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Sex, drugs and HIV in Central Asia

Kazakhstan and Kyrgyzstan have the fastest-growing HIV rates in Central Asia, fuelled by people sharing needles to inject drugs trafficked from Afghanistan into Russia. Since 2004 the Red Crescent Societies have mobilized thousands of volunteers to spread the prevention message to drug users, sex workers and communities most at risk.

CLUTCHING a large bag of condoms and syringes, Sasha makes his way to a truck stop opposite the entrance to the Mittal Steel factory, the largest employer in the central Kazakh town of Termirtau. It’s 18:00 as he checks his watch, the time when workers clock off. Nervously, two women approach Sasha as he hands over the bag to help them with their work.

For the past five years, Lena, 29, and Urla, 30, have sold themselves to workers from the steel plant for as little as US$ 6. They say they have little choice as they need the money to feed their heroin habit, a habit that costs them around US$ 20 a gram.

“Prostitution,” sighs Urla, “is like sinking into mud. It sticks to you, preventing you from ever washing yourself clean.”

Urla is HIV-positive and one of the 20 or so women Sasha will talk to over the next few hours about practising safe sex, using clean needles and getting tested for sexually transmitted diseases. Sasha, 27, a former drug user who is HIV-positive, is today an HIV trainer with the Kazakh Red Crescent Society. It is his personal experience, as well as his commitment to fighting the disease, that has made him a key activist in the National Society’s prevention efforts in Termirtau, which has the highest levels of HIV infection in Kazakhstan.

Heroin highway

A combination of history and geography has conspired against this depressed mining town where half the population is unemployed. After the collapse of communism in the early 1990s, many steel workers left for Russia and Ukraine, only to return to Termirtau later. Many, however, came back from their time abroad with HIV.

And with new drug-trafficking routes opening up from Afghanistan across Central Asia to Russia and Europe after the fall of the Taliban regime in 2001, the spread of HIV through needle sharing has compounded the situation in Termirtau. Today, 1,311 of the town’s 180,000 residents are HIV-positive — the highest infection rate in the country.

But the problem is not just particular to Termirtau. Kazakhstan has the highest rate of infection in Central Asia, with HIV reported in all its major cities. In the past decade, the number of those infected has risen to 6,616 from 548, although unofficially the number is believed to be at least three times higher. Three-quarters of those infected are injecting drug users who share needles and, in a country with an estimated 250,000 heroin users and 20,000 sex workers, many of whom take drugs, the Kazakh Red Crescent Society has made HIV prevention one of its priority programmes.

Since 2004, Red Crescent Societies across the region in Kyrgyzstan, Tajikistan, Uzbekistan and Turkmenistan as well as Kazakhstan have started HIV prevention, information and dissemination campaigns. Peer education has proved to be the most effective approach.

Street credibility

According to Sasha, his background gives him credibility among those he helps. “I took risks,” he explains, “shared needles and had unprotected sex and look what happened to me. I got infected with HIV at 19. I am determined that others won’t make the same mistake.”

After three years as a volunteer, Sasha became one of the first former drug users to become a paid trainer, earning around US$ 75 a month, less than an average salary in Kazakhstan but enough to live on.

Since the Kazakh Red Crescent started peer education in 2005, 56 sex workers and two former drug users have become volunteers. They are not paid but receive toiletries, mobile phones and Internet cards as an incentive. Most come from the deprived towns straddling the heroin highway where drugs offer an escape from poverty.

Kokshetau, a bleak industrial town near the Russian border, has also struggled since the collapse of communism. Most people live in rundown Soviet apartment blocks, buffeted by the Siberian winds that bring winter temperatures of minus 40° Celsius.

Dima, 30, who spent over half his life injecting heroin and years of misery searching for the next fix, is proud of his new-found status as a Red Crescent peer educator.

“I feel I am making a difference, distributing condoms, clean needles and syringes to those I know need them,” he says. “Everyone is worried about HIV and it is great to be doing something to help. I am clean now and have a wife, children and a job. At long last, I have turned my life around.”

However, in these small towns where everyone knows everyone, sex workers and drug users prefer to keep even their volunteering work secret.

Irina, 37, who has been working the streets of Kokshetau for longer than she cares to remember, relates that she would die of shame if her 15-year-old daughter found out about her work. She is determined to make sure her daughter won’t lead a similar life.

In a climate fuelled by stigma and discrimination, it is difficult even for the peer educators to persuade others to go for testing or visit the increasing number of centres where drug users can get clean needles and syringes.

Over the past year, the Kazakh Red Crescent has complemented government efforts and set up its own needle exchange centres to reduce the harm that drug users can do to themselves by contracting HIV through shared needles.

Earlier this year, the Red Crescent Society of Kyrgyzstan set up its first needle exchange centre in Kyrgyzstan. “We have 61 users registered, although on average one overdoses a month,” says Dr Svetlana Magizova. “Most prefer that I visit them at home due to the stigma and their constant fear of arrest.”

About 70 per cent of syringes distributed at needle exchange centres are returned, a sign of the success of a policy that staff are at constant pains to stress does not encourage drug use but reduces the harm users are already doing to themselves.

Dual epidemic

In a further attempt to stop the rise in HIV infections, the Kazakh Red Crescent began pilot projects this year to address the problem of TB/HIV co-infection. According to the World Health Organization, tuberculosis kills up to half of all people with HIV worldwide, as their low immunity means they are vulnerable to infection. In Central Asia, TB patients are also at higher risk of getting HIV as many of them come from high-risk groups such as former prisoners, drug users and sex workers. Although HIV is not yet fuelling the TB epidemic as in neighbouring Russia, nor undermining TB control efforts, the levels of both diseases in Kazakhstan are rising.

The Kazakh National Society is pioneering the region’s co-infection work, setting up special teams of doctors, psychologists, lawyers and social workers in Termirtau and Karaganda, the country’s worst-hit towns. Most of the 70 TB patients living with HIV are former prisoners as the region which, once infamous for the Gulag archipelago, is still known as the country’s jail belt.

“Our prisons are rife with TB,” says Kazakh Red Crescent psychologist Zoya Ruzhnikova. “Once the prisoners are released, many of them default on their TB treatment and risk infecting the local community.”

According to Ruzhnikova, one of the hardest parts of their work is breaking the news to a TB patient that he or she is HIV-positive. TB is one of the first diseases that occurs when HIV infection progresses to AIDS, and patients typically die within a few months if they do not get immediate TB treatment. However, if they are treated for TB, their lives can be prolonged by five years or more. Since TB is curable with a full course of drugs which costs on average about US$ 15 per patient, TB treatment is one of the most practical and cost-effective survival strategies for HIV-positive people who do not have access to anti-retroviral medication.

Alexander, 33, a former drug user, was diagnosed with HIV in 2001 and then developed TB. He was, however, quickly treated and is now a volunteer with the Red Crescent HIV/TB co-infection programme. Drawing on his own experience, he encourages people living with both infections to continue their treatment, taking them parcels of food, vitamins and hygiene products to ensure that they build up their resilience to the disease.

“After the doctors cured me of TB I wanted to give something back,” says Alexander. “So I set up a non-governmental organization (NGO) offering a needle exchange programme, and became a Red Crescent volunteer.”

Mental leap

Working with drug users, sex workers and people with HIV — groups for the most part shunned by society — is a recent development for the Kazakh Red Crescent and some staff, used to helping more conventionally vulnerable people, like orphans, the sick and elderly, are having to adjust.

At a recent regional meeting one staff member exclaimed that Henry Dunant did not found the Movement for it to work with sex workers, HIV-positive people and drug users.

While such overt opposition is rare, Red Crescent health worker Mariam Sianozova recognizes that for many it is a big mental leap. She has, therefore, started a series of regional training programmes to help staff better understand and address the needs of these marginalized groups.

Gulnara Kamedenova, an HIV coordinator for the Karangda district in Kazakhstan, candidly admits that as a doctor she found it difficult at first. She recounts how Natasha, a brothel manager, suggested Kamedenova’s husband might like to use her services. Natasha is one of three brothel managers who come to the clinic for condoms and testing for sexually transmitted diseases, including HIV.

“As a Red Crescent employee, I recognize the importance of showing humanity and treating these women first and foremost as human beings,” Kamedenova says.

Mobilizing youth

The Kazakh Red Crescent offers a lifeline to those accustomed to rejection and abuse.

When Sasha told his sister that he was HIV-positive, she replied that people like him should be rounded up and burnt at the stake, a view his mother shared.

Luda, a pretty 19-year-old from the agricultural town of Tardy Kolgan in south-eastern Kazakhstan, has her own tale of rejection. With deep cuts along her arms, self-inflicted during a bout of depression, she whispers, “I may look young, but in my heart I am old.”

A sex worker and occasional drug user, she sees volunteering for the Red Crescent as a small step on the path back to respectability.

Befriended by Jameel, a Red Crescent HIV trainer, she now distributes condoms to the other girls, some as young as 13, who operate out of the town’s saunas and bath houses.

And it is not only the sex workers who are getting younger. Rafael, also a drug user and volunteer, speaks angrily of the drug dealers who target schoolchildren, hooking them on heroin with free fixes before demanding payment.


The young are most at risk of HIV infection, whether through unprotected sex or needle sharing and, with more than 60 per cent of new infections among 15- to 29-year-olds, the Red Crescent’s biggest peer education effort is directed at this age group. More than 1,000 young people in Kazakhstan and Kyrgyzstan are involved in spreading the HIV prevention message to their peers. In schools and universities, on the streets and in the discos, volunteers from the age of 14 distribute condoms and information on sexually transmitted diseases.

“It is important that we dispel the myths about HIV and AIDS,” explains Myrza Moldobenova, 20, from the Kyrygz capital, Bishkek. “We tell people that you can’t get HIV from sharing a cigarette or a glass of water and always stress the importance of practicing safe sex.”

Although Kazakhstan and Kyrgyzstan are still culturally conservative, especially in rural areas, Red Crescent young volunteers say talking about sex is no longer taboo.

“It was a little embarrassing at first,” admits Moldobenova, “especially showing the boys in my class how to put on a condom, but you know, you can’t tell from someone’s face if they have HIV so we are all at risk.”

Hundreds of soldiers between the ages of 16 and 18 have also gone through peer education programmes.

Stopping the spread

Although the main risk group for HIV remains intravenous drug users, the number of people contracting HIV through sex has been rapidly increasing over the past ten years.

In addition, 61 children were reported to have been infected through contaminated blood in a hospital in Kazakhstan.

The increasing risk to young people of contracting HIV through sexual intercourse or needle sharing has heightened fears within the Red Crescent of an HIV disaster.

“I fear for my daughters and for my friends who take drugs,” says Sholpan Ramazanova, a health coordinator for the Kazakh National Society. “Despite the best efforts of the Red Crescent, NGOs and the government, the number of infections is still rising.”

Sasha is not only determined to fight his own battle against HIV to prolong his life, but in his words, “to ensure that I do as much as I can to prevent other people succumbing to this disease that has ruined so many young lives”.



Sasha and another Kazakh Red Crescent Society volunteer, centre, talk to two sex workers in Termirtau about preventing HIV transmission.






































Dr Svetlana Magizova hands clean syringes and needles to one of about 60 drug users at a harm reduction centre in Karabalta, Kyrgyzstan.



























Mittal Steel is the main employer in the central Kazakh city, Termirtau.





















In Kazakhstan, former drug users and Kokshetau branch Red Crescent peer education volunteers Dima and Volodya, right, talk to sex workers about preventing HIV.

Claire Doole
Claire Doole is a freelance journalist based in Geneva.


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