Tuberculosis presents a serious problem to public health all over the world and especially in countries with developing economies. In spite of the availability of effective treatment for simple tuberculosis, annually it is responsible for more than 4500 deaths worldwide. More often than not, this is connected with late diagnosis of the disease and the poor organisation of treatment systems, especially in hard to reach groups. The main such group in Russia is injecting drug users (IDU) whose contact with health services is limited by the stigma, marginalization and excessive criminalisation. Criminalization of drug use and subsequent and disproportionate sentencing threatens both the health and social status of drug users.
Russia has the second highest rate of incarceration globally and according to studies, in some cities up to 80% of prisoners are sentenced as a result of drug-related crimes. Evidence shows that drug use is common in Russian prisons, while HIV prevention programmes such as needle exchange or any form drug treatment in particularly opioid substitution treatment as recommended by the World Health Organsiation (WHO) is not available.
In spring 2010 we carried out a rapid situation assessment in Kaliningrad, North-West region of Russia, to look at problems with integration of HIV and TB services for injecting drug users. This study was carried out by the London School of Hygiene and Tropical Medicine with the support of the WHO. We interviewed 15 TB patients and 8 health specialists using a semi-structured guide to understand their experience of using or working in health services treating HIV and TB. Our accounts pointed to conditions in prisons as a major factor fuelling the TB epidemic in the city.
All but one of our 15 injectors with a history of TB treatment had been in prison and seven reported being infected with TB while in prison. Participants described conditions in prison as unmanageably overcrowded, with inadequate nutrition and limited possibility to maintain basic hygiene and infection control. Medical resources are limited and demands on the services are high. Although antiretroviral drugs are available, there is no HIV prevention and no formal drug treatment . When HIV treatment is available, the supply is inconsistent as is the treatment of TB and there are no second line drugs available to treat drug resistant strains of TB. Prisoners are assigned to mixed cells irrespective of levels of TB or HIV infection. A specialist from the Regional TB hospital complained: “As a rule, in the camps, tuberculosis is not treated. How can they treat it there? They turn it into a chronic form and the [patients] are sent to us.”
In addition to the poor medical treatment, general conditions in prison colonies are degrading, humiliating and unmanageable. Corruption is endemic and staff maintain order through a system of fear and punishments that can include withholding medical treatment.
Collaboration and integration with community health services is poor, and community hospitals are often unable to save the lives of patients who are released from prisons in poor health, only to die outside.
Many accounts provided described people being released on the edge of death as illustrated by this story: “They didn’t do [HIV] tests on us. I didn’t know my [immune] status. I didn’t know my [viral] load. I began to wither away and nobody knew why. My hair fell out, my eyebrows, my nails fell out. My legs were purple. I was dehydrated, I was skeletal. I became that way over a year. They took me to the tuberculosis prison camp. They took one look at me and were horrified. Finally they tested us and when my status arrived, I was told that I had 40 cells. I was not eating or drinking. That is it, they said, they would release me and I wondered if I would make it. I really didn’t care, I had been so ill for so long. I was like ‘let me die in peace’. They released me, my Mum came and took me in her arms. At the camp they said to her – take her away, but it won’t be for long.”
Our study adds further support to international evidence that prisons respesent a major source of spread of TB, including drug resistant forms. In Russian settings, imprisonment for drug users may equate to a death sentence, especially for people with HIV. Given the immense strain on the medical services within prison, reform of the medical service is not enough. Policy reform needs to focus on wider structural reforms that reduce the numbers of prisoners including more lenient sentences for drug related crimes and making opiate substitution therapy such as methadone and buprenorphine widely available. OST is currently banned in Russia but evidence has shown it’s role in reducing incarceration rates among drug users as well as facilitating adherence to HIV and TB treatment. . Given the current magnitude of HIV epidemic and lack of effective response to HIV and TB treatment particularly among drug users who carry the burden of HIV cases, the international community needs to focus on the problem of TB and MDR TB in Russia as it is fast becoming Russian’s biggest threat.
Anya Sarang is head of the Andrey Rylkov Foundation for Health and Social Justice, Moscow
Competing interests: Conference travel paid by the Open Society Foundations through the International Harm Reduction Association.
This study was funded by the grant from the European Comission/European Bureau of the World Health Organisation and carried out by the London School of Hygiene and Tropical Medicine, University of London. It was first presented at the 22nd Conference of the International Harm Reduction Association in Beirut, Lebanon in April, 2011.
Al the interviews were with informed consent, anonymous and confidential.