俄罗斯减低危害项目的未来
——《柳叶刀》
2009年10月8日上传。
参考文献：略
根据《柳叶刀》今日的评论，吸引滥用毒品者参加医疗保健是一项挑战。该评论关注全世界至少1600万注射吸毒者。害怕受到非难和歧视常常阻碍毒品依赖者去寻求医疗保健。但在过去十年中，减低危害项目——包括针具交换、美沙酮替代和发放安全套——的普及已经在帮助医疗保健专业人士处理注射吸毒者的需要。
1997年，《柳叶刀》上的一篇文章显示，针具交换项目降低了注射吸毒者中的HIV发病率，几年之后联合国系统开始支持这种减低危害项目。但是有些国家认为向注射吸毒者提供清洁针具和注射器会促使他们吸毒上瘾，因此拒绝把这些重要的预防措施包括在其公共健康计划中。在俄罗斯，对减低危害项目的反对意味着针具交换项目多数是由非政府组织（NGO）来经营的。政府多次拒绝允许向注射吸毒者提供美沙酮替代治疗，尽管国际社会多次呼吁支持这一基于证据的干预措施。令人担忧的是，目前得到允许的预防措施正在面临关闭的威胁。
来自全球抗击艾滋病、结核病和疟疾基金的大笔资助让超过200个非政府组织可以在公民社会行动GLOBUS——俄罗斯全球抗击艾滋病工作——项目的帮助下，向54 000名注射吸毒者（除此之外还有性工作者、男男性行为者、囚犯和街童）提供HIV预防服务。这种服务避免了该群体中大约37 000例HIV感染。由于注射吸毒者是俄罗斯HIV疫情的主要推动力量，这一数字尤其引人注目。但是由于全球基金的标准十分严格，依赖于世界银行的国民财富统计，俄罗斯现在被认为是富裕国家，没有资格接受新的资助，这导致了通过全球基金的资助来获得资金的HIV预防项目的关闭。
俄罗斯政府可能兑现其早先的承诺，继续资助这些项目来代替全球基金的资助。但是卫生与社会发展部（Health and Social Development）副部长Veronika Skvortsova已经宣称，政府目前的重点工作是提高大众的觉悟，促进健康的生活方式。
由于俄罗斯多数有文件证实的健康记录骇人听闻（总统德米特里·梅德韦杰夫承认其中三分之二是由于生活方式导致的），以及重治疗不重预防的历史和医院比社区健康项目地位高等问题，该国最近关注健康促进工作在很大程度上是受欢迎的举措。但是，如果俄罗斯政府决定，这种支持大众健康的积极的政策变革可以损害180万注射吸毒者的利益，这将是令人费解的短视。由于减低危害项目的有效性有着坚实的证据，俄罗斯政府的这种立场是违背直觉的。关闭这些项目还会拆除注射吸毒者与医疗保健服务之间的重要桥梁，并且再次突出了该群体在俄罗斯所面临的不正当的污名和歧视。
决定要资助哪个项目或许并不是互相排斥的。一般的健康促进工作当然重要，但预防HIV的减低危害项目也很重要。我们敦促俄罗斯政府除了一般的健康促进工作之外，还要继续资助有效和以科学为基础的减低危害项目。我们还建议全球基金重新审核其有资格接受资助国家的标准。财富虽然是一个重要标准，但是应该考虑到在一贯忽视最弱势人群的需要的国家中工作的NGO和公民社会团体（例如GLOBUS）也有资格获得资助，这样它们就可以向无法从其他渠道获得服务的人提供至关重要的服务了。
本月晚些时候在莫斯科举行的第三届东欧中亚艾滋病大会（3rd Eastern Europe and Central Asia AIDS Conference）上，俄罗斯政府可能会显示出巨大的领导能力，并且宣布它会向为弱势群体提供服务的减低危害项目提供财政支持。这种行动将会向国际社会显示：俄罗斯是处理HIV疫情工作中严肃认真的合作伙伴。
Gregg Gonsalves
100 York Street, 10-D
New Haven, Connecticut 06511
Email: gregg.gonsalves@gmail.com or gregg.gonsalves@yale.edu
Mobile: 1-203-606-9149
> --------------------------------------------------
> From: "Gregg Gonsalves" <gregg.gonsalves@gmail.com>
> Sent: Saturday, October 10, 2009 7:28 PM
> To: "HEALTHGAP" <HEALTHGAP@CritPath.Org>;
> "Internationaltreatmentpreparedness"
> <internationaltreatmentpreparedness@yahoogroups.com>
> Subject: ITPC The future of harm reduction programmes in Russia
>
> > READ DOWN FOR EDITORIAL TEXT.
> >
> > Editorial
> >
> > The future of harm reduction programmes in Russia
> > The Lancet
> >
> >
> > Available online 8 October 2009.
> >
> > Refers to: Management of injecting drug users admitted to hospital
> > The Lancet, Volume 374, Issue 9697, 10 October 2009-16 October 2009,
> > Pages 1284-1293,
> > Paul S Haber, Abdullah Demirkol, Kezia Lange, Bridin Murnion
> > PDF (133 K)
> > Refers to: Alcohol and harm reduction in Russia
> > The Lancet, Volume 373, Issue 9682, 27 June 2009-3 July 2009, Page 2171,
> > The Lancet
> > PDF (77 K)
> > Refers to: Russia's next president needs to tackle health reforms
> > The Lancet, Volume 371, Issue 9614, 1 March 2008-7 March 2008, Pages
> > 711-714,
> > Helen Womack
> > PDF (162 K)
> > Refers to: Russia releases draft health-care plan
> > The Lancet, Volume 373, Issue 9658, 10 January 2009-16 January 2009,
> > Pages 109-110,
> > Tom Parfitt
> > PDF (236 K)
> > Refers to: Russia's health promotion efforts blossom
> > The Lancet, Volume 373, Issue 9682, 27 June 2009-3 July 2009, Pages
> > 2186-2187,
> > Tom Parfitt
> > PDF (284 K)
> > Referred to by: Management of injecting drug users admitted to hospital
> > The Lancet, Volume 374, Issue 9697, 10 October 2009-16 October 2009,
> > Pages 1284-1293,
> > Paul S Haber, Abdullah Demirkol, Kezia Lange, Bridin Murnion
> > PDF (133 K)
> > According to a Review in The Lancet today, engaging people who misuse
> > drugs into medical care is a challenge. The Review focuses on people
> > who inject drugs, at least 16 million people worldwide. Fear of
> > disapproval and stigmatisation often discourages people with drug
> > dependence from seeking health care. But over the past decade, the
> > widespread adoption of harm reduction programmes—which include needle
> > exchange, methadone substitution, and condom distribution—have helped
> > health professionals to address the needs of those who inject drugs.
> >
> > In 1997, a Lancet paper showed that needle-exchange programmes reduce
> > the incidence of HIV in people who inject drugs, and the UN system
> > endorsed such harm reduction programmes a few years later. However,
> > some countries perceive that offering clean needles and syringes to
> > people who inject drugs helps to enable their addiction and so refuse
> > to include these important preventive measures in their public health
> > plans. In Russia, the opposition to harm reduction programmes has
> > meant that needle exchange is mostly run by non-governmental
> > organisations (NGOs). The government has repeatedly refused to allow
> > methadone substitution to be offered to people who inject drugs,
> > despite many international calls to support this evidence-based
> > intervention. Worryingly, the preventive measures that are currently
> > permitted are now under threat of closure.
> >
> > A large grant from the Global Fund to Fight AIDS, Tuberculosis and
> > Malaria has allowed over 200 non-governmental organisations, under the
> > auspices of the civil society initiative the GLOBUS—Global Efforts
> > Against AIDS in Russia—project, to provide 54 000 people who inject
> > drugs (in addition to sex workers, men who have sex with men,
> > prisoners, and street children) with HIV prevention services. Such
> > services have averted an estimated 37 000 HIV infections in this
> > group. This figure is particularly impressive given that people who
> > inject drugs are the main drivers of the HIV epidemic in Russia.
> > However, due to strict Global Fund criteria that rely on World Bank
> > statistics of national wealth, Russia is now deemed too wealthy to
> > qualify for any new grants, resulting in the closure of HIV prevention
> > programmes that were funded through Global Fund grants.
> >
> > The Russian Government could honour its earlier promise to continue to
> > fund these programmes in place of the Global Fund grants. However, the
> > Deputy Minister of Health and Social Development, Veronika Skvortsova,
> > has indicated that the government's priority is now to promote
> > awareness and healthy lifestyles among the general population.
> >
> > Given Russia's much documented appalling health record (which
> > President Dmitry Medvedev has acknowledged is two-thirds due to
> > lifestyle factors), together with a history of focusing on treatment
> > over prevention and the lofty status given to hospitals compared with
> > community health programmes, the country's recent focus on health
> > promotion is a most welcome step. However, it would be
> > incomprehensibly short-sighted if the Russian Government decided that
> > such a positive policy change for population health should be to the
> > detriment of the 1·8 million people who inject drugs. Such a stance is
> > counterintuitive given the robust evidence of the effectiveness of
> > harm reduction programmes. Closing these programmes will also remove
> > the important bridge between people who inject drugs and health care,
> > and again highlights the unwarranted stigma and discrimination faced
> > by this group in Russia.
> >
> > Perhaps deciding which programmes to fund need not be mutually
> > exclusive. Of course general health promotion is important, but so are
> > the harm reduction programmes to prevent HIV. We urge the Russian
> > Government to continue to fund effective and science-driven harm
> > reduction programmes, in addition to its general health promotion
> > efforts. Also, we suggest that the Global Fund reviews its criteria
> > for countries eligible to receive grants. Although wealth is an
> > important criterion, NGOs and civil society groups (such as GLOBUS)
> > working in countries that persistently neglect the needs of their most
> > vulnerable populations should be considered eligible for funding so
> > they can provide crucial services to people who would otherwise not
> > receive them.
> >
> > At the 3rd Eastern Europe and Central Asia AIDS Conference in Moscow
> > later this month, the Russian Government could show great leadership
> > and announce that it will financially support harm reduction
> > programmes for its vulnerable groups. Such a move would show the
> > international community that Russia is a serious partner in tackling
> > the HIV epidemic.
> >
> > --
> > Gregg Gonsalves
> > 100 York Street, 10-D
> > New Haven, Connecticut 06511
> > Email: gregg.gonsalves@gmail.com or gregg.gonsalves@yale.edu
> > Mobile: 1-203-606-9149
> >
> >
> > ------------------------------------
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