AFEW Kazakhstan Helps People Getting out of the Shadows

29,568 HIV cases were registered in Kazakhstan as of February 2017. According to the official data, in 2016 there were14,345 tuberculosis patients registered in the country. Usually, these people hide themselves, and are often afraid even to tell their relatives about their diagnosis. But there are also those who openly talk about their status, and who show that it is possible to get out of the shadow.

At the end of March, the photo exhibition ‘Life in the Shadow’ dedicated to the World Tuberculosis Day took place in Almaty. AIDS Foundation East-West in Kazakhstan organized this event. The exhibition featured photos of people affected by HIV and tuberculosis. Today we will tell the stories of some of them.

LEARN TO LOVE YOURSELF

After the death of her mother in 2008, Venera started to lose weight. The woman thought it was because of the grief she was experiencing, but still went to the hospital for the X-rays and medical tests. There it was discovered that Venera had an open form of tuberculosis.

Venera realized that it does not matter what your position in the society is, the tuberculosis makes everyone equal

“By that time, I was very weak and all the time felt sick in my stomach. I weighed 48 kilograms,” says Venera. “During three months I was out there with an open form of tuberculosis until they accepted me in the hospital. All I wanted at that time was to lie down and die! I was in darkness, alone, rejected by everyone. I did not believe that I would get out of that hospital alive. All the time I was sick because of the pills. My son and my sister, who, after my mother’s death, was taken to an orphanage, as I did not have time to register custody, were the only people who kept me alive. They called me, told me they needed me, asked not to die. It was the strongest motivation to live! After some time, I started to feel better and began recovering.”

A year later, Venera was diagnosed with tuberculosis and lung disintegration. At that time, the woman was pregnant. Since no one told her that during the pregnancy tuberculosis can be treated, Venera was advised to have an abortion.

“In the hospital they gave me the bed that was standing in the hallway, and soon the whole department knew I had tuberculosis,” Venera recalls. “People were scared of me. The gynaecologist was commenting something like, why people like me are even allowed to give births at all. That was such a humiliation!”

After she got out of the hospital, Venera realized that it does not matter what your position in the society is, the tuberculosis makes everyone equal. The woman became stronger and kinder, started to pay more attention to her relatives, helped those who needed help. Three years later, Venera gave birth to the healthy twins.

“I defeated tuberculosis. If you have such diagnosis, do not be not afraid and believe that you will recover!” says Venera. “Do not be scared of anyone, this is not a disgrace. Most importantly – do not refuse the treatment, otherwise you can infect your relatives and friends. Learn to love yourself!”

A DECISION TO LIVE

To those who only got to know about their diagnosis, Salavat advises to be strong and take care about their health

Salavat has been living with HIV since 2011. The man has heard something about this disease, but did not have a clear understanding of it. He thought it was somewhere far away, not here, and he could not even imagine that he could get infected.

“The doctor was calming me down, saying that people live with it, that it is not fatal, that in the future there probably will be a medicine… At first, of course, I felt bad, but I quickly overcame my fears,” Salavat says. “I made a decision to live. Now I know a lot about HIV. I am confident that I can work, and I am able to live. I know that we are the same people as everybody else, we are not infectious.”

To those who only got to know about their diagnosis, Salavat advises to be strong and take care about their health. It is very important to enjoy life, to share joy, and not to lapse into a cocoon of self-isolation.

ACCEPTING THE DIAGNOSIS

Oksana learned that she was HIV positive in the rehabilitation centre for drug addiction.

The acceptance of her diagnosis benefited Oksana’s professional and personal development

“It was scary, somehow I made myself believe that I had only five years left to live and I have to fill my last years with fun and unforgettable experience!” Oksana is saying. “Before my diagnosis, I thought that HIV is something that is far away and it is impossible to get it in Kazakhstan.”

At that time, the woman needed support, and she got it from her family. The first one who learned about her diagnosis was Oksana’s sister.

“Later I asked her what she felt when she found out that I was HIV positive,” Oksana remembers. “Surprisingly enough, most of all she was worried about me, because the first thing I could convince her in was that I had only five years to live. About three years later, I accepted my diagnosis. I realized that I am not dying, and started to learn how to live with HIV.”

The acceptance of the diagnosis did not only benefit Oksana’s professional development, but also her personal development.

“I am happy to be busy with my favourite things, I am with a person I love and my family is very friendly. I learned how to live with HIV. You just need take more care about your health and love life!” Oksana resumes.

TO BELIEVE IN RECOVERY

After being diagnosed, Sultanamurat started to appreciate life more

The only thing Sultanmurat knew about tuberculosis was that it is a dangerous disease. When he heard his diagnosis, he became horrified.

“I experienced haemoptysis. It was scary, but I did not even suspect that it could be tuberculosis. I thought that I had some problems with my internal organs,” recalls Sultanmurat. “I really wanted to be cured, but the treatment was going very difficult. In the beginning, I did not tolerate the medicine and developed allergies. I was fighting with myself, tried not to miss a single day of taking medications and injections. Now I feel much better.”

After being diagnosed, Sultanamurat started to appreciate life more, treated people who are ill with better understanding, began to appreciate and love his relatives even more.

“I would like to tell those who are diagnosed with tuberculosis that this disease is curable, like many other diseases. The main thing is to follow the regime in everything, do not miss taking pills and eat well, move and do sports, be friendly,” Sultanmurat says. “The most important thing is to believe in the best, that is, in your recovery.”

Join AFEW at Harm Reduction International Conference in Montréal

AFEW International is taking part in 25th Harm Reduction International Conference that will take place in Montréal, Canada next week. AFEW’s executive director Anke van Dam and program director Janine Wildschut will take part in the side event on harm reduction.

The side event ‘Future Proofing Harm Reduction’ is supported by the Dutch Funded Harm Reduction Programs – Bridging the Gaps, PITCH and the Alliance Integrated Harm Reduction Programme (AIHRP). These three alliances are represented by Aidsfonds, International HIV/AIDS Alliance, International Network of People Who Use Drugs, AFEW International, and the Mainline Foundation. The side event will take place on Monday, 15th May, 2-3.30 pm at Mansfield II, Entry hall, Centre Mont-Royal.

AFEW will be represented by the talk by AFEW International’s program director Janine Wildschut with the talk ‘Shrinking space for civil society in the EECA region’ and AFEW Kyrgyzstan’s director Natalya Shumskaya who will talk about women who use drugs in Kyrgyzstan. More detailed program of the side event can be found here.

Harm reduction goes much further than HIV prevention, and contributes significantly to the quality of life of people who use drugs and to the realization of the Sustainable Development Goals (SDG). This side event, moderated by the Dutch Ambassador for Sexual and Reproductive Health and Rights and HIV/AIDS Lambert Grijns, will share examples from the variety of grassroots harm reduction projects currently funded by the Netherlands. Current challenges in harm reduction funding beyond HIV and framing programmes within the context of the SDGs will be discussed.

The theme of this year’s Harm Reduction International Conference is ‘At the Heart of the Response’, and the programme includes presentations, panels, workshops and dialogue space sessions on innovative harm reduction services, new or ground-breaking research, effective or successful advocacy campaigns and key policy discussions or debates.

PrEP: effective and empowering

Author: Marieke Bak

Pre-exposure prophylaxis (PrEP) is a new HIV prevention method that consists of a daily pill taken by HIV-negative people to reduce their risk of becoming infected with HIV. PrEP is highly effective in preventing HIV transmission, as scientific research shows. A large international study among gay men and transgender women, the so-called iPrEx trial suggested that PrEP can reduce the risk of HIV infection by at least 92% when the pills are taken consistently. PrEP is also effective when used by heterosexual men and women, as well as by people who inject drugs.

Although PrEP is more expensive than other HIV prevention methods, it can be a cost-effective tool, especially when delivered to people at high risk of HIV. By preventing the costs of lifetime HIV treatment, PrEP may even lead to healthcare savings, especially when the drug patents expire and the cost drops.

Moreover, PrEP is the first method of HIV prevention that is directly under the control of the at-risk individual. This is in contrast with treatment as prevention (TasP), which is dependent upon partners’ HIV treatment adherence to ensure suppressed viral load. Besides, because PrEP separates the act of prevention from the sexual encounter, it can be used without sexual partners knowing and provides additional protection when condoms are not used consistently.

The World Health Organization now recommends that PrEP should be offered as a choice to key populations affected by HIV as well as to anyone else at substantial risk of HIV infection.

TRANSFORMING HIV INFECTION

PrEP is a pill consisting of anti-retroviral drugs that needs to be taken every day in order to be effective. Currently, the only drug approved for use as PrEP is sold by Gilead Sciences and is called Truvada, which consists of a combination of tenofovir and emtricitabine (TDF/FTC). Truvada was first approved for prevention in 2012 in the United States of America.

In contrast to PEP, or post-exposure prophylaxis, PrEP is taken before exposure to HIV to prevent any possible transmission. PrEP works by blocking an enzyme called HIV reverse transcriptase, thereby preventing HIV from establishing itself in the body. While PEP can be thought of as a “morning-after pill” for HIV prevention, PrEP can be compared to the contraceptive pill that is taken every day. Similarly, PrEP may transform HIV infection just like the pill transformed family planning.

The most common side effects of Truvada for PrEP are nausea, vomiting, dizziness, headache and fatigue, although these symptoms usually resolve within a few weeks. Some people in trials also experienced small changes in kidney function or a decrease in bone mineral density. An updated version of Truvada was created that contains a new form of tenofovir, which is thought to be safer for bones and kidneys. At the moment, the so-called “Discover study”, is being set up in North America and Europe to investigate the new PrEP medicine called Descovy.

By the way, PrEP does not protect from sexually transmitted diseases (STDs). Fears that PrEP might be used as a “party drug” exist. However, in the iPrEx study as well as in a meta-analysis by the World Health Organisation, it was shown that PrEP does not lead to an increase in the number of STDs and has no effect on condom use. Rather, PrEP reduces the fear and anxiety that often comes with sexual activity for those at high risk of HIV.

However, because PrEP is not 100% effective and because it does not protect from STDs, it should not be used as a standalone prevention method. According to WHO guidance, PrEP should be offered as part of so-called “combination prevention” which includes the use of condoms as well as regular follow-ups and HIV testing.

PREP IN EASTERN EUROPE AND CENTRAL ASIA

Despite the recommendation to offer PrEP to people at high risk of HIV infection, the global availability of PrEP remains limited. The PrEP target set by UNAIDS in their strategy on ending the HIV pandemic is to get three million people on PrEP by 2020. However, only 2% of this target had been reached in June 2016.

At the moment, Truvada for PrEP has been approved in the United States, Canada, Australia, Peru, South Africa, Kenya, Zimbabwe, Israel, and the European Union. Approval is pending in Brazil and Thailand. In the European Union, PrEP has been approved by the European Medicines Agency (EMA) although the implementation of PrEP programmes is the responsibility of each member state separately. To date, only France and Norway have made PrEP available as part of their healthcare system. Scotland recently announced that it will do the same.

In Eastern Europe and Central Asia (EECA), PrEP is not available yet. However, demonstration projects are currently being set up in Georgia, Ukraine and Azerbaijan. These pilot studies consist of several phases. In Georgia, the first stage of PrEP implementation included a training session for those involved in the pilot, as well as the conducting of a needs assessment among Georgian men who have sex with men (MSM) and capacity building for local NGOs, before the actual start of the pilot in 2017. In Central Asian countries, there seems to be less interest in PrEP, although the Ministry of Health of Kyrgyzstan is planning to start an evaluation on the possibilities of introducing PrEP in the country.

Challenges of introducing PrEP in EECA may include the cost of PrEP, but also the high levels of stigma and discrimination in some countries. However, with HIV incidence in EECA rising by 57% between 2010 and 2015, treatment alone will not stop the epidemic. Given its proven effectiveness, providing PrEP to key populations can be a significant step in controlling the explosive growth of the HIV epidemic in this region.

AFEW International Announces Culture Fund for the Students

AFEW International with the support of the Dutch Ministry of Foreign Affairs is announcing a Culture Fund for providing support to all sorts of cultural materials and exhibitions to address stigma and discrimination related to HIV, diversity and other related issues in general, and particularly in the EECA region.

Through the means of arts and culture, the Culture Fund will attract attention of the Dutch people and international community of policy makers, donors, stakeholders, researchers and clinicians who will visit International AIDS Conference in Amsterdam next year, to the issues, challenges and achievement of the EECA region in response to AIDS epidemic.

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

With our project, we address these barriers, and the Culture Fund will become a specific means to motivate arts and culture communities in the EECA region to attend the conference and thus attract attention of diverse groups of conference visitors including Dutch public to the EECA region and the current state of the AIDS epidemic and response to it.

Meanwhile, we are forming a Think Tank of talented and motivated people who will help us to develop Culture Fund concept; create detailed planning which will identify number of potential recipients of the funds for developing arts and culture pieces; determine criteria for selection of the ideas and initiatives submitted; develop management structure; describe activities and climax event(s); and plan for evaluation; and join coordination group to make it work.

We invite students who are based in the Netherlands to join our Task Force. By the 18th of April we expect to receive a A4 Letter with your vision of the Culture Fund. You can send your suggestions at info@AFEW.nl. More details on what to include in your letter you can find here.

Commentary: the Value of PrEP for People who Inject Drugs

Authors: Rosalind L Coleman and Susie McLean

Corresponding author: Rosalind L Coleman, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.

INTRODUCTION

HIV prevention is currently insufficient for many populations who inject drugs and who continue to bear a disproportionate burden of HIV. Across all regions, the prevalence of HIV for people who inject drugs is up to 50 times the rate of the rest of the adult population and people who inject drugs account for 30% of all new HIV infections outside sub-Saharan Africa. This inadequacy of HIV prevention is most prominently illustrated in Eastern Europe and Central Asia, where new HIV infections are up 57% compared with 2010 and more than half of these new infections are among people who inject drugs.

Pre-exposure prophylaxis (PrEP) can effectively prevent HIV when introduced in an enabling combination HIV prevention programme and chosen by people at high risk of infection. The integration of PrEP into public health programmes has been presented as an opportunity to strengthen HIV prevention for key populations when implemented in a context of linked action for human rights, supportive laws and violence prevention. PrEP is recommended as a choice for people who inject drugs by the American Centres for Disease control and in the recent WHO recommendation, but some critiques of the value and or effectiveness of PrEP for people who inject drugs are emerging, including from consultations with people who inject drugs. These consultations, co-ordinated by the International Network of People who Use Drugs (INPUD), brought together 75 representatives of people who inject drugs from 33 countries, predominantly from Eastern Europe and Central and Eastern Asia to discuss policy and programme considerations of PrEP in their situations. The implementation challenge is to design PrEP strategies that are context specific and differentiated for key populations in all their diversity, including for people who inject drugs.

The risk of HIV transmission for people who inject drugs exists in a context of other adverse health events and the high HIV rates reflect their broader health problems that include hepatitis C (HCV) and other blood-borne diseases, overdose, vein damage and tuberculosis. Much of the health risk associated with injecting drug use is exacerbated by poverty, inequality, criminalization, violence and discrimination.

WHO, UNAIDS and UNODC have defined and endorsed a range of harm reduction interventions to address and prioritize HIV and related health needs of people who inject drugs. Key interventions include needle and syringe programmes (NSP) and opioid substitution therapy (OST) to reduce unsafe injecting and manage drug dependency, as well as the promotion of condom use, facilitated access to testing and treatment for HIV and other sexually transmitted infections, TB, and HCV, and naloxone provision to prevent overdose, supported by appropriate information, education and communication interventions, and “critical enablers,” such as supportive laws, anti-discrimination interventions, interventions to make health services more accessible and acceptable to people who use drugs and anti-violence interventions. This set of interventions represents the formal list of evidence-based “harm reduction” interventions around which significant consensus lies as evidenced by their endorsement by international, regional and national organizations and governments. This harm reduction approach responds to a wide range of adverse health needs, is relatively inexpensive to implement and can have a high impact on HIV and HCV transmission, Despite this, only half of all countries that report injecting drug use provide OST and even fewer offer NSP. Where these interventions are available, they are often provided at an insufficient scale to have a public health impact.

Lack of scale of these evidence-based interventions results from a number of factors: lack of funding and prioritization, the design and delivery of services that are not targeted to reach key populations and structural barriers that prevent people who use drugs from accessing services. These factors shape the wider risk environments of people who inject drugs and constitute a form of structural violence, when associated with repeated incarceration; compulsory registration on official lists as drug users; and high rates of violence, police harassment, homelessness and poverty.

People who inject drugs will need to know about, believe in and value PrEP, alongside other interventions such as clean needles and OST. Without consideration of the sometimes violent and hostile environment in which these harm reduction services are delivered, people who inject drugs may not embrace PrEP and instead view it as a reductionist and potentially destabilizing intervention that could divert attention away from existing harm reduction services.

DISCUSSION

Concerns expressed about PrEP by people who use drugs underline the importance of identifying particular policy environments, geographies and sub-populations of people who inject drugs and their sexual partners for whom PrEP may be of value.

PREP AND HARM REDUCTION SERVICES

The people who inject drugs who were involved in the consultations agreed that, in a context where other key harm reduction services were in place, PrEP would be a desirable option for some people who inject drugs. It was felt, however, that in countries with the highest injection-drug-associated HIV burden, the reality was far from being realized. Respondents expressed opposition to any introduction of PrEP that was not part of an effort to strengthen broader harm reduction and social justice programmes.

Any new intervention, including PrEP, should strengthen broader health promotion and combination HIV prevention approaches, bolster any existent effective interventions and respond to the diverse needs of the population. A comprehensive combination HIV prevention programme includes condom and lubricant provision, immediate initiation of antiretroviral therapy and the offer of PrEP and also supports related interventions such as harm reduction programmes for people who inject drugs and voluntary medical male circumcision (VMMC) for men in eastern and southern Africa.

HIV prevention spending for key populations such as people who inject drugs in low- and middle-income countries is heavily dependent on international financing which is flattening while domestic funding for key populations is low. A change in donor priorities could destabilize existing harm reduction programmes if they compete for limited funding. This threat is intensified by weak policy and financial support by many governments who have permitted harm reduction programmes that are funded by external sources but who show no or limited commitment to funding harm reduction from national budgets when donors retreat. In contexts where harm reduction programmes are politically unpopular, PrEP could present a convenient and “magic bullet” intervention that allows governments to claim that they are addressing HIV prevention, whilst reducing funding and policy support for other evidence-based harm reduction interventions that people who inject drugs need and prioritize. The ethics of providing PrEP when HIV treatment access for people who use drugs is so poor was also questioned at the consultations.

In any situation, PrEP can only be economically and clinically effective when it is funded as part of an accessible and comprehensive HIV prevention and treatment programme.

PREP, DRUG USE AND SEXUAL TRANSMISSION OF HIV

People who inject drugs account for a disproportionate share of HIV burden whether attributable to injection drug use or in combination with sexual transmission. There is a complex and fluid interaction between the injection or other use of drugs and increased sexual HIV transmission risk. People who inject drugs report low levels of condom use. In Eastern Europe and Central Asia, where half of new infections are among people who inject drugs, 6% of new infections are among sex workers and one-third of new infections are among clients of sex workers and other sexual partners of key populations. Therefore, PrEP has possible value in the social and sexual networks of people who inject drugs where the incidence of HIV is high. These people might include the sexual partners of people who inject drugs, non-opioid drug users who also inject but for whom there is no established substitution treatment and others within the wider drug-using community who are unable to negotiate safe sex, including both women and men who inject drugs and who have sex with men, people who inject drugs and sell sex, transgender people and those who are vulnerable to sexual violence or exploitation. Given what we know of the overlap and double HIV burden of sex work and injection drug use, there is a need for synergy and a broad approach to harm reduction programming. This could include the offer of PrEP to address both sexual and injection-related health risks. The one trial of PrEP that was specific to people who inject drugs was not able to differentiate between the prevention of sexual- and injecting-related HIV transmission.

Consultations with these linked populations could identify additional situations where PrEP might be valuable. Some parallels may be drawn from the views of sex workers who also experience stigma and discrimination that prevents them from engaging with health services. A comprehensive literature search found an “enthusiasm” to use PrEP among sex workers in China, Peru, sub-Saharan Africa and the United States if it were to be distributed through user-friendly services and promoted with non-stigmatizing information and adherence support. This view is tempered with the caution that PrEP introduction should benefit sex workers and their immediate community and not be introduced only for the public health impact in the general population. For some, debate on PrEP promotion provides an opportunity to engage with policy makers on human rights.

This reaction found an echo from a North American INPUD consultation participant and emphasizes the notion that PrEP services should be in step with the varying needs and desires of the priority population for whom it is intended.

It is important to remember that people who inject drugs have the same sexual rights and sexual health needs as those in the general population and that in contexts where HIV transmission is at least partly driven by unsafe injecting in combination with risky sex, HIV prevention impact achieved for people who inject drugs can influence HIV transmission dynamics in the wider population.

PROVISION AND UPTAKE OF PREP

For all criminalized and highly marginalized (key) populations, an enabling environment where their voices can be heard, supported by legislation and zero tolerance for violence, is vital to meet HIV prevention targets and ameliorate many other adverse health events. Where these conditions are still lacking, their absence is a huge constraint to achieving better health and quality of life. Without them, improved services can remain under-utilized and inefficient since key populations will often remain underground for fear of arrest or violence. A person’s request for PrEP can require the disclosure of sometimes illegal and risky practices, along with repeated contact with sometimes hostile health services. In conditions such as these, people who are at substantial risk of HIV exposure and who could benefit from PrEP are unlikely to seek it for fear of discrimination, breaches of privacy, criminal sanctions or other threats.

The history of rights-based health interventions, including for people who inject drugs, has advanced through a series of small victories. The requirement to attend to the context, practices and priorities of key populations applies to all HIV programme implementation, and the emergence of interest in PrEP presents an opportunity to examine these factors more deeply. Current focus and debate on PrEP implementation provides an opportunity for people who inject drugs who are interested to shape the development and design of PrEP services. Health planners and decision-makers will need to engage with people who inject drugs and their sexual partners in order to understand their interest in PrEP, and how any such interest can be integrated with broader prevention services and, for example, the need for drug dependency treatment, overdose treatment, HCV and HIV treatment and the need for protection from human rights violations.

CONCLUSUIONS

PrEP is best understood as an additional potential HIV prevention option for some people who inject drugs and their sexual partners in specific circumstances. The challenge is to ensure that the potential of PrEP is not undermined by narrow and overly biomedical understandings of its value, removed from the real lives of those most at risk of HIV exposure. Harm reduction programmes are intended to address a range of interests and needs, and it is likely that harm reduction programmes could be an effective implementation platform for PrEP for people who inject drugs. (From data and experience of using the medicines in HIV treatment, no interaction is expected between PrEP containing tenofovir/emtricitabine or tenofovir/lamivudine and heroin, methadone or methamphetamine).

PrEP can be an opportunity to harness a specific intervention for longer term public health and human rights outcomes. PrEP will realize its HIV prevention potential if it is introduced in a way that complements and strengthens existing harm reduction and health promotion activities, if it contributes to reducing discrimination and empowers key populations at risk of HIV infection. Creating opportunities to hear from and engage with people who use drugs about their interests, needs, values and preferences regarding HIV prevention, alongside wider health and other needs, is a priority for health programmers and decision-makers. These are some of the factors that will ensure the potential of PrEP for people who inject drugs is realized in a variety of real-world settings.

Full abstract & sources: www.jiasociety.org

Beyond Resistance: Drugs, HIV and the Civil Society in Russia

The speech given by Anya Sarang, the President of the Andrey Rylkov Foundation, at the side event Reducing the harms of drug control in Eastern Europe and Central Asia which took place during the 60th annual meeting of the Commission on Narcotic Drugs on 17 March 2017 in Vienna. 

In 2016 the UNAIDS reported that the HIV epidemic has been taken under control in most countries of the world. The countries of Eastern and Southern Africa have reached a 4% decline in new adult HIV infections, the rates of which were also relatively static in Latin America and the Caribbean, Western and Central Europe, North America and the Middle East and North Africa. At the same time, the annual numbers of new HIV infections in Eastern Europe and Central Asia increased by 57% with Russia responsible for 80% of the new cases. There are only a few countries in the world where HIV keeps rising, and Russia has the fastest rate. According to the Federal AIDS Centre, around 300 people get infected, and 60 people die of AIDS every day. As of August 2016, the number of registered HIV cases was 1,060,000 while the estimates go beyond 3 million. And according to the Ministry of Health, only 28% of patients in need receive antiretroviral therapy.

The main group affected by the HIV in the country is people who inject drugs (PWID). From 1987 to 2008 about 80% of HIV infections were related to unsterile injections and still in 2015 almost 55% of the new cases are among drug users.  Since the beginning of the epidemic, over 200,000 people with HIV have died, the primary cause of death being co-infection with tuberculosis. According to WHO, Russia is among top countries with the highest burden of TB including its multidrug-resistant forms.  Another deadly co-infection is hepatitis C: its prevalence among people who use drugs reaches 90% in some cities. And drug users are entirely excluded from any treatment programs.

The reason for such a dramatic dynamic in public health is the Russian government’s failure to address the HIV epidemic, especially among the people most affected. The Russian government is notoriously negligent to the issue of HIV, vigorously adherent to the most repressive and senseless drug policies and openly resistant to evidence-based internationally recommended harm reduction programs and opioid substitution treatment with methadone and buprenorphine. The government not only fails to provide the financial support to these programs, it explicitly opposes them in the State strategies, such as the National drug strategy. At the same time in the past several years, the international support to HIV prevention has also dramatically shrunk. Due to the aggressive line of the Russian government towards the international aid and unkept promises to allocate own resources towards the epidemic, most international donors have left the country. That resulted in 90% decrease in the coverage of needle and syringe programs. Back in 2009, we had 75 harm reduction projects reaching out to 135.000 clients, and in 2016 there are only 16 projects to reach out to 13.800 individuals which is less that half percent of the estimated number of people who inject drugs. These few remaining projects are supported by the Global Fund to Fight AIDS, tuberculosis, and malaria, but even this symbolic support expires by the end of this year, and there are no new sources on the horizon.

To make the situation even more tragically absurd, in 2016 the Russian government started to attack non-governmental organizations that provide prevention services to people who use drugs and to LGBT. In one year alone, eight AIDS organizations were registered as “Foreign Agents” based on the fact that they receive funding from the Global Fund. Inclusion into the list means four times more reporting, expenses for administrative work and increased risks of fines and administrative charges. It also means that the organizations will not be able to receive any money that comes from the governmental sources.

All of the above has created the situation when the AIDS Service NGOs are blocked from the potential governmental funding while at the same time, most international donors have terminated their support to the Russian NGOs. Some donors, including USAID and several UN agencies, had to cease their operations in Russia due to the government pressure, a supporter of advocacy and human rights initiatives in the area of public health, the Open Society Foundations have been blacklisted by the authorities. But many potential donors also believe that a) situation in Russia is hopeless, and there is no way to improve and b) that their support may exacerbate the risks for the NGOs. Our organization believes that its necessary to provide more truthful information to the international partners about the situation in Russia and possibilities to express support and solidarity.

Our team works since 2009 providing daily health services on the streets of Moscow to people who use drugs. We do outreach work to sites where drug users get together, where we give our HIV prevention materials: sterile needles and syringes, condoms, rapid tests for HIV and Hep C, peer counseling, and support as well as referral to various health institutions. We see from 10 to 30 people daily, and last year alone almost three thousand people contacted our small service. We carried out more than 300 consultations on HIV and hepatitis, and in the last three years, we received reports of 735 lives saved with Naloxone we provide to the clients to prevent deaths from overdoses. We also run a street lawyers project, helping drug users to stand for their rights and dignity, providing them with legal skills and empowerment to represent their interests in courts and state institutions. We have a team of 4 lawyers and around 20 social workers and volunteers. We also provide secretarial support to the Forum of people who use drugs in Russia and facilitate documentation and submission of reports on human rights abuse to the state parties as well as the international human rights bodies. Several strategic litigation cases that came out of the Forum’s work aim to improve the legal context in Russia with regards to access to health and justice, including a case currently under review by the European Court of Human Rights on lifting the ban on opioid substitution therapy in Russia and in Crimea.

In 2016 our organization has been registered as a Foreign Agent, and we were subjected to a fine for not volunteering ourselves into the registry. There was some skepticism concerning our ability to continue the work with this status, but we didn’t want to lose our services because of the bureaucratic inadequacy of the Ministry of Justice. We have challenged their decision in court which surprisingly supported us by finding the Ministry’s decision illegal and lifting the fine. We are still listed as a Foreign Agent, but we also fight this decision by the legal means including, if necessary in the European Court of Human Rights. With the help of our partners and supporters, we have generated a fiscal security fund to sustain our work in case of financial sanctions on behalf of the Ministry. We have also received a lot of support for our cause from the mass media and the general public, including the recently started parliamentary debates on the inadequacy of application of the Foreign Agents law to the AIDS prevention NGOs.

Our experience and the experience of like-minded organizations demonstrate that it is still possible to provide AIDS and drug services in Russia, even in the context of political suppression of the NGO work. The only and the most important condition is the commitment to the protection of rights and health of our community. We are learning by doing and hope to develop creative approaches and a practical model of operations for organizations or groups who find themselves in similar politically restricted circumstances not only in Russia but other countries of our region.

We believe that the western NGOs and governmental organizations should not ‘give up on Russia.’ In fact, now more than ever we need the support and solidarity to continue our work and keep saving lives, health, and dignity, despite the political oppression.

Roman Dudnik: “People with HIV and Tuberculosis are the Same as We Are”

A photo exhibition dedicated to the World Tuberculosis Day will be opened in Almaty, Kazakhstan on March 18. The purpose of this exhibition is to show that people living with HIV or tuberculosis are the same as everyone else. This exhibition is one of the first important public events held by AFEW-Kazakhstan in 2017. We are talking about this and discussing other plans for this year with the executive director of AIDS Foundation East-West in Kazakhstan, Roman Dudnik.

– How was the year of 2016 for you? What were the new and exciting things that happened?

– Even though the year of 2016 was difficult, it was successful for us. We moved to a different office. Before, we were in the small office building. Now we are in the new building with much more space. The repairs were made based on our requirements, using our colours. There is a very good energy here, and it helps to work good.
In 2016 we finished the first part of the project HIV React that is financed by USAID/Central Asia, and we got the extension for the next three years. This is our main project. It is regional: we work in Kazakhstan, Kyrgyzstan and Tajikistan. Being the part of this project, we are working in preventing HIV among injecting drug users in prisons. We also work with people living with HIV who are getting ready to be released, and those who are already released. With specially developed START plus program, we prepare a person for his release two months before it happens, and then continue to work with a person for another four months after the release. Additionally, we train medical and non-medical staff of correctional facilities and employees of non-governmental organizations. This program is unique and does not work in many countries of the world. All efforts are aimed at preventing HIV infection and supporting those who live with HIV. The main goal, of course, is to encourage a person to get tested for HIV. If the test is positive, then we send a person to the AIDS centre, and we motivate him to start treatment with antiretroviral medicine, if necessary. We also help to restore needed documents, find jobs, renew social connections. This program is unique because it has a human face. We are aimed at a specific person, at solving of his or her problems. We also try to form skills so that people can solve their problems in the future themselves.

– Working in three countries in Central Asia with the same groups of population in HIV React project, can you observe the common tendencies?

– The general trends in all three countries are that HIV in places of detention exists, and the number of new cases of HIV transmission is increasing. Convicts is the group that requires intense attention and constant work. There is a very high level of stigma from prison staff. Of course, the reason for this is a lack of information, and this is what we are trying to correct through the trainings. The most successful project is implemented in Kyrgyzstan, where the criminal executive system is more open and sympathetic to such activities. In Kazakhstan and Tajikistan it is a little more difficult, but despite this, we manage to work and implement all planned activities within the framework of the project.

– Besides this, what were other projects that you worked on in 2016? 

– Since January we started with the new City Health project with the financial support of the Global Fund, where the main grant recipient is the International Charitable Foundation “Alliance for Public Health”. The project works in five cities of the EECA region. We are responsible for work in Almaty. Implementing this project, we will involve the city administration in the prevention of HIV infection among vulnerable groups: injecting drug users, men who have sex with men, and sex workers. We plan to create a city council on HIV/AIDS. We know that the project is not simple, but it is interesting for us. For Almaty, the project is very important, since it is the most populated city in the country, and the problem of HIV infection is especially relevant here. It will be important for us to make this a successful model and to duplicate this experience to other cities and countries.

– A year ago you had a school of tolerance, the goal of which was to reduce stigma on the part of health care providers. Please, tell us if you can see the results of this school?

– It is difficult and too early to talk about the results. Stigma and discrimination are big problems for Kazakhstan and whole Central Asia, and this is one of our main areas of work. One school of tolerance cannot solve this issue. Without any doubt, there is a big difference in how people come to the training, and what they think after three or five days of the training. In our training, we focus on the personal qualities of a person, perform the situations when the participant himself acts as a client or the representative of a vulnerable group, and is experiencing everything what the client is experiencing by himself. Human intolerance was formed long ago, and one year of work cannot change it. Nevertheless, there is already some progress in this field.

– On the 18th of March you will have the photo exhibition dedicated to the World Tuberculosis Day. Please, tell us more about it.

– The exhibition is intersecting with the topic of stigma and discrimination. We invite everybody to come and see it. It will be held from 18 to 31 of March in the gallery June 24. During the exhibition, there will be master classes, lectures, and talks with people who are depicted on the photos. On the photos, there are 15 Kazakhstani people who live with HIV, or who were cured of tuberculosis. The name of the exhibition Life in the Shadow speaks for itself, because due to the human ignorance, the heroes of our photos should hide their diagnosis from others and live with their problem alone in fear. Now they have opened their faces for the exhibition and they are not afraid to share their experiences. By each photo, there is a written piece with the story of the person: what he was going through, what he was thinking about. The purpose of the exhibition is to shed light on everyday life of people affected by HIV and tuberculosis. They are just like us. The only difference is that they know their diagnosis and they have to fight for their health. Myths and prejudices about HIV and tuberculosis make them hide this part of their lives. Although, the understanding and support of others is what helps them to defeat the disease. The exhibition is positive; people are smiling on the photos. We made only colour photos that show people in everyday life: in the flower shop, in the metro, during painting. During the exhibition, we will tell the visitors about HIV and tuberculosis, tolerance. We will also distribute flyers with the information about where you can bring, for example, bags with clothes that are no longer needed and help people who live with HIV in such a way.

– Even though it is almost the end of the first quarter of 2017, I still would like to ask you about the plans of AFEW-Kazakhstan for this year.

– We plan to work with our projects further. In April, we will be having big regional training about gender violence. We already invited a very good professional in this field to be our trainer. This is a new topic for us, and everything new is interesting for us.

Looking for the Consultant for the Cities TB/HIV Regional Project

LogoAFEW3Consultant for the development of a situation assessment tool in the framework of the Cities TB/HIV Regional project, funded by the Global Fund

It is well known, that the HIV/AIDS epidemic in Eastern Europe and Central-Asia is still driven by most affected key populations, which are concentrated in urban areas. On average, the share of representatives of key population among all PLHA is assumed to be up to 70 percent, while the majority of them are PWID (about 80% of all HIV-infected representatives of key populations). Despite the paramount role of key populations in the development of HIV epidemics in the region, reaching them with key services remains low. The overall coverage of essential HIV prevention services of PWID, sex workers (SW) and men having sex with men (MSM) in Bulgaria, Georgia, Kazakhstan, Moldova, and Ukraine is around 40% (at the level of 50% for PWID and SWs and 16% for MSM).

City level data reveals that from about 18,000 PLHA 5,665 are receiving ART, which corresponds with 20% coverage in Almaty, 22% in Beltsi, 29% in Odesa, 54% in Sofia and 82% in Tbilisi. Given the overall low access to ART, access of key populations is assumed to be even lower, but data is largely unavailable. Out of 5 project cities only Almaty and Odesa could provide disaggregated data on ART access by key population.  Similarly, the results of TB and MDR treatment in the 5 project targeted cities are poor, with low treatment success even for new TB cases and relapses, not reaching the targeted 90% (highest in Almaty – 85.4%, lowest in Odessa – 54.2%), while the MDR TB treatment outcome is even worse, from extremely low in Odesa (47.5%) to 69.9% in Almaty.

Three main areas of programmatic/other gaps have been identified as handles for strategy development and interventions in the proposed regional project for selected cities:

  • Programmatic and data gaps: reaching key populations, HIV and TB treatment cascade gaps; low treatment efficiency and effectiveness, increase of MR-TB and repeated treatment cases; slow transition to the patient-oriented model of health care delivery and to out-patient ambulatory care; weak integration between HIV and TB services; gaps in essential city level data.
  • Political, governance, partnership gaps: lack of political will to address health issues in key populations and promote human rights and access to services by these key groups.
  • Financial gaps: sustainability of the HIV/TB responses is a major threat to programs for key populations in EECA.

Aims and objectives of the Cities TB/HIV Regional project

The goal of the project is to develop models of sustainable city responses to HIV and TB in key populations in EECA that significantly contribute to achieving 90-90-90 HIV/TB targets for key populations. The goal is supported by the following four objectives:

  1. Development and implementation of a model for key populations for the ’90-90-90’ targets of the HIV and TB response in selected cities of the EECA region.
  2. Establishing effective partnerships between municipalities and NGOs/CSOs in selected EECA cities.
  3. Ensuring sustainable allocations of municipal funding for key population programs in project cities.
  4. To increase knowledge management and popularize city responses on HIV and TB in cities of the EECA region and globally.

Project will be implemented in 5 cities in 5 countries: Almaty (Kazakhstan), Beltsi (Moldova), Odesa (Ukraine), Sofia (Bulgaria) and Tbilisi (Georgia).

The project is implemented by the Alliance for Public Health (APH) as lead agency, together with AFEW International and Licit.

One of the planned activities is:

Situation Assessment tool development and training on its use

At the beginning of the project, a needs or situation assessment will be carried out in 5 project cities aiming at identifying particular HIV/TB key populations needs, services, data gaps, barriers to access and sustainability of services resourcing.

Terms of Reference:

Job Location:

  • In Europe, Eastern Europe and Central-Asia

Period and duration:

  • Starting date 13 March 2017
  • A first outline of the tool should be ready by 30 March 2017
  • Provide an update of data every 1 week
  • The final version of the tool should be ready by mid-April 2017
  • A training in how to use the assessment tool in the second part of April 2017
  • A workload of 20 working days is expected

Overall Job Objective:

The development of instruments for the assessment with broad consultations with the project partnership and a training provided to implementers on how to use it. Specifically, the assessment addresses improvements in city data systems, availability of population size estimates and their mapping, improvements in city cascade information, HIV, TB, prevention, treatment, health and social integration, human rights of key populations, legal issues, city and country drug policy, accessibility to existing services, existing coordinating bodies and city governance, role and practice of law enforcement, attitudes of media, programs and their resourcing and potential areas for cost optimization.

Description of core responsibilities and tasks:

– collect information and results from assessments done by ECUO’s regional EECA project looking at challenges in transitioning from one stage of cascade to the other
– collect information and results from the situation assessment methodologies on the combinations of services available and the level of funding for interventions within the EHRN regional project
– identify relevant sources for HIV and TB data at national and city level
– consult with the project partners about the relevant topics, the sources and how to do the assessment
–  identify software to be used for mapping the data
– write a comprehensive tool to conduct the assessment
– train contact persons on how to use the assessment tool

Requirements

– Epidemiology and/or research background at university level
– Knowledge about HIV and TB in Eastern Europe and Central-Asia
– Familiar with the governmental and non-governmental landscape in EECA
– Speaking and writing in English and Russian

Contacts/Key Relationships:

–            Project partners
–            AFEW International for reporting and updating

Please, send your application to Anke van Dam’s email: anke_van_dam@AFEW.nl. The deadline is 15 March.

Dutch Students will Learn about HIV in EECA

TV_screen_stillOn March 28, 2017, AFEW International and WEB.foundation are jointly organising the Culture Cures & Kills II symposium  in de Tolhuistuin in Amsterdam. The symposium will focus on the role of culture in prevention, treatment and care of HIV in Eastern Europe and Central Asia (EECA).

The programme is designed with and by students from different fields of study. The aim of the conference is not only to increase students’ awareness about the successes and challenges to address the HIV epidemic in EECA but also to link students to the International AIDS Conference of 2018 in Amsterdam, and explore opportunities for future research.

Students who are based in the Netherlands, can get their free tickets to symposium here. Please, mind that the seating is limited!

You can find the timetable of the symposium here.

You can find the information about the workshops of the symposium here.

AIDS Foundation East-West becomes AFEW International

ImprimirAIDS Foundation East-West, an international network of civil society organisations that is dedicated to improving the health of key populations, has changed its name to AFEW International.

A new logo and communication strategy have been created, and now they are part of the organisation’s identity. “With this new name we keep the recognisability and our brand as many partners in the field already know us,” says the executive director of AFEW International Anke van Dam. “With the new name we also acknowledge that we do more than HIV and AIDS. AFEW has built a track record for projects on TB, viral hepatitis and sexual and reproductive health and rights as well. AFEW strives to social inclusion of the key populations at risk and a healthy future of Eastern Europe and Central Asia!”

AFEW is dedicated to improving the health of key populations in society. With a focus on Eastern Europe and Central Asia, AFEW strives to promote health and increase access to prevention, treatment and care for major public health concerns such as HIV, TB, viral hepatitis, and sexual and reproductive health.

AFEW International is an uniquely positioned organisation as one of the few HIV, TB, hepatitis and sexual and reproductive health and rights organisations working in Eastern Europe and Central Asia. This is a region where the work is critical, as HIV and sexually transmitted infections are on the rise, sexuality education is deficient and gender-based violence goes largely unrecognized. Further, cases of multidrug resistant and extensive drug resistant tuberculosis are increasing; and there is a very high prevalence of hepatitis C. The group with the highest risk for HIV and HIV related diseases are people who use drugs. However, transmission through sexual contact is increasing and the prevalence among women and men who have sex with men is increasing.