The 31-year-old had been injecting drugs since he was a teenager and started the therapy two years before Moscow took over the peninsula.
He died two months after the Russian annexation of Crimea — when his treatment was abruptly revoked.
Substitution therapy is used widely internationally as part of strategies to reduce HIV and other health and social harms associated with illegal drug use. In Ukraine, it has been included in the national HIV-prevention strategy since 2006, with 800 patients in Crimea by 2014.
In Russia, however, the treatment is criticized for not “curing” drug addiction, or allegedly being a plot by western pharma to increase profits. Banned since 1998, its use carries a 20-year prison sentence.
For Yudenko, the Russian takeover may as well have been a death sentence. His mother Olga says that when he realized the program would be closed, he simply gave up.
“He sat with his head in his hands and said, ‘Mum, it’s the end. It’s the end,’” she said.
After the annexation in March 2014, Moscow announced a “transition period” until the end of the year for Crimea to adapt to Russian law. The Alliance for Public Health, which runs substitution therapy programs in Ukraine with funding from the Global Fund to fight AIDS, TB and malaria, tried to negotiate for an extended reduction period for substitution therapy over those nine months, while patients sent a letter of appeal to Russian President Vladimir Putin.
It was to no avail. Then Russian drug czar Viktor Ivanov visited Crimea on March 20 that year and announced the program’s immediate closure. Patients received their last doses of methadone exactly two months later.
Visitors from the Russian drug control agency and from state rehabilitation networks — well-groomed young women or men in suits — promised patients free inpatient detoxification courses in Crimea and rehabilitation in Russia. In reality, Olga recalls patients in Feodosia arriving at the drug treatment clinic with packed bags on May 21, only to be turned away with a few tranquilizers and painkillers.
“I can’t forget the picture, how they sat on those bags and begged,” she said.
About 70 patients left to take up emergency places on substitution therapy programs on the Ukrainian mainland, with subsidized travel and accommodation. But Yudenko had begun drinking heavily to alleviate agonizing withdrawal symptoms as soon as doctors began reducing methadone doses in late March. By late April, he could barely walk and his skin had taken on a yellow tinge.
Olga looked for posters around town advertising rehabilitation; the few courses were run by religious organizations and cost too much. The only medical help she received for Yudenko, other than a few tablets, was from a doctor who came out of the drug treatment clinic where she had driven her son, looked at him through the car window and said, “He’s got two to three weeks left.”
Yudenko died of liver failure on May 25, 2014. When his family took his body to the morgue, they met the body of another substitution therapy patient being removed to be buried.
At the end of 2014, the Russian authorities in Crimea publicly burned the program’s leftover methadone.
No one denies that Crimea has a drug problem. This March, the Russian-installed parliament adopted a new law on the prevention of drug abuse. Since the annexation, Crimea has also experienced an increase in already high rates of HIV. At the end of 2016, the peninsula had more than 24,000 registered cases (in a population of about 2.2 million), according to Russian state agency Rospotrebnadzor — a 12 percent increase from the previous year.
The two problems are linked. In Russia, as in Ukraine, drug use is the driving force of HIV infection. Russia has the largest, fastest-growing HIV epidemic in the European and central Asian region, affecting an estimated 1 percent of the population.
The epidemics are similar; the countries’ approaches to them are not. More than 9,000 patients nationwide in Ukraine are enrolled in substitution therapy, of whom 41 percent are HIV-positive. The therapy is integrated with health services and allows many patients to hold down jobs and return to their families. Research shows that patients are more likely to receive HIV care, while new cases of HIV among both injecting drug users and the general population are falling.
Russia, despite the evidence in Ukraine and worldwide, continues to reject substitution therapy.
“Substitution therapy was always the No. 1 stumbling block for Russian drug policy,” said Pavlo Skala, associate director for policy and partnership at the Alliance for Public Health. “Russia furiously opposed its introduction in Ukraine, including Crimea, since it brought into question its ideology based on the old repressive Soviet school of drug policy, which recognizes only a drug-free approach.”
A repressive approach
There is no verifiable information about how many clients have died since the Crimea program ended. Based on accounts from former patients and staff, the Alliance for Public Health puts the figure at 80 to 100, mostly from overdose or suicide.
Few staff from the medical centers and non-government organizations that provided the therapy in Crimea want to talk about it now.
“Any link to substitution therapy is a threat to their existence because it’s such a politically sensitive topic,” Skala said. When he spoke publicly about the deaths that followed the Russian ban, his colleagues in Crimea told him, “Please be careful, because we have to live here. And if you say these things, they will just bury us.”
That’s a position AIDS-service organizations in Russia understand. Pragmatic approaches to tackling HIV — including outreach to drug users and the distribution of clean needles — are increasingly under attack as the Kremlin focuses on promoting abstinence and traditional family values. The new Russian national HIV strategy (2017-2020) does not include harm reduction for vulnerable groups like drug users.
“All the NGOs who worked for many years with these groups are being destroyed,” said Maksim Malyshev from the Moscow-based Andrey Rylkov Foundation for Health and Social Justice. “The government is applying huge efforts to that end, from no state financing to naming them ‘foreign agents.’”
Russia provides anti-retroviral treatment to just 37 percent of people with HIV. Without the links to health care that substitution therapy provided, people using drugs are the first to drop out of limited treatment and prevention services.
“There’s not enough money and not enough treatment,” Malyshev said. “It’s awful. Doctors have to choose who to treat and who not. And you can imagine a doctor deciding who to treat: a drug user, or a housewife and mother of two?”
Of the Crimean patients who moved to mainland Ukraine to continue substitution therapy, about 10 remain. Their arrival was soon followed by another flood of treatment refugees after programs in the east of the country were also forced to shut down by the Russian-backed separatists waging war with the Ukrainian government since 2014. Emergency funding for new treatment places ran out in mid-2016.
Malyshev and his colleagues continue to raise the issue of introducing substitution therapy in Russia and the territories it controls. His calls are backed up by experts, like Vadim Pokrovsky, the head of the Russian Federal AIDS Center. But, Malyshev said, “Sometimes it feels like you’re banging your head against a wall.”
In its absence, the estimated 1.8 million Russian citizens injecting drugs are offered only limited abstinence-based rehabilitation, an important part of anti-drug strategies, but one that’s not effective for many, especially when — according to Malyshev, who has undergone it — it resembles the punitive psychiatry employed by the Soviet regime against dissidents.
“There’s no choice,” Malyshev said. “Either you get cured, or you die.”
Author: Lily Hyde