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HIV & AIDS in Russia, Eastern Europe & Central Asia
Around 1.4 million people in Russia, Eastern Europe and Central Asia were living with HIV at the end of 2011, representing an HIV prevalence of 1 percent.1 Around 140,000 became infected in 2011 and 92,000 died from AIDS-related illnesses; there was a 21 percent increase in AIDS-related deaths between 2005 and 2011.2
It is estimated that over two-thirds of the area’s infected people live in Russia, and combined with Ukraine, these two countries account for almost 90 percent of the region's newly reported HIV diagnoses.3 Both countries also have the highest number of people living with HIV relative to the general population; adult HIV prevalence is 0.8 percent in Ukraine and between 0.8 and 1.4 percent in Russia.4 Significant numbers of people infected with HIV live in Belarus (20,000) and Kazakhstan (19,000).5
Since 2001, HIV prevalence in Russia, Eastern Europe and Central Asia has increased by 250 percent, making the region home to the world’s most rapidly expanding epidemic. In contrast, over the same period, prevalence in sub-Saharan Africa fell from 5.8 percent to 5 percent, and stabilised in South and Southeast Asia at 0.3 percent.6
This page focuses on the 15 former Soviet republics that constitute the Caucasus (Georgia, Armenia and Azerbaijan), the Baltic states (Estonia, Latvia and Lithuania), Central Asia (Kazakhstan, Kyrgyzstan, Azerbaijan, Turkmenistan, and Uzbekistan), as well as Ukraine, Belarus, Moldova and Russia. (UNAIDS, however, do not include the Baltic states in their Eastern Europe and Central Asia data).
The rise of HIV in the region is closely linked with increasing rates of injecting drug use that developed in the mid-1990s during the socioeconomic crisis that followed the break-up of the Soviet Union. At this time, nearby Afghanistan became the world’s largest producer of opium, from which heroin is derived, and drug trafficking increased throughout the region. Initial outbreaks were detected in Ukraine, Russia, Belarus and Moldova.7
Sharing of contaminated drug taking equipment is a highly efficient HIV transmission route. In Eastern Europe and Central Asia around 3.7 million people inject drugs; this represents a quarter of injecting drug users across the world. An estimated one quarter of IDUs in this region are living with HIV.8 Many countries in the region have experienced rapid increases in the number of new HIV infections among IDU’s, and now 40 percent of all new HIV infections are transmitted via injecting drug use.9
In Estonia, HIV prevalence among IDUs is estimated at 50 percent, and at 20 percent in Ukraine.10 Whilst the most recent HIV prevalence is lower among IDUs in Russia, at 16 percent in 2009,11 the overall number of injecting drug users is extremely high at around 2 million.12 Therefore, despite the lower HIV prevalence of 16 percent in Russia, compared to 50 percent in Estonia, a much greater number of people are living with HIV in Russia (2 million) than in Estonia (9,900).13
It has been reported that around 16 percent of IDUs in Tajikistan and 8 percent in Uzbekistan are infected with HIV.14 Georgia, Lithuania, Bulgaria and Czech Republic have lower rates of IDU infection relative to the rest of the region.15 16
Sex workers are at risk of HIV because of the overlap with injecting drug use as well as unsafe sexual behaviours including low consistent condom use and multiple sexual partners. The HIV prevalence among sex workers in Eastern Europe is 11 percent.17In Russia, it is estimated that almost a third of sex workers have injected drugs.18 In Ukraine, HIV prevalence among female commercial sex workers who also inject drugs is 43 percent, compared to 8.5 percent among female sex workers who do not inject drugs.19
HIV knowledge among sex workers in the region is generally low; just 8 percent of sex workers in Georgia, 29 percent in Moldova and 36 percent in Uzbekistan were able to correctly identify ways of preventing sexual transmission of HIV and reject major misconceptions about HIV transmission.20
Sexual partners of risk groups
Partners of IDUs and sex workers are at risk of becoming infected with HIV through sexual transmission. An estimated 50 percent of women living with HIV in the region have acquired the infection through a sexual partner who injects drugs.21 Heterosexual contact, which accounts for nearly two-thirds of infections among women in Russia, accounts for an ever-growing proportion of new infections. In 2000, women comprised just over 20 percent of new infections, and in 2012 close to half of HIV infections are among women in many countries in this region.22 23
UNAIDS has stated that it is unlikely the regional epidemic will spread independently of transmission among injecting drug users and sex workers.24 However, one study has concluded that the HIV epidemic in Russia may be transitioning from one fuelled by injected drug use to an epidemic spreading through heterosexual sex.25
Other affected groups
Precise information on patterns of HIV in prisons is hard to obtain, especially from lower and middle-income countries which dominate the region.26 In Russia, over one in ten of all new HIV diagnoses during 2006-2007 were registered to prison populations. Overall HIV prevalence in Russian prisons is estimated at around 5 percent with the majority of inmates already infected before entering.27
In Ukraine, an estimated 15 percent of prisoners are living with HIV.28 Reports from 2008 suggest that 14 percent of prisoners in Estonia, (a country with one of the highest imprisonment rates in the European Union), are living with HIV.29 The potential danger that prison conditions pose to drug users is indicated in an HIV outbreak in Lithuania’s Alytus prison in 2002 that infected 263 inmates, almost doubling the nation’s total epidemic.30 This highlights that although HIV rates in prison are often concentrations of the epidemic among the general populations, prisons usually have independent HIV epidemic characteristics.
Five countries implement needle and syringe exchange programmes (Armenia, Kyrgyzstan, Moldova, Romania and Tajikistan), and 18 countries implement OST in prisons.31
Men who have sex with men (MSM) comprise a relatively small proportion of total HIV cases in the region in comparison to Western European and North American nations. It is reported that just 143 men who have sex with men were living with HIV in Ukraine in 2011.32
It is believed that the epidemic is thriving among this group but is being kept hidden and underreported due to a reluctance by MSM to reveal the cause of their infection for fear of stigmatisation.33 Small surveys among MSM in Russia have identified a prevalence of 6 percent.34 It is believed by some that the underground epidemic among MSM has been allowed to escalate due to very little funds targeting this group:
"Governments everywhere are reluctant to spend money on sex workers, on drug users, but MSM comes at the top of the reluctance list. It is probably the last programmes that the governments will start." - Roman Gailevich, UNAIDS Regional Programme adviser35
Children and young adults
HIV prevalence among young people aged 15-24 in the region increased by 20 percent between 2001 and 2011.38 Young women are particularly affected; among the 20-24 age group, women accounted for around two-thirds of new diagnoses in Eastern Europe in 2009.39 It has been argued that this increase has been compounded by the lack of HIV prevention programmes targeting young people.40 Many HIV/AIDS organisations are afraid to work with younger people due to legal or other repercussions.41
A significant proportion of sex workers are young people, with about 20 percent of females selling sex in Ukraine believed to be younger than nineteen years. Younger children are also affected in the region. A recent study, conducted across three cities, of Ukrainian street youth who were both orphaned and homeless found that HIV prevalence reached as high as 28 percent.42 The study showed that providing care and housing can be a method of preventing HIV within this population, and recommended practices such as extending foster care through to twenty-one year olds, conditional cash transfers and alternative family initiatives for orphans.43
Children and young adults in Eastern Europe are also suffering from the knock-on effects of the region's epidemic. Children born to HIV positive mothers, for example, are more likely to be abandoned than other children. In the Russian Federation and Ukraine, between 6 to 10 percent of children with HIV positive mothers are abandoned in paediatric hospitals, maternity wards and residential institutions.44
Given that injecting drug use accounts for the overwhelming majority of new HIV infections in the region, the availability of needle exchanges and drug substitution therapy is vital if HIV is to be effectively tackled. Additionally, information regarding safer sex is also necessary to ensure the epidemic does not bridge to wider populations. Services to prevent the spread of HIV among IDUs are inadequate and it is estimated that just 9 percent of injecting drug users at best utilise harm reduction programmes.46
Russian law does not support harm reduction policies, claiming it threatens drug control; opiod substitution therapy is banned, however some needle exchange programmes are in place.47 In 2008 UNAIDS estimated that just 7 percent of all IDUs had access to such preventive measures.48 49 In some cities more than half of all people who inject drugs are infected with HIV, with the prevalence reaching up to 59 percent in St Petersburg and 64 percent in Yekaterinburg among IDUs.50
Drug users are heavily stigmatised in Russia and often come into contact with the law, driving them away from initiatives that could avert the risk of becoming infected with HIV. There are reports that IDUs have been harassed and arrested by police outside needle exchange programmes and pharmacies where they have bought syringes, a practice that further deters other drug users from accessing them.51
A vigorous debate has occurred over whether OST should be legalised in Russia. In 2005, leading figures in the government and scientific community authored a memorandum entitled “Say No to Methadone Programs in the Russian Federation”. The letter, which presented evidence against the measure, was printed in Russia’s Medical News and Issues in Narcology, and distributed throughout the region. The following year, a rebuttal by over fifty HIV and addiction experts from around the world was sent to the memorandum’s authors highlighting its errors and pointing to the scientific evidence supportive of such treatment:
“Methadone is currently being administered to more than 750,000 patients in more than sixty countries, including all twenty-five members of the European Union. The medication has been proven to reduce illicit opiate injection and criminal activity, and to decrease HIV risk and increase adherence to HIV medication. “The errors in your memorandum are all the more alarming since methadone’s effectiveness as an HIV prevention measure is of particular importance in Russia, where eighty-five percent of cumulative registered HIV cases were among injecting drug users. Failure to provide a lifesaving means of drug treatment will mean more HIV infections and lives lost.”52
Substitution therapy’s illegal status can in part be explained by Russia’s attitude towards drug addiction and drug users. Practices to tackle drug use are defined by ‘narcology’, a sub-speciality of psychiatry originally developed in relation to alcohol addiction. One heavy critique of this approach is that treatment for drug addiction in Russia is seen only within the bounds of ‘cure’ or ‘failure to cure’. This ignores the most effective practice of pursuing multiple outcomes, not just abstinence, including reductions in injecting and exposure to HIV and other blood-borne viruses.53 Instead of relying on the scientific evidence of harm reduction measures to treat drug addiction, Russian policy towards drug users emphasises criminalisation. “(As) in the US, mass incarceration of drug users in Russia, under brutal conditions, produces a set of predictable adverse results for the individuals affected, and enables the continued spread of HIV throughout the general population.”54
“Conditions within drug treatment facilities in Russia remind more of prisons than hospitals”
Vitaly Djuma, Executive Director, Russian Harm Reduction Network
Detoxification and psychotherapy at state-run narcological dispensaries (health centres focusing on problematic drug and alcohol abuse) are the primary methods of treating drug addiction.55 One study found this to be largely ineffectual with over half returning to drug use after one month, and 96 percent returning after two years. These poor results are despite the willingness of addicts to quit, with one study showing 91 percent of IDUs having tried once, and 64 percent attempting to quit at least five times.56
In December 2006, a fire at a Moscow drug rehabilitation unit killed 44 HIV-positive women and two nurses trapped behind barred doors and windows. This was seen by some as reflective of an inhumane and repressive attitude towards drug users. One leading Russian harm reduction advocate went so far as to say, “Conditions within drug treatment facilities in Russia remind more of prisons than hospitals.”57
Standard addiction therapy also does not offer sexual behaviour counselling to drug users - vital services needed to prevent sexual transmission of HIV between IDUs and their partners. One study found sexual practices were likely to be safer when IDUs were offered sexual behaviour counselling at the same time as receiving addiction treatment.58
Since 2004, harm reduction programs in Russia have been funded by the UN's Global Fund to Fight AIDS, Tuberculosis and Malaria. However, funding constraints resulted in the Global Fund terminating its funding to Russia in 2012, placing uncertainty around the future of the 20 Global Fund funded harm reduction programs currently in Russia.59 Whilst Russia has allocated a total of around $600 million for HIV services in 2012, only a small amount (3 percent) of this has been earmarked for prevention services. In the absence of prevention services, particularly for Russia's most at-risk groups, it is likely that HIV will have an increasingly severe impact on Russia in the coming years. For Russia to substantially cut new HIV infections, UNAIDS recommends a shift in strategy, embracing harm reduction and reprioritizing resources.60
In recent years Ukraine has put considerable effort into addressing the HIV epidemic among IDUs.61 The All-Ukrainian Network of People Living with HIV receives the bulk of Global Fund provisions and is entirely competent in managing it. Provision of opiate substitution therapy began in 2004 with IDUs being offered buprenorphine. In 2007, the Ministry of Health made methadone legal, and relaxed the criteria regarding who could receive such treatment. By April 2010 harm reduction services were operating in all twenty-seven Ukrainian regions, 62 and now 7,000 IDUs are benefitting from OST.63
Despite Ukraine’s generally positive approach to prevention, IDUs still face barriers to accessing harm reduction services. In 2009 only 32 percent of IDUs were reached with HIV prevention programmes,64 and in 2011, approximately 75 sterile needles/syringes were distributed per IDU, per year.65 Furthermore, drug users wishing to receive substitution therapy are placed on an official register that can be used to exclude them from certain professions, and information is often shared between medical and law enforcement institutions.66 Such problems could deter other IDUs from using available services. Police raids on drug treatment clinics in 2010 marked a turn in Ukraine's approach to HIV and harm reduction services.67 This new line towards drug substitution therapy threatens to undermine the progress made since 2004.
Both needle and syringe exchanges and opioid substitution therapy are available in Azerbaijan, Kazakhstan, Kyrgyzstan and Tajikistan, whilst only needle exchanges operate in Uzbekistan and Turkmenistan.68
According to reports, Turkmenistan's government deny that HIV/AIDS is a problem in their country and claim that only 2 people have ever been infected with the virus.69 70 Nevertheless, there have only been two needle/syringe exchanges in the country since 2008.71 There are also serious concerns surrounding the safety of Turkmenistan's blood supplies, with reports of inconsistent screening of donor blood products for HIV, particularly blood donated from relatives.72
Kyrgyzstan has some of the most developed harm reduction programmes in Eastern Europe and Central Asia, with clean needles being provided in prisons and pharmacies.73 Offering drug users OST instead of prison sentences has halved the number of people in prison, despite the number of drug users rising 50 times in the last two decades.74 This is facilitated by cooperation between primary health care providers and NGOs to improve access and reduce the stigma of needle exchange programmes. The Global Fund is promoting methadone substitution therapy, which is being provided to an estimated 730 drug users.75 76
In 2009 nearly 60 percent of IDUs in Kazakhstan were reached by HIV prevention programmes, whilst 88 percent of sex workers and more than two thirds of MSM were also covered.77 Around 154 syringes are distributed on average per IDU each year.78 Knowledge of HIV status is also relatively high in Kazakhstan, with 61 percent of people who inject drugs having had an HIV test in the last year and knowing the results.79 There have been moves towards providing substitution therapy, though as of 2011 there were just three projects.80
Harm reduction in Uzbekistan is fairly limited for a population of 80,000 injecting drug users.81 With 235 needle exchange sites, which reach about 40 percent of IDUs, access to needle exchanges has improved, and the number of needles and syringes each IDU receives per year is 173.82 83 Despite plans to implement opioid substitution therapy (OST) in Uzbekistan, no form of OST is yet available in the country.84
In Azerbaijan there are approximately 300,000 injecting drug users; an estimated 10 percent of whom are infected with HIV.85 Both needle and syringe exchanges are available in the country (between 12 and 14 in 2011), as well as two OST sites offering methadone.86
The 14th European AIDS Conference, held in 2013, placed particular emphasis on the specific challenges faced in Eastern Europe. This part of the region is facing intersecting epidemics of injecting drug use, HIV, tuberculosis (TB) and hepatitis C that made specific treatment programmes very difficult to implement. Perhaps as a result of this, HIV infections are on the rise, and are estimated to have grown by 140 percent in the past ten years. In addition to this, Eastern Europe is the only region in the world where AIDS-related deaths continue to grow.87
Around 40 percent of HIV infections in the region are listed as ‘exposure route unknown’, a categorisation likely to include high levels of unreported transmission between MSM. MSM and IDUs are highly stigmatised, and sometimes criminalised in the region, meaning that they are far less likely to disclose how they became infected with HIV.88
Access to harm reduction services is fairly low in the region: around 14 percent of IDUs accessing needle exchanges in Armenia where injecting drug use accounts for half of all HIV infections. Only 17 percent of IDUs in Belarus accessed harm reduction services, with a slightly improved picture in Moldova where over a quarter did so. 89 In 2011, Global Fund funding for HIV prevention and harm reduction in Romania ceased when Romania joined the EU, coinciding with a 20-fold increase in HIV incidence amongst IDUs.90 Some harm reduction programmes providing methadone treatment in prisons have been in place in the Baltic countries (Latvia, Lithuania, Estonia) since 2006, as a result of a United Nations Office on Drugs and Crime (UNODC) project.91 Despite evidence of the effectiveness of opioid substitution therapy in reducing both injecting drug use and the risk of HIV infection, access is restricted due to the objections to its use by drug enforcement agencies in the region.92
Restrictions such as this are hugely limiting the potential impact on HIV transmission. The 2013 AIDS Conference emphasised that if opioid substitution therapy, needle and syringe exchange and antiretroviral therapy for everyone with CD4 counts below 350 were provided to half of all injecting drug users, HIV incidence in the region could be reduced by as much as 63 percent in five years.93
Ultimately, the 2013 conference called for governments in the region to commit much more decisively to enabling universal access to treatment by engaging with multiple HIV and AIDS interventions. It was also implied that increased focus on the region by the EU could greatly aid governments with HIV prevention.94
Just 25 percent of adults and children in need of antiretroviral therapy (ART) in European and Central Asian countries were receiving it by the end of 2011.95 Some members of Ukraine’s government have been accused by advocacy groups of buying treatment at unnecessarily high prices, choosing suppliers that offer financial incentives to Health Ministry officials in return for their custom.96 In Latvia, the 2009 financial downturn led the government to cut the HIV and health services budget and introduce a cap on the number of people who are provided with free antiretroviral treatment.97
Most countries in the region lag severely behind the treatment coverage in several African countries with severe epidemics, including Botswana (>95 percent), Namibia (90 percent) and South Africa (83 percent).98
Because of stigma and doubts about adherence to therapy, IDUs in Russia have limited treatment access. It has been projected that a strategy specifically targeting drug users for antiretroviral therapy would be a significantly more effective and cheaper method of preventing infection among all people, including non-IDUs.99 This further highlights the great extent to which drug users will have to be involved in treatment and prevention efforts if HIV is to be tackled.
As Russia does not produce its own generic versions of antiretroviral drugs, unlike other large transitional countries such as Brazil and India, they can be costly to provide. The World Health Organization warned in 2006 that shortages of drugs and breaks in treatment could lead to drug resistant strains of HIV developing and spreading.100 The situation has reportedly led to doctors switching the drug regimens of their HIV positive patients, with the resulting risk of severe side effects and drug resistance.101
Attitudes and awareness
As in many regions of the world discrimination exists against people living with HIV in Eastern Europe and Central Asia. Given that the most at-risk groups in the region – IDUs, sex workers and MSM – are involved in what are viewed as socially unacceptable activities, this stigma is perhaps intensified. Peter Piot, former head of UNAIDS, has said stigma and discrimination against drug users and homosexuality in the region act as deterrents to seeking treatment, and according to the United Nations Development Programme (UNDP), most people living with HIV are more fearful of discrimination than they are of the negative health effects.102 103
A United Nations Development Programme (UNDP) study of people living with HIV in the region examined the difficulties encountered in the areas of healthcare, education and employment. In the health sector, people living with HIV experienced substandard care, hidden expenses and sometimes denial of treatment. Negative attitudes among health professionals were believed to result from inadequate education, training and hospital resources to treat people with HIV. A lack of universal precautions and procedures in medical settings also contributed to an unwillingness to treat people with HIV.104
Adding to negative attitudes towards people with HIV is the fact that, in Russia, patients are treated at AIDS centres that are segregated from the rest of the health care system. This separation has also led to a disparity in HIV knowledge between AIDS specialists and nurses and doctors in the general health system, with the latter “shockingly ignorant of basic facts about the disease,” according to an article in The Lancet.105
The UNDP has found that teachers and school officials believe students with HIV would be discriminated against by their peers, and that parents of HIV-negative children would remove their children from the school if an HIV-positive child was enrolled.106
“Yes, they are really dangerous. I think that such children [living with HIV] should not attend neither schools nor kindergartens as the other children will not be safe.” - Teacher from Georgia107
In the same research, people with HIV said disclosing their status would be a hindrance to finding employment and would result in discrimination at work. Many people had therefore resigned themselves to unemployment or informal employment. Further, people with HIV in low-skilled jobs were considered more vulnerable to discrimination and firing. Adding to the problem is a lack of confidential legal action that could be taken in the event of unfair dismissal or discrimination.108
"I know beforehand my status will certainly hinder the chance to get job or to be promoted… I do not search for a job as I think they will have a negative attitude towards me." - Person living with HIV from Georgia109
The following initiatives have been launched over the years to try and confront the negative attitudes towards people living with HIV:
- A Miss HIV Positive beauty pageant was held in 2005 to mark World AIDS Day.
- A poster campaign was launched by UNAIDS and a Russian community group in 2004 featuring famous paintings alongside slogans such as ‘HIV is NOT transmitted through sport’.
- The Russian Media Partnership to Combat HIV/AIDS was launched in 2004, with sponsorship from over 40 media companies, and places public service messages across all Russian media. According to its website, 85 percent of Russians had seen its StopAIDS brand in 2008, and those who had done so were more likely to take preventive measures and be tested.110
- Ukraine launched its own public information campaign in September 2005 with a World Bank-backed advertisement being broadcast daily for three months highlighting the fact that eight Ukrainians die of AIDS every day.111
- A mass campaign directed towards Ukrainian students in 2008 resulted in 15,000 free and anonymous rapid tests, and 100,000 receiving information on HIV and where they could be tested.112
- Other awareness efforts include that of the UK government’s Central Asia HIV and AIDS Programme (CARHAP) that is providing £5.4 million in Kyrgyzstan, Tajikistan and Uzbekistan. As well as aiming to improve HIV services it is also addressing stigma and discrimination issues to increase access.113
- Three large scale conferences in Moscow addressing HIV and AIDS in Eastern Europe and Central Asia were held in 2006, 2008 and 2009, which could be an indicator the epidemic is receiving more attention.
- A touring photo exhibition, Stars against AIDS, launched in May 2008, featuring 25 famous women from Russia and Ukraine, to raise awareness of HIV and tackle discrimination. A calendar of the exhibition will launch on World AIDS Day.114
The extent to which these messages are getting through is debatable.
Recent funding initiatives
External donors fund over 60 percent of prevention programmes throughout the region.115 However, Russia is able to fund almost all of its AIDS response domestically, although the main aims and focus of the response don't align with the groups most in need of HIV services.116 Future expansion of funding has been criticised, however, for directing too small a proportion to prevention, projected to be less than 9 percent in 2010. With the cuts in Global Fund funding since from late 2011, until 2014, it is important that countries in this region move to heighten domestic resources.117
In Ukraine, a bill was passed in September 2008 to greatly expand HIV prevention, treatment and care for the 2009-13 period. The programme will require around $730m in funding.118
While many areas of the world have kept their HIV epidemics relatively stable, the region encompassing Russia, Eastern Europe and Central Asia is a glaring exception. Although there are signs of a heightened awareness of HIV, demonstrated by funding commitments, conferences and public awareness campaigns, far more needs to be done. Unless IDUs, the drivers of the regional epidemic, are at the core of HIV prevention and treatment efforts, little headway will be made. Political will to tackle stigma and discrimination directed against people with HIV, injecting drug users and other vulnerable populations is imperative as is the introduction and expansion of universally tried and tested HIV prevention methods.
It has been predicted that Russia will experience the greatest number of AIDS-related deaths between 2009 and 2015, indicating the worst is yet to come.119 It will be tragic if thousands more AIDS-related deaths are needed in order to prompt the countries of the region to effectively address their epidemics.
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