Substitution Therapy: The missing link to curbing HIV in Eastern
Europe and Central Asia
Montaner, President, and Craig McClure, Executive Director,
International AIDS Society (IAS)
universal access to HIV prevention, treatment and care by 2010
in Eastern Europe and Central Asia (EECA) will not be possible
without dramatically expanding access to opioid substitution
An estimated 3.7 million people in EECA inject drugs, the vast
majority of whom are dependent on heroin or related opioid
drugs. This is close to four times higher than the overall
prevalence of injecting drug use (IDU) worldwide.  Sixty-two
percent of the HIV epidemic in this region is attributable to
injecting drug use; over 35% of HIV positive women were infected
through sharing of contaminated injecting equipment; and another
50% of women living with HIV were infected via
unprotected sex with an infected IDU.
OST, using methadone or buprenorphine, has been endorsed by WHO,
UNAIDS, UNODC, The Global Fund, and countless researchers and
health care professionals as one of the most effective
interventions for the treatment of opioid dependence.[3,4,5,6]
leads to substantial cost savings in health care and criminal
justice. Research also demonstrates that OST enhances
HIV-related prevention, care and treatment, as well as IDUs’
contact with the primary health care system. To date, methadone
is one of the few treatment interventions for IDU which has
shown efficacy for prevention of HIV infection in controlled
trials. [7,8,9,10] .
Misuse of methadone and/or buprenorphine poses some challenges,
including the potential for illegal diversion of these medicines
to the black market which can lead to illicit,
use and compromise public acceptance of OST programmes .
However, these challenges are overblown by critics of OST and
can be addressed by strengthening support and supervision of OST
patients and securing the supply of these medicines. 
OST is a vital tool in the response to the public health
problems posed by both HIV and IDU. Without it, IDUs are more
likely to be tested late and delay care, with resultant
increases in morbidity and mortality.[5,13,14]
Despite such overwhelming evidence,
as of 2007, less than 2 percent of IDUs in EECA countries with
injection-driven HIV epidemics had access to OST.[14,15]
important progress has recently been made in introducing OST
together with other harm reduction interventions through Global
Fund and government-funded pilot projects in a number of
countries in the region,
coverage remains woefully inadequate.
programmes exist largely as perpetual pilot initiatives, with
the numbers of IDUs participating remaining stable or increasing
very slowly. [14,15,18] In
Russia, a country with over 1.8 million IDUs and an epidemic
that is overwhelmingly due to injecting drug use, methadone
remains illegal. [1,14,15] The
continued polarization of the issue across societies in the
region has hampered efforts to introduce OST.
From 17-18 October 2008, the IAS convened a meeting of 25 senior
narcologists, psychiatrists and infectious disease specialists
from across EECA in Yalta, Ukraine. These
whose work focuses on injecting drug use and HIV, reviewed the
current state of HIV among IDUs in the region, the body of
evidence supporting the use of OST and country experiences with
this intervention. In addition, the significant challenges and
opportunities for expanding access to OST were discussed.
this review, the IAS has identified the following obstacles to
the adequate scale up of OST in EECA:
against drug dependence trumps science.
A serious chasm exists between the scientific evidence on OST
and the views and actions towards OST among policy makers, law
enforcement authorities, the medical community and the general
and awareness of the evidence is severely lacking in the region.
There is a virtual absence of reliable information in Russian
and other languages spoken in EECA regarding research, policy
and programme development of OST.
Burdensome law enforcement regulations and criminal justice
strategies undermine IDU participation in programmes where they
criteria for entry into treatment, varying standards of care,
and policies such as those requiring the involvement of multiple
specialists to authorize initiation of treatment, or those
forbidding take home doses of medication further undermine
efforts to reach more IDUs.
[14,15,16,18] Where OST has worked, high level political
support has been critical. [14,17]
research questions further hamper scale up.
Some research gaps, including
estimating IDU populations and defining adequate levels of
coverage required to curb injection-driven HIV epidemics in EECA,
are hampering efforts to set targets and measure progress.
effort in EECA to rapidly scale-up OST is urgently needed to
improve HIV-related and other public health outcomes associated
with opioid drug injection. Action on the part of all
stakeholders in the region is needed, including researchers and
other health professionals, parliamentarians, policy makers and
civil society, for the swift removal of legal and policy
barriers to OST. The alternative will be the tragic loss of
hundreds of thousands, if not millions, of young lives. In a
region with rapidly falling population levels, supporting all
young people to reach adulthood and lead productive lives is
essential, including those who have fallen victim to a
devastating health condition – dependence on illicit drugs.
B.M. et al. Global epidemiology of injecting drug use and HIV
among people who inject drugs: a systematic review. The Lancet
(online edition) September 24, 2008.
2008 Report on the Global AIDS Epidemic. July 2008.
Michels II, Stover H, Gerlach R. Review: Substitution treatment
for opioid addicts in Germany. Harm Reduction Journal
4. Donaher PA and Welsh C. Managing Opioid Addiction with
Buprenorphine. American Family Physician 2006; 73: 1573.
5. Wodak A and McLeod L. The role of harm reduction in
controlling HIV among injecting drug users. AIDS 2008; 22
6. WHO/UNODC/UNAIDS. Substitution maintenance therapy in the
management of opioid dependence and HIV/AIDS prevention.
Position Paper. 2004. (accessed September 2008).
7. Institute of Medicine. Preventing HIV Infection among
Injecting Drug Users in High Risk Countries: an Assessment of
the Evidence. Institute of Medicine of the National Academies
(2006) Washington DC: The National Academic Press.
8. Farrel M, Gowing L, Marsden J, Ling W, Ali R. Effectiveness
of drug dependence treatment in HIV prevention. Int J Drug
Policy 2005; 16: 67-75.
9. Spire B, Lucas G.M, Carrieri M.P. Adherence to HIV treatment
among IDUs and the role of opioid substitution treatment (OST).
Int J Drug Policy 2007; 18: 262-270.
10. Lert F and Kazatchkine M.D. Antiretroviral HIV treatment and
care for injecting drug users: An evidence-based overview.
Int J Drug Policy 2007; 18: 255-261.
11. Varenbut M. et al. Tampering by office-based methadone
maintenance patients with methadone take home privileges: a
pilot study. Harm Reduction Journal 2007; 4: 15.
12. Bell J. The Role of Supervision of Dosing in Opioid
Maintenance Treatment; Background document prepared for third
meeting of technical development group (TDG) for the WHO
“Guidelines for Psychosocially Assisted Pharmacotherapy of
Opioid Dependence”. London: National Addiction Centre, 2007.
(accessed November 2008)
13. WHO. Effectiveness of Drug Dependence Treatment in
Prevention of HIV Among Injecting Drug Users. Evidence for
action technical papers. 2005. (accessed September 2008).
14. WHO Europe. Progress on Implementing the Dublin Declaration
on Partnership to Fight HIV/AIDS in Europe and Central Asia.
15. Harm Reduction Developments: 2008 Countries with
Injection-driven HIV Epidemics. International Harm Reduction
Development Program (IHRD) Open Society Institute, 2008.
16. Bruce R.D, Dvoryak, S, Sylla L, Frederick L.A. HIV treatment
access and scale-up for delivery of opiate substitution therapy
with buprenorphine for IDUs in Ukraine—programme description and
policy implications. Int J Drug Policy 2007; 18: 326-328.
17. Sarang A, Stuikyte R, Bykov R. Implementation of harm
reduction in Central and Eastern Europe and Central Asia. Int
J Drug Policy 2007; 18: 129-135.
18. Barriers to Access: Medication-Assisted Treatment and
Injection-Driven HIV Epidemics. International Harm Reduction
Development Program (IHRD) Open Society Institute, 2008.
19. Donoghoe M.C. et al. Setting targets for universal access to
HIV prevention, treatment and care for injecting drug users (IDUs):
Towards consensus and improved guidance. International
Journal of Drug Policy, April 2008.
Julio Montaner and Craig McClure, confirm the following: We
agree that we have seen and approved the final version of this
text, and that we have no conflicts of interest to declare in
was written by Jacqueline Bataringaya (IAS Policy and Advocacy
Coordinator) and edited by Regina Aragon (IAS Communications
Consultant). It has been approved for submission to the Lancet,
in this form, by the declared authors, Julio Montaner and Craig