Preserving substitution maintenance therapy in Kazakhstan: the history of advocacy

In most cases, doctors refuse to include new people to the program, even taking into account the referrals from medical commissions to methadone treatment.

Article written by the Eurasian Harm Reduction Association (EHRA)

In the middle of 2017 there was an alarming situation with methadone opioid therapy (OST) in Kazakhstan, which had been initiated there earlier in 2008 in accordance with the recommendations of various international organizations such as WHO, UNAIDS and UNODC. The program couldn’t get unanimous support from politicians, law enforcement and health agencies and was under the threat of closure.

In the summer of 2017, one of EHRA partners in Kazakhstan, the Kazakhstan Union of People Living with HIV, expressed serious concern about the threat of closing the supporting substitution therapy program (this is what OST is officially called in Kazakhstan, it’s usually abbreviated as “SMT” – “substitution maintenance therapy”) and revealed the facts of pressuring program participants by law enforcement agencies.

In June 2017, the Ministry of Internal Affairs with the support of seven MPs has demanded to close OST programs immediately. The Office of the Prime Minister soon ordered the evaluation of OST programs for opioid dependent people, which was launched at the end of September by a specially created Intersectoral Working Group consisting of 17 people. On October 30, 2017, the Working Group prepared a resolution concluding that the program was effective and should continue after some improvements to accessibility and quality of services.

However, some members of Intersectoral Working Group were not satisfied with the positive recommendations and initiated the “alternative research” that was performed without appropriate methodology and with the assistance of the police, which consequently led to serious violations of the rights of OST clients. This study resulted in the document named “Special opinion” of four members of the working group, which said that the program was not effective and should be closed.

From November 27 till December 1, 2017, the team of the Eurasian Harm Reduction Association held three meetings with OST program participants in Pavlodar and Temirtau during its visit to Kazakhstan. The meetings were held in the office of NGO “Ty ne odin” (“You are not alone”), at OST site in Pavlodar and at the crisis center for women in Temirtau. 30 people attended the meetings. During the meetings, EHRA conducted the interviews to find out how an “alternative study” of the effectiveness of OST programs was really conducted. The interviews with the participants of OST programs in Pavlodar and Temirtau revealed numerous violations in the work of the commission during their visits: most of the interviewed patients were not informed about the purpose of the study, they were threatened and accused of not being able to stop using drugs without medical support, were forced to participate in the survey and provide urine samples for drug testing without their informed consent. The police visited some OST clients at their homes and demanded to share their experience of participating in the program.

Despite the serious violations recorded by the civil society in the work of the members of the Intersectoral Commission and the false data indicated in the Special Opinion, the document was attached to the main report of the Intersectoral Working Group, which led to the decision to stop the recruitment of new participants in the OST program starting from January 2018.  On June 27, 2018, the new commission, with the participation of the National Security Committee and the Foreign Intelligence Service, had to decide the future of people receiving methadone treatment in the Republic of Kazakhstan.

At that point it became obvious that the situation at the national level should be viewed from the international perspective, so the Eurasian Harm Reduction Association in cooperation with the Kazakhstan Union of People Living with HIV and in partnership with several international organizations, held a series of advocacy activities. It was decided to draw the attention of journalists, international human rights organizations, representatives of the embassies of the Republic of Kazakhstan in foreign countries to most serious violations of human rights, including the right to access scientifically proven life-saving treatment in the Republic of Kazakhstan

Advocacy actions of EHRA and its partners

  • January – April, 2018: EHRA, together with the Canadian HIV / AIDS Legal Network, filed a complaint based on the documented cases of violations to the UN Committee on Economic, Cultural and Social Rights.
  • The threat of closure of substitution treatment programs was announced by EHRA at the April meeting of the Committee’s Working Group. As a result, the questions were asked to the government of Kazakhstan (Question 26) about the plans for the expansion of the program.
  • EHRA experts analyzed the arguments of the opposition with respect to their scientific validity, interpretation, and evidence. Based on the analysis, EHRA published the explanatory note “Why you shouldn’t rely on the special opinion of a group of committee members on the continuation of OST“. This document includes the facts which the leaders of the civil society in Kazakhstan have used in their advocacy actions.

On 26 June 2018 the International Campaign “Support, Don’t Punish!” defended OST in Kazakhstan.

Based on the appeal of the participants of the substitution therapy program and the Kazakhstan Union of PLWH to decision-makers in Kazakhstan, the Eurasian Harm Reduction Association appealed to the international community and civil society in the countries of Eastern Europe and Central Asia to support the following initiatives:

  • Sign an appeal to the President of the Republic of Kazakhstan to sustain the substitution therapy in the country.  As a result, 64 international and national organizations have signed the appeal. This appeal was circulated to journalists and announced at a press conference by Oksana Ibragimova on June 26 in Astana, on behalf of the Kazakhstan Union of People Living with HIV.
  •  On the International Day Against Drug Abuse and Illicit Trafficking – June 26 – come to the embassies of the Republic of Kazakhstan, send the appeal to the President of Kazakhstan and post photos near the embassy on Facebook with hashtags #KazOST, #EHRA, #SupportDontPunish.
  • On June 26, 2018, participants of substitution therapy programs, along with harm reduction organizations in Lithuania, Estonia, the UK, Ukraine, Moldova, Belarus, Russia, held rallies near the embassies of the Republic of Kazakhstan and published photo and video messages calling to save the OST program in Kazakhstan.  A community of people who use drugs and people living with HIV in Kazakhstan, our friends and partners held the event in Astana to support the program.
  • On June 27, 2018 the Joint Commission for the Study of the Effectiveness of Opioid Substitution Treatment was held in Astana, chaired by Elzhan Birtanov, the Minister of Health; the event was attended by Gerra Gilberto, Head of the Department for Drug Use Prevention and Care at UNODC, Oleg Chestnov, WHO Permanent Representative to the Republic of Kazakhstan, Zhanat Suleimenov, First Deputy Minister of Internal Affairs of the Republic of Kazakhstan, representatives of the General Prosecutor’s Office, Nikolai Negai, Director General of the Republican Scientific and Practical Center for Mental Health, Bauyrzhan Bayserkin, General Director of the Republican Center for AIDS Prevention and Control, and other law enforcement and public health agencies, Department of Organization of Medical Assistance, representatives of the Global Fund for HIV, Tuberculosis and Malaria and the human rights organization “Aman-Saulik”.
  • As a result of the meeting, the representatives of the Ministry of Internal Affairs signed the protocol of the Joint Commission on the continuation of the program of substitution therapy in Kazakhstan. A roadmap for improving and implementing the program of substitution therapy with opioid agonists in the Republic of Kazakhstan for 2018-2019 was developed. Within the framework of this Roadmap, it is planned to include methadone into the list of medicine for outpatient mental health treatment in 2019 (amending the Order No. 666 of August 29, 2017).
  • As a result of advocacy work, intersectoral cooperation with international organizations and specialized NGOs has intensified in terms of improving the quality of service delivery and monitoring the quality of OST. Also, UNAIDS will redirect previously allocated funds for UNODC to continue advocacy through public hearings for the advocacy of the OST program among general public.
  • The final decision on the continued support of substitution therapy hasn’t been made yet. A new joint meeting of the Intersectoral Working Group and the Intersectoral Commission will take place in November 2018, which will decide the future of the methadone treatment program in Kazakhstan. Also within the framework of the Roadmap it is planned to carry out the analysis of economic effectiveness of SMT in comparison with traditional methods of drug dependence treatment with the involvement of an independent accredited expert, the Republican Scientific and Practical Center for Mental Health, the Republican AIDS Center, UNODC and UNAIDS in December 2018.
  • The team of the Kazakhstan Union of People Living with HIV constantly monitors the processes affecting the sustainability of the program in the country through advocacy at the national level, documenting the positive results of treatment on human life and family, as well as organizes and actively participates in public hearings at the national and local advocacy venues, saving the opportunity to receive vital treatment for people in need.
  • According to the experts of the Kazakhstan Union of People Living with HIV and other civil society organizations and the data available as of 17 September 2018, the methadone program available in 13 cities has started recruitment of new clients to the substitution treatment program. However, in most cases, doctors refuse to include new people to the program, even taking into account the referrals from medical commissions to methadone treatment.
  • We will continue protecting the right of access to scientifically based treatment by methadone, which is included to the list of vital medicines of the World Health Organization. #KazOST