There is understandably much cause for hope in the current talk around an AIDS-free generation and Ending AIDS. As last week’s UNAIDS World AIDS Day Report pointed out, intensive scale-up of treatment, prevention and care has now resulted in dramatic reductions in AIDS-related deaths and new HIV infections in most parts of the world, including in sub-Saharan Africa. Scientific advances such as the demonstration that treatment may suppress transmission of HIV have also fueled this wave of optimism.Yet as the report also acknowledges, reaching the UN General Assembly targets of decreasing by half the number of new infections and having 15 million people on AIDS treatment by 2015 still faces formidable challenges. Not the least among those is overcoming the barriers in accessing marginalized and stigmatized groups such as injecting drug users and men who have sex with men.
This is precisely the reality in Eastern Europe and central Asia, home to what is now the world’s fastest-growing HIV/AIDS epidemic. It saddens and disappoints me that in just over a decade the estimated number of people living with HIV in the region has almost tripled from around 400,000 in 2001 to about 1.4 million today, and continues to grow. HIV prevalence is estimated to be 1 percent or higher in both the Russian Federation and in Ukraine and together both account for 90 percent of the new infections in the region.
The epidemic in the region is concentrated mainly among people who use drugs and their sexual partners. High HIV prevalence has also been found in prison populations, particularly among prisoners with a history of injecting drug use. Aggressive drug law enforcement, driving people who use drugs away from available services, and lack of adequate access to harm reduction programs have driven high-risk behaviors that have contributed to high levels of HIV and hepatitis infection.
Access to HIV anti retroviral treatment in the region remains unacceptably low, with only 23 percent of those estimated to be in need of urgent treatment accessing it, compared to 55 percent worldwide.
Stigmatization together with a complex combination of other political, societal, cultural, and policy-related factors pose major obstacles to the fight against the epidemic in the region.
However, I will always fall on the side of hope and for that reason, I look to the Ukraine itself for some encouraging signs that some of these obstacles are in fact being overcome in what are – let’s not kid ourselves — extremely trying circumstances. What is more inspiring, though, is that the country’s recent successful experience in dealing with HIV/AIDS demonstrate what we have known elsewhere for three decades now — that scaled-up programs based on evidence do work.
Let’s take a quick snapshot of the Ukraine experience:
The estimated number of people living with HIV in Ukraine is 230,000, or 0.8 percent of the adult population and injecting drug use accounts for over 60 percent of reported HIV infections.
For a decade now, Ukraine has been conducting an effective prevention and treatment program. The Global Fund to Fight AIDS, Tuberculosis and Malaria has been a major funder since 2003. The fascinating thing is that, following corruption issues and the dismissal of a governmental recipient, the principal recipient of Global Fund grants has been the All-Ukrainian Network of People Living with HIV. The Ministry of Health later became a secondary recipient.
The All-Ukrainian Network of People Living With HIV has grown into a strong and formidable organization that demonstrated without measure that it could adapt to all the requirements of the Global Fund including its audits. Its work has been strongly supported by NGOs such as the International HIV/AIDS Alliance in Ukraine, who have been active in leading HIV prevention programs, expanding access to antiretroviral treatment and successfully advocating for the legalization of methadone.
The successful management and implementation of the Global Fund Rounds has contributed to significant decreases in the price of drugs, by-passing some of the former complex circuits of procurement that were previously in place. Patients are now receiving antiretroviral therapy and the number of people on Opioid Substitution Therapy sits at around 7,000, half of whom are living with HIV.[1]
An evaluation of the OST program has confirmed an expected decrease in crime, and increased the chances for treated patients to build relationships around family and find employment.[2]
This has not happened without considerable pain. The program has been a roller coaster of strong phases of expansion and success and phases of attack. At regular intervals, it has been challenged with various pressures, illogical legislation and decrees. The process has required constant and intensive attention due to the frequent turnover of ministers but has also been aided in the last years by the commitment of Prime Minister Azarov who in meetings has convinced me that he is at the same time both well aware and alarmed by the epidemic in his country. The country’s bureaucratic mechanisms, the constant tensions between law enforcement and health departments and other ongoing all around pressures keep unfortunately slowing down the effort which means that the scale up against the epidemic is not where it needs to be.
The potential is there. If the country were to reach a more meaningful scale, Ukraine would undoubtedly be in a position to demonstrate that the epidemic in the region can be reversed. A rounded Ukrainian success story would bring hope to hundreds of thousands of people infected with HIV in neighboring countries, where progress remains far too slow.
References:
[1] All-Ukranian Network of People Living with HIV (figure taken from Ukranian Ministry of Health)
[2] WHO Collaborating Centre, “Final Monitoring and Evaluation Report on Opioid Substitution Treatment in Ukraine,” June 2010,
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