Meeting the challenge of Injection drug use and HIV in Armenia
Injection drug use (IDU) rates and HIV rates in some countries of the former Soviet Union (FSU) are skyrocketing.
The epidemic of injection drug use is an epidemic of the young. These young people deserve attention and care, irrespective of how society feels about drug use. Stigmatizing them could risk the survival of a generation on which the promise of transition depends. Their drug use, the reasons behind it, and its consequences must be addressed with effective evidence-based methods - even if those methods may make some people uncomfortable.
Compared to the known prevalence of HIV in other countries in the region, such as Russia and Ukraine, that in Armenia is not high. Between 1988 and November 1, 2005, 375 people with HIV were registered in the country, and the estimated HIV prevalence rate in 2002 was less than 0.1%.
This relatively low rate may not be enough alone to justify an immediate effort to develop an HIV prevention program.
Armenia’s socio-economic crisis, however, in addition to other factors such as poverty, mass unemployment, and a considerable population of internally displaced persons and refugees, makes the HIV/AIDS epidemic a real danger for this small country of approximately three million people. As declared at the Caucasus Area Meeting on National Responses to HIV/AIDS, “. . . the alarming situation and experience of Ukraine, Belarus and Russia demonstrate that the number of HIV cases can increase from hundreds to thousands within a year. Tomorrow can be late. We have to act today. . . .”
Official statistics show that the HIV epidemic in Armenia, as in other countries of the FSU, is driven mostly by injection drug use (54.5% of all registered cases). In recent years, a significant increase in the number of cases of infection resulting from the injection of drugs has been observed. So far, all of the individuals infected via IDU in Armenia have been men, the majority of whom were living temporarily in the Russian Federation (Moscow, St. Petersburg, Irkoutsk, Surgut, and Rostov) and Ukraine (Odessa, Mariupol, and Kiev).
Studies have demonstrated that when an HIV epidemic is driven by IDU, early intervention becomes critical: once HIV has been introduced into a local community of injection drug users, there is a possibility of extremely rapid spread. Moreover, once HIV prevalence exceeds 5-10% among injection drug users, overall infection rates can climb as high as 50% in fewer than five years. The potential for the rapid spread of HIV among injection drug users means that any delay in implementation of HIV prevention interventions carries particularly serious consequences.
Data on the prevalence of drug use in Armenia are scarce and vary widely at times. According to the operative data of the Ministry of the Interior, the number of drug users in Armenia in 2000 was about 20,000 (50% residing in the capital city, Yerevan), with 2,000 of them using injection drugs.
In its study, “Rapid Assessment of the Spread of HIV Infection Including Intravenous Drug Users,” the National Center for AIDS Prevention in Yerevan found higher rates. It showed that in Yerevan alone in 2000, there were from 19,000 to 20,000 drug users, of whom approximately 10% were injection drug users. According to the World Health Organization (WHO) EURO databases, the estimated number of injection drug users in Armenia in 2003 was between 7,000 and 11,000. Even taking into account the differences in these estimates, the numbers are disturbing and reveal the need for intervention.
The Sentinel Epidemiological Surveillance carried out in 2000 found the HIV prevalence among injection drug users to be about 15%, demonstrating that they are key to the dynamics of the HIV epidemic in Armenia. To prevent a generalized epidemic, there is an urgent need to address the linkage between IDU and HIV infection.
Why Focus on Human Rights?
The evolving HIV/AIDS pandemic has led to an increased understanding of the importance of human rights as one of the primary factors in determining people’s vulnerability to HIV infection. By the end of the 1980s, the first WHO global response to AIDS included reference to the protection of human rights as a necessary element of a worldwide public health response to the emerging epidemic.
The human rights discourse is crucial in relation to HIV/AIDS for several reasons. First of all, conceptualizing something in rights terms emphasizes its exceptional importance as a social or public good. Second, use of rights language in connection with any issue emphasizes that the dignity of each person must be central to all aspects of that issue. And finally, framing an HIV strategy in human rights terms anchors it in international law, thereby making governments and intergovernmental organizations publicly accountable for their actions toward people living with HIV/AIDS, as well as those vulnerable to HIV/AIDS.
The key human rights document of the modern human rights movement is the Universal Declaration of Human Rights (UDHR), adopted by the United Nations General Assembly in 1948. The UDHR recognizes health as a fundamental human right. The International Covenant on Economic, Social, and Cultural Rights (ICESCR,1966) further elaborates the concept of the right to health by declaring “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health,” which encompasses the right to control one’s health and body, including sexual and reproductive freedom. The ICESCR also includes the right to be free from interference, such as the right to be free from torture and non-consensual medical treatment as well as the right to a system of health protection that provides equality of opportunity for people to enjoy the highest attainable level of health. Health and government responsibility for health in the context of the HIV/AIDS epidemic is codified in some form in other treaties including the International Convention on the Elimination of All Forms of Racial Discrimination (1965), the International Convention on the Elimination of All Forms of Discrimination against Women (1979), and the Convention on the Rights of the Child (1989). In addition to the right to health, human rights relevant to HIV/AIDS include (but are not limited to) the right to non-discrimination and equality; to liberty and security of the person; to privacy; to seek, receive, and impart information; to participate in developing policies and programs that affect oneself; to marry and found a family; to work; and to have freedom of movement, association, and expression.
Having ratified the aforementioned treaties, Armenia committed itself to respect, protect, promote, and fulfill the rights recognized in them. The study summarized here sought to find out whether the nation has in fact done so.
The goal of this study was to analyze the Armenian illicit drug- and HIV-related laws, policies, and practices through a human rights lens in order to:
- identify areas of inconsistency between the Armenian approach and human rights principles;
- demonstrate how a lack of human rights-based policies may challenge effective responses to drug use and HIV; and
- draw conclusions and propose recommendations for bringing the Armenian legislative framework and its practices into compliance with international standards, which would also help control the twin epidemics.
The study included these methods:
- Desk research that was done through the review and analysis of relevant materials, both printed and electronic. The materials included legal documents, resolutions, position papers, research articles, books, and mass media articles on drugs, human rights, and HIV in general and in relation to Armenia in particular.
- Primary research that was carried out through key informant interviews.
Study subjects were selected in accordance with data from the literature identifying the key stakeholders and groups of people associated with the issues being examined.
Key informants included officials from the Ministries of the Interior, Health, Education, Culture, and Youth Affairs; parliamentarians; health care providers; policemen; and representatives of nongovernmental organizations (NGOs) and the mass media. This study had a serious limitation, which was the inability of researchers to reach out to injection drug users and interview them. This restricted the knowledge available and thus the entire thrust of this article.
As was stated above, the HIV epidemic in Armenia is mostly driven by IDU. Therefore, a primary component of the research was an analysis of the cornerstone of illicit drug-related legislation in Armenia, the Law of the Republic of Armenia on Narcotic Drugs and Psychotropic Substances, adopted December 26, 2002 (hereinafter the Armenian Law on Narcotic Drugs). The purpose was to find out if and how this legislation poses obstacles to comprehensive rightsbased approaches to HIV. Armenia assented to the three major UN Drug Control Conventions in 1993, and the Armenian Law on Narcotic Drugs closely tracks their provisions.
The policy-makers developing the Armenian Law on Narcotic Drugs were guided by the government’s stated slogan, “Armenia Free of Drugs.”
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Karine M. Markosyan, Aramayis Kocharyan, and Artur Potosyan
Karine M. Markosyan, PhD, MPH, is Director of the Health Education Association (Armenia); Aramayis Kocharyan, LL.M, MD, is a Legal Expert for the Standing Committee on Social Affairs, Health Care, and Environment of the National Assembly of Armenia, as well as Program Coordinator, Open Society Institute Assistance Foundation - Armenia; and Artur Potosyan, MD, MBA, is NGO Networking Project Manager at the UNDP/Southern Caucasus AntiDrug Programme, “Antidrugs Civil Union.”
Revision date: July 9, 2011
Last revised: by Andrew G. Epstein, M.D.