Doctor, researcher, diplomat and human rights activist. Michel Kazatchkine is the United Nations Secretary-General's Special Envoy for AIDS in Eastern Europe and Central Asia. In 1985, he founded a specialized HIV/AIDS clinic in Paris. Before his appointment to the UN, he headed the Global Fund to Fight AIDS, Tuberculosis and Malaria.
When did you start tackling HIV internationally? What was happening in our region at the time?
I remember I was working on healthcare and AIDS at the French Ministry of Foreign Affairs; we were looking at Africa and weren’t so concerned about Eastern Europe. We are talking about the early 2000s, and one could say there was no HIV/AIDS in the region, just a few cases.
What does the epidemic look like in Africa in comparison?
It’s horrible. In South Africa, one person in five has HIV. But here we thought we had a way to stop the epidemic. The ARVT drugs were there; this was eight years after they became available on the market. The economic situation wasn’t that bad although it was hard.
In 2008, I became the head of the Global Fund and spoke to the Russian Ministry of Health. They clearly said, “Thank you, your assistance was really useful in the beginning of the epidemic. Now we’re going to be working independently and would like to thank you. We would like to become a donor and will return the 270 million dollars that your Foundation has spent.”
After 2008, the Russian drug policy and AIDS strategy have been developing incomprehensibly. The epidemic has been growing really fast. They were confounded and paralyzed, and didn’t know what to do. The politicians, ideologues, extremists and the Church said one thing but the epidemic was developing exponentially.
Because people didn’t realize immediately that the most important thing when dealing with an epidemic is to stop the chain of transmission. And in order to stop it, you need three things: prevention among injecting drug users, harm reduction and antiretroviral therapy. If you decrease the viral load, people receiving therapy won’t transmit the virus.
Looking at what happened in Russia between 2008 and 2016, you see that there is virtually no prevention. There’s no place for it even in the budget, there’s no budget line. Prevention is largely based on civil society and its interaction with government. Russian NGOs were supported by the Global Fund, and when the Fund reduced its involvement in 2010, the number of NGOs has been declining.
And now they’re called foreign agents...
And there’s no mechanism for social contracting, for government to fund NGOs. Even if we are concerned with the issue of which NGOs should receive government funding, these mechanisms aren’t working. The whole prevention is about producing billboards every once in a while. Then there’s no harm reduction. The needle exchange programs are very small-scale and they’re running out of international funding. Then, of course, substitution therapy is crucial for motivating people to start antiretroviral therapy. It’s also absent. And finally, the antiretroviral therapy itself. Currently, I believe, it covers 25-35% of all registered people who need it.
Now that we have talked about the Russian situation, what’s going on in other countries of our region?
Well, Belarus for example has taken some positive steps. The psychiatrists and doctors have realized early on that this is a clear and effective way to work. Although they are very close to Russia, they don’t have Mr. Ivanov (the head of Russia’s Drug Enforcement Agency in 2008-2016) and a system in which everything is prohibited. For example, Mr. Lukashenko called drug users parasites, but substitution therapy has been introduced in the country. You need to look not just at the words but also at the acts.
What about Ukraine?
In Ukraine, civil society is playing a huge role. They are real heroes because not only did they lobby for substitution therapy but also, the outreach work in Ukraine has reached a very high level. According to my information, there are about 300,000 drug users in Ukraine and about 230,000 people have been covered with outreach work. In Ukraine, 10,000 people are receiving substitution therapy, which proves that outreach work is a fundamental strategy. It can be used to begin a dialogue with the clients, engage them in healthcare work, tell them about prevention.
If we turn from Europe to Asia, what will we see?
It’s also diverse. Take Uzbekistan. You know about the political situation there. I hope it will all begin to change now. Kazakhstan is very interesting. It’s a country that wants to look good. They worked quietly in the background and made substitution therapy a part of their national health strategy. For 9 years, it had existed as a “pilot” program all over Kazakhstan. This is a smart way to legalize it. The Global Fund is helping a lot in Kyrgyzstan and Tajikistan. These are the poorest countries in the region and their programs are all supported by the international system.
What is the main factor for introducing harm reduction programs? Is it public stigma, political will, or doctors’ opinions?
It all begins with talking, with information. There’s more and more of it, although different information is available. In Kazakhstan, I heard some crazy things being said about methadone, but the more we talk the more chances we have to clarify these things. People and society are much more rational than we think. A second factor is, our efforts at making drug policies part of social policy and healthcare rather than criminal policy are certainly helping. Ask a drug user’s mother if she wants her son to end up in prison or to get into treatment. The answer will be absolutely clear, because families understand (not all, but many do).
Not all. “City Without Drugs” is still speculating on people’s fierce, 90s-style reaction to problems related to drug use and the diseases.
This is true but I still think everything is changing incrementally. For example, in Georgia I spoke with police officers a lot. They thought the law that stipulated that in case of an overdose you had to call the police before calling an ambulance was crazy. Or that doctors must report everything to the police. Both police and doctors agreed this is wrong. Finally, the law was changed.
What does the future hold for the region? Which is more important, communicating with politicians or with society?
All directions are important. The first stage is to open debates. Even in Russia, journalists are seeing the situation differently. The second stage is, both society and government need to understand that the problem is part of healthcare and social protection. The third stage, decriminalization. Western Europe is approaching liberalization, legalization and regulation. I always say: drugs are dangerous, therefore they must be legalized and regulated. We don’t prohibit people from driving cars but we ask them to stop at the red light. I think Ukraine is close to debating decriminalization. Governments are learning to treat these issues from a pragmatic standpoint. In general, the region finds itself between the first and third stage.