I was asked to give a short presentation explaining how the HIV virus
has been documented to follow drug trafficking routes, as well as the intersection
between HIV in this setting and human rights issues.
Introduction: Lessons learned from Southeast Asia
Based on research done in Southeast Asia, Chris Beyrer predicted the
outbreak of HIV which exploded in Almaty in 2000.
The study that preceded that prediction was designed to examine the
link between drug trafficking routes in Asia and outbreaks of HIV. The
team used molecular subtyping of HIV to track different strains of HIV
in infected people living on four drug trafficking routes out of Burma
and Laos. Subtyping involves isolating the HIV virus from the blood of
infected people and sequencing the DNA of the virus. By mapping out where
the subtypes are found geographically as well as the risk factors of those
infected with the specific subtypes, it is possible to create an accurate
picture of where HIV has entered a population and how it is moving.
For example, in Urumchi, the capital of Xinjiang province in China,
the virus is very close genetically to the virus in infected individuals
in Yunnan. Heroin trafficking routes lead out of Burma into Yunnan, then
go east to Nanning or Hong Kong, or north to Urumchi. Dr. Beyrer and his
team looked at the map of trafficking routes which continued further north
from Urumchi on into the destination market of Russia. Almaty was directly
on one of these routes, which led to the prediction that there would soon
be an HIV explosion in that city, which is otherwise remote from the epidemics
that were occurring in neighboring countries. Likewise, Irkutsk was the
overland terminal point for another route, and currently has the second
highest prevalence of HIV in the Russian Federation.
Mechanism of HIV spread
The spread of HIV along heroin trafficking routes begins with uptake of
heroin use, leading to injecting drug use outbreaks, followed by explosive
HIV outbreaks. It is quite significant that Central Asia is a trafficking
route, as there are distinct differences in heroin use and subsequent HIV
epidemics along the heroin supply continuum, which begins in production
zones, follows trafficking routes and ends in destination markets.
In cultivation and production zones, such as Afghanistan, there is an
abundance of opium, making it accessible and inexpensive. Most users in
these areas smoke the opium, with a minority snorting it. Neither of these
methods presents a direct risk for HIV.
However, as one progresses along drug trafficking routes, opium is less
abundant. It is much easier to transport refined heroin than opium, as
10 kilograms of opium are concentrated to 1 kilo of heroin. Also, the further
away from the source one goes, the more expensive pure heroin becomes,
as handlers along the way add on their fees. Many people begin by smoking
the heroin, then transition to injection. Once addicted, the economic drive
to injection is overwhelming, as it is far cheaper to inject drugs for
a more effective high.
Once the heroin reaches the destination markets, users almost immediately
begin injecting, as smoking is neither economical or effective to become
high, as the drug has been cut so much that it must be injected for the
desired effect.
Along the trafficking route, there are several factors that come together
to lead to effective person-to-person transmission of HIV. It appears from
experience in many diverse settings across the world, that regardless of
culture, religion or other societal factors, when heroin is present, a
certain percentage of people will try it and become addicts. Many traders
and traffickers self-test heroin by injecting themselves. It has been seen
in SE Asia that due to repressive drug laws, traffickers do not carry their
own injection equipment, rather they share with those with whom they trade
with or stay overnight with along the route. Drug laws are similarly repressive
in Central Asia. The amount of heroin which legally constitutes a "very
large amount," thus labeling the owner a dealer or trafficker, is 7/1000
gram, resulting in imprisonment of seven or more years.
The speed with which HIV moves through an injecting population is incredible,
as can be seen in this slide, which shows how HIV prevalence among IDUs
jumps in just one year in various settings. In Central Asia, the cities
of Timertau, Kazakstan; Yangi Yul, Uzbekistan; and Osh, Kyrgistan, have
some of the highest documented rates of HIV in the region and all lie directly
on drug trafficking routes.
Central Asia: what we don't know
While numbers of people documented as being infected with HIV are certainly
growing, we do not yet have a clear idea of the true prevalence of HIV
in the region. Case-finding surveillance is still used in Central Asia,
testing those that are arrested for drug possession or otherwise "registered"
as drug users. In addition, there is a shortage of assays and adequate
facilities to perform the tests.
Central Asia also remains a mystery in terms of HIV subtypes. The region
is surrounded on all sides by different subtypes, A in Russia, C in Pakistan
and India, and B/C recombinant form in China. Discovering which subtypes
are present will tell us much about trafficking patterns and risk behavior
in the region.
Central Asia: what we do know
Despite our precise lack of knowledge about HIV prevalence and subtypes,
much is known about drug trafficking and other factors which make the Central
Asian region vulnerable to HIV. Illicit drug trafficking, while a serious
problem in many countries, takes place most efficiently in settings where
there the following conditions exist: 1) proximity to production zone;
2) porous borders; and 3) poverty and corruption, where revenues act as
"tax" for protection.
We know that Central Asia is a critical drug trafficking route, the
corridor through which much of the world's hard drug trade from Afghanistan,
Pakistan and Central Asia itself, is conducted. The quantities of raw poppy
seeds that have been seized in the past year indicates that heroin production
laboratories may now exist in Tajikistan. The Open Society Institute estimates
that 10 percent of the drugs being produced and trafficked are consumed
in-country. The region is estimated to contain approximately 500,000 drug
users.
The government of Tajikistan has acknowledged that security forces are
corrupt, and that most citizens keep silent rather than risk retaliation
from the police. In the southern regions of the country, many border guards
are involved in the drug trade and the local population has made numerous
complaints of harassment and abuses committed by them. Traffickers include
individuals who rose to positions of power and wealth as field commanders
during the Tajik civil war, the so-called "warlords."
One striking piece of evidence of CAR drug trafficking success is the
explosion of HIV among IDUs in Russia, Ukraine and Belorus, which are both
destination markets and transit routes as drugs continue on to Western
Europe.
We also have ample data on the economics leading to and supporting trafficking.
For instance, one report on Tajikistan found that 30 percent of the population
is economically dependent on the illicit drug business. In an OSI study,
it was shown that economic factors were also responsible for many people
initiating drug use, due to stress, boredom and unemployment.
One rarely mentioned phenomenon facilitating HIV spread along drug trafficking
routes is the linkage between trafficking of women into sex work and trafficking
of narcotics. Many of the same people are involved, both within the government
and official structures, as well as members of organized crime groups.
For instance, over 1000 women were trafficked from Tajikistan in 2000.
Many times, these women are used to transport drugs as they themselves
are being trafficked into sex work, either out of the country or being
forced to service men moving along the trafficking routes. Many of them
become users themselves, exponentially increasing their risk of HIV and
that of their clients.
Urgently needed measures to counteract HIV
The vast majority of measures directed at the region have involved reduction
of drug supply through seizures and passing laws that levy harsh penalties
upon people possessing even tiny amounts of illicit drugs.
In order to slow the spread of HIV in this region, the problem must
be confronted openly and honestly. Repressive drug laws do not stop people
from using drugs, they simply drive addicts further underground, making
them harder to reach and resulting in riskier behavior.
Two measures are urgently needed in Central Asia. The first is access
to drug treatment. Methadone maintenance therapy has been shown to reduce
HIV risk behaviors, particularly needle use, giving us strong evidence
that methadone prevents HIV among IDUs.
The second measure which could limit the spread of HIV in Central Asia
is an effective system of needle exchange programs, which would reduce
the practice of needle sharing. OSI has established or sponsored many needle
exchange points in this region, as well as in the destination markets of
Russia, Ukraine and Belorus. However, adequate coverage will not be reached
if the most vulnerable addicts are afraid to access their services, due
to repressive drug laws.
Thus, the intersection of heroin trafficking, HIV spread and human rights
issues forces individuals and governments to consider the needs of the
heroin user along trafficking routes. It is only by respecting his or her
rights to information, to adequate medical treatment and to dignity that
we can hope to slow the spread of HIV in the Central Asian region.
