Interview with Dr Emilis Subata, Director, Vilnius Centre for Addictive Disorders
Q: What is the main mode of HIV transmission in eastern Europe and central Asia?
A: Injecting drug use (with non-sterile equipment): it’s a very high proportion, 75–80% of all HIV cases.
Q: And here in Lithuania?
A: For the last 12 years, 73.4% of all HIV cases in Lithuania are related to injecting drug use; but the proportion of new HIV cases caused by injecting drug use has been steadily decreasing [this is because sexually transmitted cases have been increasing while cases among injecting drug users have been decreasing ]. In 2007, 55.6% of new HIV cases were caused by injecting drug use; in 2008, 44.2%.
There may be some under-reporting but the rates of HIV in Lithuania are the lowest in eastern Europe. In 2008, 37 people per 100 000 of the population in Lithuania were diagnosed with HIV. This represents less than one tenth the rate of some neighbouring countries.
Q: How do you explain your country’s relatively low HIV rates?
A: Harm reduction programmes in Lithuania had started before the first wave of HIV among drug users began to be reported in 1997. In the first five years of implementation, there was a large number of patients--hard-core, chronic drug users--coming into the programme in Vilnius, so they had contact with our nurses and social workers and found out how not be infected. Then in 1997, needle exchange began in Klaipeda, the seaport; then in Vilnius in 1998.
Estonia did not have pharmacotherapy with methadone [opioid substitution therapy] until 2006.
Q: Your drug-dependence treatment clinic is considered a model of best practice. Why?
A: In 1995, we were the first methadone programme to be established in the countries of the former Soviet Union.
People dependent on heroin or other opioids come to the clinic daily to get their methadone, or buprenorphine, from a nurse. They feel more normal and have a more stable lifestyle, so they do not inject drugs as often.
A recent multi-country WHO study, which we contributed to, shows that risky behaviour is reduced tenfold in methadone patients in low- and middle-income countries: less drug use, fewer injections, and better health.
Q: What other best practices distinguish your clinic?
A: We offer a broad menu of services:
Our 'Blue bus' (mobile needle-syringe exchange) is probably why Vilnius has low HIV rates. Injecting drug users are often very marginalized, and do not seek health care. The social workers who run the bus go to the places they frequent—a Roma village and the train station—five days a week. Users not only get sterile equipment, they can get advice about health and social services. In some cases, our staff motivate them to come to the methadone programme at the Vilnius Centre for Addictive Disorders.
For motivated patients, the Centre also offers a one-month psychosocial programme, which is drug-free, as well as an eight-month drug-free rehabilitation programme. Also, detoxification patients can be referred to therapists.
When the patient starts pharmacotherapy with methadone, the social worker can increase the menu of services by directing them to vocational training and other municipal and medical services--for HIV and hepatitis C, for instance.
Q: How have WHO guidelines and advocacy strengthened your clinic?
A: There are a lot of WHO publications that we have used for advocacy. For example, Principles for preventing HIV infection among drug users - there was great demand for this publication when it came out in 1998. We translated it into Lithuanian and used it as justification of what we do; because, at the time, methadone and harm reduction were still very controversial, even within the UN system.
HIV/AIDS treatment and care for injecting drug users, clinical protocol, published by WHO Regional Office for Europe in 2006, was also important. This publication gives extensive information about the interaction of methadone with antiretroviral medications. As methadone is delivered by psychiatrists, who do not know a lot about HIV, this document filled a gap.
Furthermore, WHO’s Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence were a stimulus for Lithuania’s national protocol (finalized in 2009). This new protocol is based on research data and meta-analysis; so the recommendations are very strong.
Q: What do you do for the WHO-supported Harm Reduction Knowledge Hub for Europe and Central Asia?
A: I was asked by the Hub to develop a training module on methadone pharmacotherapy for eastern Europe and central Asia in 2005, and we have used this for many trainings organized by UNODC and the WHO Regional Office for Europe, as well as by the Hub: for example, in Belarus, Estonia, Latvia, Kyrgyzstan, Republic of Moldova, Tajikistan. Also in Lithuania, we developed a three-day module for physicians, based on the Knowledge Hub course, which is now used by Vilnius University’s Medical Faculty. Through the Hub, these trainings will be adapted and institutionalized in other countries.
Q: What do trainees in Hub courses see when they visit your centre?
A: They see the units in the Centre first: methadone, detoxification, psychosocial rehabilitation. And they meet with social workers and patients. They also go to the 'Blue bus' on the first day. The goal is to show that different kinds of services are needed.
Q: Do trainees implement the best practices that they learn in training?
A: Yes. For example, we did two trainings this year, for a group from Tajikistan (ten health professionals and decision-makers) and a session in Minsk, Belarus, for 40 practitioners. The Tajiks planned to start methadone programmes this fall (2009). And after our training in Minsk, in April, Belarus opened its second methadone programme. As a result of the training, we also had a request from our Belarus partners to host four physicians from future methadone programmes planned for the oblasts (regions) of Svetlagorsk and Minsk.
Q: What was your most rewarding moment as a trainer outside Lithuania?
A: When Kyrgyzstan used our advice to decentralize pharmacotherapy with methadone to family medical centres all over the country. We had worked with Kyrgyzstan since 2000, and useful things were done through consistent advocacy, training, evaluations and study visits. In a short time, since 2006, this decentralization has helped Kyrgyzstan to significantly increase the coverage of pharmacotherapy with methadone. In addition, implementation of pharmacotherapy in prisons has made Kyrgyzstan a leader in the provision of pharmacotherapy for all of central Asia.
Q: What is the added value of the WHO Harm Reduction Knowledge Hub?
A: The Hub provides training and technical assistance of quality as it has developed different modules, and it has good national and regional trainers and specialists who understand the different countries. The Hub is an important part of the Eurasian Harm Reduction Network, which is very active in advocacy at the global level—in meetings with governments and other international NGOs.
Q: What do you enjoy most about your work?
A: To be on the 'positive side' in solving the global drug problem makes my work feel meaningful. Substance-dependent people, for the most part, are 'not guilty' – they become dependent because of genetic predisposition, early childhood experiences, stresses in everyday life. They are sick people because they have altered brain function. Unfortunately, drug users are still treated in many parts of the world as criminals and are denied normal access to adequate medical and social care—the most effective way to solve the problem.
- "http://data.unaids.org/pub/Report/2008/lithuania_2008_country_progress_report_en.pdf p4
- The Lithuanian National Drug Report 2009. http://www.nkd.lt/bylos/dokumentai/leidiniai/2009-pranesimai/NKD_metinis-2009web.pdf p123.
- Lawrinson, P. et al, Addiction 2008 Sep;103(9):1484-92 http://www.ncbi.nlm.nih.gov/pubmed/18636999