AFEW is Looking for Digital Producers

AFEW International is looking for an organisation or individuals to produce a series of materials on knowledge and skills required for successful preparation for AIDS 2018, including but not limited to creating conference profile system, abstract development, scholarship applications submission, applying for workshops, taking part in the Global Village and Youth Program etc.

AFEW International with the support of the Dutch Ministry of Foreign Affairs is implementing a range of activities to empower CBOs, NGOs, activists, policy makers, stakeholders, researchers and clinicians from Eastern Europe and Central Asia (EECA) region to take part in the 22nd International AIDS Conference 2018 in Amsterdam AIDS 2018.

There are several barriers for the delegates from EECA region in their participation in the AIDS conferences: lack of skills on scientific writing and abstract development, costs of participation, and language barrier.

Because of these barriers, the delegates from EECA region have traditionally been disproportionally underrepresented at the AIDS conferences since its inception.

AFEW International is implementing several strategies to support delegates from EEAC region to meaningfully participate in AIDS2018.  Among them webinars and trainings on community-based participatory research for NGOs from EECA, free online resources on writing and submitting abstracts developed by AFEW International and Health[e]Foundation, and newsletters with information from the EECA region and the Netherlands on the preparation for AIDS 2018.

The application deadline is 31st August. More details about the procedure and requirements can be found here.

AFEW Tajikistan’s Offers the Range of Unique Services

Success with harm reduction has recently been achieved in Tajikistan. HIV epidemic amongst injecting drug users also seems to stabilize and even decline. Unfortunately, HIV is still increasing as now it also enters wider community around people who use drugs (PUD) and other key populations. Sexual transmission of HIV is rising, and women is the most vulnerable group in this new wave of HIV infections. Besides, in Tajikistan there are other health related issues with tuberculosis, hepatitis and sexual and reproductive health. These are the observations of AFEW International’s director of the programs Janine Wildschut who visited Tajikistan last week to monitor the work of ‘Bridging the Gaps: health and rights for key popualtions’ programme.

Empowering women is the aim

Within ‘Bridging the Gaps’ programme, AFEW Tajikistan with its partners are focusing on service delivery mainly for female drug users, female prisoners, wives and spouses of PUD. Through the Comprehensive Service Delivery Centre in Qurghonteppa, AFEW Tajikistan is delivering a broad range of services for vulnerable groups, where all groups are welcome.

“We face the issues with health and with the rights of individuals. We want to empower women to take care about themselves, and it is very important to support them in speaking out for their interest and needs,” Janine is saying. “AFEW Tajikistan offers the unique opportunity to have HIV test on the base of the NGO. They also offer wider psycho social support and client management for women based on their needs.”

In Tajikistan Janine also conducted assessment amongst PUD that have labor migration experience. With the support of Open Society Institute Tajikistan, AFEW Tajikistan is supporting labour migrating women returnees with client management. During the focus groups, different women were asked about their needs, quality of services they received, ideas for further improvements and their lives.

Starting vocational training

Janine Wildschut also conducted interviews with NGO partners about the situation for civil society in Tajikistan, spoke with governmental partners within the health department and penitentiary system and worked with AFEW Tajikistan staff on the development and strategies within the next years of the ‘Bridging the Gaps’ programme.

“During the focus group, opioid substitution therapy (OST) clients expressed the uniqueness of the service centre in Qurghonteppa. The biggest challenge for people is to travel every day to the OST point to pick up their methadone, since some of them live quite far and have little resources to spend on transportation,” Janine noticed. “Located nearby, AFEW branch is of big help since they can, after picking up OST, go for health checkup, self-support group or use some other support. Nowadays they are experiencing less discrimination and not such bad treatment of public health facilities because with the AFEW partner network and the AFEW referral vouchers, the attitude and climate in the health facilities in Khatlon region improved a lot. Besides, the support of social workers decreased the level of self-stigma which makes people less fearful to visit  public health services.”

The biggest challenge people still face is the lack of work and education. For that reason, AFEW Tajikistan is considering the option of starting vocational training and enterprise. These plans will be developed in collaboration with experts and micro credit organizations that are part of the partner network.

Almaty is the first city in Central Asia to sign the Paris Declaration

Paris Declaration in Almaty was signed by Deputy Akim of Almaty city Murat Daribaev and UNAIDS Director in the Republic of Kazakhstan Alexander Goleusov

Author: Marina Maximova, Kazakhstan

The world movement, which already includes more than 70 major cities around the world, has reached Central Asia. The first city, whose authorities signed Paris Declaration with an appeal to stop AIDS epidemic on July 20, 2017, was Almaty. Signing of the declaration became possible and was organized within the framework of the project “Fast-Track TB/HIV Responses for Key Populations in EECA cities”, implemented by AIDS Foundation East-West in Kazakhstan.

Almaty is the largest city in Kazakhstan. It is cultural, financial and economic centre of the republic with a population of more than 1.7 million people. For many years it was the capital of the country. The megapolis, along with Pavlodar and Karaganda regions, has the highest rate of HIV infection in the country. Therefore, signing Paris Declaration gives Almaty opportunity and hope to improve the sad situation.

“This fact will undoubtedly attract city residents’ attention to HIV issues. People will get tested more actively, and will start their treatment in time if necessary. Almaty will participate in international health events and will have access to the most advanced achievements and developments in the field of HIV and AIDS. The best world practices will be included into the City Improvement Plan on HIV and tuberculosis until 2023. This will stop the growth of HIV epidemic and improve population’s health,” Valikhan Akhmetov, the head of the Almaty Public Health Department said during the ceremony of signing the declaration.

Sexual transmission of HIV increases

Today, there are more than five thousand registered HIV cases in the city. A quarter of the cases is observed among internal and cross-border migrants. For many years, the main route of transmission was parenteral. To stabilize the situation, the Akimat (regional executive body in Kazakhstan – editor’s comment) has introduced harm reduction programs targeted to key populations: people who inject drugs, sex workers, men who have sex with men. There are 18 syringe exchange points in the city and six friendly cabinets at polyclinics. This year, despite strong public confrontation, site for substitution therapy has been launched.

The trend of the HIV infection spread has changed dramatically in recent years. Today, the sexual transmission is already 65%. Infection, as doctors say, is now targeting general population, but people are still not aware of it and live as if it has nothing to do with them.

“It is very difficult for people from secured families and those who have good jobs to accept the positive HIV status. Women who live in a civil marriage, refuse to name their sexual partners. There can be another situation: imagine a girl coming to us with her mother, who claims that her daughter is a pure child, and she simply cannot have HIV infection,” Alfiya Denebaeva, deputy head physician of the Center for Prevention and Control of AIDS in Almaty is saying.

Some pregnant HIV-positive women do not take antiretroviral therapy (ART) because of the disbelief. Several years ago, there were cases in the city where mothers who did not believe in HIV-infection refused to take medicine, and their infants then died. Now there is an occasion to discuss this topic at the 22nd International AIDS Conference AIDS 2018 in Amsterdam, in which participants from Kazakhstan will also take part.

Regardless of what was mentioned before, Kazakhstani doctors manage to achieve high results. 99 percent of HIV-positive women give births to healthy children. There are several cases when HIV-positive women become mothers for the second and even third time. It is mostly possible thanks to mandatory two-time testing of every pregnant woman when timely diagnosis and starting of ART is possible to establish.

Almost 90% of PLHIV, who need treatment, receive ART

Regional Director of UNAIDS in Eastern Europe and Central Asia Vinay Saldana

In Almaty, testing and treatment of HIV infection is possible at the expense of the city and republican budgets. Back in 2009, the country was the first in Central Asia to start purchasing ARV drugs for adults and children. Today Almaty is the leader: more than 88% of people living with HIV (PLHIV) in need of ART, receive this treatment. This figure is higher than the same figure in the republic by eight percent. The megapolis is much closer to achieving AIDS targets 90-90-90 than any other city in the country: 90% of people living with HIV should be aware of their HIV status; 90% of people who are aware of their positive HIV status should receive antiretroviral treatment; and 90% of people receiving treatment should have a suppressed viral load that will allow them to stay healthy and reduce the risk of HIV transmission.

Another statistic data is showing the advantages of life-saving therapy. The effectiveness of treatment for PLHIV is more than 76%. Thanks to the early beginning of ART, there has been a 20% decrease in new tuberculosis cases among HIV-positive people. This is a very important achievement because the combination of HIV and tuberculosis infections is the main cause of death among PLHIV. Over the past year, this number has increased by 20%. The main reasons for this are late detection of HIV and amnestied patients, who arrive home from places of detention in critical condition. In every third case, the death was inevitable due to the specifics of the damage of the immune system and other organs. Mostly it was cancer or general body atrophy.

“Thanks to United Nations assistance, Kazakhstan has developed a new mechanism for purchasing ARV drugs. Only three years ago, we were spending several thousand dollars per year for a single patient. Now this cost is reduced to the minimum. Therefore, previously we could not advise people living with HIV to start treatment immediately, but now this treatment is available to everyone,” Vinay Saldana, Regional Director of UNAIDS in Eastern Europe and Central Asia is saying.

The Need for a European Union Communication and Action Plan for HIV, TB and Viral Hepatitis

Author: Anke van Dam, AFEW International

For a couple of years, European civil society organisations advocate for a new European Communication and Action Plan for HIV. In the World Health Organisation, new HIV diagnosed infections in European region increased by 76%. These infections more than doubled in Eastern Europe and Central Asia (EECA) from 2005 to 2014. The whole European region accounted for 153 000 reported new infections in 2015 (ECDC 2017). The cumulative number of diagnosed infections in the European region increased to 2,003,674, which includes 992,297 cases reported to the joint ECDC/WHO surveillance database and 1,011,377 infections diagnosed in Russia, as reported by the Russian Federal AIDS Center.

Co-infection in the EECA region

According to ECDC monitoring and the WHO Europe HIV action plan  adopted in September 2016, these underline the high rate of tuberculosis (TB) and hepatitis B and C coinfection among people who live with HIV (PLHIV). In 2014, TB was the most common AIDS-defining illness in the eastern part of the region.

Of the estimated 2.3 million PLHIV who are co-infected with hepatitis C virus globally, 27% are living in the EECA region. An estimated 83% of HIV-positive people who inject drugs live with hepatitis C in the eastern part of the region.

Plan was prolonged

The European Union had a Communication ‘Combating HIV/AIDS in the European Union and neighbouring countries, 2009–2013’ and its associated Action Plan.

The overarching objectives of the Communication were to reduce the number of new HIV infections in all European countries by 2013, to improve access to prevention, treatment, care and support, and to improve the quality of life of people living with, affected by, or most vulnerable to HIV/AIDS in the EU and neighbouring countries. This Plan has been prolonged for another three years. It was followed up with a Commission Staff Working Document: ‘Action Plan on HIV/AIDS in the EU and neighbouring countries: 2014-2016.’’

Already during the period of the prolongation and for three years, the European civil society organisations, including AFEW International, that work in the field of HIV, are advocating for the new communication and action plan. So far without success, despite the fact that according to the evaluation, the Communication and its Action Plan were seen by stakeholders to have provided the necessary stimulus, continuous pressure and leverage for various stakeholders to advocate for and take actions against HIV/AIDS in Europe.

Response is developed

The epidemiology of the three diseases – HIV, TB and viral hepatitis – urged the European Commission to develop a ‘Response to the Communicable Diseases of HIV, Tuberculosis and Hepatitis C’ in 2016. Next to this, the European Commission changed the civil society forum on HIV and AIDS, an advisory body to the European Commission into a civil society forum on HIV, TB and viral hepatitis in 2017, in which AFEW International takes part. This combined focus from the European Commission and civil society organisations could give an impulse to meet the needs for prevention, treatment and care for the three diseases.

Actions within the plan

The European civil society organisations developed a list of actions that should be included in the new communication and action plan.

Prevention needs to be scaled up: HIV can be prevented by a combination of proven public health measures. Yet two third of the European countries do not have a prevention package at scale. Pre-exposure prophylaxis (PrEP) is only provided in a couple of countries.

Treatment access needs to be scaled up: treatment and early treatment improves the health outcomes of the patient and prevents onward transmission. Therefore, countries should scale up testing and offer treatment upon diagnosis and remove barriers to testing and linkage to care. Governments should remove political, legal and regulatory barriers preventing communities most affected by HIV (people living with HIV, gay men and other men having sex with men, migrants, people using drugs, sex workers, transgender person, people in detention) to access health services.

Medicines should be affordable: the price of medicines is still a major barrier to the implementation of treatment guidelines and combination preventions strategies including pre-exposure prophylaxis (PrEP).

Community-based services as one of the components of the health system: include and recognise community base services who can deliver services closer to affected populations as important part of the health system. Invest in them.

AFEW advocates for the plan

In July 2017 the European Parliament adopted the resolution on the EU’s response to HIV, tuberculosis and viral hepatitis. This is an important step towards a communication and action plan. The EU commissioner for Health and Food Safety Mr. Andriukaitis expressed that he is in favour, and a couple of governments also feel a need for such plan. The European Commission and the Commission on Public Health Directorate are still silent though.

AFEW International, together with many governmental and non-governmental organisations, think that the International AIDS Conference in Amsterdam in July 2018 would be a wonderful opportunity and the right moment for the European Commission to present its intentions and good will to fight HIV, TB and viral hepatitis by a communication and action plan. Civil society will not stop to advocate for this. Otherwise we feel that European citizens will be left behind.

New Technologies and Youth Sexuality Education in Georgia

Author: Gvantsa Khizanishvili, Georgia

Improving access to and awareness of health issues among youth using new technologies has become a new way for non-profit sectors around the world to advance issues on their agenda. IntiMate by Bemoni is the first application of such type in Georgia, and it is an excellent example of sexuality education using innovative technologies. It is available for download both by App store and Google play. The app has been developed by Public Union Bemoni as a part of the project “Investing in Sexual and Reproductive Health Promotion and HIV Prevention among Young People in Georgia”.

Non-profit for sex education

Georgia has inadequate policies in the area of sexual and reproductive health and rights. There are strong religious and conservative powers and gender inequality in addition to a fragile civil society that especially influences the lives of adolescents and young people. Much progress has been made in recent years in advocacy to advance youth sexual and reproductive health and rights, for example. In May of 2017, the Georgian Ministry of Education and Science signed a Memorandum of Understanding with the United Nations (UN) Joint Programme for Gender Equality to assist the ongoing revision of the national curriculum and help integrate the issues of human rights, gender equality and healthy living into the educational programme. Additionally, this February, United Nations Population Fund (UNFPA) Georgia initiated an interactive learning module for evidence-based family planning called Virtual Contraception Consultation (ViC), which was introduced at Tbilisi State Medical University.

Despite these advances, there are still many gaps in advancing youth sexual and reproductive health and rights for young people. For example, there are no state supported sex education programs that exist in many countries of Eastern Europe and Central Asia including Georgia. Since there is no state supported sex education programs including information about HIV/AIDS, no information targeted specifically at young people is available, and health service providers are not equipped with the skills to meet young people’s needs for information, counselling and confidentiality of services. Therefore, the non-formal education mostly led by non-profit sector play a significant role in youth sex education.

New ways to raise awareness

The IntiMate app aims to improve knowledge of young people around issues of sexual and reproductive health and rights including HIV/AIDS. With the goal to spark the conversation around the issues, by containing easily comprehensible, fun, attractive content and to encourage participation of young people in prevention of HIV/AIDS. Containing quiz games, video information, definitions, calendar, list of youth friendly services among others, now young people in Georgia will have access reliable information on sexual health and wellbeing at their fingertips. Launched in July 2017, it already has already attracted international media attention.

Russia is Dancing for Life

Author: Anastasia Petrova, Russia

“Congratulations to “FOCUS-MEDIA” and dance4life for the victory in presidential grants competition!” This was the message Ekaterina Artemenko, the coordinator of projects in Moscow “FOCUS Media” foundation, got from her colleague around midnight on July 31. The happy news spread quickly and all danc4life project members knew about it the next day. The initiative was supported this year by the Presidential Grant Foundation.

Starting from 2006, non-commercial organizations in Russia are supported by the president. This was the first year of the presidential grant competition. For 10-year existence, the system of finance distribution was quite complicated: at first the head of the state approved the list of non-commercial organizations (NCO) – the receivers of grants with his decree, and then the NCOs were included into the finance distribution system. In 2017, the procedure was simplified: grant participants may apply online. There has appeared the unified operator – presidential grant foundation.

Coordination committee summed up the results of the first competition on 31 July, 2017. There were 970 NCOs-winners from 79 regions in the winner list, which is around 15% of all applications. There were 6,623 projects that participated in the competition. Three Russian NCOs, included in the register as “foreign agents,” are among presidential grants recipients. Operator has distributed grants with the total sum of 2.25 billion Russian Rubles within the first competition. The most financed project among the 12 grant departments was “Citizen Health Protection, Promotion of Healthy Lifestyle.”

Recognition of merit

Public Health and Social Development Foundation “FOCUS -MEDIA” celebrated its 20th anniversary last year. “We are happy to have received this grant, but frankly, we are also a bit surprised,” the employees of the foundation are saying.

There is a lot of work ahead even after receiving the grant. Financing will allow to run the project dance4life in 14 Russian cities. It will also include a module on tobacco addiction prophylaxis and anti-tobacco campaigns. Besides, the project will include additional component in the form of helping teenagers and young people with HIV. They will be able to volunteer in the project and take part in all of the activities.

Dancing is a universal language

Dance4life project, which won the grant, is a unique international initiative. The initiative aims at promotion of healthy lifestyle among young people, preservation and promotion of reproductive health, HIV infection prevention and many more socially important diseases. More than two million people from 20 different countries have been a part of the programme over the years of its existence.

The project started in 2005 in Russia. It began after “FOCUS Media” Foundation director Evgenia Alekseeva met the Dutch creator of the project Ilco van der Linde. After this meeting, she decided to take this international initiative to Russia. “FOCUS Media” Foundation existed for seven years by that time, dealt with health protection and, in particular, with AIDS prophylaxis among youth. That is why the aim of the project (which includes the prophylaxis of socially important diseases, addiction formation and strengthening young people) coincided with the foundation’s activity.

Now dance4life is a project with 12-year-old history in Russia, and it runs in more than 14 regions. During the years of its activity, it managed to involve around 220,000 young people, who say that dance4life has changed their lives. The keys to the uniqueness of the project are youth culture, energy and creativity that help spread the information on preserving health and taking responsibility for one’s life. Dancing as a part of the project is a universal language, connecting dance4life participants from all over the world.

The results will be presented on AIDS 2018

There were some guests in the ““FOCUS -MEDIA” Foundation office a week before receiving the news about winning the grant. Yulia Koval-Molodtsova, a former project coordinator in Russia and now an associate in the main dance4life office in the Netherlands, came to Russia to talk about the new working models.

After running the same programme since 2005, the international dance4life team has been working on the analysis and improvement of the project methodology. While the old working model made an accent on youth education, the new programme aims at self-realization of society. Now the programme invites young people on a journey: from relationship with oneself, to the relationships with partners and society in general. The components of HIV and sexually-transmitted infections (STI) prophylaxis, issues of contraception and gender equality are now skillfully connected with such important for young people topics: self-knowledge, establishment of personal boundaries, and control of social stereotypes. The principles of work have not changed: to inspire, teach, involve and celebrate. Due to the “peer to peer” approach, young people become the driving force of the project.

New model of work will be approved during this year. The pilot project is running in two regions. In Nizhny Novgorod, where the project is successfully running from the start, they work in cooperation with local schools. The new contacts will be established from scratch in Kolomna, a city in Moscow region, where dance4life is just starting. The model of the project is universal and can be used for both learning and leisure purposes of young people.

Even though the project will be financed by the Presidential Foundation till the end of 2018, the managers of the project would like to sum up the first results of work by next summer. The results of work and experience in the area of HIV/AIDS among youth will be introduced on the International AIDS Conference in 2018. The focus of this conference will be on Eastern European and Central Asian countries.

AFEW Shared Techniques of Relaxation in Kyrgyzstan

The community dialogue platform gathered for the summer school last week in Kyrgyzstan. This summer school was organised within ‘Bridging the Gaps’ programme. The director of programs of AFEW International Janine Wildschut attended the school. After some days of serious work in which the community discussed struggles they face in Kyrgyzstan and how they can come up with a united voice, a training on burnout syndrome and how to prevent it was arranged.

“For many community leaders life is hectic and full of stress. First of all, they do their work with their full heart, which makes them also more sensitive for the stories and troubles of people they help. Secondly, the community members were mostly not trained as managers and leaders of NGOs, and now they are carrying this responsibility with big feeling of commitment. Besides, daily life in Kyrgyzstan for many people consists of a lot of struggle: family responsibilities, economic challenges and little time for relaxation,” Janine Wildschut shares. “This results in feelings of stress, little division of private life and work and little awareness of spending time on hobbies or personal time. Besides, within NGOs there is not much awareness of the need for staff to relax, take holiday time, have some breaks or breathing exercises. Women seem to have more pressure than men, as women are the main caretakers of the household.”

Thіs summer school gave the community members an opportunity to become more aware of stress factors. For one week they were thinking more about themselves, exchanged their worries and learned relaxation techniques.

“As I am not drinking or taking drugs at the moment, I do not know how to relax since that normally was my relaxation,” says one participant of the training who stopped to use drugs. Most of the participants of the summer school also feel that it is very important to be together during such studies since it is the only opportunity for them to gather together outside of official gatherings.

Janine Wildschut shared her experience with stress and burnout. Some of her lessons were taken as eye opener for many.

“When your system stresses up, it “tells” you to run harder, and that is the moment to stop yourself and slow down completely,” Janine said. “To have a boss that understands that this is important and supports you taking a break sometimes is also very important. As the problems around you are a fact of life, you are the only one that can change how you handle this: with stress or by contributing the best you can, but not more than you can.”

Besides, on her trip in Kyrgyzstan, AFEW’s director of programs conducted a focus group about community advocacy to see if change in this area is occurring, what is required to have a greater involvement of the community, and how the dialogue platform contributes to that. Janine also interviewed community NGOs on the situation of shrinking space for CSOs in Eastern Europe and Central Asia. The situation in Kyrgyzstan nowadays is stable. Wider coalitions are initiated and hard work is done with the government to show the invaluable work that NGOs are doing.

Tuberculosis and HIV are the “Imported” Diseases of Migrants

Author: Nargis Hamrabayeva, Tajikistan

A big amount of working age population in Tajikistan (where the entire population is eight million people) take part in labour migration to Russia. After their return to homeland, migrants get diagnosed with tuberculosis and HIV.

A 32-year-old labour migrant from Tajikistan named Shody has just returned from Russia. The doctors have diagnosed him with tuberculosis. The man states that he spent six years working in Russia. He went back home only a couple of times during that period.

The fear of deportation – reason for tuberculosis

“I worked at the construction site. Along with several other fellow countrymen we lived in damp and cold premises. A year ago, I started feeling weak, suffered from continuous coughing, but did not seek any medical advice. First of all, I did not have spare money, and secondly, I was afraid to lose my job. If I was diagnosed with tuberculosis, I would have been deported. Who would take care of my family then? Every day I felt weaker and weaker and I had to buy the ticket home,” told the migrant. Now Shody gets the necessary treatment according to the anti-tuberculosis programme, and his health is getting better.

A few years ago, the results of the research on tuberculosis spread prevention were revealed in Dushanbe. These results have shown that hundreds of Tajik migrants return from Russia with tuberculosis.

Experts say that around 20%, or every fifth patient, from the newly diagnosed patients turn out to be labour migrants.

“For instance, in 2015, 1007 people (which is 19.7% cases from the entire number of patients diagnosed with tuberculosis) were labour migrants. In 2016 there were 927 or more than 17%,” Zoirdzhon Abduloyev, the deputy director of the Republican Centre of Population Protection from Tuberculosis in Tajikistan says.

According to him, the research has shown that most of the migrants became infected during their labour migration period.

“The main factors that lead to the spread of this disease among migrants are the poor living conditions. Big amounts of people in small areas, unsanitary conditions and poor nutrition, late visits to the doctors, and most importantly the fear of deportation from Russia,” says Abduloyev.

HIV is “brought” due to the migration

Many experts say the same thing about the spread of HIV in Tajikistan. That “it is being brought from there, due to the migration.”

Dilshod Sayburkhanov, deputy director of the Republican HIV/AIDS centre in Tajikistan, says that big number of Tajik migrants go to work in countries with significantly higher HIV prevalence rate compared to Tajikistan. Usually these are seasonal migrations, and after the end of the season migrants come home.

“Official statistical data shows the dynamical growth of the number of people who have been in labour migration among the new cases of HIV in Tajikistan. In 2015, there were 165 people diagnosed with HIV, whose tests were marked under the labour migrant category. Among them there were 151 men and 14 women, which is 14.3% from the whole number of new HIV cases. In 2016 – 155 (14.8%), in the first half of 2017 – 82 people (13.1%). In 2012, 65 migrants (7.7%) were diagnosed as HIV-positive,” says Sayburkhanov.

Statistics demonstrates the connection between international Tajik labour migration and the growth of new identified HIV cases, according to him.

Ulugbek Aminov, state UNAIDS manager in Tajikistan, also agrees with this. He thinks that migration and HIV are closely connected and result in a social phenomenon.

“There is an assumption that migrants, being in tough emotional and physical conditions, can behave insecurely in terms of HIV and thus have risks of the virus transmission in destination countries. Tajikistan HIV import issue is still in need of an in-depth study,” believes Ulugbek.

It is important to consider that migrants often represent vulnerable to HIV groups of population (for example people who inject drugs), and not knowing their pre-migration HIV status complicates the future process of HIV monitoring. Apart from that, the chances for migrant to receive the necessary specialized treatment go down. The treatment would prevent the spread of HIV to migrant wives and partners in their home country.

“Therefore, experts’ first priority task is the timely identification and quality monitoring of the disease in the countries where migrant live and transfer to, until the return of the migrant back home,” notes Ulugbek Aminov.

Experts believe that there should be a complex of prevention activities for HIV, sexually transmitted diseases and tuberculosis among such vulnerable groups as migrants and their sexual partners.

Drug-Resistant Tuberculosis on the Rise in Eastern Europe

Author: Ingrid Hein

An epidemic of drug-resistant tuberculosis (TB) is mounting in Eastern Europe, and without intervention on multiple fronts there is little hope the spread will slow. For several years, we have been hearing that there is “a need for urgent action,” said Daria Podlekareva, MD, PhD, from Rigshospitalet at the University of Copenhagen. It needs to be addressed now, she told Medscape Medical News.

However, cultural and political issues mean that it is “not always easy to adopt international guidelines or initiate research projects,” she said at the International AIDS Society 2017 Conference in Paris.

“It’s difficult to go into Eastern Europe and initiate projects and do studies,” she explained. “Some Eastern Europe countries are still behind an iron wall.”

It can be easier to conduct research into infectious disease in other places — even African countries — than in most formerly Soviet Union countries. To help curb the epidemic in Eastern Europe, the World Health Organization (WHO), the Stop TB Partnership, and the European Union should collaborate to encourage governments to recognize TB as a public health emergency and to implement international programs and standards of care, said Dr Podlekareva.

Eastern Europe Is a “Perfect Storm” for TB

TB continues to be a major public health issue, according to the 2017 WHO report — Tuberculosis Surveillance and Monitoring Report in Europe 2017 — released in March. Most of the 323,000 new TB cases and the 32,000 deaths due to TB in the WHO European Region in 2015 occurred in Eastern Europe and Central Asia.

Eastern Europe is a “perfect storm” for the spread of TB because it has high rates of incarceration, HIV infection, and injection drug use, and it has disintegrated healthcare systems, suboptimal TB diagnosis and treatment, and poor adherence rates, Dr Podlekareva said.

In addition, nearly half of all TB cases are multidrug-resistant, which requires longer, more expensive treatment than drug-susceptible TB, and leads to more adverse effects. Treatment is also less accessible in the region.

And because rates of HIV infection are on the rise in Eastern Europe, where antiretroviral therapy coverage is low, the fast progression of immunosuppression leads to increases in the rate of TB and HIV coinfection.

More Likely to Die From TB in Eastern Europe

In an international cohort study on the management of concurrent HIV and TB, Dr Podlekareva and her colleagues found that TB-related deaths were significantly more common in Eastern Europe than in Western Europe or Latin America (Lancet HIV2016;3:e120-e131).

In that study, 1406 consecutive HIV-positive patients aged 16 years or older with a tuberculosis diagnosis were followed up for 12 months at one of 62 HIV and tuberculosis clinics in 19 countries.

The prognosis was far worse for the 834 patients treated in Eastern Europe than for the 317 treated in Western Europe or the 255 treated in Latin America.

Of the 264 (19%) deaths in the study cohort, 188 (71%) were related to tuberculosis.

Cause of Death Eastern Europe, % Western Europe, % Latin America, % P-Value
All 29 4 11 <.0001
TB 23 1 4 <.0001
 “Latin America and Eastern Europe have comparable economies, as middle-or poor-resource settings,” Dr Podlekareva said. But “Latin American patients did better — much better — than the Eastern European patients.”

In Eastern Europe, diagnosis is often made on the basis of clinical judgment, not laboratory confirmation, she pointed out. And treatment is often suboptimal, including very few active drugs. Moreover, disintegrated healthcare systems in Eastern Europe are detrimental to treatment, and care centers for TB and HIV are not combined. Plus, opiate-substitution therapy — an effective treatment for drug dependence — is limited or prohibited in most regions.

“Nearly 40% of our cohort had multidrug-resistant TB,” Dr Podlekareva reported.

Eastern Europe does not have to invent its own solutions; it can adopt “what we already know,” she told Medscape Medical News. Experience from the 1980s HIV epidemic in Western countries can be a guide. There are thousands of publications on the strategies and standards of care that work.

Prisons and Drugs Contribute

In Russia, illicit drug use is a criminal offense, and “methadone treatment is prohibited,” Dr Podlekareva said. “In Eastern European countries, like the Ukraine and Belarus, there are some drug-treatment programs, but they are not widely used as a standard of care.”

With no methadone support and very few social supports for injection drug users, access to treatment, adherence, and retention in care are a challenge.

Clinicians need to ramp up their efforts to convince patients to get treated. “There is a need for clinicians to be more willing to work together, to support these patients,” she said. “When we ask why a patient is not on antiretroviral therapy, they say the patient refused it, but I think it’s the clinician’s task to convince the patient.”

When injection drug users are thrown in jail, as they are in Russia, TB transmission proliferates, Dr Podlekareva explained. A previous study showed that intrapopulation transmission in prisons, population-to-prison transmission, intraprison transmission, and prison-to-population transmission have driven overall population-level differences in TB incidence, prevalence, and mortality rates in countries of the former Soviet Union (Proc Natl Acad Sci USA.2008;105:13280-13285. 

She is not alone in her assessment. “The problem in Eastern Europe will not go away, especially multidrug-resistant TB, if the infrastructure is not improved,” said Christoph Lange, MD, from the tuberculosis unit of the German Center for Infection Research and Research Center Borstel in Germany.

“Patients have been getting treatment on and off,” so new strains of multidrug-resistant TB are emerging, he told Medscape Medical News. “People are now getting infected with drug-resistant strains,” and most Eastern European countries are not equipped to treat multidrug-resistant TB.

Dr Lange said that in the past year he has seen five Armenian patients with multidrug-resistant TB looking for treatment at his clinic. He referred to them as “health-seeking migrants,” and said, “we expect to see more.”

“The number of people with drug-resistant TB is increasing more than 20% every year,” he reported. The current targets of elimination are not credible and they don’t work under the current circumstances; health organizations and governments have to acknowledge that.

“Instead of having the goal of elimination, we need to work toward low incidence,” Dr Lange said. “We have to redefine our goals and address what is most endangering public health.”

Drs Podlekareva and Lange have disclosed no relevant financial relationships.

Source: International AIDS Society (IAS) 2017 Conference. Presented July 2017.

AFEW’s Intern Researches PrEP in Kazakhstan

Is Kazakhstan prepared for pre-exposure prophylaxis (PrEP)? Master student majoring in International Public Health at VU University in Amsterdam Marieke Bak was finding the answer to this question during her recent internship with AFEW International. For this reason, she spent five months in Almaty, Kazakhstan, doing her research.

“For the past five months, I have had the opportunity to do an internship at AFEW International,” says Marieke. “From the start, I felt very welcome in this inspiring organisation and it was great to experience what it is like to work for an NGO. As part of my internship, I went to Kazakhstan to explore the potential implementation of a new HIV prevention method among men who have sex with men. The interviews were incredibly interesting and I learned a lot from the people I met. Moreover, I had the opportunity to do some travelling, which made me fall in love with the region. I hope to go back there someday and I will keep following the work of AFEW with much interest.”

The global HIV/AIDS epidemic remains a major public health issue. Among the countries with the fastest accelerating incidence rates is Kazakhstan, which is characterised by a concentrated epidemic among key populations. Addressing the epidemic requires effective primary prevention, but current methods are often of limited use. PrEP is a new method of HIV prevention consisting of a daily pill combining two anti-retroviral drugs, which has been found very effective when taken consistently. Generally, men who have sex with men (MSM) are seen as the target group for PrEP. As the most developed country in Central Asia, it seems that Kazakhstan could act as a frontrunner in providing PrEP. However, in order to inform the implementation of PrEP, there is a need to understand the awareness and attitudes of MSM towards this new method.

The aim of Marieke Bak’s study was to explore the possibilities for future PrEP initiatives in Kazakhstan by investigating the potential of this prevention method among men who have sex with men. You can find the report on the study findings here.