The HIV/AIDS crisis in Eastern Europe and Central Asia

1. 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

2. 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 non-governmental sector • Significant issues around financial sustainability

3. 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

4. Incidence and Mortality in EECA vs. Globally -24% -41% + 51% + 21% Source: UNAIDS Gap report, 2014; WHO/ECDC disaggregated data for Europe.

5. 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.

6. 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 from Turkmenistan and Uzbekistan excluded due to inconsistent reporting during the period; cases from Estonia excluded due to incomplete reporting on transmission mode during the period Cases from Turkmenistan and Uzbekistan excluded due to inconsistent reporting during the period; cases from Estonia excluded due to incomplete reporting on transmission mode during the period Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

7. 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

8. Source: Open Society Institute, Harm Reduction Developments 2008

9. Treatment increasing but slower than the growth of the HIV epidemic Cases from Turkmenistan and Uzbekistan excluded due to inconsistent reporting during the period; cases from Estonia excluded due to incomplete reporting on transmission mode during the period Cases from Turkmenistan and Uzbekistan excluded due to inconsistent reporting during the period; cases from Estonia excluded due to incomplete reporting on transmission mode during the period Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013 Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013

10. 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.

11. EECA: 90-90-90

12. 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.

13. 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)

14. 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

15. Estimated annual numbers of syringes distributed per person who inject drugs (PWID) and estimated number of opioid substitution treatment clients per 100 PWID (latest year) Percent of estimated PWID or opioid injectors who received OST, 2014 or latest year available Based on country reported GARPR data to UNAIDS, 2014 & to EMCDDA, 2015

16. 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 cost-effective

17. A model to reduce HIV prevalence/incidence by half over 10 years in St Petersburg To halve incidence: • 79% on high coverage NSP • 30-40% on paired interventions • 20% on all three interventions 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.

18. Harm reduction • Evidence-based policy vs policy-biased evidence

19. 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

21. Within-prison drug injecting practices among HIV-infected inmates in Ukraine Izenberg et al, IJDP, 2014

22. 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 non-governmental sector into an effective and meaningful partnership for health.

23. Coverage of clients with minimum package of services (consultation + condom/syringe + info) in Ukraine in 2014 129 CSOs in almost 3,000 sites distributed 14.5 M condoms and 20.5 M syringes in 2014

24. Percentage of HIV programme spending on key populations from international funding sources .

25. 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

26. 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.

27. A rapidly changing international and regional context • Global trend for more regional (multi-polar) AIDS responses • Ukraine, Georgia, Moldova have signed association agreements with the EU • Ukraine is confronted with major economic challenges and conflict • Complex geopolitics in Central Asia and in the Caucasus • Eurasian economic space • Strong influence of the Russian Federation in the region

28. 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.

29. Testing and counseling in Liviv, Ukraine (Natalia Kravchenk / Alliance 2013)

30. 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

35. ACNOWLEDGEMENTS 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