Friday, September 21, 2018

HIV in Russia/Central Asian Republics

  UNAIDS calculates that between 2010 and 2015, Russia accounted for more than 80% of the new HIV infections in the entire Eastern European and the Central Asian region.  By Russia’s own estimates, the epidemic grew 10% per year during that period, with the new infections roughly split between people who inject drugs and heterosexual transmission.  At about the same time, new infections in the rest of Europe and North America dropped by 9%.  By the end of 2017, the Russian Ministry of Health estimates, just shy of 1 million people were living with HIV.  Even official accounts acknowledge that only one-third of those receive ARVs.
Many people, even within the government, think those estimates understate the epidemic.  Vadim Pokrovsky, who heads the Federal Scientific and Methodological Center for Prevention and Control of AIDS in Moscow, an epidemiological surveillance arm that’s independent from the Ministry of Health, does battle with the divisions that oversee HIV and tuberculosis (TB).  His group estimates that between 1.1 million and 1.4 million Russians are infected with HIV.  And Michel Kazatchkine, special adviser to UNAIDS in Eastern Europe and Central Asia, and colleagues concluded in a study published last year that the true number of infected people may be as high as 2 million.  They based their number on an estimate by Pokrovsky’s team that only half the infected people in Russia knew their HIV status in 2013.
HIV took off in Russia in the mid-1990s, later than in Western European countries, and at first the spread was limited mainly to heroin users sharing needles and syringes.  Even before he took over The Global Fund in 2007, Kazatchkine and others urged the government to use proven “harm reduction” prevention strategies, including needle and syringe exchange programs and opiate substitutes such as methadone.  Several nongovernmental organizations (NGOs) started programs for drug users, but the government offered no funding for what it saw as “Western” ideas that went against conservative Russian culture—and to this day opiate substitutes remain outlawed.  The government also did little for another highly stigmatized group, men who have sex with men (MSM), who also are at high risk of infection.  Since 2013, a “propaganda law” has made posting or discussing information geared toward MSM illegal.  They rely on NGOs for many HIV services, as do sex workers.
Compounding the problem, several NGOs left the country starting a decade ago after Russia, emboldened by a strengthening economy, began phasing out The Global Fund’s support—which to date has totaled $378 million.  “They said, ‘We don’t need The Global Fund or money from outside; we’ll cover everything ourselves,’ but they didn’t do it,” Pokrovsky says....
Kasaeva and her colleagues stress that the number of people getting treatment has increased severalfold over the past few years, and they note that they recently completed their first strategic plan to battle the disease.  “We understand that now we have a problem and we’re trying to solve it,” she says.  Everyone who requests treatment receives it, she insists, although some “people are trying to hide” and don’t request it.  Yes, shortages of ARVs occurred in some places last year, but that was only because of speed bumps in a shift away from regional drug purchase and distribution to a more streamlined, cost-effective federally run program.
Kasaeva recognizes that harm reduction programs might slow HIV’s spread in the short term, but they don’t address underlying problems, she says.  “They’re very popular and they look so smart and pretty, but in fact if we look into the problem deeply, it’s not solving the problem.”  Harm reduction, “according to the opinion of a huge number of Russian experts,” focuses on the symptoms and not the causes of addiction, she says.  In contrast, the country’s “systematic program of rehabilitation for drug users,” she insists, has long-term effectiveness.
-Yevgeny Roizman, former mayor of Yekaterinburg, Russia, has opened a museum of religious icons.  He has taken a hardline stance against drug users.

Roizman sees no need for harm reduction programs for drug users; NGOs that offered needle exchange in Yekaterinburg failed to make a dent, he says.  He visited Ukraine, which legalized opiate substitution therapy, to see how it worked.  “An army of heroin addicts,” he says, was “reconfigured into an army of methadone addicts.”

Kazan in 1999 began aggressive needle and syringe exchange programs and other harm reduction efforts with support from NGOs, the semiautonomous republic itself, and eventually The Global Fund.  “We’ve had a stable epidemic,” says Larisa Badrieva, an epidemiologist and researcher there.  “We really reached a lot of people very, very quickly.” The city recorded about 1000 new HIV cases in 2001, she says, and that number fell to about 150 in 2008, with little evidence that the virus was spreading to the general population.  A relatively high percentage of HIV-infected people in Tatarstan—about 50%—is being treated with ARVs.  Yet Larisa Badrieva, an epidemiologist and researcher, is worried about the future. With the pullout of The Global Fund and with other outside assistance drying up, Badrieva says only one of seven centers in the city dedicated to drug users is still operating, and she is unsure whether it will remain open much longer.  “Unless there’s a dramatic shift in the drug scene, we’ll see an increase of HIV infection across all groups,” Badrieva predicts....
Saldanha says he’s particularly heartened about the latest data from the city.  “We’re hoping that St. Petersburg has now turned the corner,” he says.  In 2016, new infections in the city dropped below 2000 people a year for the first time since the epidemic took off, according to the city’s AIDS center.  Of the 36,000 residents who know they are living with HIV, about half now receive ARVs, and 82% of that group have undetectable levels of virus in their blood, meaning they are adhering to their treatment regimens.  “We’re doing something right,” says Tatiana Vinogradova, deputy director of the St. Petersburg AIDS Center.
St. Petersburg still faces serious challenges, Vinogradova notes.  Recent surveys that tested large groups of sex workers and MSM both showed double-digit prevalence of HIV, and only about 5% of the people already knew their status.   Many migrants who have HIV also come to the region from former Soviet countries and do not have the proper St. Petersburg registration necessary to receive treatment and care.   “It’s a big problem, and we have no instruments to do anything about it,” she says....But St. Petersburg is only one city in a highly populated, geographically expansive country.  “They have a treatment coverage level that is half what it is in Zimbabwe,” he stresses.   “This epidemic is not going to go away on its own.”
• Eastern Europe and Central Asia is the only region in the world where annual rate of HIV infections continues to rise at a concerning rate. 

• The HIV epidemic has, for the most part, hit people who inject drugs the hardest. Harm reduction service coverage remains low and where it does exist the services offered are often are not comprehensive. 

• Antiretroviral treatment coverage remains well below the global average at 36%. New infections continue to outpace ART enrolment.

• Conservative legislation around same sex relationships, drug use and sex work continues to fuel stigma, obstructing the HIV response in some countries within the region.

• Improved surveillance of the HIV epidemic is needed, often data is unavailable for populations or disputed. 
At the end of 2017, an estimated 1.4 million people were living with HIV in Eastern Europe and Central Asia.1 It is the only region in the world where the HIV epidemic continues to grow rapidly, with a 30% increase in annual HIV infections between 2010 and 2017.2
In 2017, there were roughly 190,000 new HIV infections - 80,000 more than in 2013. In the same year there were 40,000 AIDS-related deaths: a 22% increase from 2010.3By the end of 2017, 73% of people living with HIV were aware of their HIV status, a 4% increase from 2016.4
The vast majority of people living with HIV in Eastern Europe and Central Asia live in Russia (70%), where new infections are on the rise, followed by Ukraine. Outside of Russia, the rate of new HIV infections is stable.5
The region’s epidemic is concentrated predominantly among key affected populations – in particular, people who inject drugs (sometimes referred to as PWID) – yet there is low coverage of harm reduction and other HIV prevention programmes in key countries within the region.6 Unprotected sex is causing an increasing number of HIV infections and is now the leading cause of transmission in some countries. The sexual partners of key affected populations, in particular sex workers and people who inject drugs, are at elevated risk of HIV infection and accounted for 33% of new infections across the region in 2014.7 Indeed, the number of new HIV infections acquired through heterosexual sex increased by 150% between 2002 and 2012.8...
The average cost of first-line ART has also dropped from almost $2,000 USD per person, per year to less than $200 USD per person, per year, making treatment expansion more achievable.13
There are roughly 3.1 million people who inject drugs in Eastern Europe and Central Asia. The region is home to roughly one in four people who inject drugs worldwide.14 Russia has the highest number of injecting drug users 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 this population.15

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