Civil Society of Kyrgyzstan in the Fight for Availability and Affordability of Medicines

Director of the Partner Network Association Aibar Sultangaziev

Author: Olga Ochneva, Kyrgyzstan

Kyrgyzstan is gradually switching to state drug provision system. Some of the tuberculosis medicine will be purchased out of the budgetary funds this year, and some of the antiretroviral (ARV) medicines – starting from the next year. Respective financial resources are planned to be allocated in the budget. At the same time, the question regarding the national legislation remains. A number of important documents is currently under the review. We discussed how these documents consider patients’ needs as well as the results of the analysis regarding the availability of medicines for HIV, hepatitis C and tuberculosis treatment with Aibar Sultangaziev, the representative of public council at the Ministry of Health and the Director of the Partner Network Association.

– Your organization and you personally are actively researching medicine availability and affordability. What are your successes so far?

– We started our work in 2009 with the issue of intellectual property. A respective study was conducted and, on the basis of the facts of high cost on brand medicines used for hepatitis C treatment, we advocated for the amendments to the Patent Law. In 2015, the Law was adopted; it also included the flexible provisions of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). Due to this, it became possible to bring more generic medicine into the country. To date, seven medicines have been registered. We keep the cost of hepatitis C treatment at the lowest level in the region: from 615 US dollars for a 12-week course.

Back then, the legislation lagged far behind the needs. We developed an intra-organizational strategy for ensuring the availability of medicines and started to work in several directions. In 2014, we approved the clinical guidelines for the treatment of hepatitis C that became a clinical protocol in 2016 that included a full range of medicine available within the country. Hepatitis C treatment was added to the State Program on HIV/AIDS, and from 2018 onwards, 150 people living with HIV (PLHIV) will receive it free of charge annually. We participated in the revision of protocols on HIV treatment, and now they include modern and inexpensive medicine, such as dolutegravir, darunavir, rilpivirine.

– The Essential Drugs List (EDL) is currently undergoing a revision. It is an important document related to the availability and affordability of medicines and holding public procurement. Did you participate in its elaboration?

“For the availability and affordability of hepatitis C treatment!” Campaign on amendments to the Patent Law

– In 2015, we conducted a study on five diseases: HIV, tuberculosis, hepatitis C, oncological diseases, conditions after transplantation, and found out what medicines for their treatment were registered in the country or included to the EDL and clinical protocols. We identified the differences between the WHO recommendations and the situation in the country, and then submitted a List of necessary medicines to the Ministry of Health (MoH). All of them were added to the EDL and will be approved soon after several amendments to the Law on Circulation of Medicines are introduced. By the way, the Law provides a List of medicines that can be imported and used in the country without registration. This List is used for socially significant diseases, and, as part of the working group of the MoH, we are currently working to determine the procedure for its formation.

– Will it allow the pharmacological companies not to register medicine in Kyrgyzstan?

– Registration is needed. However, in cases when the government urgently needs medicines that are not available on the market, it will be possible to legalize them by the decision of the commission without registration. Of course, there are criteria: medicine must be of high quality, prequalified by the WHO, etc. This list already exists. Last year in November, together with UNDP, (the organization manages grants of the Global Fund in the country – author’s remark), we submitted a list of 12 essential tuberculosis and antiretroviral medicines for the Ministry of Health to consider the possibility of importing them. This is a matter of political will and one commission’s meeting, but there has been no progress with the documents yet. That is why we are preparing a new regulation so that another commission could formalize it via a new procedure.

– Does it mean that practically all conditions for public procurement are in place?

Activists’ campaign to support the amendments to the Patent Law allowing the import of generic medicines to the country

– A lot has been done but the risks still remain. We have to make every effort to regulate the process by autumn. The point is that this year the state’s responsibility is to purchase 10% of second-line tuberculosis medicines, none of which has yet been registered in the country. In 2019, the state should purchase 20% of the required amount of ARV medicines, and in 2020 the share will increase up to 30%. Not all pharmacological companies enter the national small market, and those that do, inflate prices. We are determined to promote the possibility of medicine purchase through international mechanisms. For example, if Kyrgyzstan purchases medicines through UNICEF, one can expect a 5-7-fold decrease of the cost since UNICEF places a single long-term order that covers several countries with the medicine producers.

– What other plans do you have and what is the ultimate goal of your work?

– We carry out constant monitoring of procurement. Price regulation remains one of the priority tasks. We want people to have unhindered access to inexpensive and effective treatment, and the state to provide medicines for socially significant diseases.

Persecution and Activism of Sex Workers in Kyrgyzstan

Author: Olga Ochneva, Kyrgyzstan

For almost a year and a half, law enforcement agencies have been persecuting sex workers in Kyrgyzstan. During this period, the number of sex workers receiving HIV prevention services in some regions of the country reduced twice. Civil society organisations registered more than 450 cases of sex workers’ rights violations by the police every year.

Extortion, detentions, and threats

In 2017, 81% of all reports of abuse and human rights violations submitted to the Shah-Aiym Sex Workers Network were complaints against police officers on extortion. Shah-Aiym documents such cases with the support of Soros Foundation-Kyrgyzstan and street lawyers of public associations all over Kyrgyzstan within the framework of the Global Fund via Soros Foundation-Kyrgyzstan. Both sources recorded 475 cases of sex workers’ rights violations by law enforcement agencies in 2016 and 459 cases in 2017. Most often, those are cases of extortion, arbitrary detention, threats, blackmailing, pressure and degrading treatment.

“The wave of mass raids started in mid-2016 when City Directorate of Internal Affairs in Bishkek announced that it was going to “clean the city by getting rid of prostitution.” They even asked local people to conduct night raids, make photos of sex workers and pass such photos on to the policemen,” tells Shahnas Islamova, head of NGO Tais Plus. “At first, press service of the Chief Directorate of Internal Affairs was reporting detentions, not even hesitating or not understanding that they were, in fact, announcing unlawful acts of the law enforcement agencies.”

In Kyrgyzstan, sex work is decriminalized, which means that it is neither an administrative nor a criminal offense. To punish sex workers, law enforcers use other provisions of the Administrative Offences Code. Most often, sex workers are detained for alleged disorderly conduct or petty crimes.

“Sex workers try to avoid court proceedings: they buy off. There are some cases when law enforcers know what a girl does to earn her living and start blackmailing her. They threaten to take photos of the girls, tell their relatives about their occupation or take them to a police station, so the girls agree to pay: the standard charge is up to 1,000 soms ($15),” tells Alina (the name is changed), a street lawyer of a civil society organization. “If girls try to defend their rights, law enforcers find other ways to detain them: they draft reports of disorderly conduct or failure to obtain registration. Those who have bad luck or are not able to buy off may be arrested for three to five days.”

According to Alina, many sex workers have gone underground: they often change their rented apartments and phone numbers. Such situation in some regions of the country hinders the access of NGOs to sex workers to conduct HIV prevention interventions: distribute condoms, offer testing, conduct awareness-raising activities, and consultations.

“Since the start of the “purge”, our organization has been monitoring the dynamics in the coverage of sex workers with prevention programmes in Bishkek,” says the head of Tais Plus NGO. “In a year and a half, the coverage has reduced twice, and in the second quarter of 2017 the actual indicator went down to 39% of the planned coverage.”

Activism in the challenging environment

Mass raids of 2016-2017 echoed almost in every region of the country. Groups of people who explained their actions with the “religious motives and interests of the society” helped law enforcers in their “fight” against sex workers. As the end of 2017 approached, things calmed down: sex workers got used to the new conditions, while the pressure from the side of police weakened a bit and the mass raids ended. However, “police marks” stipulating sex workers paying money to the law enforcers for the so-called “protection” and “permit to work” are still there.

“Currently, in most cases pimps are the ones to keep contact with police, while there are almost no girls who work on their own,” says Nadezhda Sharonova, director of the Podruga Charitable Foundation about the situation in Osh. “Recently, our street lawyer has been more and more often reporting complaints of sex workers against their pimps who beat and blackmail the girls.”

Despite the fact that civil society organizations in Kyrgyzstan offer legal support, sex workers rarely report their offenders. Representative of the Tais Plus NGO thinks that this fact is easy to explain: to go through all the legal prosecution process, one needs boldness and strength as well as certain savings – not to cover the legal expenses, but to be able not to work for a while and keep out of the law enforcers’ sight.

At the same time, the sex workers movement is growing and becoming stronger. The Shah-Aiym Network unites sex workers in Kyrgyzstan, Tajikistan, Russia. The network documents human rights violations and provides support to the victims of human rights violations, actively protects the interests of sex workers’ community and publicly campaigns against violence towards sex workers. The network ensures conditions for strengthening activists’ capacity to claim and defend their rights.

“We have seen cases when sex workers defend themselves,” says Shahnas Islamova. “For instance, at the court hearings on administrative offenses some sex workers now openly say that they are engaged into sex work and do not violate any laws, while the police has violated the law when detaining them. As a result, such sex workers have left the courtroom free from any accusations.”

Bridging the Gaps in Clinical Guideline to Care in Pregnancy for Women Using Psychoactive Substances

All the regions of Kyrgyzstan already received the developed clinical guideline

The estimate number of people who use injected drugs (PWID) in Kyrgyzstan is about 25,000 people. Many of these people are women. Such is the data from the research that was conducted within the framework of the Global Fund’s grant in 2013.

Applying recommendations in practice

In 2016, Public Fund (PF) Asteria, a community based organisation that protects rights of women who use drugs in Kyrgyzstan, applied to AFEW-Kyrgyzstan seeking for a help in developing a clinical guideline to care in pregnancy for women who use drugs. Within the framework of the project Bridging the Gaps: health and rights for key populations, AFEW-Kyrgyzstan decided to support this initiative as there were no modern standards for working with women who use drugs in the country before. A working group that included an expert in narcology, an obstetrician-gynecologist, an expert in evidence-based medicine, and a representative of the community of women who use drugs was created. In January 2017, the clinical guideline “Care in pregnancy, childbirth and the puerperium for women who use psychoactive substances” was approved by the order of the Ministry of Health and became mandatory for doctors’ use.

“When the guideline was approved, we realized that it is not enough to simply distribute it among the doctors. It was necessary to organize a comprehensive training for the family doctors, obstetrician-gynecologists and other specialists so that they could not only apply the developed recommendations in practice, but also share their experience with their colleagues,” said Chinara Imankulova, project manager of the Bridging the Gaps: health and rights of key populations at AFEW-Kyrgyzstan.

In April 2017, trainings were organized for the teachers of Kyrgyz State Medical Institute for postgraduate students. The manuals for teachers with presentations have been developed so that in the future trained teachers could deliver reliable information to the course participants. This approach gives an opportunity to train all healthcare professionals in the country and provides them with an access to the protocol.

In August 2017, trainings were offered to obstetrician-gynecologists of the centers of family medicine and obstetrical institutions. During the trainings, specialists got acquainted with the latest research in this field, studied the peculiarities of pregnancy, prenatal and postnatal period of women, who use drugs, as well as ways to avoid or minimize the risks of drug exposure to women and children.

“Two or three years ago, when our pregnant women who use drugs visited doctors, they were afraid that doctors would force them to have an abortion. In September 2017, our client Victoria, who at that time was on methadone therapy, visited the obstetrician-gynecologist. Victoria gave birth to a healthy girl, and doctors treated Victoria and her child very well. Moreover, the doctor even helped Victoria to get methadone so she could spend enough time in the hospital for rehabilitation after the childbirth,” said Tatiana Musagalieva, a representative of PF Asteria.

Women should not be discriminated

During the trainings, 100 specialists who are working in the republic of Kyrgyzstan were trained. Doctors from the regional centers were also invited for the training. It is very important to provide access to quality medical services for women who use drugs in the rural areas. Doctors also learned to get rid of their stigma towards women who use drugs and always treat them with respect. A class on stigma and discrimination was taught by women from the community of drug users. They told the participants of the training their stories, talked about how difficult it was when doctors refused to treat them or insulted them. This part was useful in reducing stigma and discrimination among doctors, in showing them that women who use drugs are just like the others.

“Before the training I met several pregnant women who use drugs. To be honest, I was not sure that they could give birth to healthy children. Having received the clinical protocol, and with the knowledge I have got in the training, I realized that these women should not be discriminated. I learned about scientific recommendations for conducting pregnancy in the situations that cannot do harm to either mother or child. This helped me a lot,” said the participant of the training, obstetrician-gynecologist Kaliyeva Burul.

All the regions of the republic already received the developed clinical guideline. Doctors who have been trained, share their experiences with their colleagues and help women who use drugs to safely plan their pregnancies and give births to healthy children. AFEW-Kyrgyzstan continues to monitor the work of specialists who have been trained, and monitors if all health specialists have access to the guideline. In the future, AFEW-Kyrgyzstan will continue to work on improving the quality of life of people who use drugs, and will monitor the usage of this protocol by doctors.

In Kyrgyzstan, Fines for Drug-Related Offences will Grow 30-Fold

Street lawyers of the Ranar Foundation provide legal counselling to people who use drugs

Author: Olga Ochneva, Kyrgyzstan

Kyrgyzstan has adopted new legislation on drug-related crimes. Amendments have been introduced into a number of national legal codes within the broad judiciary reform in the country. The amendments will come into force starting from 2019. Initiators of the reform declare the ideas of humanisation and decriminalisation, but the practitioners and the community expect an opposite outcome.

Unaffordable fines or imprisonment

Aybek (the name is changed) has recently been released from jail. He spent three years behind the bars for 3.5 grams of hashish, which he bought for his own use.

“In 2014, Aybek was caught with drugs and was told to pay a fine of 30,000 Kyrgyz Soms (375 euros) and was let go. Soon, he was seized again for a similar offence. The fine was left in force and in addition, Aybek was sentenced to three years of imprisonment,” the street lawyer of the Ranar Foundation Denis Kucheryaviyis telling. “Now Aybek lives in our social dormitory. He has no passport and he has no job. During his years in prison, he was able to pay only 30% of the fine. He has been told he cannot get his passport unless he pays the whole sum. How can he find a job with no documents? Recently, we learned that he was put on a wanted list due to his failure to pay the fine, so now he faces the threat of imprisonment again.”

According to the Criminal Code currently in force, possession of drugs with no intent to sell in big amounts exceeding one gram for heroin and three grams for hashish is now punished with a fine of 250 to 650 euros or with imprisonment for a term of up to five years. In the new Criminal Code, the fines will be increased up to 3,250-3,750 euros.

“There will be a huge increase in fines. The minimum fine will be 3,250 euros. Will a person injecting drugs be able to pay such a sum at least once in his life?” asks Sergey Bessonov, Executive Director of the Harm Reduction Network Association. “An alternative to paying the fine is deprivation of liberty for up to five years, though the fine will not “disappear” completely and will only move to another category of 1,250-1,750 euros. Now Aybek does not know how to pay 375 euros, and starting from 2019 people will be released after years in prison with fines, which will be 3-5 times higher.”

Humanisation or criminalisation

Fines for the small amounts of drugs (up to 1 gram of heroin and up to 3 grams of hashish) will also be increased. The administrative fine will grow 30-fold: from 12-25 euros to 370-750 euros.

Sergey Bessonov: “We need alternative punitive measures and effective treatment programmes”

“The punishment for the small amounts of drugs will be toughened in the Code of Administrative Offences depending on the number of similar offences during a year. For the first offence, the fine will amount to 2,000 Kyrgyz Soms (23 euros); for the second offence, an administrative arrest for five days will be applied; for the third offence, the fine will amount to 650 euros. In the new Code of Offences, the punishment will not be toughened and there will be no criminal record. Probably this is what the humanisation is about,” assumes Sergey Bessonov. “However, if we look at the practice, most people are seized with the amount of heroin 1.2 -1.5 g which is considered to be a big amount and falls under provisions of the Criminal Code. After the fines are increased, there is a probability that the number of people seized with small amounts of drugs will be growing. The worst thing is that violation of the Code of Offences may also lead to the imprisonment in case if the fine is not paid on time. A person will have two months to pay 370 euros. After this term, the fine will be doubled and the payment period will be extended by one more month. After this month is over, if the fine is still not paid, article 351 of the Criminal Code will come into force meaning from 2.5 to 5 years of imprisonment.”

Currently, Sergey Bessonov and the lawyers of his organisation desperately fight not only for Aybek to stay free, but also to change the legislative amendments proposed. They are due to come into force in one year so there is still a chance to collect evidence that such amendments will lead to the criminalisation of people who use drugs.

“Introducing heavy fines may lead to the growth of corruption practices and increase in the number of prison population, which will have a negative impact on the national budget. Now we are making attempts to show the evidence of all the risks to people developing the new codes,” says Sergey Bessonov. “We need alternative punitive measures and effective treatment programmes. Members of the community were not able to take part in the development of the new codes, but we hope that our voices will be heard. We are doing our best at the national level and we also plan to tell about the recent developments in the drug policy to the international community at AIDS 2018 Conference.”

Five People Disclosed their HIV Status to Mark the World AIDS Day in Kyrgyzstan

Author: Olga Ochneva, Kyrgyzstan

The Shukurov family tells about their HIV status during the campaign in the Kara-Balta school

Kyrgyzstan marked the World AIDS Day on December 1 under the Slogan “My Health, My Right.” Competitions, quizzes, a flash mob, debates, a race, a fashion show, and meetings with journalists were dedicated to the World AIDS Day. The most surprising thing during these events was the number of people who publicly disclosed their HIV status.

“Live” stories

Every year on the first winter day mass media publish a year’s supply of reports on the situation with HIV and its prevention. This time, the main message in this load of media reports was the topic of fighting stigma against people living with HIV (PLWH). This message was delivered by people who decided to publicly disclose their HIV status and tell their stories. The start to this spontaneous campaign for the freedom from fears, myths and prejudices was given by Baktygul Shukurova in September this year at the National HIV Conference. Baktygul says that she decided to make this step for all PLWH, to refute myths and give people an opportunity to reflect on the fact that everyone has a right to life and health. Back then, Yevgeniy Yuldashev also made a decision to have an open conversation with journalists.

Charitable race to help children living with HIV was supported by people of different ages and occupations

Following the example of his wife Baktygul, Umid Shukurov also disclosed his HIV status during the December 1 campaign in his home town of Kara-Balta. The spouses opened the truth, which they had been hiding for seven years, and that, as they say, helped them to feel free. On November 29, two more women disclosed their status.

Race to support people living with HIV

A charitable race “My Health, My Right” was organized in one of the Bishkek parks with the USAID support. Despite the cold Saturday morning, over two hundred people took part in the three- and six-kilometre races. Participants had a chance to donate some money to buy New Year presents for children living with HIV. The task of this race was to raise the awareness on the need to be responsible about one’s health and to prevent the spread of HIV.

HIV Quiz Night

Participants of the Quiz Night had only one minute to think over the questions, but many of them replied ahead of time

UNAIDS organized a Quiz Night dedicated to the topic “Right to Health” in the context of HIV. The battle for the title of the smartest brought together 18 teams, each of them making a money contribution. Among the participants, there were teams of journalists, health professionals, students, staff members of AIDS organizations and fans of the Quiz Night game. The participants had to answer 20 questions. Questions about HIV related to the areas of medicine, cinema, history, and music. The best performing team got the game bank and the viewers learned many unexpected facts about HIV and health.

Prevention month

The Republican AIDS Centre dedicated its activities within the month to mark the World AIDS Day to prevention and fighting stigma against PLWH. There was a contest for the best materials on HIV among college and high school students and journalists in three nominations: video, poster, and article. Twenty teams took part in the debate tournament.

Female penal colony against HIV and violence

Women from the penal colony No. 2 demonstrate creativity while talking about important issues

This day was also marked in the penal institutions. AIDS Foundation East-West in the Kyrgyz Republic organized a creative contest in the female penal colony No. 2. Each team presented a leaflet, a dance, a song and two theatre performances on two cross-cutting topics – how to prevent HIV and how to protect yourself from violence. Women spent a month on working on the scenarios and creating the costumes and, as a result, the event was very informative and impressive.

 

 

Fifteen Years of HIV Prevention in Kyrgyz Prisons

A convict takes methadone therapy in a correctional colony

Author: Olga Ochneva, Kyrgyzstan

Kyrgyzstan is a leading country in the Central Asia in terms of implementation of harm reduction and HIV prevention programs in the correctional settings. Syringe exchange programs have been available in prisons since 2002, and today over one thousand five hundred people receive clean injecting equipment in all twelve correctional facilities. Atlantis rehab centers have been gradually introduced since 2004 for those convicts who made a decision to quit drugs. Currently, eight such centers are functioning, with the ones who have almost succeeded in stopping with drugs continuing treatment in a separate, so-called “clean compound.” In ten institutions, including two pre-trial detention centers and one penal settlement, people have access to the methadone substitution therapy. Besides, governmental agencies, together with donors and civil society organizations, conduct awareness-raising activities, diagnostics and treatment of HIV infection, tuberculosis, and provide social support for ex-prisoners. Such programs have been implemented for 15 years, and local experts share their best practices.

Correctional settings form adherence

Roman had been enrolled into the opioid substitution treatment (OST) program before he got into prison, but he was still using heroin. Due to drugs related crime, he had to go to jail, where at first his HIV test showed a negative result. However, in a while, the virus has shown itself. Now Roman is free. He works in the Ranar Charitable Foundation offering people released from prisons the same kind of support that he got back when he walked out of the jail: accompanies them to the sites providing OST services, antiretroviral therapy (ART), makes contact with the law enforcement agencies, and provides support with employment seeking and accommodation as well as with the restoration of personal documents, if needed.

“For three years in prison, I was sharing needles with everyone and had no idea that I had HIV till I developed tuberculosis and pleuritis,” Roman says. “When I was in prison, I did not even think about what I was going to do after the release. I thought I was just living out my days. When I got out, my state was really bad: I was taking high doses of methadone and was not taking any ARV drugs. Then my friends showed me some sober guys, whom I knew back in prison. Before that, I could not even imagine that one can quit methadone.”

Today, convicts with HIV amount to 5% of all the people living with HIV (PLWH) in the country, whereas in 2010 this share was 13.7. There has been access to ART in the correctional settings since 2005; and currently, 305 out of 357 officially registered PLWH serving their sentences receive the treatment.

In prison, Roman received ARV drugs but did not take them. He admitted that he took the pills only because they were given together with motivational food packages distributed in Kyrgyzstan to develop an adherence to treatment. Next year, those who receive the treatment for over one year will no longer be getting such packages because their adherence has already been formed.

“In correctional settings, there is a favorable environment where an outstanding program to form adherence may be implemented as the patients are always in plain sight,” Natalia Shumskaya, AFEW Chairperson in the Kyrgyz Republic says. “The quality of treatment and care of people living with HIV, unfortunately, leaves much to be desired. There is a deficit of qualified health professionals and a lack of proper attention to the patient. It is important to make sure that the officers of the department for the execution of sentences see additional benefits for this work. Currently, donor organizations provide funding for additional support, but starting from next year there will be no funds to cover those needs. In this context, it is rather difficult to ensure quality performance of all the guidelines on implementation of the programs aimed at harm reduction, HIV prevention, diagnostics, and treatment, which have been developed over the years.”

How it works “from the inside”

Atlantis: rehabilitation of drug users in correctional institutions

On the average, in penal colonies 85 prisoners attempt to overcome their drug dependence in the Atlantis rehab centers every year. About half of them successfully complete the program and are transferred to the Rehabilitation and Social Adaptation Center (RSAC) or the “clean compound” in the colony No. 31. In this compound, the convicts who decided to quit drugs get additional professional training and are prepared for the release.

OST in closed settings was introduced in 2008, and today such treatment is provided to 479 patients. According to ex-convicts, the methadone substitution treatment program in the places of confinement has been to a great extent discredited by the patients who take additional illegal substances. Access to services varies depending on the type of institution.

“When I found myself in a pre-trial detention center, I got no access to methadone,” tells Roman. “It was not available there, and local staff members only organize transportation to the OST sites if there are at least 4-5 people who take part in the OST program. To get ART, it was also necessary to go outside of the center territory. Sometimes, people have to wait for a court decision for several years there and for all this period of time they may have no access to medications. In a prison, once a day they take you to a sanitary unit, where you get your methadone. There are also ARVs and clean syringes available. You must always give back the used equipment, but if there is a search in the ward, the guards take away all the syringes and needles. In colonies, it is much easier to get all those services.”

The “Kyrgyz miracle”

Madina Tokombayeva, whose Association “Harm Reduction Network” (AHRN) has been providing support to convicts for fifteen years, says that the existence of such programs in the country may already be called a miracle.

HIV prevention training for staff of the State Department for the Execution of Sentences

“We started our activities in correctional settings with self-help groups for PLWH back in 2002 through the first community organization of people who use drugs uniting PLWH and ex-convicts,” tells Madina. “We saw that after the release people need support, so at our own initiative we started helping them after they got out. We were speaking about all the problems existing in prisons, and thus we found people and donors who were ready to support our ideas. At that time, AFEW Kyrgyzstan supported the establishment of the first social bureau in colony No. 47, activities of the Ranar Charitable Foundation aimed at ex-convicts and helped to purchase a house for them, which is still functioning with the support of AFEW Kyrgyzstan. Later, the CARHAP project disseminated social bureaus and support services in all the correctional facilities.”

Currently, harm reduction programs in prisons are financed by the Global Fund and the US Centers for Disease Control and Prevention (CDC). AFEW Kyrgyzstan strives to build the capacity of staff members of the State Department for the Execution of Sentences and, together with the AHRN, provides HIV prevention and social support services to ex-convicts with the support of the USAID.

“We conduct regular monitoring of the harm reduction programs, in particular in correctional settings. I have a feeling that they are still in the bud, but they have got a chance,” says Madina Tokombayeva. “We have to make the adopted laws and the approved guidelines work in these three years, while we still have the donor funding. We need to consult with our clients and, together with the governmental agencies, organizations working in the area of HIV and communities develop a totally new approach to the implementation of such programs so that their quality is really high by the moment when we face the transition to the state funding. They must not be closed under any circumstances or otherwise, we will go back to the parlous times when prisons were the driver in the spread of HIV.”

Communities in Kyrgyzstan Explore their Needs for the First Time

Community research provides an opportunity to objectively assess the existing services. Focus group in the office of Ulukman Dariger NGO in Issyk-Kul area

Author: Olga Ochneva, Kyrgyzstan

Sex workers over the age of 30 desperately need employment; women living with HIV have a need for women’s dormitories – these are the preliminary conclusions of two different studies conducted in Kyrgyzstan. The complete results of the needs’ assessment and HIV prevention programs in the country will be presented at the 22nd International AIDS Conference (AIDS 2018). The research is conducted by these communities for the first time. AFEW International provided this opportunity for key populations in Kyrgyzstan and other countries of East Europe and Central Asia (EECA) within the Small Grants Program.

New and unexpected discoveries

International AIDS Conference is a platform for the community to express their voices. Currently, community organizations from the EECA countries supported by AFEW International are carrying out the research, the results of which will be presented at the International AIDS Conference in July 2018 in Amsterdam. There are two research teams in Kyrgyzstan.

“Our organization has wanted to conduct a similar assessment for a long time. This is the first full-scale study among sex workers in the country,” Ulan Tursunbayev, the director of Ulukman Dariger NGO says. His organization assesses the effectiveness of HIV/AIDS prevention program with the help of the sex-workers themselves. “The preparation of the research and data collection took us four months. We traveled the country – four people, two of which being consultants. First, we tested our questions in mini sessions, so that they were clear to the community members and could open them up for the dialog.”

Another organization from Kyrgyzstan – PF Prosvet – conducts research work among women living with HIV. They study the impact of HIV-positive status on women’s lives.

“Community representatives are the main executors of the project,” Margarita Sabirova, a psychologist at Prosvet is saying. AFEW International has provided all training opportunities: trainings, online modules, technical expert support. Community education has become one of the most important and long-lasting pre-research phases. Nowadays, they possess new knowledge and skills, and we have honest and frank research data.”

Data mining has been conducted since April, and the final reports are being currently prepared. It has already become clear that the research contains new and unexpected discoveries.

“It was really interesting to see how the needs of sex workers differ before and after they turn 30,” Ulan Tusunbaev says. “They even sat apart from each other during the focus group meetings. Young women said they had enough condom supplies from prevention projects, outreach work and legal assistance. Older sex workers wanted to change the area of work and asked for the assistance with this.”

Many said that they rather would not provide sex services for the rest of their lives, and wanted to start building their future then.

“In course of my work, I was able to buy some land where I am starting to build a house, and where I will then open a store. I have already prepared the materials for construction,” says one of the interviewees of the research. “I hope this store will help me and my child when I will no longer do sex-work. Therefore, it is good to have some skills training programs available. After all, we have all been working here for 5-8 years and have no education. In order to engage in something different, we would need additional skills.”

The South and North have different needs

Women with HIV: “We need special support.” The head of Public Foundation Prosvet conducts a focus group in Bishkek

Employment is also one of the most important problems for women living with HIV. According to the representative of PF Prosvet, women say that many of them have no spouses and thus they need to take care about their own financial well-being. Some of them are the only ones who financially support their children. Employers often unreasonably demand HIV and medical examination and refuse employment.

“Thanks to the research, we are sure now that the services need to be divided according to the needs of a certain group,” Margarita Sabirova shares. “We have not only identified the priority needs, but also clearly noticed the difference in the set services needed in the North and South of the country. For instance, people in the South need social support, while people in the North of the country are more socialized clients who have different needs.”

The next phase in the Small Grant Program by AFEW International is the training on how to write abstracts (thesis) for organizations in preparation for AIDS 2018 and teaching them how to present their research results.

“The lack of gender approaches in the provision of services and the specifics of different areas of the country often limit access to the health care, legal, social, and psychological support. We hope that the presentation on the results of our study during AIDS2018 will encourage participants from other countries to pay attention to this problem in their own part of the country,” Margarita Sabirova is saying. “The research has identified a number of specific service needs for women, which are not met now either fully or partially. We hope that funds will be available to finance this unmet need. We have many recommendations in our report, and these will help to improve existing services. In any case, as an organization, in whom the community trusts, we should express community needs to the government, donor and non-governmental organizations.”

Hepatitis A Prevails in Kyrgyzstan

Author: Olga Ochneva, Kyrgyzstan

Hepatitis Prevention Month to commemorate the World Hepatitis Day was organised for the first time in the history of Kyrgyzstan by the Ministry of Health in July this year. Over the recent years, the list of registered and allowed for import medications to treat hepatitis C has been expanded, the new clinical treatment protocol has been approved and a six-year target program to counteract viral hepatitis was adopted. Hepatitis is one of the leading causes of death among people living with HIV and higher-risk populations. Without a doubt, the discussion of availability of hepatitis diagnosis and treatment, introduction of treatment guidelines and implementation of the national viral hepatitis interventions will be an important part of the International AIDS Conference in Amsterdam in 2018. We discussed the reasons for the increased attention to the problem of hepatitis in KyrgyzstanIn with Nurgul Ibraeva, Chief Officer of the Department of Health Services and Medications Policy of the Kyrgyz Ministry of Health.

Statistics and the real picture

“The problem of viral hepatitis in Kyrgyzstan is growing every year. Blood-borne hepatitis B and C remain a challenging concern, as patients consult the doctors whey they already have advanced illness and complications, such as liver cirrhosis and cancer. During the Hepatitis Prevention Month, we raised awareness in the population about the need to get tested and offered discounted tests that were supported by private laboratories. Many people in Kyrgyzstan find the price for hepatitis testing (around $50) challenging, so patients often discover their disease at an advanced stage,” Nurgul Ibraeva says. “Following the official statistics, in the last five years 11,000–22,000 people with viral hepatitis were registered on an annual basis. Health services provide treatment to more than 2,000 patients with parenteral hepatitis (hepatitis B, C and D – author’s note), but we believe that the actual number of those infected is much higher: more than 250,000 people.”

Prevalence of hepatitis A is the highest. It accounts for 96% of the registered cases, with blood-borne hepatitis B coming second. According to the National Immunization Schedule, since 2000, hepatitis B vaccine is administered to all newborns free-of-charge. As a result, hepatitis B incidence had a fourfold decrease over the last 16 years. Currently, our health services register around 300–400 new cases of hepatitis B among adults annually, while incidence among children dropped to several isolated cases.

“Immunization brings its fruit. According to the Ministry of Health regulation, health workers exposed to blood should be vaccinated, yet no funds are allocated for it, and not every health worker can afford a vaccine,” Nurgul Ibraeva is saying. “Unfortunately, there is no vaccine against hepatitis C. Even if you use means of protection and take the necessary precautions, there is always a risk. Some health care staff remain untested, and it is our estimate that around 1000 health workers have hepatitis C.”

According to the Republican AIDS Center and the Research and Production Association “Preventive medicine” of the Kyrgyz Ministry of Health, in 2014–2015, the share of health personnel with hepatitis C in the general HCV prevalence amounted to 2.5%. The same percentage is attributed to the general public.

Hepatitis C prevalence is the highest among people who inject drugs (PWID). In 2010, 50% of all hepatitis C cases was registered among PWID. By 2015, this share dropped to 35%. Inmates are also among those especially vulnerable to hepatitis C. Over the last six years, 24–53% of all cases were identified in correctional institutions.

“Needle exchange services and opioid substitution therapy are available in Kyrgyzstan, including prisons,” Nurgul Ibraeva is telling. “Prevention programs strive to break the chain of transmission, but the share of infections remains high, even though we managed to stabilize the situation.”

As is the case with other population groups, key populations are still inadequately covered by diagnostic services. According to the official data, from 100 to 200 new cases of hepatitis C are annually registered in Kyrgyzstan. However, the estimated number of people with hepatitis C is much higher: 101,960 cases among the general population and more than 11,000 cases among people who use injecting drugs.

Availability of treatment

In April 2014, the coalition of non-governmental organizations under the initiative of the “Partner Network” Association of Harm Reduction Programs successfully lobbied changes in the Kyrgyz patent legislation. This allowed Kyrgyzstan to import and license generic medications to treat hepatitis C. Currently, a 12-week treatment course on the basis of an officially registered drug costs $615 for a generic and $1500 for the original.

“We have access to several licensed medications produced in China, Egypt and India,” Nurgul Ibraeva says. “If earlier treatment for one patient amounted to $15 000–20 000, today patients can choose medications they can afford. With the expansion of the list of available drugs, producers have been lowering their prices. Yet, patients still have to pay for treatment, which is a challenge for key populations.”

All imported medications have been included in the Essential Medicines List, which is a pre-requisite for the potential state procurement in the future. A Target Program to Address Viral Hepatitis for the period till 2022 has been approved, yet it does not guarantee treatment and does not have financial backing for the planned activities. At the same time, only among people living with HIV, the prevalence of parenteral viral hepatitis exceeds 14%. Over the past six years, the registered number of people with HIV and hepatitis C co-infection increased twofold and reached 701 cases in 2015. Advocates succeeded to include annual hepatitis C treatment for 100 people with HIV into the State Program for HIV Control. Treatment will be financed by the government for the period of five years. Besides, this year a Clinical Protocol for Diagnosis, Treatment and Prevention of Viral Hepatitis B, C and D has been approved. The document is aligned with the latest WHO recommendations and treatment regimens based on direct acting antiviral drugs that are widely available on the market.

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.

The Path to the Self-Financing of the HIV Programmes in Kyrgyzstan

Author: Olga Ochneva, Kyrgyzstan

A significant reduction of funding for the programs against HIV infection was registered during the recent years in Kyrgyzstan. Last year the news that the Global Fund – the main donor of the HIV and tuberculosis programmes in the country – cuts their funding, got into the headlines.

Needs and opportunities

Funding for HIV programmes from the Global Fund over the past two years in the country has actually decreased by 30%, from $7.5 million in 2014 to $5 million in 2016 and 2017. The trend continues to grow: in the application for 2018-2020 only $3.7 million per year were pre-approved, and that is one more million less than before.

“$7.8 million per year are divided in the new Global Fund application between HIV and tuberculosis, but previously such amount of money was allocated only for HIV. Notice that reduction of funding comes amid the growth of demands. The situation with HIV in the country is now getting close to the concentrated phase, and the number of people on treatment over the past two years has grown almost twice,” said the head of Harm reduction programmes association “Partner Network” Aybar Sultangaziyev. “We have enough funds for this year, but in the next three years we expect the budget gap to grow. Only for persons who need treatment – about 6,000 people – we need $3.5 million by 2020, but for HIV we only have $3.7 million allocated in the budget.”

From donor to national funding

The general global trend of reducing grant support and the rise of Kyrgyzstan in the qualification of the World Bank from the level of countries with low income to the level of countries with lower middle income encourages the transition of the country to national funding. It is a difficult process for the state, because from the very beginning the prevention programmes in the country (about 15 years) were funded by international donors.

Ulan Kadyrbekov

“Previously money from the state budget was allocated only to support infrastructure and salaries of the AIDS-service employees,” Director of the Republican AIDS-center Ulan Kadyrbekov says. “Starting from the year before last, the state started to allocate 20 million soms ($289 thousand) annually for HIV programmes. The condition of awarding $11 million grant for HIV from the Global Fund for the next three years was the state contribution of 15% of the whole grant amount. Nowadays we set the national program on overcoming HIV in the Kyrgyz Republic until 2021 and in the budget we have allocated these 15% of the national contribution.”

Until the last November it was not clear if Kyrgyzstan receives the Global Fund money or not. This fact became the main argument for the civil sector in their work on promotion of national funding.

“In fact, the result of our work was the development of the roadmap, i.e. the transition plan to national funding, which comes as an addition to the National program on overcoming HIV,” says Aybar Sultangaziev. “In addition to already allocated budget we have received further 23 mln. soms ($333 thousand) in 2018 and 50 million soms ($725 thousand) per year starting from 2019. It is still not enough. In fact, we requested up to 4.5 times more in 2018 and 2.5 times more starting from 2019 from the state budget.”

Now the National program for overcoming HIV in the Kyrgyz Republic until 2021 and Roadmap for the transition to national funding are submitted to the Government of Kyrgyzstan. The program must be approved this August. It will become known if this money is included in the Republican budget by the end of 2017.

Costs saving and optimization

Upon the condition that the government will fulfill the financial obligations under the National program until 2021 and the country will receive donor funds, there still will be a deficit in the amount of $1.5 million per year. Global Fund’s money has not been finally divided between programme activities. It will be decided which expenditure headings will be underfunded in the nearest future.

Aybar Sultangaziev

“We expect that deficits will be covered by funding from the other donors and by reduction of preventive measures,” Aybar Sultangaziev is saying. “For example, it is likely that we will close social centers. Nowadays six social centers are already closed, we excluded the treatment of STIs (sexually transmitted infections – ed.), we also partly excluded diagnosis and treatment of opportunistic infections, we decreased the number of condoms and syringes for distribution. There are other donors for HIV in our country, the largest of which is the USAID project Flagship. It allocates about $700 thousand a year on drug users. With this money we are able to cut funds from the budget of the Global Fund for this group. Now we have a narrower task of responding to the epidemic. Therefore, the only must have budget items are methadone and antiretroviral (ARV) drugs. We are trying to increase or at least keep these budget lines at the same level.”

Another step in cost optimization and in the transition to national funding is the transfer of control of Global Fund grants from the current recipient – UNDP – to the Ministry of health. Experts predict that it will happen no earlier than during the second half of 2018, as the Ministry of health needs to get prepared.

“Nowadays the treatment is provided by the Global Fund. Even after funds were allocated in the national budget, we still cannot use them for the purchase of ARVs for key vulnerable groups, because there is no mechanism for procurement of drugs and for social procurement. Our priority is to provide all the necessary documents for these procedures,” Ulan Kadyrbekov said. “Thanks to funds reallocation and optimum employment of resources, the National programme for the next three years will be able to slow down the spread of HIV. Even now we have good chances to reach the 2020 UNAIDS goals of 90-90-90. The process of transition to national funding and running programs in the face of cutbacks of donor funding is a great challenge. The Ministry of Health has already submitted the preliminary topics of presentations at the conference AIDS 2018 in Amsterdam, I think, by July of the next year we will have a great practical experience to share.”