – the first pilot project with buprenorphine was launched in Kherson, then there was another one in 2004 in Kiev, supported by UNDP, then a research study based on the Kherson project was started and Emilis Subata got involved in it, too.
Liudmila: -Since October 2014 all substitution therapy rooms have been funded by the state, the Global Fund money is only used to buy dispensing systems for distribution of methadone and methadone itself. Unfortunately, the coverage by substitution therapy programs has decreased and about 300 people have dropped out.
- How did your co-operation with EHRN look like at the time?
Leonid: - EHRN helped us very much with preparing abstracts needed for scholarships.
Liudmila: - Our health care officials, law enforcement officers and civic activists would visit Lithuania to look into the way harm reduction programs, rehab centers and intersectoral partnership was organized. I think EHRN was the only source of research and legal information one could use as reference, it was the only place, the only website where one could find reliable information and evidence-based data. We had no other resource like this in the Russian language. I believe the whole concept of „drug control policy“ was introduced to us by EHRN. They would also provide much assistance with conference participation, financial as well as technical.
When we first started working with harm reduction programs under the Global Fund, we had to start launching them. Many of them. Our people lacked training and when I started as a program coordinator, the first person I asked for help was Raminta Stuikyte. She came to speak at the first meeting of harm reduction programs in Belarus. I remember her in a big hall packed with audience: the EHRN Director, the person who inspired us all so much. Thanks to the technical assistance provided by EHRN in early 2000 we could also start building our first outreach teams. All members of the EHRN Secretariat are the experts one can ask for help any time and always get it.
Leonid: - Yes, in the region of Central and Eastern Europe and Central Asia (CEE/CA, EHRN) one could meet quite unique personalities working in harm reduction. Take Kyrgyzstan, for example, the country that did everything on its own, without any grants – take such a man as Tynchtykbek Asanov (Chief Addiction Officer at the Ministry of Health and Director of the Republican Center for Addiction Control in Bischkek, Kyrgyzstan). He was the one who introduced substitution therapy in the region of Central Asia, in Kyrgyzstan, he did practically everything by himself. In my own country, Ukraine, the chief addiction officer at the time was Anatoly Vijevsky, a substitution therapy advocate, he wrote the first guidelines on the use of methadone in cooperation with the association of addiction specialists he was chairing.
Liudmila: - We had Vladimir Maximchuk (former chief addiction officer at the Belorussian Ministry of Health, EHRN) who was quite unique, too. He managed to get approval for substitution therapy implementation in Belarus. Alexei Alexandrov, another former chief addiction officer at the Ministry of Health, also did a lot for the implementation of substitution therapy in the country and got many new cities on the list for OST.
Leonid: - It is never easy with governmental structures. I remember a story about Kestutis (Кеstutis Butkus, program coordinator of self-organization of people who use drugs, NGO Resetas, Lithuania, EHRN) and his activist friends, who were to attend some event in Odessa in 2003. I was just back from Lithuania and knew that Kestutis was taking part in a methadone program. I got in touch with him and said, “Look, why don’t you drop by in Dnepr on your way back and speak at our round table discussion about substitution therapy?” (We had no such programs at the time). He agreed. So he comes to our round table talk, our university rector is among the audience, some generals as well…They are sitting there and Kestutis is talking about substitution therapy - quietly, calmly, in his usual manner. I notice that the head of our local department for illegal drug control looks seriously confused about the whole thing. He gets up and asks: “When did you stop taking methadone?” And Kestutis says, why, I still take it. “How did you cross the border then?” Well, Kestutis pulls his flask with methadone out and says, “Because I have all the documents, all the papers on me”. The head of department seems to be satisfied. Later this man came to Kestutis and said, “Look, I have known enough drug addicts. They are usually nuts but you – well, you are perfectly normal!” And Kestutis says, “Sure I am, it´s methadone I am taking”. And he goes on telling the man about the basics of substitution therapy. Kestutis left but since then this guy, the head of Dnepropetrovsk Department for illegal drug control, has never ever put any obstacles on our way.
- Liudmila, Leonid, what are your personal stories – how did you end up in harm reduction?
Liudmila: - My story started almost at the same time with the HIV outbreak in Svetlogorsk. Only they had HIV there and in our Soligorsk city I had to deal with a rise in the incidence rates of viral hepatitis B and C. As an epidemiologist I was investigating the situation and at some point I did see the link between the epidemic and drugs. In Svetlogorsk they had already started two syringe exchange program, so one day the Soligorsk district executive committee leased a bus, put there governmental officials and civic organization activists and travelled to Svetlogorsk. I remember how we arrived at a trust point - they show us around and tell us how important it all is and then one of the Soligorsk Executive Committee officials (local government, EHRN) says, why, it may happen that my own granddaughter mingles with drug users?! I say yes and tell her about hepatitis. The officials were very impressed. So we started applying to various donors for funds to run syringe exchange programs in Soligorsk. We were supported by the Republican HIV/AIDS Prevention center, their Head of Department Svetlana Bruzkaya helped us write the first application for funding of a harm reduction program. So when the first grant arrived, we decided to open a “trust point” in the Soligorsk center for hygiene and disease control, right at the entrance. We opened on February 1, 2000 and I remember how we were sitting there the first two weeks waiting for our first clients, we were so afraid no one would turn up. But by the end of the year we had as many as 1 200 clients among PUD. By the way, our first visitors were no clients but the guys from the local Christian Evangelic Church who came to invite our clients to come to their church for rehabilitation. Eventually clients started coming too, once weekly, it all worked on the principles of bush telegraph, they come and they tell the others, so the others come, too…They got to know me and were not afraid anymore. During the day I was working and in the evenings I would come straight to the exchange point. I knew we could have another Svetlogorsk here if we denied help to PUD and stopped counseling them on safe behavior and providing protection.
The syringe exchange point was next door to the local police department. But our relationship with the police was so good that they changed the routes of their patrol officers so as not to scare our clients away.
Apart from EHRN we got lots of help from others: Anna Moshkova from IHRD, Alexander Slatviskas from Klaipeda, Andrei Protopopov from Poltava, Anna Sarang from Moscow.
In 2005 I got a job in the Global Fund Grant Management Group in charge of HIV. I was coordinating anonymous counseling points for drug users (a Belarussian term for PUD) and self-help groups of PLHIV. When I was part of the Belorussian civic association “Positive Movement”, which has been coordinating the work of SEP countrywide, I met many remarkable people. They are totally dedicated to harm reduction, love and respect their clients. This is the only thing that makes harm reduction work.
Leonid: - I worked in addiction control area, was a trained psychiatrist. In 1998 I got a job as head of med (head of medical services, EHRN) at a regional drug addiction control clinic in Dnepr (formerly known as Dnepropetrovsk, Ukraine, EHRN). I was very little concerned with any prevention and syringe exchange programs, we were not really interested in them at the time, thought them the prerogative of AIDS centers and besides, there were no such programs in the city. In 2002 I saw that the American Exchange Program, IREX, was offering 4 months of internship. I applied for it and chose substitution therapy programs, as I did have some theoretical knowledge, just no real life experience…Dennis Poltavetz connected me to some colleagues in New York, they got in touch with Bob Newman, the legendary methadone treatment advocate in the US, so I got lucky to be doing my internship in Beth Israel Medical Center in New York and later, in Chicago. I saw a whole range of different programs, including syringe exchange programs in lower Eastside and Chicago, I met Dan Biggs from Chicago Recovery Alliance, drove in his minivan around all Chicago areas and saw how syringe exchange could be done. Anna Moshkova from IHRD was of great help with planning my stay, she was organizing meetings and site visits, later she would visit us in Dnepr and monitor the implementation of our own syringe exchange programs. As soon as I was back in the Ukraine, I plunged into substitution therapy work – I quit my official job and joined the addiction specialists association. We were writing guidelines for substitution therapy, then launched some pilot projects. At the same time our friends in Dnepr were busy organizing a charity fund named Virtus, one of them was Olya Belyaeva (who is now Manager of Membership and Community Strengthening Team at EHRN, EHRN). We started working together and then the Global Fund arrived at the scene – which resulted in launching syringe exchange programs and, subsequently, the Association of OST Program Participants. This is how I came to the civic movement, it was my professional interest at first that brought me there.
Liudmila: - Everyone in harm reduction strikes me as absolutely devoted to this job. I think no outsiders ever came to work in it.
Leonid: - Emilis Subata was also Medical consultant at the World Health Organization Regional Office for Europe (WHO, EHRN). In this capacity he managed to “marry” us to serious research. We were always told that substitution therapy was “ineffective”, that “it was poisonous”. Well, this man brought us experts from as far away as Australia to help prove otherwise. I remember those materials very well – substitution therapy practices in the Ukraine, Indonesia and other countries were compared….a huge research project. And it did prove the efficacy. As early as in 2004!
You know, when you are working in the field, it is never restricted to just one thing. When I started another research in the Kherson pilot project I used to see clients, they would come to me to fill out questionnaires and I would interview them a few times. Eventually some kind of rapport was built, they started asking questions about harm reduction, wanted to know more about it, so I was telling them more. As a result they launched their own organization. Then another wave of activism developed itself in the southern Ukraine regions. The guys would go there to push, to advocate, to educate about harm reduction.
Liudmila: - Our addiction specialists who were to open substitution therapy rooms were trained by Emilis, too. They would travel to Lithuania and then Emilis would come to Belarus as an expert and with the WHO mission, too, he did training for OST personnel.
- Was it any different from the harm reduction of today – what has changed in the region of Eastern Europe since then?
Leonid: - My personal impression may be wrong but I think there was much more action then, when it was only starting in the region. People would travel around, communicate with each other. It was very effective.
Liudmila: - I agree, we used to have many training events, site visits. Now we don’t have any routine training for SET and OST staff to educate them about harm reduction and professional burn-out. However, it is good that we have the regional EHRN program “Harm Reduction Works – Fund it!”. The program ensures ongoing cooperation between the organizations from 6 countries under the project and has contributed to the self-organization of the people who use drugs (PUD).
Leonid: - I can give you a very good example of what once happened here, in Dnepr. When the decision of substitution therapy was about to be made, we brought some of our staff to Lithuania and trained them. Two of the group were sent to America. And then, back at home, at yet another meeting of the medical officers, one of these two, the head of local health care department known as a furious opponent to substitution therapy (“what methadone?!”) gets up and says, “Well, I was wrong”. His way of thinking was changed. I believe it is even more important than any other incentive, like extra pay for doctors, something we do for those who help with harm reduction and they welcome it. However, sometimes all it takes is to go out of your shell, to open your eyes and look around – what is happening in the rest of the world. And think of what I can do in my own place.