Drug scene, drug use and drug-related health consequences and responses in Kulob and Khorog, Tajikistan

BACKGROUND: Tajikistan and other Central Asian republics are facing intertwined epidemics of injecting drug use and HIV. This paper aims to examine drug scene, drug use, drug-related infectious diseases, drug treatment and other responses to health consequences of drug injecting in two Tajik cities of Kulob (Khatlon Region) and Khorog (Gorno-Badakhshan Autonomous Oblast). METHODS: We conducted 12 focus group discussions in Kulob and Khorog and analysed peer-reviewed literature, published and unpublished programme and country reports and other publications that focused on substance use and/or HIV/AIDS in Tajikistan and included the Khatlon and Gorno-Badakhshan regions. RESULTS: In both Kulob and Khorog, heroin is used by the overwhelming majority of people who inject drugs (PWID), with one dose of heroin in Khorog costing less than a bottle of vodka. Opioid overdose among PWID in Tajikistan is a serious issue that appears to be substantially underestimated and inadequately addressed at the policy and practice levels. In integrated bio-behavioural surveys (IBBS), HIV and HCV prevalence in both Kulob and Khorog varied widely over a short period of time, raising questions over the quality and reliability of these data. Access to opioid substitution therapy (OST) and antiretroviral therapy (ART) by PWID is either lacking or inadequate. Very few women who inject drugs access needle and syringe programmes in Kulob and Khorog. HCV treatment cannot be afforded by the overwhelming majority of PWID due to high costs. CONCLUSION: Tajikistan IBBS data point to the potential problems in using composite national prevalence as an adequate reflection of the HIV epidemic among PWID in the country and highlight the importance of examining site-specific prevalence rates for better understanding of the dynamics of the epidemic over time as well as potential problems related to the reliability of data. Furthermore, our analysis highlights that in a country where almost all PWID inject opiates, agonist treatment should be an intervention of choice. Scaling-up both OST and ART coverage must be seen as the top priority for reducing HIV prevalence and incidence in Tajikistan. Naloxone distribution programmes need to be expanded and drug treatment, harm reduction and HIV services that meet the specific needs of female injecting drug users should be put in place