Mental Health Problems of Drug Injecting PLHIV in Kazakhstan Conducted by: The Mental Health and HIV/AIDS Kazakhstan Expert Centre, with support from Global Initiative on Psychiatry (GIP)
Almaty, Kazakhstan, May 2007
Marasheva Aigul Vladimirova Nadezhda Kolodin Vladimir
Mission statement on Mental Health and HIV/AIDS Mental health and HIV/AIDS Mental illness is inextricably linked to HIV/AIDS, as a casual factor and as a consequence, while mental health treatment and support for people living with HIV/AIDS is key to both improving their quality of life and preventing the further spread of the infection. The issue is of particular concern to central and Eastern Europe and the Newly Independent States, where the AIDS epidemic is growing fast while rates of mental illness are also rising, and the limited resources and facilities available to treat both conditions pose major challenges. Addressing the needs The GIP Mental Health & HIV/AIDS project is a project of the Global Initiative on Psychiatry (funded by the Netherlands Ministry of Foreign Affairs from 2005 – 2008) that addresses the often-overlooked connection between mental health and HIV/AIDS. The Network supports efforts to improve the quality of life and to diminish the suffering of people with HIV/AIDS. The Network strives for increased knowledge regarding the overlap between mental health and HIV/AIDS, and promotes the development of a comprehensive system of mental health assistance to people affected by HIV/AIDS. Furthermore, it supports efforts to increase the understanding of the general public and health professionals and to decrease the stigma associated with mental illness and HIV/AIDS. The Network works through local expert centres that focus their work on research and training, advocacy and awareness building, networking and a wide variety of other interventions. Global Initiative on Psychiatry (GIP) GIP aims to promote humane, ethical, and effective mental health care through the world, and is particularly active in countries where mental health care is still usually substandard and where patients‘ human rights are frequently violated. GIP‘s work is based upon the underlying principle that every person in the world should have the opportunity to realize his or her full potential as a human being, notwithstanding personal vulnerabilities or life circumstances. Every society, accordingly, has a special obligation to establish a comprehensive system for providing ethical, humane and individualized treatment, care, and rehabilitation, and to counteract the stigmatisation of, and discrimination against, people with mental disorders or histories of mental health treatment. For inquiries regarding this report, please contact:
kz@mh-center.org www.mh-center.org
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TABLE OF CONTENTS EXECUTIVE SUMMARY
6
1. INTRODUCTION
7
2. STUDY DESIGN AND METHODOLOGY
10
3. STRUCTURE, LEGAL BASIS AND MANAGEMENT OF PLHIV/IDU PROGRAMS
11
4. HIV/AIDS AND MENTAL HEALTH SERVICES FOR IDU
13
5. MENTAL HEALTH PROBLEMS of HIV-POSITIVE IDU 5.1. Features of the psycho-emotional state of HIV-Positive IDUs 5.2. Mental health problems, behavioral characteristics and needs of PLHIV/IDUs
15 15
CONCLUSIONS
23
RECOMMENDATIONS
25
REFERENCES
28
LIST OF ON-LINE SOURCES OF INFORMATION
29
APPENDICES Appendix 1. FGD guidelines on Mental Health Problems of HIV positive IDUs Appendix 2. Guidelines for interviews with medical staff of national and international organizations working with IDUs Appendix 3. Documents determining the current national policy, strategy and content of the programs in RK
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31 33 34
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ABBREVIATIONS AIDS
Acquired Immunodeficiency Syndrome;
ARV
Antiretroviral treatment (Highly active treatment against HIV)
BSS
Behaviour Surveillance Survey
FG
Focus Group
FGD
Focus Group Discussion
FSW
Female Sex Worker
GIP
Global Initiative in Psychiatry
GFATM
The Global Fund to Fight AIDS, Tuberculosis and Malaria
GF
Global Fund
GO
Governmental Organization
IDU
Injecting Drug Users
HIV
Human Immunodeficiency Virus
MSM
Men who have sex with men
NGO
Non-Governmental Organization
PLHIV
People living with HIV
PAS
psychoactive substances
RK
Republic of Kazakhstan
RSPC of DAMSP Republican Scientific and Practical Center of Drug-addiction Medical and Social Problems RSPC of PPN Republican Scientific Practical Center of Psychiatry, Psychotherapy, and Narcology S&D
Stigma and Discrimination
UNAIDS
The Joint Nations Program on HIV/AIDS
UNICEF
United Nation Children‘s Fund
UNDP
United Nation Development Program
UN
United Nations
VCT
Voluntary Counseling and Testing
WHO
World Health Organization
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Acknowledgements This assessment was conducted by the team of the Kazakhstan Expert Center within the context of the Global Initiative in Psychiatry project ―Mental Health and HIV/AIDS‖. The project partner in the Republic of Kazakhstan is the Public Fund ―Mental Health‖. The authors of the Report express their sincere gratitude and appreciation to: 1. The Global Initiative in Psychiatry for: - financial support to the project; - providing assistance in the development of tools; - interesting and efficient work; 2. GIP research consultant Mrs. Katinka de Vries and GIP research coordinator for Central Asia Mr. Alisher Latypov for their guidance and support throughout the study. 3. Center for AIDS Prevention and Control Almaty for supporting the concept of the project 4. The Republican Scientific Practical Center of Psychiatry, Psychotherapy, and Narcology, and in particular Mr. Sagat Altynbekov for providing statistical data and moral support. 5. The Republican Scientific-Practical Center of Drug-addiction Medical and Social Problems, and in particular Mr. Aleksandr Katkov for providing statistical data. 6. The team of the NGO "Social Bureau" and in particular Nataliya Komarova, Roza Oleinikova and Dilyara Belkesheva for their assistance in the organization and realization of focus group discussions (FGD). 7. AFEW Project Manager in the Republic of Kazakhstan - Mrs. Surtayeva Saltanat
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EXECUTIVE SUMMARY In March-April 2007 a rapid assessment was conducted to investigate the psychosocial problems of IDU/PLHIV in Almaty. This took place within the context of the GIP project ―Mental Health and HIV/AIDS‖ in Central Asia. For the study goals, 3 Focus Groups (17 participants) were organized at the office of the non-governmental organization ―Central Asian Youth Alliance‖, which implements the project ―Social Support‖ for IDUs/PLHIV in Almaty. To motivate IDUs to participate, we provided an incentive (about 5 USD) that basically covered the cost of a meal. 11 semi-structured interviews were conducted with medical staff, local and national key stakeholders, NGO employers and people from the close surrounding of IDUs/PLHIV were conducted. The discussion questions concerned the types and prevalence of mental problems among IDUs, the influence of HIV-infection on drug usage and sexual behavior, access to drug addiction treatment, harm reduction programs and psychological health services for IDUs, the role of families and friends in support, awareness of HIV testing opportunities, and the attitudes of IDUs to the disease. The study confirmed the existence of the following mental health problems: when being informed of their HIV status, IDUs often react with depressive disorders, shock, aggression, and self-aggression with suicidal intentions. Self-isolation, difficulties in communication with other people and emotional instability were mentioned as well. Among IDUs/PLHIV there is a higher prevalence of mental health problems than of physical ones. The study also looked at the assistance and support needs of IDUs/PLHIV. The major support that they would like to have, is medical and psychological assistance at IDUfriendly institutions where they feel free and do not fear arrest. Families, friends and religion were listed as the main factors that may have positive influence on their life style. Although some IDU reported that they rely only on themselves and do not trust anybody else. 17 IDUs/PLHIV, 9 representatives of non-governmental, international and medical organizations and 2 persons close to IDUs/PLHIV participated in the study. The findings indicate that IDUs have limited access to medical - and in particular psychosocial - assistance in Kazakhstan. They also have limited opportunities to participate in harm reduction programs. IDUs have a little trust in any treatment institution and seek support mostly from their family members, among friends and in religion.
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1. INTRODUCTION Since the middle of the 1980‘s the whole of Central Asia has seen a significant increase in the spread of drug-addiction and HIV/AIDS. As a result, all central Asian countries acknowledge that drug-addiction and its relation to the HIV/AIDS epidemic are a serious problem. Thus, national authorities actively started to take measures to address these issues. Recent representative studies (January 2007) state that the Republic of Kazakhstan has between 180 and 250 thousand IDUs. This constitutes between 1,3% and 1,7% of the total population, or about 3% of the population of working age. These official statistical data on the prevalence of drug addiction, especially among children and teenagers, do not reflect the true acuteness of the situation, which requires the development and application of urgent measures1. In the opinion of UN observers, the epidemic situation in the republic can be characterized by: 1) Rapid increase of HIV infection among IDUs. 2) Substitution of sexual transmission of HIV with transmission through drug injection among IDUs, the main risk group in Kazakhstan. 3) A predominance of HIV-infection among young people of working and reproductive age. 4) A predominance of unemployed among HIV-infected persons. 5) An increase in the number of the HIV-infected persons in prisons and correctional institutions. 6) Aggravation of the HIV situation due to the increase of drug-addiction, sexually transmitted diseases and tuberculosis. The common tendencies of drug-addiction proliferation are the following: uncontrolled increase of drug usage among the population; the main drug - especially for injection use - is low-quality heroin, which costs 1—2 dollar per dose. Drug injection is the main cause of the rapid spread of HIV/AIDS and other blood-transmitted diseases.2. It is well-known that regular drug use results in a significant increase of infectious diseases, especially hepatitis and HIV. The high incidence of these diseases is caused mainly by the fact that a single injection instrument is used by different individuals. In January 2007, 60968 people received a first diagnosis of mental and behavioral disorders as a result of PAS consumption. Compared to 2005, 2006 saw a 0,36% increase in the officially registered spread of mental and behavioral disorders caused by PAS consumption (F11-19) in the Republic of Kazakhstan. The most significant increases were noted in the Eastern-Kazakhstan region (9,2%), Astana (6,7%), Almaty city and the Zhambyl and Pavlodar regions (6,4%). This tendency may be related to a higher rate of industrialization in these areas and the higher number of young people migrating here from other regions in search of wellpaid jobs.
1
Altynbekov S., Katkov А.., Rossinskiy YU. The Drug Users Medical and Social Rehabilitation Program in Kazakhstan . 2 ―Narcological Situation Monitoring in the Republic of Kazakhstan in 2006‖ – Analytical Report RSPC of DAMSP, -Pavlodar 2007
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Analyzing the data of registered drug addicts in the Republic of Kazakhstan for 2006, an increase of 1500 people in comparison with 2005 is noted. The increase in the number of drug users should be viewed in combination with the data on the number of HIV-infections3. Thus, in the Republic of Kazakhstan, as mentioned above, 84,2% of the HIV-infected persons are IDUs. In 2006, 1743 new cases of HIV-infection and 132 cases of AIDS were registered in the republic (Table №1). This exceeds the number of occurrences noted in 2005. The growth of HIV-infection cases is noted in all regions except for NorthKazakhstan, Aktyubinsk and Akmolinsk. During the 12 months of 2006 the highest growth of HIV-infection cases was registered in the Eastern-Kazakhstan region – a fourfold increase; the Southern-Kazakhstan region – 2,4 times more cases; the Karaganda region – 2,1 times more cases; Astana – 2,1 times more; Almaty – 1,8 times more; and Zhambyl region – 1,7 times more. Table № 1- Number of HIV-infected people, new cases in 2006 (Official Report of the Republican Center for fight against HIV epidemics in Kazakhstan)
Regions The Republic of Kazakhstan Astana Almaty Akmolinskaya region Aktyubinsk region Almaty region Atyrau region Eastern-Kazakhstan region Zhambyl region Western-Kazakhstan region Karaganda region Kostanai region Kyzylorda region Mangistau region Pavlodar region North-Kazakhstan region South-Kazakhstan region
3
Number of HIV-infected individuals Including total children under 14
Including people with AIDS total
Including children under 14
1743
93
132
1
31 591 17 17 116 7
0 4 0 0 2 0
1 3 6 3 1 0
0 0 0 0 0 0
171
1
0
0
33
0
0
0
21
0
2
0
249 77 9 12 115
2 1 0 0 0
90 1 0 0 15
1 0 0 0 0
20
0
3
0
257
83
7
0
―Epidemic situation on HIV/AIDS in RK as the end of 2006‖ - Analytical Report, RC AIDS, - Almaty, 2007
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According to official data, on 1 March 2007, 84,2% of the PLHIV registered in the Republic of Kazakhstan are IDUs and 74% are men. 76% register as ―unemployed‖ because when they are tested for HIV, many do not indicate their place of work as they are afraid of losing their job. 85,8% are people aged 15 from to 29. In total, on 1 March 2007, 7 709 people with HIV-infection were registered, 488 of whom have AIDS. Mental health problems, alcohol and drug addiction may affect the behavior of people and thus lead to greater risks of HIV transmission. Mental health problems may appear at all stages of HIV-infection. However it is most prevalent at the time of receiving the HIV test results and the early stages of the development of AIDS. The health care system in Central Asia is excessively institutional and underdeveloped. IDUs are frequently characterized as ―hard-to-reach‖, due to the following reasons: high level of stigma and discrimination, frequent cases of imprisonment, and unwillingness to be treated in governmental organizations.4 According to the official data on March 2007, IDUs make up 84,2% of the total number of people with HIVinfection in the Republic of Kazakhstan. Many authors note that emotional disorders of IDUs occur in the form of depression and dysthymia. Social and psychological adaptation disorders in the form of suicidal behavior are noted at the time when the HIV results are received. In some cases, affective disorders cause PAS usage, which also increases the risk of HIV infection. 5 The goal of this research is to assess the mental health problems and identify the needs for support of IDUs/ PLHIV. In order to achieve this goal, the following objectives were defined: To gain insight into MH/HIV-related problems among IDUs To gain insight into drug injecting PLHIV‘s knowledge, relationships and behaviour related to HIV To define the implications of these results for future MH/HIV-related research, policy and support programs for drug-injecting PLHIV To propose a set of MH/HIV interventions which would be appropriate for IDUs and facilitated by GIP To formulate recommendations for further research, strategies and the development of programs to reduce mental health problems among IDUs/PLHIV. The present research raises the question on the importance of interaction between three sectors: mental health, HIV/AIDS and narcology services organizations, for improvement of care for PLHIV/IDU
4
Sultanov М.G., Katkov А. L. The Implementation of the UN Program «The HIV/AIDS prophylaxis and treatment networking in Central Asia» 5 ―Epidemiologic Situation on HIV/AIDS in RK on the end of 2006‖ – Analytical Report, RC AIDS
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2. STUDY DESIGN AND METHODOLOGY In March-April 2007 a rapid assessment was conducted to study the psychosocial problems of IDU/PLHIV in Almaty, Kazakhstan within the context of the GIP project ―Mental Health and HIV/AIDS‖ in Central Asia.
A combined methodology Rapid Assessment and Response was applied to study the mental health problems and needs for support among IDU/ PLHIV in Kazakhstan. In order to obtain information, focus group discussions and semi-structured interviews were conducted among PLHIV, medical staff, local and national key stakeholders. The FGD and interview tools (see annex 1, 2) were prepared in cooperation with Regional Coordinator and the teams of Expert Centers of Kyrgyzstan and Tajikistan. An overview was made of existing studies and statistical data on mental health problems of IDUs/PLHIV in Kazakhstan. Scientific works and articles of Kazakh scientists were used. For the study 3 Focus Groups (17 participants) were organized at the office of nongovernmental organization ―Central Asian Youth Alliance‖ that implements the ―Social Support‖ project for IDUs/PLHIV in Almaty. An incentive (about 5 USD) was provided to motivate the IDUs, basically covering the cost of a meal. 11 semi-structured interviews were held with medical staff, local and national key stakeholders, NGO employers and people from the close surrounding of IDUs/PLHIV. All participants knew that the focus groups were held in the context of a qualitative study on the mental health problems and support needs of IDUs/PLHIV and all respondents were ensured of the confidential use of the research data.
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3. STRUCTURE, LEGAL BASIS AND MANAGEMENT OF PLHIV/IDU PROGRAMS In order to make a rapid assessment of the situation regarding the consumption and distribution of drugs in the Republic of Kazakhstan for 2006, the following data and sources were used: data from the narcology services of the Republic of Kazakhstan including the Republican scientific and practical Center of Medical and Social Problems of Drug Addiction and the Republican AIDS center - on the following issues: the structure of governmental and non-governmental organizations rendering assistance to drug addicts; the level of qualification of, and training systems for their staff; methods of financing narcology services in RK; as well as the total numbers of IDUs, HIVinfected drug users and drug users with AIDS. At the end of 2006 the following organizations were operating in the Republic of Kazakhstan: - 1 Republican Narcological Center with 150 beds - 21 narcological dispensaries with 2930 beds - 9 specialized patient care institutions with 1535 beds - 7 narcological departments with 175 beds in mental hospitals and 5 narcological beds in the general treatment system. 16 departments of medical and social rehabilitation of drug addicts are equipped with 605 beds. In the narcological dispensaries there are 14 departments for obligatory treatment of PAS addiction, with 1040 beds. In 2006 the ambulatory narcological service consisted of 176 narcological units (excluding dispensaries), 3 narcological outreach units, 30 units for alcohol intoxication detection, 18 units for anonymous treatment, 23 youth units and 14 units for alcohol abuse prevention.
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Organizational Structure Kazakhstan, 2006
of
National
Policy
Implementation.
Republic
of
The President of the Republic of Kazakhstan Resolutions of the President of RK (Decrees, Laws) National level Government of RK headed by the Prime-Minister, Council of Ministers
National Coordination Council on Healthcare (Vice-Minister) Resolutions of the Government of RK (Decisions, Strategies) in pursuance of and with the purpose of fulfillment of resolutions issued by the President of RK (Decrees, Laws) Complex cross-sector Governmental Program in pursuance of and with the purpose of fulfillment of resolutions issued by the Government of RK, resolutions issued by the President of RK (Decrees, Laws) Level of the Ministries and Departments (orders) Interdepartmental coordination councils (plans, strategy) Ministry Ministry of Ministry Ministry of Ministry of Labour of Health Internal of Justice Education and and social Affairs Science protection of population RK Republica Republican The republican scientifically-practical centre NGO n centre of the Medico-social problems of drag addiction AIDS Healthy way The republican scientifically-practical centre centre of life Psychiatry, psychotherapy and narcology Regional level: Akimat, regional public health National (regional) coordination council departments, formations, internal affairs, on health protection internal policy Regional AIDS Regional narcological clinics Regional of the Healthy way centres of life Departments (preventive maintenance, treatment, etc.), interdepartmental coordination councils) Needle exchange points
NGO
Medical institutions
Educational institutions
Prisons
Social services
IDUs
In 2007, there were 42 non-governmental organizations working in the field of harm reduction, drug addiction prevention and HIV/AIDS prevention, compared to 37 registered organizations in 2006. The increase in the number of NGOs is related to the fact that trust in and government funding for NGOs is increasing. The data on the system of AIDS service organizations are provided in the report on the structure of AIDS service organizations in Kazakhstan6 In Kazakhstan there is an organizational and informational system for the implementation of the national policy, strategy and programs aimed at decreasing the demand for drugs and better HIV/AIDS prevention among IDU, based on the legislative documents (see annex 3).
6
Mental Health and HIV/AIDS Services Structure in Kazakhstan/Expert center Mental Health and HIV/AIDS
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4. HIV/AIDS AND MENTAL HEALTH SERVICES FOR IDU According to the data of the Republican Scientific and Practical Centre of MedicoSocial Problems of Drug Addiction and the Republican AIDS Center, the following types of services for treatment and rehabilitation are available for IDUs/PLHIV7: - Harm Reduction Programs, which include needle exchange programs, information campaigns on safe use of needles, distributions of condoms, VCT, psychological counseling and issuing appointment cards to medical institutions. Such programs are organized and financed by international donors organizations - Detoxification Programs, offered both in governmental narcological hospitals and in private drug-addiction treatment centers. - Rehabilitation Programs, which include measures aimed at supporting a patient after detoxification. In the Republic of Kazakhstan these programs are implemented by governmental and non-governmental organizations. The most effective program is that of the Republican Center of Narcology for formation of properties of mental health stability. The center introduced a concept – ‗neoabilitation‘, which means formation of new personality. There are also rehabilitation programs linked to religious organizations, for example, the Center ―Petrovka‖, and Dianetics Centers. There are protocols and standards for diagnosis and medical treatment for IDUs in the case of HIV-infection and AIDS. These protocols state that for IDUs/PLHIV medical assistance in combination with social, psychiatric and narcological assistance is the most successful. Looking in more detail at the main points on Harm Reduction Programs and substitution therapy, one sees that according to Republican Center reports (2006), in different regions of Kazakhstan between 5 and 15 % of drug-users receive some type of specialized care. At the same time, only 4% of the IDUs benefit from harm reduction services. That is why the effectiveness of programs to prevent drug addiction and the spread of HIV/AIDS among IDUs, including harm reduction programs, is evaluated as insufficient. According to the 2001-2005 National HIV/AIDS Strategic Program on the Counteraction of AIDS Epidemics in the Republic of Kazakhstan, the following activities need to be implemented: 1) Education of IDUs on safety surrounding HIV-infection, in combination with the provision of sterile disposable syringes, needles, condoms and disinfectants to IDUs; 2) Total eradication of compulsory HIV testing, also for people considered to be part of a high-risk group; 3) Research on the use of substitution therapy in Kazakhstan; 4) Outreach work among IDUs and establishment of functioning needle exchange points. The program observes that stigmatization of IDUs/PLHIV makes access to this group more difficult and limits the possibilities of involving them in prevention programs. Possible approaches to improve this situation include the involvement of IDUs in such activities as peer education and user self-help organizations. The most successful NGOs 7
I.V. Vassilenko «Tertiary Prevention of Mental and Behavior Disorders of Opium Users (clinic-social and organizational and economic aspects)
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in this category are ―Osvobozhdeniye‖ and ―Help‖, but the impact of these programs is insufficient for the total number of IDUs/PLHIV. Thus, in Kazakhstan there is a legally approved system of treatment and prevention programs as well as methadone programs, These programs are in different stages of realization.8 About 20 projects on harm reduction were realized in Kazakhstan in 2006, and 122 IDU trust-points were opened. Most efforts were made in Temirtau (Karaganda region), which saw an outbreak of HIV-infection among IDUs in the middle of the 1990s. At present harm reduction programs are only sufficient to serve 10% of the high-risk groups in Kazakhstan.9 The latest research reveals that there is still a significant level of high risk behaviour. According to a doctor of the AIDS centre in Almaty they currently work with 2-3% of the IDUs in the city.10.
All traditional methods - except for substitution therapy - are used in harm reduction programs implemented in Kazakhstan. This method is currently not used in Kazakhstan and Russia, in spite of the Order of the Ministry of Health of the Republic of Kazakhstan of December 8, 2005, No.609 ―About Implementation of Substitution Therapy‖. Pilot projects were started up in Karaganda and Pavlodar region, but were stopped due a lack of methadone. Over the past few years governmental, international and non-governmental organizations have set up projects aimed at the development of a network of services for HIV/AIDS prevention and drug addiction treatment. For example, since 2003 the UN project ―Development of a Network of Services on HIV/AIDS Prevention and Treatment of Injection and other Drug Users in the Countries of Central Asia‖ is functioning in Shymkent and Pavlodar region. Although the need is evident, it is hard for IDUs/PLHIV to gain access to the different services, and there are not enough services for the all drug addicts. The system of mental health care for IDU/PLHIV is not well developed and exists partly within harm reduction programs and in narcological centers. 8
A.L. Katkov Substantiation of the through model of treatment, rehabilitation and prevention of narcological dependence spreading in the Republic of Kazakhstan. 9 A.L. Katkov, I.V. Vassilenko: The main provisions of the concept of primary narcological assistance, renedered with the framework of the damage mitigation programs. 10 Катков А.Л,, Василенко И.В. Основные положения концепции первичной наркологической помощи, реализуемой в программах снижения вреда
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5. MENTAL HEALTH PROBLEMS of HIV-POSITIVE IDU 5.1. Features of the psycho-emotional state of HIV-Positive IDUs (review of the available studies) We conducted a desk-review of the studies on mental health problems among HIVpositive IDU in Kazakhstan that were available and analyzed scientific studies about mental health problems among PLHIV/IDUs. The information can be considered valid and representative. These scientific studies contain valuable information on mental health problems of IDUs/PLHIV at different stages of the disease. HIV infection entails social and psychological problems. An unfavorable disease prognosis, especially in combination with drug addiction, leads to further deterioration of the mental health of a person with HIV-infection and results in a deterioration of their quality of life11. A characteristic of mental health such as satisfaction with life is in itself an indicator of quality of life12. In 2004 a study aimed at mapping emotional disturbance and assessment of quality of life among HIV-positive IDUs was conducted in Kazachstan. It consisted of a comparative analysis of two groups (HIV-positive IDUs and HIV negative IDUs)13: 1. The issue of self-mutilation is very urgent, because along with aggressive intentions directed at others, severe lack of social and psychological adaptation is observed in patients, in the form of suicidal behavior in the period when the disease is diagnosed. 2. lack of mental adaptation among HIV-positive persons is noted from the early stages of HIV-infection onwards, but behavioral disorders may occur even before HIV infection. According to the information of A. Yeskaliyeva, the following types of mental disorders were observed in the groups compared (HIV-positive IDUs and HIV-negative IDUs): depression, chronic affective disturbance of mood (Ch.ADM), and mental adaptation disorders (MAD). The risk of depression is on average 3.7 times higher for HIV-positive IDUs than for HIVnegative IDUs. The risks of suicidal intentions among IDU/PLHIV(+) are 3,4 times higher and the risks of suicidal attempts 18,2 times higher.14 11
S. Imangazinov: Features of Psycho-emotional State of PLH Kazakhstan A. Katkov, Yu. Rossinskiy ÂŤIntegrated Study of State, Level and Main Tendencies in Forming Mental Health of the Population of the Republic of Kazakhstan Âť Kazakhstan 13 A. Yeskaliyeva Emotional Disorders and Quality of Life of HIV-positive Opium Abusers / Abstract from the dissertation of the Candidate of Medical Science, Tomsk-Pavlodar Kazakhstan 12
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Table No.3 – Mental Disorders of Opium Users with HIV-positive and HIV–negative statuses. 2006 Kazakhstan15 Ch.ADM
MAD
Suicidal Attempts
47,50%
Suicidal Intentions 69,20%
IDU/HIV-positive
5,50%
IDU/HIVnegative
8,50%
41,80%
20,10%
2,80%
51,00%
Among IDU/PLHIV more mental health problems than physical problems are noted. Depressive disorders are more frequent than anxiety disorders and dysphoria. The behavior of IDU/HIV+ compared to IDU/HIV- is characterized by strong emotional excitement, negative feeling (anxiety, tension, embarrassment, irritation), a distant attitude towards people and problems in interpersonal relationships. The necessity to hide one‘s HIV-status, fear of double stigma and expecting others to have a negative attitude towards you worsen the emotional state of IDUs/PLHIV The studies led to recommendations on the need to include rehabilitation in the process of psychosocial support. Experts insist that psychotherapy is needed for IDUs/PLHIV and those in their close environment. 5.2 Mental health problems, behavioral characteristics and needs of PLHIV/IDUs Reactions to a HIV-positive diagnosis: Each IDU reacts differently to a HIV-positive diagnosis. The majority of IDUs stated that this information did not have much impact on them, and that they decided to continue using drugs, since they now ―definitely had nothing to lose‖. The research conducted showed that the majority of IDUs experienced shock, depressive reactions, aggression and auto-aggression when learning about their HIVpositive status. Some focus group participants did not believe the diagnosis, and some experienced fear for their life and future. “I found out in prison in 2004. I walked out and my legs were shaking. I had a strong shock. It was indescribable; that’s the end, emptiness, nothing left; why be released, why live…?” - Male, 25 years old, Almaty “I felt guilty and blamed myself. I didn’t know I was pregnant, and found out after tests were conducted. My husband was also tested and burst into tears when he found out. It all sank in only a week later and I decided to hang myself. My husband took me 15
A. Yeskaliyeva Emotional Disorders and Quality of Life of HIV-positive Opium Abusers / Abstract from the dissertation of the Candidate of Medical Science, Tomsk-Pavlodar Kazakhstan
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out of the loop, but later I calmed down. When I gave birth to a child I had no time for that as I had to raise my children”. - Female, 25 years old, Almaty I was also angry with the person who had infected me, there are many who know but don't say anything. I’m still angry; half a year has passed since I found out in prison. - Male, 38 years old, Almaty First I was angry with the person who had infected me. He knew about it but had not warned me. I was ready to slit my wrists. But now I think I should use more heroine as long as I can, because there’s no difference between dying of an overdose or of AIDS. - Male, 38 years old, Almaty During the discussions the participants in the focus-groups frequently referred to the issue of suicide. Suicidal intentions among IDUs/PLHIV may be seen in the form of an increase in drug dosage - a ―golden injection‖ and in refusal to care about life altogether. During the interviews most specialists noted that being informed of a HIV+ status either causes no reaction at all in the IDUs, or makes them very aggressive. Specialists are not in a position to identify mental health problems, so they assume IDUs do not need any psychological support. “If the blood test is done for the second time, IDUs guess they might be infected. They often say that it makes no difference to die of one thing or of another…” Narcologist, 38 years old, Almaty “It’s all over for these people, they have no future. They are very difficult patients; frequently there are no changes except for more aggressive behavior towards the doctors” Psychiatrist, 45 years old, Almaty Once patient is discriminated by just one doctor, he begins to behave aggressively towards all of them. Influence of a HIV-positive status on further behavior While discussing the problem, most FGD participants did not note the influence of their HIV+ status on further drug usage. Some refused to use drugs and a minority increased their drug usage. “I started thinking more about my health. I don’t use drugs and haven’t even smoked for 8 months”. - Male, 32 years old, Almaty “I became quite indifferent about my situation, it’s too late to take care of myself and I need to take more drugs, so that everything will come to an end”. - Male, 31 years old, Almaty “Nothing has changed, everything is like it was and I feel no changes”. - Female, 27 years old, Almaty A publication of the Mental Health and HIV/AIDS Project (2005-2008) of The Global Initiative on Psychiatry (GIP)
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Many of those who stopped using drugs after our meeting consider that only their status played a decisive role in changing their lifestyle, relationship to self and others, y determine their role in life and define values and priorities. Some of them found hope in their children and became more aware of everyday problems. Others are afraid they might infect somebody of their close environment. “Now I don’t use drugs as I have to raise my children. My husband is in prison and I carry the burden alone, I have already taken on a second job. I don’t know how to explain my illness to my children and I am afraid I might infect them.”. - Female, 25 years old, Almaty “I see my life differently now. Because I will probably live less long now, I started taking an interest in things I had never been interested in before”. - Male, 39 years old, Almaty “In my experience there were a lot of cases where people seemed to acquire a new sense of life when their HIV infection came to a critical stage. Many such people work with us as volunteers”. NGO employee, 32 years old, Almaty Most IDUs noticed changes in their state of drug intoxication and experienced psychical and mental discomfort, irritation and aggression, bad temper, inexplicable dissatisfaction and suicidal thoughts. As far as sexual behavior is concerned, many noted that at first they refused to have intercourse at all, as they were afraid of infecting their partner, but after receiving information about safety measures they started using condoms. Almost half of the IDUs did not use condoms during sexual intercourse. Some respondents noted that many of their acquaintances, mostly women, use sex as a means of earning money, and they rarely use condoms. PLHIV/IDU satisfaction with AIDS related services Both pre- and post-testing counseling and the level of satisfaction of PLHIV/IDUs with these services were discussed during the focus group meetings. The discussions showed that most did not seek VCT because they assume that medical staff in narcological centers and in prisons do not pay attention to drug-addiction problems connected with HIV. “I found out in prison in 2004. The doctor said I had HIV.” - Male, 28 years old, Almaty “When blood samples are taken in our ward, different situations happen. Sometimes the patients are not even aware that their blood is taken for HIV analysis. We have no HIV-consultant, which is why little attention is paid to this issue”. Narcologist, 41 years old, Almaty
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“We try to find out where and how he/she could have gotten infected. Moreover, we provide information on responsibility for deliberate infection and how this can be prevented”. Medical consultant of AIDS-Center, Almaty In most cases participants did not receive the necessary pre- and post-test counseling, or even a minimum of information about the disease, such as ways in which it is transmitted, prevention and treatment. According to the majority of the respondents, this resulted in long-term depression. The majority of the respondents mentioned that they receive support from family, close relatives and friends. “When I found out,, I went to my boyfriend immediately (I had sexual relationships with him). I told him about it. He took it easy and said: “Well, I am not going to end my life because of it. We told each other some jokes and I felt some relief”. - Female, 22 years old, Almaty “The guys often ask us for some help and, although providing psychological support is not our job, we try to help them. Many of them come back again later.” NGO employee, 25 years old, Almaty Some of the respondents commented that they felt a strong reluctance to stay in touch with their relatives and had difficulties communicating with other people after they found out that they were HIV infected. Some FGD participants talked about the negative and sometimes aggressive attitudes of people in their surroundings, in particular medical personnel in polyclinics. PLHIV often face discrimination. Attitudes of doctors and hospital nurses have deteriorated significantly: medical aid is provided either with delays or not at all; additional payment is demanded for services that doctors are legally required to provide free of charge; and medical secrecy and confidentiality are not observed – the status of the patient was immediately conveyed to all medical personnel and all patients of this hospital. “People differ; major discrimination may occur in institutions, and cannot be avoided in polyclinics, from paramedical personnel, doctors, legal institutions, family, neighbors and friends”. - Male, 43 years old, Almaty “I did not tell my relatives, the doctor told them. My brother called my father and said: “She’s got HIV. Take her child away from her”. My father did not talk to me even by telephone for a month and a half. It was a major problem to deal with him. In the family they made me eat separately and until I brought them some brochures to read about this infection, they washed the dishes and the bathroom with chlorine. A publication of the Mental Health and HIV/AIDS Project (2005-2008) of The Global Initiative on Psychiatry (GIP)
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Everything was resolved. I was frustrated and upset with them because they did not want to understand my problems”. - Female, 25 years old, Almaty ―I made a mistake when I decided to tell my colleagues. I felt I had to warn them because sometimes we hit our fingers with a hammer or something else. After this I was dismissed from my job‖. - Male, 32 years old, Almaty “When a HIV+ is delivered to our hospital, everybody hears about this immediately. We provide treatment but try to discharge him/her from hospital as soon as possible. People in the department panic, and the nurses are afraid to put an IV. I suppose that this is caused by a lack of knowledge about HIV. Moreover, drug addicts are inadequate and troublesome people”. Psychiatrist, 34 years old, Almaty The only people who understood the problem of people with HIV were their relatives (spouses, brothers or sisters). Of course, some of them also experience shock, mainly due to a lack of information. Not all HIV-positive persons were able to restore relations with their families and find understanding and support in this difficult situation. Not all people with HIV told their relatives and friends about their status. There are a lot of reasons for this, such as relationships that were already bad, unwillingness to upset family and friends, and fear of loosing their reputation. Most participants mentioned difficulties in obtaining treatment. Generally, they use the standard services of the AIDS-center. Others say that generally they turn to other people who are HIV positive for help, because they feel that these people will be able to understand and support them. Some factors that might prevent respondents from seeking harm reduction services, such as fear of being known as a drug-addict and fear of the negative attitude of other people, remain widespread. Another reason why many IDU hesitate to approach the trust-points is the fear of facing cold or even aggressive treatment. Staff themselves note that trust-points should be more hospitable and less official. They believe that staff should be selected from among sociable and kind people, and that the environment should be more pleasant. “We would like to create much more of a family-like environment in the needle exchange points…. We need to talk to the people and offer them a cup of tea, not just give a syringe and ask if they want anything else… then people will feel like coming again…” Volunteer of a harm reduction program, 27 years old, Almaty Another important factor that reduces the efficiency of harm reduction programs is that all IDUs are afraid of being apprehended by the police.
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In general the general needs of IDUs/PLHIV are: access to medical aid, legal counselling, good information, psychological assistance and social aid. The medical aid focuses on psychological support at the time the diagnosis is made (pre- and post-test counselling), establishment of separate hospices for PLHIV, establishment of rehabilitation departments for PLHIV/IDUs, and attitude improvement, especially among medical personnel. “First of all, people’s attitude need to be changed. In hospitals, educated people are unable to present the information as psychologists. Sometimes, they say it straight away and you have to decide how to live with it or not to live”. - Male, 39 years old, “Nobody talks with them or solves their problems. Treatment is provided, and we discharge them”. Narcologist, 38 years old, Almaty Legal support for PLHIV must be provided in order to respect their human rights, ensure compliance with legislative standards, guarantee confidentiality and provide different types of medical services. Units with independent consultants who monitor patient rights should be opened in each medical department, also for PLHIV. “My friend had a leg wound and was sent from hospital to hospital. From the AIDScenter to the surgery hospital, then to the trauma center, then to the detoxification center, and then back to the AIDS-center again. But they did not manage to help him. We had to find a lawyer and pay him in order to get aid”. - Female, 22 years old, Almaty Support in the form of providing information to IDUs consists of offering complete and accurate information on the progression of HIV/AIDS epidemics, HIV transmission and prevention, as well as complete and accurate information on approaches to stop using drugs, the influence of drug consumption and progression of the disease. “It is not only we who need this information, but also doctors of various disciplines and drug addicts without HIV”. - Female, 29 years old, Almaty Psychological and social support is considered very useful by all respondents of the study. It would consists of establishment of units or counselling services that provide physiological support to PLHIV. ―I believe that if psychologists and psychiatrists talk with us and understand us without judging, we would go and see them to discuss our problems or concerns. This help may reduce drug consumption, since many people cannot handle hearing about their status and start to use more drugs. And it does not matter whose syringe it is and who is at your side”. - Male, 29 years old, Almaty “There is a need for more peer support groups for ex-PLHIV/IDUs so that people who use drugs can come, and we can help them deal with their addiction”. A publication of the Mental Health and HIV/AIDS Project (2005-2008) of The Global Initiative on Psychiatry (GIP)
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- Male, 32 years old, Almaty Most respondents state that it is not important whether a consultant is HIV positive or not, the main point is his or her ability to understand and listen. The respondents stated that the main characteristic of a good consultant is interest in the individual. Some preferred assistance from peers, because they trust those who are familiar the problem. Most wished to participate in support groups and self-help groups. As for the opportunities to use ART, most respondents were positive towards this, i.e. they believe that this method of treatment is efficient. Others do not believe it may lead to positive results and consider this method to be risky and harmful for one‘s health. It was very important for us to learn that a small part of the respondents was extremely interested in training and work related to HIV. It reveals an active attitude and a desire to change their current situation. The respondents in question were invited to participate and may become change agents for IDUs/PLHIV.
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CONCLUSIONS 1. Most registered HIV-positive individuals are injection drugs users. According to data of 1 March 2007, 84.2% of all HIV-positive individuals are intravenous drugs users. 2. In spite of implementation of harm reduction strategies, many drug addicts still have dangerous injection habits. 3. Kazakhstan has a National HIV/AIDS Program for 2006-2009, as well as a legally ratified system to implement national policy, strategy and programs for reduction of drug consumption and prevention of HIV/AIDS among injecting drugs users. 4. On January 1, 2007 the number of individuals receiving a first diagnosis of mental and behaviour disorders caused by the use of psychoactive substances was 60 968. 5. Protocols and standards for diagnosis and medical treatment of HIV infection and AIDS for PLHIV/IDU have been drafted. The introduction to these documents note that a combination of medical and social, psychiatric and detoxification aid is the most successful. 6. The prevalence or severity of depressive disorders among HIV-positive drug addicts in Kazakhstan is 1.6 times higher than that of HIV-negative addicts. 7. Mental health problems of IDUs/PLHIV include: depressive disorders, shock, aggression and self-mutilation with suicidal thoughts. Reclusive behavior, difficulties in communication with other people and emotional instability were mentioned as well. 8. Psychological complaints of HIV-positive IDUs tend to prevail over physical ones. 9. Most respondents say that their HIV positive status does not influence their drug use; one third of the respondents refused to use drugs and only one fifth of the respondents increased the amount of drugs used. Many respondents noted that they do not use condoms during sexual intercourse, even after being diagnosed with HIV. 10. Testing for HIV is obligatory for IDUs. There is no system of voluntary testing and consulting. There is lack of specialists and educational programs. Most respondents received no or only partial pre-test counseling. Only one-third of the respondents received post-test counseling, which may have resulted in low awareness of the virus itself and transmission of the infection. 11. Quite often PLHIV face discrimination from medical service staff. Most respondents of our study encountered this problem. Thus, most of them do not mention their status when seeking medical care. Specialists note the low level of awareness of HIV/AIDS problems, and indicate a need for educational programs in this area. 12. According to most respondents. support is provided by traditional systems which are common to our culture, such as family, close relatives and friends. They provide psycho-emotional support, understanding and material assistance to PLHIV. The respondents also noted that non-governmental organizations provide legal support and information. They noted that such assistance is not sufficiently available. A publication of the Mental Health and HIV/AIDS Project (2005-2008) of The Global Initiative on Psychiatry (GIP)
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13. Regarding their needs in general, PLHIV/IDUs mention medical care, legal counseling, access to information on HIV/AIDS, and psychological and social assistance: Provision of complete and reliable information on methods, approaches and possibilities to stop using drugs; Provision of complete and reliable information on the influence of the drug consumption on the progression of the disease; Provision of information on substitution therapy; Establishment of rehabilitation groups and care centers for HIV-positive IDUs; Establishment of peer support groups for HIV-positive IDUs; Change of attitude towards HIV-positive IDUs in society at large and among medical staff in particular, respect of legally established rights, including the right to the free medical treatment. 14. The substantial demand for mental health care among PLHIV must be noted.
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RECOMMENDATIONS In order to overcome the problems faced by IDUs/PLHIV which are mentioned in this study, significantly more resources need to be made available to prevent the spread of HIV-infection in the Republic of Kazakhstan. According to our research findings, one of the priorities is access to detoxification services, including substitution therapy and psychological support (crisis centers and counseling centers that can provide professional psychological assistance). Recommendations for GIP Program Staff Include specific topics related to mental health of IDUs/PLHIV in educational programs and information campaigns to institutions providing medical, social and psychological assistance to IDUs/PLHIV. Establish educational programs related to confidentiality and the consequences of disclosure of diagnosis information. Participate in the development of recommendations about the mental health aspects of work with IDUs/PLHIV. Assist PLHIV associations in organizing peer support groups for HIV-positive IDUs; when provided with support and up-to-date information, IDUs/PLHIV can improve their quality of life, benefit from rehabilitation programs, and improve their relations with relatives, doctors and people in their close environment. Establish a program to help family members and care-givers obtain practical skills in providing assistance and psychological support. Develop voluntary testing and consulting programs as well as programs that will help increase the motivation of consultants. Organize seminars and conferences with the purpose of exchanging experience among governmental and non-governmental AIDS-service organizations, mental health services and detoxification centers working in the field of IDU/PLHIV problems. Prepare training programs for the staff of drop-in centers in order to improve their knowledge of the mental health problems of PLHIV. Recommendations for National AIDS Program Managers Mechanism of medical, social and psychological assistance to IDUs/PLHIV and their families need to be developed and maintained on the basis of interdepartmental cooperation between health and social security authorities, in particular detoxification centers and social security centers. A multidisciplinary team can be formed, made up of representative of the above-mentioned organizations. Its tasks may include: - assessment of the medical, psychological and social status of people with HIV and members of their families. - mapping of the types and severity of the behavioral problems, conflict risks and problems faced by IDUs/PLHIV. - definition of methods to provide medical, psychological and social assistance to people with HIV and members of their families. - coordination of activities among those seeking to find solutions to IDU/PLHIV problems. Establishment of a specialized center to train professionals dealing with HIV/AIDS, mental health and drug addictions. A publication of the Mental Health and HIV/AIDS Project (2005-2008) of The Global Initiative on Psychiatry (GIP)
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Preparation of scientifically-based programs and handbooks that are adapted to the training level of specialists working with IDUs/PLHIV; Preparation and development of new educational standards and programs related to HIV/AIDS issues and mental health problems for personnel working in the sphere of HIV prevention, treatment of drug addiction and mental health services. Improvement of personnel qualification requirements, in accordance with the data of the Republican Center of Psychiatry, Psychotherapy and Narcology (medical training on mental health issues does not meet all requirements of providing practical health care). The current system of staff training is not fully adapted to the new goals and objectives of the service provision process. There is no explicit definition of requirements or competence levels for the various specialists within the mental health field. Consider implementation of substitution therapy programs. Establishment of an interdepartmental coordination committee in order to meet major non-medical needs of the people with psychological and behavioral disorders and ensure closer cooperation between the departments involved. Provision of support to all non-governmental organizations (associations, unions) working in the field of mental health in the Republic of Kazakhstan, who should participate in the work of the interdepartmental coordination committee and psychiatric and detoxification organizations. Intensification of training on pre- and post test counseling. Consideration of the possibility of establishing a hospice network. Recommendations for National and Local AIDS and MH Organizations Crisis centers for IDUs/PLHIV, offering counseling by multidisciplinary specialists, should be set up. It is also important to involve the clergy when working with IDUs/PLHIV as for many addicts religion is important. Production, publication and free distribution among specialists and IDUs/PLHIV of printed materials containing up-to-date information on HIV-related issues, mental health problems and ways to overcome these, as well as information on the availability of services. Creation and implementation of anti-stigma and antidiscrimination programs using the mass media. Assistance in the establishment of peer support groups for IDUs/PLHIV; Implementation of activities aimed at changing the attitude of society at large and medical staff in particular, respect for the legal rights of IDUs/PLHIV, including the right to free medical treatment. Establishment of efficient systems of mental health care and access to psychiatric and psychotherapeutic aid through the setting up of community mental health services. Development of a network of complex psychological health teams, including home care and prevention, where the personal needs, wishes, cultural/religious beliefs and sexual orientation of IDUs/PLHIV are taken into consideration. Recommendations for Medical and Mental Health Staff and Counselors Development of training programs aimed at increasing the knowledge of mental health problems faced by PLHIV. Providing IDUs/PLHIV and their family members with complete and reliable information on how to end drug addiction; A publication of the Mental Health and HIV/AIDS Project (2005-2008) of The Global Initiative on Psychiatry (GIP)
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Provision of complete and reliable information on the influence of drug use on the progression of the disease (also within the framework of pre- and post-test counseling); Provision of information on substitution - and ART therapy. Provision of ongoing and reliable information to family members of IDUs/PLHIV. Recommendations for International Organizations Development and implementation of projects to improve the quality of life of IDUs/PLHIV, with active participation of donors in the development of professional services (psychotherapeutic health, psychological counseling, social and pedagogical services, voluntary counseling). Implementation of a mental health promotion policy, with long-term investment and development of corresponding long-term educational and informational programs with mass media participation. Recommendations for additional research For the purpose of further research in the field of IDUs/PLHIV mental health problems it is our view that specific target groups (teenagers, female, prisoners, etc.) need to be defined. Conducting specific studies for more efficient assistance to specific groups based on characteristics such as gender and ethnicity. The use of more standardized research methods in order to obtain more reliable data which may be used when comparing the situation in the Republic of Kazakhstan to that in other countries.
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REFERENCES 1.
М. Sultanov, А. Katkov - The Implementation of the UN Program «The HIV/AIDS prevention and treatment networking in Central Asia»
2.
Epidemiologic Situation on HIV/AIDS in RK on the end of 2006 – Analytical Report, RC AIDS
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Narcological Situation Monitoring in the Republic of Kazakhstan in 2006‖ – Analytical Report RSPC of DAMSP, -Pavlodar 2007
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Epidemiologic Situation with respect to HIV/AIDS in RK as the end of 2006‖ Analytical Report, RC AIDS, - Almaty, 2007
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Mental Health and HIV/AIDS Services Structure in Kazakhstan/Expert center Mental Health and HIV/AIDS
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I. Vassilenko «Tertiary Prevention of Mental and Behavior Disorders of Opium Users (clinic-social and organizational and economic aspects)
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A.Katkov Substantiation of the through model of treatment, rehabilitation and prevention of narcological dependence spreading in the Republic of Kazakhstan.
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A.Katkov, I.Vassilenko: The main provisions of the concept of primary narcological assistance, renedered with the framework of the damage mitigation programs.
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S. Imangazinov: Features of Psychoemotional State of PLH Kazakhstan
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A.Katkov, Yu. Rossinskiy «Integrated Study of State, Level and Main Tendencies in Forming Mental Health of the Population of the Republic of Kazakhstan » Kazakhstan
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A.Yeskaliyeva Emotional Disorders and Quality of Life of HIV-positive Opium Abusers / Abstract from the dissertation of the Candidate of Medical Science, Tomsk-Pavlodar Kazakhsatan
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T.Buzina Justification of psychological factors registration in HIV-infection prevention among IDU. - Moscow ., 1998
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Qualitative Research and Focus Group Studies: A Compilation Guide. Katinka de Vries, MPH, MSc. 2007
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LIST OF ON-LINE SOURCES OF INFORMATION Global Fund, http://www.globalfund.org/ International Council of AIDS Service Organizations: http://www.icaso.org AIDS Education Global Information System: http://www.aegis.com HIV InSite: http://hivinsite.ucsf.edu/InSite.jsp AIDS Summary (from International Planned Parenthood): http://www.ippfwhr.org/whatwedo/aidssummary.html Family Health International: http://www.fhi.org/fhi1.html International HIV/AIDS Alliance: http://www.aidsalliance.org Horizons: http://www.popcouncil.org/horizons Global Health Council: http://www.globalhealth.org International and National Public Health Organizations U.S. Centers for Disease Control and Prevention: http://www.cdc.gov/hiv/dhap.htm World Health Organization/Organization Mundial Salud: http://www.who.int/homepage Pan-American Health Organization: http://www.paho.org John E. Fogarty International Center: http://www.nih.gov/fic/ U.S. National Institutes of Health: http://www.nih.gov U.S. National Institute of Mental Health: http://www.nimh.nih.gov United Nations Agencies UNAIDS: http://www.unaids.org UNICEF: http://www.unicef.org/aids/ UNDP (UN Development Programme): http://www.undp.org/hiv/ UN Population Fund: http://www.unfpa.org/aids/index.htm UN Office for Drug Control and Crime Prevention: http://www.undcp.org/drug_demand_hiv_aids.html UN Development Fund for Women (UNIFEM): http://www.unifem.undp.org/hiv-aids/ International Council of AIDS Service Organizations: http://www.icaso.org AIDS Education Global Information System: http://www.aegis.com HIV InSite: http://hivinsite.ucsf.edu/InSite.jsp AIDS Summary (from International Planned Parenthood): http://www.ippfwhr.org/whatwedo/aidssummary.html Family Health International: http://www.fhi.org/fhi1.html International HIV/AIDS Alliance: http://www.aidsalliance.org Soros Foundation: http://www.soros.org/health A publication of the Mental Health and HIV/AIDS Project (2005-2008) of The Global Initiative on Psychiatry (GIP)
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The Global Fund to Fight AIDS, Tuberculosis, and Malaria: http://www.globalfundatm.org/index.html World Bank: http://www.worldbank.org/aids European Union: http://europa.eu.int/comm/development/sector/social/health_en.htm USAID: http://www.usaid.gov/pop_health/aids AIDS information site. News, articles, useful information, links: http://www.aidsinfosite.by.ru International HIV/AIDS Alliance in Ukraine. http://www.aidsalliance.kiev.ua "AIDS Infoshare" NGO website. http://www.hiv-aids.ru WHO-supported Russian AIDS Training and Community Development Project, also known as "Russian-Canadian Project". Most recent news and news archive, unique Russian-translated journal article review source, and links: http://www.aidsrussia.org Open Society Institute. http://www.osi.ru Gay-related AIDS news, http://www.gay.ru/health/aids
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Appendix 1 FGD guidelines on Mental Health Problems of HIV positive IDUs I set of questions: directed on identification of mental health problems of HIV positive IDUs: 1. How did you feel when you learned you are HIV positive? - Feelings guilt aggression (including auto-aggression) loss of interest fear How often do you feel depressed? How often do you feel anxiety? - Thoughts (note: in case if suicide is not mentioned, could be asked directly were there any suicidal thoughts or not) - what to do next - Behavior (note: in case if suicide is not mentioned, could be asked directly were there any suicidal attempts or not) - increase in frequency of IDU -changes in IDU pattern -self-isolation -attitude to health (health seeking behavior) 2. What changes in your feelings/thoughts/behavior have taken place over time? (adaptation/ disadaptation; development of new skills/behavior patterns) ; social changes 3. Did you receive pre-and post HIV test counseling? Have you been satisfied with pre- and post HIV test counseling? What we can have as an outcome-information out of asking these questions: * spectrum of MH problems * dynamics/phases/stages of adjusting to the diagnosis and living with HIV/AIDS * spectrum of social changes * availability of VCT and client satisfaction Which response actions have you undertaken to cope with changes in your feelings/thought/ and behavior -
disclosure (to whom); health seeking behavior/use of service (access to HIV treatment), probe for mental health services
II set of questions: directed on identification of the supportive and non-supportive environment for PLWHA 1. Supportive environment - Who supported you (informal surrounding, formal surrounding) and how? Probe here for lot of detail; role of partner, friend, parents, colleagues, children, peers - Who supports you now? - Who else could be supportive, in your opinion, for PLWHA? 2. Non-supportive environment: - Which obstacle and problems do you face related to your HIV status? A publication of the Mental Health and HIV/AIDS Project (2005-2008) of The Global Initiative on Psychiatry (GIP)
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informal surrounding, formal surrounding (family, neighbors) police health care providers Peer IDUs Employment and education What we can have as an outcome-information out of asking this questions: * info about supportive and non-supportive environment III set of questions: directed on evaluation/improvement of services 1. What kind of services have you been receiving since you learned about your HIV status? 2. Which services were/are helpful and how and which were/are not? Can you evaluate them (public health services, drug treatment, psychiatric care, substitution therapy program, ARV therapy, services provided by NGOs (e.g. needle exchange), counseling services) 3. What other types of services are needed, in your opinion, for PLWHA? (and by whom) What we can have as an outcome-information out of asking this questions: * respondents’ perception of the effectiveness of the services available (for cross checking), demand for services/treatment, needs
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Appendix 2 Guidelines for interviews with medical staff of national and international organizations working with IDUs 1. What feelings do you think IDU has when learned on HIV+ status? guilt aggression (including auto-aggression) interest loss fear How often do they feel depressed? How often do they feel anxious? - Thoughts (note: in case if suicide is not mentioned, could IDU/PLHIV be asked directly whether they have any suicidal thoughts or not?) - Behavior (note: in case if suicide is not mentioned, could IDU/PLHIV be asked directly whether they had any suicidal attempts or not) - increase in frequency of drug usage - changes in drug usage pattern - self-isolation - attitude to health (health seeking behavior) 2. What changes do you think appear in feelings/thoughts/behavior of IDU/PLHIV over time? (adaptation/disadaptation; development of new skills/behavior patterns); social changes 3. How does the process of pre- and post-test counseling for IDU/PLHIV go in the organizations you know? Which response actions have you undertaken Which response actions do you think IDU/PLHIV undertake to cope with changes in their feelings/thought/ and behavior? - disclosure (to who); - health seeking behavior/use of service (access to HIV treatment), probe for mental health services II set of questions: directed on identification of the supportive and non-supportive environment for IDU/PLHIV 1. What types of support for IDU/PLHIV do you think are necessary? informal surrounding, formal surrounding (family, neighbors) police health care providers Peer IDU Employment and education III set of questions: directed on evaluation/improvement of services 1. What kind of services may IDU/PLHIV be provided with in your organization? 2. What other types of services are needed, in your opinion, for IDU/PLHIV? (and who they must be provided by?)
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Appendix 3 Documents determining the current national policy, strategy and content of the programs in RK 1. The order of the Minister of Health of the Republic of Kazakhstan as of February 23, 1994 № 445”On the Measures for Realization of the Law of the republic of Kazakhstan “On Prevention of AIDS”; 2. The Decree of the President of RK having the force of law as of April 7, 1995 № 2184 “On Compulsory Treatment of Alcoholics, Drug and Toxicomania Addicts”; 3. Resolution of the Council of Ministers of the Republic of Kazakhstan as of April 19, 1995 № 514 “The Issues of Compulsory Treatment of Persons Suffering from Alcohol and Drug Addiction and Toxicomania, and Evading Voluntary Treatment and their Medical and Social Rehabilitation”, as amended by the resolution of the Government of RK as of May 30, 1997 № 906; 4. The order of the Agency of RK on Health Care Matters as of December 19, 2000 № 820 “On Improvement of Measures to Fight against the spread of Drug Addiction”; 5. The Order of the Agency of the Republic of Kazakhstan on Health Care Matters as of March 2, 2001 № 207 “On the Establishment of Medical and Social Rehabilitation of Drug Addicts in the Republic of Kazakhstan”; 6. The Order of the Agency of the Republic of Kazakhstan on Health Care Matters as of September 17, 2001 № 846 “On Creation of the Hospital Departments for Treatment of Juveniles and Holding Competitions of the Programs for Treatment and Rehabilitation of Drug Abusers”; 7. The Law of the Republic of Kazakhstan as of May 27, 2002 № 325-II “On Medical and Social Rehabilitation of Drug Addicts”; 8. The Order of the Ministry of Health of the Republic of Kazakhstan as of July 9, 2002 № 656 “On Realization of the Law of RK “On Medical and Social Rehabilitation of Drug Addicts”; 9. Resolution of the Government of the Republic of Kazakhstan as of June 4, 2003 № 528 “On Approval of the Rules for Direction of Examination for the Subject of Intoxication and Execution of the Results of such Examination” and the Order of the Ministry of Health of the republic of Kazakhstan as of June 11, 2003 № 446 “On Approval of the Instruction for Medical Examination for Determination of the Fact of Psycho-Active Substance Use and Alcoholic Intoxication”; 10. The Order of the Minister of Health of the Republic of Kazakhstan as of February 12, 2004 № 150 “On Introduction of the Regular Protocols (Standards) of Diagnostics, Treatment and Medical Assistance Provision to HIV and AIDS Infected People”; 11. The Order of the Ministry of Health of the republic of Kazakhstan as of March 9, 2004 № 228 “On Approval of Regulations on Organization of Activities of the Help Stations for Intravenous drug Users”; 12. The Order of the Ministry of Health of the Republic of Kazakhstan as of June 18, 2004 № 637 “On Approval of Regulations on Narcological Organizations (Hospitals, Dispensaries, Centers and Departments)”; 13. The Order of the Ministry of Health of the Republic of Kazakhstan as of June 18, 2004 № 638 “On Approval of Rules for Direction of the Drug Addicts, Conditions of Keeping and Scope of Assistance to the Drug Addicts in the Centers (Departments) of Medical and Social Rehabilitation”; 14. The Order of the Ministry of Health of the Republic of Kazakhstan as of August 16, 2004 № 618 “On Approval of the Regulations for Arrangement and Carrying-out of Forensic Narcological Expert Examination”; A publication of the Mental Health and HIV/AIDS Project (2005-2008) of The Global Initiative on Psychiatry (GIP)
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15. The Order of the Ministry of Health of the Republic of Kazakhstan as of October 26, 2004 № 764 “On Approval of Standard Structure and Established Norms for Narcological Organizations”; 16. The strategy of fight against drug addiction and drug business in the Republic of Kazakhstan for 2006- 2014 approved by the Decree of the President of the Republic of Kazakhstan as of November 29, 2005 № 1678; 17. The Order of the Ministry of Health of the Republic of Kazakhstan as of December 8, 2005 № 609 “On Introduction of Substitution Therapy”; 18. The Order of the Ministry of Health of the Republic of Kazakhstan as of December 30, 2005 № 655 “On Approval of the Protocols of Treatment and Diagnostics”.
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