In 2013, there were an estimated 1.1 million people living with HIV in Eastern Europe and Central Asia - 3% of the global total. In the same year, there were roughly 110,000 new HIV infections and 53,000 AIDS-related deaths. Between 2005 and 2013, AIDS-related deaths increased by 5%.1 In Eastern Europe alone, AIDS diagnoses have doubled in the past decade.2
In comparison to Western and Central Europe, the HIV epidemic in this region continues to grow, particularly in Russia, Ukraine and Uzbekistan. 85% of people living with HIV in the region live in Russia and Ukraine. Russia also accounts for eight out of ten new HIV infections, and reported in excess of 85,252 new diagnoses in 2014 alone.3 4
Antiretroviral treatment (ART) coverage for the region remains inadequate at 35%. Most countries are only just beginning to implement the World Health Organisation's (WHO) 2013 treatment guidelines, despite the most recent WHO guidelines of 2015 recommending treatment for all people living with HIV.5 Many people are tested late and do not receive the treatment they need.6
The epidemic particularly affects people who inject drugs, sex workers and men who have sex with men (MSM), although heterosexual sex is the predominant route of HIV transmission in Eastern Europe at 66%. This is in direct contrast to Western Europe where the majority of infections are among MSM (43.9%).7
Key affected populations in Eastern Europe and Central Asia
People who inject drugs (PWID)
In Eastern Europe and Central Asia, there are roughly 2.9 million people who inject drugs. Russia has the highest number of PWID in the region (1.8 million) - about 2.3% of the adult population. Moldova (1%), Belarus (1.1%) and Ukraine (0.8-1.2%) also have significant numbers of PWID.8 Across this region, HIV prevalence is much higher among PWID than among the general population. For example, in Russia, between 18% and 31% of this group are thought to be living with HIV.9
Regionally, HIV prevalence among men and women who inject drugs is similar, at 9% and 10% respectively. In some countries, women who inject drugs also engage in sex work which puts them at greater risk of HIV transmission. 62% of women in Kyrgyzstan and 84% of women in Azerbaijan who inject drugs, also engage in sex work.10 In Ukraine, HIV prevalence has been found to be much higher among PWID over 25 years of age (21.7%) compared with PWID under 25 (6.4%).11
HIV prevalence is also reportedly high among sex workers in Eastern Europe (10.9%).12 Though these estimates are based mainly on data from Ukraine, a study from Chisinau, Moldova, found that 11.6% of sex workers were living with HIV.13
Despite limited data, it is thought that HIV prevalence is higher among male sex workers than female sex workers. Many sex workers also inject drugs, increasing their risk of HIV transmission.14 In Central Asia, HIV prevalence is estimated to be 20 times higher among female sex workers (FSWs) who also inject drugs.15
Men who have sex with men (MSM)
HIV prevalence data concerning men who have sex with men (MSM) in this region is equally limited. According to the most recent survey in 2010, HIV prevalence among MSM is 6% in Ukraine, 7% in Georgia and 9.2% in Moscow, Russia.16
Prisoners are another group thought to be at particular risk of HIV infection in Eastern Europe and Central Asia.
In 2010, 55,000 of Russia's 846,000 inmates were thought to be living with HIV. Four studies from Estonia have reported HIV prevalence among prisoners to be between 8.8% and 23.9%.19
HIV among prisoners is a growing issue in Central Asia. In Tajikistan and Kyrgyzstan, HIV prevalence among inmates is reported at 8%.20
Young people in Eastern Europe and Central Asia are thought to be increasingly at risk of HIV. Studies from Ukraine indicate that young people who are homeless or orphaned are more likely to be living with HIV, and inject drugs.21 22
Age-appropriate HIV prevention services are needed for young people who use drugs. Additional research is also required to understand the extent of the epidemic among this group.23
HIV testing and counselling (HTC) in Eastern Europe and Central Asia
The WHO European Action Plan for 2012-2015 called for a reduction in the number of undiagnosed people by increasing early uptake of HTC, especially among key affected populations (KAPs). The Action Plan set a target of 90% of PWID aware of their HIV status by 2015. Despite significant progress in the scale up of HTC in some countries in Central Asia, the number of people belonging to KAPs who have been tested remains well below WHO’s recommended coverage of over 90%.24
For example, between 2009 and 2011, HTC coverage among PWID increased from 52% to 65% in Kazakhstan, and from 40% to 54% in Tajikistan. In some countries, testing coverage has actually fallen - from 40% to 36% in Kyrgyzstan, and from 34% to 29% in Uzbekistan.25
HTC coverage among PWID is higher than coverage among MSM in all Central Asian countries except for Uzbekistan (29% for PWID and 31% for MSM in 2011). For example, in 2011, 77.1% of FSWs were tested in Kazakhstan versus 64.7% of PWID. This can be explained by mandatory testing of detained FSWs in all Central Asian countries.26
Even where testing is available, people are often diagnosed at a late stage of infection. One study from Armenia reported that since 2005, 40% of people newly diagnosed with HIV had a CD4 count below 200 - far below both 2010 and 2013 WHO treatment initiation guidelines. Moreover, 60% of this number did not consent to treatment or could not be found following their diagnosis.27 This is a considerable problem now that all people diagnosed with HIV are recommended to start treatment straight away.28
Across the region, HIV testing services need to be scaled dramatically and referral onto treatment strengthened, in order to halt the rise in new infections and meet coverage targets.
HIV prevention programmes in Eastern Europe and Central Asia
- Needle and syringe programmes (NSPs)
Between 2011 and 2013, there was a 30% increase in the number of syringes distributed across the region and an increase in the number of syringes distributed per PWID.30 For example, Tajikistan has expanded its coverage from 88 to 199 syringes per person.31
However, coverage varies significantly between countries - 50% in Kazakhstan compared to 22% in Tajikistan.32 Moreover, the regional average is only 106 syringes per PWID - half the recommended target for effective harm reduction programmes.33
- Opioid substitution therapy (OST)
In 2014, opioid substitution therapy was available in nine countries in the region across 263 sites reaching nearly 17,000 PWID - less than 1% of this group. Armenia, Belarus, Georgia, Kyrgyzstan and Ukraine have all significantly scaled up access to OST. By comparison, in Azerbaijan, Kazakhstan, Moldova and Tajikistan, access to OST is limited. In Russia and Turkmenistan, OST remains illegal, and in 2009, Uzbekistan stopped its OST programmes.34
Prevention programming for other key affected populations
Despite evidence showing how specialist HIV prevention services targeting sex workers can reduce HIV transmission among this group, access to these types of services is very low. Moreover, data on the provision of these services is very limited for Eastern Europe and Central Asia. In Russia, only 0.2 in every 1000 female sex workers (FSW) are thought to be accessing the services they need.35
By contrast, between 2009 and 2012, HIV prevention programme coverage for MSM in this region rose from 43% to 64%. However, the provision of these services remains inadequate in many places as national governments often do not highlight the need for them.36
For example, while Ukraine's National Target Program calls for tolerance and less discrimination towards people living with HIV, it does not specifically mention stigma against MSM as well as transgender (TG) people. As a result, MSM and TG people have very limited access to specialised programmes targeting these groups - even in comparison with other key populations like PWID and sex workers.37 In addition, many programmes are typically focussed on medical interventions and do not take into account human rights issues.38
Antiretroviral treatment (ART) in Eastern Europe and Central Asia
Though access to antiretroviral treatment has expanded significantly in many countries in this region, (Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Lithuania, Moldova, Russia, Tajikistan, Ukraine and Uzbekistan), new HIV infections continue to outpace enrolment onto ART. Access to ART is particularly low for key affected populations like PWID, sex workers and MSM.39
In 2012, an estimated 177,000 adults were accessing antiretroviral treatment equating to a coverage of 35% under the 2010 WHO treatment guidelines.40 More recent statistics report a treatment coverage of just 21% among 18-24 year olds.41
Ukraine is an exception to this, and since 2008, has invested significantly in the provision of ART. In 2010, roughly 12,500 people were receiving ART - by January 2014, nearly 56,000 people were on treatment.42
The percentage of pregnant women accessing ART is very high. In 2013, over 18,500 pregnant women were on treatment (95% coverage).43
With the release of the latest WHO treatment guidelines in 2015, the region is currently facing a huge strain considering all people living with HIV are now eligible for treatment.
Barriers to HIV prevention in Eastern Europe and Central Asia
A lack of funding remains a significant barrier to the scale-up of HIV prevention programmes to tackle the epidemic effectively in this region. Indeed, many countries are heavily reliant on international financing from donors such as the Global Fund to Fight AIDS, Malaria and TB, which provides the majority of HIV prevention funding for this region.
In 2014 and 2015, Ukraine received $51 million from the Global Fund. However, with the country reaching a higher income status, local health authorities are expected to take over the country's HIV response. As a result, in 2017, Ukraine is expected to see its Global Fund financing halved, raising fears about country's ability to tackle the epidemic effectively in the future. Since the Global Fund withdrew funding from Romania in 2010, the government has been unable to continue supporting needle and syringe programmes and HIV prevalence among PWID has increased dramatically - from 3% in 2010, to 29% in 2013.44
Any domestic financing usually comes from medical insurance funding, with KAPs likely to have less access to health insurance. For instance, around 30–50% of PWID in Estonia are uninsured.45
Stigma and discrimination, particularly where key affected populations are concerned, play a big role in preventing people living with HIV from accessing the services they need.
One study from St Petersburg, Russia, found that 25% of people living with HIV had been refused healthcare, 11% refused employment, 7% fired and 6% forced from their family as a result of their HIV status.46 Negative attitudes towards people living with HIV and people belonging to key affected populations have also been documented among medical students in Kazan, Russia.47
Many women who are marginalised because they inject drugs, also experience gender-based violence, both domestically and from the police and find it especially difficult to access HIV prevention services. In Georgia, less than 1% of women who inject drugs have accessed OST.48
Key affected populations face a number of legal barriers to accessing essential HIV programmes and services.
While many countries in this region have repealed laws prohibiting same-sex relationships - Uzbekistan and Turkmenistan continue to enforce them. In 2013, Russia adopted a law banning “propaganda of non-traditional sexual relations among minors” in order protect children from content that promotes homosexuality as a norm in society and protect '"traditional" family values. Similar legislation is being considered in Belarus, Kazakhstan and Kyrgyzstan. Such legal measures facilitate a culture of homophobia fuelling stigma towards MSM in particular.49
Punitive drug laws also inhibit access to HIV testing and treatment for PWID. Criminalisation of drug use and discriminatory practices restrict access to NSPs and NGOs where these services are located. Police in some countries arrest PWID who access harm reduction services and confiscate drugs and syringes or extract bribes for the possession of syringes or needles.50 51 In one study from St Petersburg, Russia, 60.5% of PWID had been arrested for needle possession or had drugs planted on them by the police and were subsequently arrested.52
In many countries in this region, people must be over 18 years to access harm reduction services.53
Physical and geographical barriers
Poor surveillance of the HIV epidemic in these countries also hampers prevention efforts. For example, official reports in Kazakhstan estimate an HIV prevalence of 1.2% among MSM. By comparison, NGO studies indicate a prevalence of between 7-20% among this group but the Kazakh government disputes the statistics.54
As a result, the epidemic among MSM and other key affected populations remains largely hidden and the need for HIV services is not recognised. Indeed, coverage of ART, NSPs, OST and other HIV prevention programmes remain very low or non-existent.55
Even where they do exist, a number of organisational barriers to accessing HIV prevention services have been identified including inconvenient opening hours, distant locations, and transportation costs. Despite the scaling up of HIV services, most are located in urban areas limiting access for those in suburban and rural areas.56 In Georgia, study participants cited unemployment and the cost of healthcare as barriers to accessing voluntary counselling and testing (VCT) services.57
The future of HIV and AIDS in Eastern Europe and Central Asia
In Eastern Europe and Central Asia, the number of new HIV infections continues to rise. As a result, the scaling up of antiretroviral treatment and other HIV prevention programmes, particularly for key affected populations is of urgent priority. However, a number of barriers need to be overcome in order for people living with HIV to be able to access the services they need.
Countries in this region remain heavily reliant on donor funding, and with external financing anticipated to drop, national governments will have to make up the shortfall. Even if longer term funding is secured, many people, particularly those belonging to key affected groups, face a number of legal and social barriers to accessing HIV prevention services, which also need to be addressed.
Better HIV surveillance in many countries would help identify those at risk and to what extent HIV prevention services need to be scaled up in order to tackle the epidemic in this region effectively.
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