The HIV/AIDS crisis in Eastern Europe
and Central Asia
Professor Michel Kazatchkine
UN Secretary General Special Envoy on
HIV/AIDS in Eastern Europe and Central Asia
HIV in Eastern Europe and Central Asia
• An expanding HIV epidemic, largely driven by unsafe injection
drug use; heterosexual transmission now also a major
component of epidemic growth
• Access to antiretroviral treatment remains low, particularly for
key affected populations
• HIV prevention is not accessible at sufficient scale; access to
harm reduction remains very limited
• Health systems are vertical and provider-centered
• High levels of stigma and discrimination; numerous structural,
cultural, societal and political obstacles to the AIDS response
• Low levels of co-operation between government and the nongovernmental sector
• Significant issues around financial sustainability
Newly diagnosed HIV infections by geographical area and
year of diagnosis in the WHO European Region, 2004-2013
Sources: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013. Federal Scientific and Methodological
Center for Prevention and Control of AIDS. Reference: HIV-infection Newsletter number 39. Moscow: The
Federal Service for Surveillance of Consumer Rights Protection and human well-being; 2014
Incidence and Mortality in EECA
vs. Globally
3000000
-24%
2005
-41%
2500000
2014
2000000
1500000
1000000
+ 51%
500000
+ 21%
0
New HIV
infections
globally
Newly diagnosed AIDS-related
HIV infections deaths globally
EECA
Source: UNAIDS Gap report, 2014; WHO/ECDC disaggregated data for Europe.
AIDS-related
deaths in EECA
Cumulative HIV cases and deaths among PLHIV
in the Russian Federation 1987-2013
Most people in the region living with HIV are in the Russian
Federation (population 143.5 million) and Ukraine
(population 43 million). The two countries account for about
90% of new HIV infections in Eastern Europe and Central Asia
Reference: Federal Scientific and Methodological Center for Prevention and Control of AIDS. HIV-infection bulletin number 39.
Moscow: The Federal Service for Surveillance of Consumer Rights Protection and human well-being; 2014.
East: heterosexual and injecting drug use related
transmission is high and increasing
Newly diagnosed HIV infections by transmission mode and year of diagnosis in the East of the WHO
European Region, 2004-2013
+207%
+427%
+48%
-5%
Cases
Cases
from
from
Turkmenistan
Turkmenistan
and
and
Uzbekistan
Uzbekistan
excluded
excluded
due
due
to to
inconsistent
inconsistent
reporting
reporting
during
during
thethe
period;
period;
cases
cases
from
from
Estonia
Estonia
excluded
excluded
due
due
to to
incomplete
incomplete
reporting
reporting
onon
transmission
transmission
mode
mode
during
during
thethe
period
period
Source:
ECDC/WHO
HIV/AIDS
Surveillance
inin
Europe,
2013
Source:
ECDC/WHO(2014).
(2014).
HIV/AIDS
Surveillance
Europe,
2013
Key populations at high risk in EECA
•
•
•
•
•
People who inject drugs (PWID)
Sexual partners of PWID
Men who have sex with men
Sex workers
Incarcerated people
• Migrants and their sexual partners
• Concentrated epidemics now co-existing with an
independent heterosexual epidemic unlinked to
these risk groups
Source: Open Society Institute, Harm Reduction Developments 2008
Treatment increasing but slower than the
growth of the HIV epidemic
Cases
Cases
from
from
Turkmenistan
Turkmenistan
and
and
Uzbekistan
Uzbekistan
excluded
excluded
due
due
to to
inconsistent
inconsistent
reporting
reporting
during
during
thethe
period;
period;
cases
cases
from
from
Estonia
Estonia
excluded
excluded
due
due
to to
incomplete
incomplete
reporting
reporting
onon
transmission
transmission
mode
mode
during
during
thethe
period
period
Source:
ECDC/WHO
HIV/AIDS
Surveillance
inin
Europe,
2013
Source:
ECDC/WHO(2014).
(2014).
HIV/AIDS
Surveillance
Europe,
2013
Treatment cascade of adults living with
HIV in Russia, 2014
Dr. Natalya Ladnaya and Anastasia Pokrovskaia, Federal Scientific and Methodological Center for Prevention
and Control of AIDS, 2014.
EECA: 90-90-90
HIV, HCV, TB/MDR-TB and drug use are major and closely
interlinked challenges in the region
• 25 % of the > 3.5 million PWID in the region are infected
with HIV, with large variations (10-55%) between
countries.
• Two thirds of PWID are infected with HCV. Prevalence of
HCV RNA among PWID estimated to be 45%.
• HCV co-infection rates among HIV-positive PWID are
particularly high, often ranging between 70 and 90 %.
• HIV-positive PWID have a two- to six-fold higher risk of
contracting TB. Almost all countries in the region are
high burden countries for MDR-TB.
Association between HIV and MDR-TB in Europe
TB surveillance and monitoring in Europe 2014. ECDC/WHO, Stockholm
Post et al, Journal of Infection (2014) 68, 259-263, (Belarus, Latvia, Romania, Russia & Ukraine)
Rapid growth of the HIV epidemic among
people who inject drugs
• A punitive approach to drug use and repressive drug
policies. Fear of violence from police is associated
with lower capacity for HIV risk reduction
• Lack of appropriate social and health services for
PWID. Harm reduction not accessible or not at the
needed scale
• High levels of stigmatization and social
marginalization
• Vertical health systems
• Low access to treatment. Less than 20 % of people
who inject drugs living with HIV access ART in the
region. In Ukraine, PWID make up 12.7% of people
on ART
Estimated annual numbers of syringes distributed per person who
inject drugs (PWID) and estimated number of opioid substitution
20%
40%
60%
treatment clients per 100 PWID0%(latest year)
Uzbekistan
Serbia
Russian Fed
Macedonia
Azerbaijan
Latvia
Kazakhstan
Belarus
Tajikistan
Armenia
Moldova
Georgia
Belarus
Poland
Kosovo
Azerbaijan
Armenia
Lithuania
Ukraine
Bulgaria
Latvia
Moldova
Kyrgyzstan
Ukraine
Romania
Albania
Bosnia-…
Serbia
Albania
Bosnia-Herzegovina
Uzbekistan
Georgia
Tajikistan
Lithuania
Czech Rep
Poland
Kazakhstan
Bulgaria
Estonia
Estonia
Kyrgyzstan
Montenegro
0
200
400
Number of syringes distributed per PWID a year,
2013 or latest year available
Based on country reported GARPR data to UNAIDS, 2014 & to EMCDDA, 2015
Macedonia
Czech Rep
Croatia
Percent of estimated PWID or opioid injectors who received
OST, 2014 or latest year available
Harm reduction: compelling evidence of
effectiveness
• NSP and OST reduce the sharing of injection
equipment and avert HIV infections
• In combination with ART, NSP and OST:
– Reduce HIV transmission
– Decrease mortality
– Promote initiation of and compliance with ART
– Reduce drug-dependency
– Reduce crime and public disorder
• Harm reduction interventions are highly costeffective
A model to reduce HIV prevalence/incidence
by half over 10 years in St Petersburg
To halve prevalence:
• Not possible for just NSP
• Twice coverage needed to
halve incidence
*coverage just amongst HIV+ PWID
Vickerman P, Platt L, Jolley E, Kazatchkine MD,
Rhodes T, Int J Drug Policy. 2014
Nov;25(6):1163-73.
100%
50% decrease in HIV incidence
50% decrease in HIV prevalence
Required coverage of each intervention
To halve incidence:
• 79% on high coverage NSP
• 30-40% on paired
interventions
• 20% on all three
interventions
80%
60%
40%
20%
0%
NSP only
NSP+ART
NSP+OST
Intervention combination
NSP+OST+ART
Harm reduction
• Evidence-based policy vs policy-biased
evidence
Prisons: a high risk environment
• The Russian Federation and many countries in
the region have some of the world’s highest
incarceration rates
• Many prisoners wait for months in pre-trial
detention
• Overcrowding; poor physical conditions;
poorly trained and often corrupt prison staff
• Unsafe injection drug use and unsafe sex
• High prevalence of TB and MDR-TB
Proportion of people incarcerated for drug possession
without intent to supply
Georgia
43%
Kyrgyzstan
61%
Latvia
44%
Lithuania
55%
Poland
48%
Russia
Tajikistan
72%
16%
Ukraine
Uzbekistan
67%
21%
Within-prison drug injecting practices among
HIV-infected inmates in Ukraine
Izenberg et al, IJDP, 2014
Non-governmental sector
• Remarkable examples of strongly engaged individuals
and activists throughout the region.
• Few structured and recognized civil society and
community-based organizations in most countries of
EECA.
• Restrictions on funding from international sources:
foreign agent law, foreign grant registration.
• No mechanisms to contractually engage the nongovernmental sector into an effective and meaningful
partnership for health.
Coverage of clients with minimum package of services
(consultation + condom/syringe + info) in Ukraine in 2014
PWID
Estimate Reach
310,000
196,992
CSW
%
Estimate
63.5
80,000
MSM
Reach
%
37,061
46.3
Estimate
Reach
176,000
28,500
129 CSOs in almost 3,000 sites distributed
14.5 M condoms and 20.5 M syringes in 2014
PWID p/a
CSW p/a
MSM p/a
Syringes
143
--
--
Condoms
20
300
100
Lubricants
2
150
100
%
16.2
Percentage of HIV programme spending on key
populations from international funding sources
.
The middle income challenge
• Transition from donor to domestic funding of the HIV
response is slow and far from self-sustaining
• Governments in the region have limited “willingness to
pay” for programs aimed at vulnerable groups. Less than
2% of national AIDS funding goes to PWID in Armenia,
Azerbaijan, Moldova, Russia, Ukraine and Uzbekistan
• Global Fund significantly reducing investments in the
region
• Medicines are procured at much higher prices than most
other countries with similar income levels
• Transition to state funding carries high risks of
procurement disruptions
Health is politics
• Drug policies heavily relying on prohibition law enforcement
hamper access to OST and NSP. Methadone is illegal in the
Russian Federation, Uzbekistan and Turkmenistan.
• High rates of incarceration for drug offences in most countries
in the region.
• Low / very low proportion of national HIV budgets devoted to
prevention and to vulnerable groups.
• Anti-LGBT legislation being proposed or introduced
throughout the region.
• Discontinuation of OST in Crimea following annexation.
• Discontinuation of OST in the Donbass associated with
ongoing violence and government restrictions on the delivery
of humanitarian aid in the conflict areas.
A rapidly changing international and
regional context
• Global trend for more regional
responses
• Ukraine, Georgia, Moldova have
agreements with the EU
• Ukraine is confronted with
challenges and conflict
• Complex geopolitics in Central
Caucasus
• Eurasian economic space
• Strong influence of the Russian
region
(multi-polar) AIDS
signed association
major
economic
Asia and in the
Federation in the
Key recommendations, UNAIDS-Lancet
Commission, 2015
• Get serious about HIV prevention and continue
the expansion of access to treatment , while also
working to address structural determinants of
health that put people at risk.
• Forge new paths to uphold human rights and
address
criminalization,
stigma
and
discrimination using practical approaches to
change laws, policies and public attitudes that
violate human rights.
• Urgently ramp up and fully fund AIDS efforts
efficiently, and emphasize sustainability.
Testing and counseling in Liviv, Ukraine (Natalia Kravchen
Alliance 2013)
Acknowledgements
• Annemarie Rinder Stengaard, Irina Eramova, Martin
Donoghoe, WHO Copenhagen
• UNAIDS
• Natalia Ladnaya and Anastasia Pokrovskaia, Federal AIDS
Center, Moscow
• Eurasian Harm Reduction Network, Vilnius
• Tetiana Deshko, HIV/AIDS Alliance, Ukraine
• Eurasian Network of People Living with HIV
• Peter Vickerman, LSHTM, London
• Barbara Rehbinder, Raminta Stuikyte, Geneva
• Stefanie Stradhee, Thomas Kerr, Ian Grubb
ACNOWLEDGEMENTS
Annemarie Rinder Stengaard, Irina
Martin Donoghoe, WHO Copenhag
UNAIDS
Natalia Ladnaya and Anastasia Po
Federal AIDS Center, Moscow
Eurasian Harm Reduction Network,
Tetiana Deshko, HIV/AIDS Alliance,
Eurasian Network of People Living w
Peter Vickerman, LSHTM, London
Barbara Rehbinder, Raminta
Geneva
Stefanie Stradhee, Thomas Kerr, Ian
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