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.
Myths
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”.
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Sasha and another Kazakh Red Crescent Society
volunteer, centre, talk to two sex workers in Termirtau about
preventing HIV transmission.
©CLAIRE DOOLE / INTERNATIONAL FEDERATION
Dr Svetlana Magizova hands clean syringes and
needles to one of about 60 drug users at a harm reduction
centre in Karabalta, Kyrgyzstan.
©CLAIRE DOOLE / INTERNATIONAL FEDERATION
Mittal Steel is the main employer in the central
Kazakh city, Termirtau.
©CLAIRE DOOLE / INTERNATIONAL FEDERATION
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 /
INTERNATIONAL FEDERATION
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