Sitting on his bed in a tiny hostel room in Kiev, Georgii Gaydamaka plays an acoustic guitar. His voice is powerful, boldly taking the highest notes, only to plunge into desperation a few moments later. He is 28 years old but his features look vulnerable, almost boyish.
"Heal me bird, heal me girl, kill my fear," he sings in Russian, keeping his blue eyes shut. "People don't remember, people don't know how difficult it is to make the first step."
Gayadamaka is refugee from Simferopol, the capital of Crimea and a patient on opioid substitution therapy, known as OST, used to treat drug addiction by replacing dangerous street narcotics with less potent and longer lasting prescribed medication.
By taking a daily dose of buprenorphine, an opioid, Gaydamaka has been able to lead a fairly normal life and hold down various jobs. That is, until Russia invaded Crimea at the end of February and subsequently annexed the region, shutting down OST programs on the peninsula. More than 800 patients had to stop treatment, about 200 of which were HIV positive.
Drug users have been a traditionally vulnerable and ostracized group even in Ukraine, but under Russian rule the situation has considerably worsened for them.
Unlike Ukraine and the countries of the European Union, the Russian Federation does not allow for opioid substitution therapy, which it considers ineffective and highly contentious. In 2011 the head of Russia's Federal Anti-Narcotics Agency, Viktor Ivanov, argued that there are "no clinical trials to prove the effectiveness of the method," despite the fact that the World Health Organization considers OST "one of the most effective treatment options for opioid dependence."
Meanwhile, the armed hostilities in eastern Ukraine have resulted in the disruption of OST for hundreds of others. Pro-Russian separatists have particularly targeted drug users, alcoholics, and homosexuals as "immoral elements" and have often forced them into involuntary labor.
Before the start of this year's conflict, Ukraine had over 8,700 patients on OST, serviced by over 170 health facilities all around the country. It has been one of the great success stories in the region, significantly reducing the rates of HIV infection among drug users.
With the help of The International HIV/AIDS Alliance, an NGO network, about 60 patients, including Gaydamaka, have been able to leave Crimea to continue treatment in Kiev and the central Ukrainian city of Dnepropetrovsk.
"I couldn't have survived without the therapy," says Oksana Gritsenkina, a 35-year-old woman and OST patient from Crimea, who also escaped to Kiev on the Alliance refugee program. "After I started the therapy, my life took a positive turn - personally and socially. I started living normally. Then the Russian authorities came in and they didn't even give us time to decrease our dosage slowly. They just stopped the program and basically left us on our own. We protested but nobody heard us."
Most people have not been as lucky as Gritsenkina or Gaydamaka. According to interviews with Alliance representatives and drug users in and outside Crimea, a large percentage of former Crimean OST patients (many of whom already had stable jobs and had even started families) have gone back to street drugs or have encountered severe physical and psychological obstacles after the closure of the program. Between 20 and 30 of them have already died due to complications related to drug overdose or chronic illness.
"Crimea's OST was considered one of the best in Ukraine," says Pavel Skala, the associate director of the Policy and Partnership Program at Kiev's branch of Alliance and a long-time expert on drug policy. "But the program became a victim of politics. It was basically sabotaged."
Things didn't have to be that way. Ukrainian laws are supposed to keep functioning in Crimea, in parallel with Russian ones, until the end of 2014, and at least in theory the OST program should have still been open or allowed to wind down gradually. The political acrimony after the annexation of Crimea, however, made any kind of cooperation between Ukrainian and Russian authorities nearly impossible.
Immediately after the annexation the new Crimean authorities officially asked the Ukrainian Ministry of Health for a six-month supply of methadone and buprenorphine, so that the OST program could continue to operate in the short term, but the request was quickly rejected by Kiev, as the new Crimean government was seen as illegal. When Ukraine's Ministry of Health finally agreed to provide the medial supply after vocal protests from patients and activist organizations, the Crimean authorities announced in their turn they could not accept it and were closing down OST permanently. By the end of May it was all over.
"I think the Ukrainian responsibility is not any smaller than the Russian one. Russia behaved as it usually does - it stuck to its traditional policies on substitution therapy. But Ukraine used the closure of OST programs as another political instrument to show the cruelty of Russia," says Igor Kouzmenko, an activist, videographer, and the former Crimean representative of the Association of Substitution Treatment Advocates in Ukraine.
"It seems to me that the wellbeing of the patients wasn't important for either side, Ukrainian or Russian. A patient on pills is a medical issue, while a suffering patient is a political one," he adds.
Some former OST patients, who have decided to stay in Crimea, have been offered treatment in Russian hospitals, but that usually includes simple detoxification and, occasionally, a follow-up religious rehabilitation. According to Skala, from Alliance, about 90 percent of patients relapse after such treatment.
The closing down of OST programs would also inevitably result in increased risk of HIV infection among injection drug users. In the past decade, according to UNAIDS, HIV infections in Russia have skyrocketed, from 170,000 people in 2004 to over 1.2 million last year, mainly among drug addicts. Overall, Russia accounts for over 55 percent of all new HIV infections in the European region, the European Center for Disease Prevention and Control reports.
Russia's harsh laws and sweeping actions of the Federal Anti-Narcotics Agency in Crimea have also sent a number of drug users to prison, instead of to the hospital, as they are generally seen as criminals rather than people in need of treatment.
"I definitely don't want to go back to Crimea. What awaits people like me there is either prison or death, sooner or later," says Gaydamaka, when he finishes playing his song on the guitar at the Kiev hostel - his tiny refuge for now. "I'm not interested in politics, but I'm interested in the right of OST patients to receive treatment. Nobody is thinking that these are human lives. In essence, to deny us treatment is not that different from murder."
Travel for this story was funded by The Pulitzer Center on Crisis Reporting