HIV Prevention in Key Populations: an Overview of Service-Delivery Projects in Russia

The Blue Bus mobile prevention unit, the bus of hope

Author: Anastasia Petrova, Russia

According to the World Health Organization, about half of new HIV cases occur in key populations: injecting drug users, men having sex with men and sex workers. Social stigma, violation of human rights, lack of access to the necessary services create barriers to protection of health for millions of Russian citizens. That being said, providing care to people with an HIV-positive status and those who are at risk of infection is an essential measure to safeguard health of the whole nation. By implementing service-delivery projects for key groups, non-governmental organizations play an important role in preventing the spread of the HIV epidemic both in the communities and among the general population.

The bus of hope

The Blue Bus mobile prevention unit, engaging clients in service provision

The Blue Bus of the Humanitarian Action Foundation is the first mobile prevention unit for drug users. In 2017, the project celebrates its anniversary: 20 years ago, the Blue Bus started its first journey in St. Petersburg.

Throughout these 20 years, Humanitarian Action has been true to its principles of helping those most vulnerable to the HIV epidemic. Many clients have double or even triple diagnosis: HIV, tuberculosis, hepatitis B and C, and addiction to psychoactive substances.

People are referred to service-provision programs through street outreach, mobile units and stationary needle exchange centers. Peer counsellors provide motivational counselling, assist with hospitalization to specialized medical institutions and follow-up their clients to increase retention in treatment programs.

The Blue Bus mobile prevention unit, distribution of materials, motivational counselling

Bus workers distribute sterile syringes, needles, water for injections, alcohol swabs, cotton balls, bandages, vitamins, vein ointment, naloxone, etc. People who use services are not always ready to change their behavior just like that. Talking to the project staff, they get important information on how to reduce infection risks and protect their health.

For most clients, the Blue Bus is the only safe place where they are treated with respect and understanding, and the only possibility to take a rapid test, receive primary medical counselling, get access to HIV and TB testing and treatment, be referred to public institutions and learn how to protect human rights. The team of the Blue Bus proudly values these trustful relationships between project staff and clients that have been built over the years of program implementation.

Dialogue between equals

Outreach work in the Cabaret bar

NGO Positive Dialogue is one of the oldest HIV-service organizations in St. Petersburg. Since its establishment in 1996, Positive Dialogue has gained substantial experience in working with key populations. In July 2015, the organization launched HIV prevention projects for closed population groups: men having sex with men (the Positive Dialogue project) and sex workers (the Silver Rose project). Both projects are community-driven, with the main goals to promote safer sex practices among MSM and SWs, increase access to services, including HIV/STI testing, uphold human rights, strengthen communities and counteract stigma.

The outreach team of the Positive Dialogue project conducts weekly field work in the night clubs visited by MSM and the LGBT community. The clients talk to peer counsellors and ask questions about HIV and other STIs, learn about pre- and post-exposure prophylaxis, receive condoms and lubricants.

Outreach work in the Priscilla club

The Silver Rose staff members provide counselling for sex workers in their office and conduct outreach work in the local saloons and street sex work areas. The project helps the girls preserve their health and human rights, protect themselves against violence, receive contraceptives, get tested for HIV and get referrals to trusted doctors. Peer counsellors also provide psychological support and involve sex workers in client management programs.

Training on how to use a female condom

Legal components make up an important aspect of the project’s work – the so-called “street lawyers” trained by the project provide legal aid and support in cases of violations of MSM/LGBT and SWs rights. Project clients take part in educational trainings and seminars.

Particular attention is devoted to community development and mobilization, to encourage community-driven HIV responses. Project activists organize campaigns and round table discussions aimed at overcoming societal stigma.

Women plus

Social support center for women, pre-test counselling

HIV-positive women are the focus of one of the projects run by EVA Association. In October 2017, a social support center for women affected by HIV will be launched by EVA – a low-threshold service offering comprehensive individual assistance to HIV-positive women in crisis situations.

The project team unites specialists with various experiences: peer counsellors, client management officers, lawyers, psychologists. Clients will be offered counselling, rapid HIV testing with pre- and post-test counselling, and individual management of each case. Women will be able to obtain contraceptives (condoms) here and take part in self-help group sessions for women living with HIV and their family members.

Social support center for women, rapid testing for HIV

Experienced specialists working in EVA will do their best to make the center as client-friendly and as responsive to clients’ needs as possible – for example, by allowing clients to bring their children, organizing distribution of clothes for women and kids, giving out hygiene kits. EVA collaborates with the municipal public services and socially oriented NGOs, which will improve activities aimed at informing women about the existing support services, providing access to various specialists and representing women in these institutions.

The center will give special attention to the prevention of violence and dependent and co-dependent behaviours. It is pilot project, unique for the region, with a focus of preventing negative social consequences of HIV among women.

Social support center for women

Prevention projects for vulnerable groups in Russia were launched 20 years ago by our western colleagues. However, international funding for these and other social projects has been significantly reduced. Unique low-threshold HIV prevention programs are becoming as vulnerable as their clients. Some organizations manage to secure financial support from the government. Others try to change their structure. We would like to believe that projects that help thousands of people representing very closed populations to protect their health will not become extinct in Russia.

Cry for Access to Treatment for People Living with HIV in Russia

The event dedicated to the Day of Remembrance of People who Died from AIDS, Moscow, May 2015

Author: Anastasia Petrova, Russia

“Medicines for the treatment of HIV, hepatitis C, and tuberculosis are provided free of charge to all needy patients in Russia.” This phrase is the first thing we see on Pereboi.ru main page – the resource where people living with HIV in Russia can tell their stories about how they were refused treatment.

Professional patients

Pereboi.ru is one of the projects of the Patient Control – a public movement whose members are people living with HIV and other socially significant diseases, as well as their supporters. The movement has existed for seven years in Russia. The initiative group, not being an organization or legal entity, has grown into a professional community of patients who have risen to defend their rights.

In addition to direct actions, activists of the Patient Control monitor government procurement of antiretroviral therapy (ART), write complaints and make appeals to public authorities. Representatives of the community also work with pharmaceutical companies: one of the main obstacles to treatment is inflated prices for medicines.

Founded in autumn 2010, the movement’s goal is to ensure effective control of the provision of high-grade medical care and the improvement of quality of life for HIV positive people. Activists say that any person sharing their views can join them. The main concern on which activists are working is the disruptions in medical supplies for people living with HIV, hepatitis and tuberculosis in Russia.

Fighting with supply disruptions

“For more than six years there have been interruptions in medical supplies for the treatment of HIV/AIDS in Russia. Life-saving medicines, that have to be taken strictly by the clock and in a certain order are partially or completely lacking in AIDS centres,” activists are saying.

This situation is interconnected with repeated changes in the system of procurement of medicines for people living with HIV. The latest change is the transition to a centralized system in 2017. Before that, the medicines in regions were bought according to special schedules, and now the Ministry of Health of the Russian Federation is the responsible party. These changes have led to the slippages in the procurement schedule and serious supply disruptions this year.

The event by the Ministry of Health of the Russian Federation, Moscow, July 2013

At the moment, supply disruptions of medicines happen almost everywhere throughout the country. People living in different regions of Russia such as Nizhny Novgorod, Norilsk, Tomsk, Kostroma write messages to pereboi.ru almost every day. Only in 2016, the activists counted appeals from more than 30 cities. These cities are also situated in such prosperous areas as Moscow, the Leningrad and Moscow regions.

Last summer the activists of Patient Control facilitated the situation with interruptions in treatment of children and pregnant women in the AIDS centre near Moscow. 30 patients signed the petition after which the Federal Service for Surveillance in Healthcare conducted an unscheduled inspection at the AIDS centre near Moscow and in the regional Ministry of Health office.

In order to avoid the following situations, activists get updated on the formation of purchases for 2018 by raising the issue at a high authority level. On August 14, 2016 there was a meeting of patients with representatives of the Federal Service for Surveillance in Health Care and the Ministry of Health of the Russian Federation. The government informed activists about the expected additional financing in the amount of 4 billion rubles this year and the planned annual increase by 1.5 billion rubles in the budget for the purchase of medicines. However, according to the representatives of the movement this is not enough to solve the problem completely.

Improving quality

Side effects from the low-quality medicines is another issue patients are talking about. Due to the strong health issues that arise in response to therapy, people often abandon the existing treatment. A short list of the issues they face includes rash, kidney problems, lipodystrophy. It is difficult to get treatment replacement afterwards if the therapy scheme was changed according to medical or pseudo medical indications, because formally the therapy is still being provided.

Day prior to the meeting of the Commission on Vital and Essential Drugs (VED) on September 4, 2017 in Moscow Patient Control representatives addressed the Minister of Health of the Russian Federation. The request was to include VED in the list of contemporary drugs in 2018 for the treatment of HIV-infection and chronic hepatitis C. Following the meeting, the Commission made a decision to add six medications, four of them were also in the activists’ list. The Commission included two medicines for HIV infection treatment: dolutegravir, raltegravir for children and two for hepatitis C: dasabuvir/ombitasvir/paritaprevir/ritonavir and daclatasvir.

Activists are also working on the ways to achieve patient feedback in cases when ART was proven ineffective or had side effects. Patients along with the physicians will now be able to fill out an online form on the Federal Service for Surveillance in Health Care. This will help to improve the quality of medication control.

Treatment as prevention

The internationally recognized principle of treatment as prevention is one of the most effective and yet most underestimated ways to prevent the spread of HIV infection in Russia. The number of HIV infections in our country keeps growing and thus patients’ collaboration is extremely important.

At the Red Ribbon Award 2012 during AIDS 2012 in Washington, USA

The Patient Control movement is one of the communities in the Eastern European and Central Asian (EECA) countries dealing at a highly professional level with access to therapy of people living with HIV. SIMONA+ project is one of Patient Control initiatives aimed at systemic problem solving. This project studies access to medical and non-medical services for people living with HIV, as well as reacts to violations of patients’ rights by direct actions, press conferences and round-table discussions. Nowadays, SIMONA+ covers more than 13 entities of the Russian Federation. Its main goal is to improve the quality of HIV treatment and diagnostics, as well as to increase adherence among the representatives of key groups. Apart from serving patients’ interests, the project tries to minimize HIV spread among the general population.

The Patient Control projects are a community response to the epidemic. These projects consider the needs of people living with HIV and facilitate cooperation between specialists working in the AIDS control field. These merits have already been recognized once: at the 19th International AIDS Conference in Washington in 2012, the Patient Control initiative group was awarded the Red Ribbon Award for outstanding work concerning the AIDS epidemic. Promotion of such initiatives is declared as one of the leading goals for the 22nd International AIDS Conference, which will take place in Amsterdam next July. Representatives of the Patient Control movement plan to submit the report on their work in 2016-2018 to AIDS 2018.

The HIV Epidemic in Russia as the Consequence of State Political Ideology

www.poz.com

Author: Ivan Varentsov, employee at Andrey Rylkov Foundation, Russia

“HIV-positive patients keep complaining about the lack of medicines”; “The Archangelsk HIV Centre to be left without its own office building”; “The number of HIV-positive migrants increased 15 times in the last five years”, “The most common deaths among prisoners in Russian Federation are from HIV”, “HIV dissidents are luring the doubters in their communities.” All these Russian media headlines on HIV were published only during the last several weeks. It seems that the issue with HIV situation has been just recently recognized at the highest state level. It was finally decided to create the state strategy on HIV spread prevention in Russia till 2020. Vice-premier Olga Golodets even made a statement that HIV/AIDS subject is one of the most important in Russia. Although, it still feels like all these statements are just mere words. The situation with the spread of HIV, its prevention and treatment in Russia keeps getting worse. It is especially widespread among such vulnerable groups: injecting drug users, sex workers, men having sex with men, and migrants.

Some statistics

A few weeks ago, the Federal AIDS Centre released the information on HIV situation in the Russian Federation as of 31 December 2016. The total number of registered cases of HIV infection among the Russian Federation citizens has reached 1,114,815 people. There were 870,952 HIV-positive Russian citizens as of the end of the year. Herewith, there were 103,438 new cases of HIV infection registered in 2016 among Russian population (morbidity rate of 70.6 per 100k individuals), which is 5.3% higher than in 2015.

A hundred thousand new cases each year! To compare: a little more than 17,000 cases were registered in Ukraine (morbidity rate of 40 per 100k individuals) in the same year. As for the whole epidemic history, since 1987, there were 300,000 registered cases. If you take Montenegro, for example, where Russians like to go for their vacations, there were only 200 registered cases in 30 years. 100k is a population of Tobolsk or Khanty-Mansiysk.

This situation in Russia has been observed for quite a long time now. The constant increase of new cases in the country has been registered since 1998. In 2011-2016, the annual increase on average was 10%. According to the new UNAIDS report, the number of new registered cases of HIV infection from 2010 to 2016 increased by 75% in the Russian Federation. Russia is the “driving force” of the epidemic in the EECA region – in 2016 it accounted 81% of the new HIV cases. It is important to mention that HIV treatment coverage in the country is little more than 30%. According to the global strategy adopted by World Health Organisation, in HIV health sector on 2016-2021 for the cessation of the HIV epidemic, it is necessary to identify about 90% of possible number of HIV-infected population and to provide no less than 90% of the HIV infected patients with antiretroviral therapy.

Profanation of the fight against HIV

Historically, the main HIV epidemic affected group among the Russian Federation population is injecting drug users (IDUs). By some estimates (UNODC, 2009), the prevalence of HIV among IDUs in Russian Federation is more than 37%. It means that there is a concentrated epidemic among this population group. In the period from 1987 to 2008, there were about 79.78% cases of HIV infection connected to the use of injecting drugs. The sexual transmission has been rapidly growing in numbers in the recent years. In 2016, in 48.7% recorded cases the risk factor was heterosexual transmission. Nevertheless, the injecting way of transmission has been consistently enormous – 48.8% in 2016.

Could there be any better signal to authorities to start taking urgent actions in epidemic spread prevention among this risk group? What are they waiting for? There are several effective programs such as “harm reduction” and substitution therapy, which are scientifically proven ways of HIV prevention worldwide. Moreover, they helped reducing the spread of HIV among IDUs in Ukraine. Nevertheless, the above-mentioned programs are not supported by the state HIV prevention strategy in the Russian Federation.

Different level officials, from “specialists” to ministers, keep making statements about no found evidence for effectiveness of these programs. They also tend to say that methadone therapy is a lie invented by the Western pharmacological companies. Following statements would be questioned in any other country, but Russia. Meanwhile, the social establishments dealing with HIV prophylaxis among IDUs and other social groups are listed as foreign agents. Only in 2016, the Ministry of Justice registered seven such organizations.

The ideology of traditional inaction

It is hard to understand what caused such long-lasting stubbornness of authorities in Russia, and why they refuse to accept effective measures in HIV prevention. Most likely, the reason lies in Russian conservative political outlook. Based on the traditional and social values, politicians do not accept such social groups as drug users and LGBT community. This leads to failures and neglect in observance of consumer rights, including health rights.

The problem is that this attitude is not only perverse and inhumane, but also dangerous to the whole community from the public health perspective. The HIV epidemic is not limited to certain population groups and it is not dying with them, as some may think. It has already surpassed all boundaries. For example, drug user’s sexual partners, on one hand, are very sensitive HIV group, and on the other hand (from the epidemiological point of view), a connecting link between IDUs and the entire population. The number of HIV-positive women is constantly increasing. Therefore, apparently, there will be no changes in the situation with HIV epidemic. Not until we change the ideology.

One in Sixth People Infected with HIV in Tajikistan This Year is a Migrant

Author: Nargis Hamrabayeva, Tajikistan

Approximately five thousand citizens of Tajikistan, which were found to be infected with HIV, tuberculosis and hepatitis during their stay in the territory of the Russian Federation, were declared personae non gratae for lifetime by the government of Russia in June this year. How could this expulsion of infected fellow citizens affect the Republic of Tajikistan?

Generally, after returning from Russia, migrant workers, unaware of their status, may unintentionally put the health of the members of their families at risk by spreading and transmitting infectious diseases including HIV/AIDS, believes Takhmina Khaidarova, the head of the Tajik Network of Women (TNW) Living with HIV/AIDS.

“The consequences of transmitting and spreading of infectious diseases depend solely on the will of the state. Providing that a state fully implements their commitments within the framework of the National Strategy for the Response to HIV/AIDS Epidemic for 2017-2020, it would be possible to avoid drastic consequences. If the government of a state cannot conduct awareness-building work about infectious diseases and their transmission amongst their population on adequate level, despite the fact whether or not infected migrants would be deported, the increase of the epidemic will stay high,” she considers.

According to Takhmina Khaidarova, the main problem is the low level of awareness about infectious diseases, including HIV/AIDS, before the migrants leave the country, during their stay in the host country, as well as on their return to their home country. “Migrant workers have little information and preparation, they are not aware about their status before leaving the country and they do not observe any safety measures during their stay in labour migration. After contracting infectious diseases, they return to their home country and, generally, do not undergo medical examinations; so, unaware of this, they transmit infectious diseases to their sexual partners,” says Takhmina Khaidarova.

She believes that another problem lies in the fear of stigma and discrimination, therefore, migrant workers who have returned do not undergo examination until their health deteriorates considerably.

According to figures provided by the Ministry of Health of the Republic of Tajikistan, there have been noted 384 cases of citizens infected with HIV in the first quarter of 2017, whereby one in sixth is a migrant, who had left in search of work outside the country. Presently, the total number of people living with HIV-positive status in Tajikistan is around nine thousand.

It should also be reminded that Eastern Europe and Central Asia will be a prime focus in the 22nd International HIV/AIDS Conference in 2018, which will take place in Amsterdam in July 2018.

Tatiana Vinogradova: «Only public organizations are able to work with vulnerable groups»

Tatiana Vinogradova

Author: Anastasiya Petrova, Russia

Last year a major event in the field of HIV in Russia became the adoption of the National strategies of counteraction with the spread of HIV-infection in the Russian Federation until 2020. One of the key objectives of the Strategy was the consolidation of efforts of governmental and nonprofit organizations in their fight against the epidemic. Today we discuss the implementation of this interaction in the most progressive city of Russia with the Deputy chief physician of St. Petersburg Center for prevention and control of AIDS and infectious diseases, holder of Doctoral degree in Medicine, third-generation doctor Tatiana Vinogradova.

– Tatiana, do you support the idea of implementation of cross sectoral programs on HIV prevention among vulnerable groups in cooperation with socially oriented non-profit organizations?

– In addition to the scientific-organizational work in the AIDS Center, I am responsible for the interaction with public organizations in the context of HIV-infection in Saint-Petersburg. I think, this is very important. HIV is a socially sensitive disease, and groups of HIV vulnerable people – people who inject drugs, men who have sex with men, sex workers – usually are not easy to approach. I am deeply convinced that only nonprofit organizations, organizations that deal with this issue and have experience in the field, are able to work with the key groups. Even if we have an opportunity to send “a man in a white coat” to interact with these key groups, there is no guarantee that this health worker will be accepted and will be able to perform all the necessary tasks. Nonprofit organizations have access to these closed groups, they are able to work on the principle “peer to peer.” Representatives of vulnerable groups perceive them appropriately and they are able to provide medical assistance as well. This is the most important! We can find a lot of new HIV-cases by testing a large number of people, but when we test the general population or key populations, our work is not limited with testing and identifying, we also should provide medical support. Peer consultants and employees of nonprofit organizations are the best in this field.

– How does the Center for prevention and control of AIDS and infectious diseases cooperate with NGOs? Is there any model or mechanisms?

– AIDS Center in St. Petersburg works with community organizations from the very first day of its existence. In the beginning, there was no AIDS Center in its modern sense, but there was an office based in Botkin hospital, which started this interaction. The first nonprofit organization was registered by Nikolay Panchenko. Therefore, we can say, that here in St.-Petersburg we already have thirty years of cooperation experience between public institutions and community organizations. We work together since the early 90’s.

Committee on health care through the Center for prevention and control of AIDS and infectious diseases provides financial support for the HIV prevention offices, which work in the city. Nowadays there are four such offices based on public medical institutions. These offices work in close cooperation with community organizations that employ peer consultants. Together with nonprofit organizations we conduct events, various events like testing days, for instance. Nonprofit organizations also hold round tables, press conferences, which our doctors always attend.

Nonprofit organizations also participate in the Coordinating Council affiliated to the government of St. Petersburg. This Council consists of the leaders of the organizations representing each of the key groups: those who work with people who inject drugs, or who work with LGBT community, or with women, or who provide legal support. In our city, the Health Committee as well as the Committee on social policy work in cooperation with NGOs in the context of HIV infection. I do not think there is another similar model in other regions. NGOs in Saint-Petersburg receive grants and funding not only from health but also from social policy institutions. There are many offices across the city, where peer consultants officially and legally work with the vulnerable groups, provide them support and accompany them to the AIDS Center.

– It seems to me, that we have adopted a western model of interaction, is it true?

– Yes. Basically HIV-infection appeared in Russia later than in Western Europe and the United States. Why to reinvent the wheel, if there is already some experience that can be used? I remember in the late 90s – early 2000s, when the first wave of HIV-infection started, and it spreaded very quickly among people who inject drugs. In one year 10,000 cases were found. At that time, it was something terrible. People were dying. At that time, it was a fatal diagnosis. Then the first bus appeared on the basis of the AIDS Centre, and our head nurse Marina Petrova was sitting in that bus nearby the metro station Gostiny Dvor, taking blood. Back at the time there were no rapid tests, and no one could predict that they will once appear. We used test tubes. This work was done in cooperation with public organizations.

– Are there any effectiveness indicators of such an interaction and what are they?

– Our AIDS center is one of the largest AIDS centers in Russia. 35,000 patients are registered, and a lot of them come from mobile laboratories of local public organizations. There are several organizations in our city that are doing rapid testing and providing counselling about HIV infection. 80% of people, who get their diagnosis during the testing in these organizations, then go and get registered in the AIDS Center. This is very important, because it is not enough just to identify a new case. A person needs some health survey to decide if the therapy is necessary. We must provide some psychological support to help him or her deal with the stress, which is unavoidable when the person learns the diagnosis. We must motivate him or her to be followed up by a doctor. After all, if she or he will be followed up by a doctor, she or he will stay alive. This is the most important thing. If a person receives antiretroviral therapy, he or she does not transmit the virus further. A person lives, and a virus is not spreading.

– The 22nd AIDS conference – AIDS 2018 – will be held in Amsterdam, and the organizers would like to see a wide representation of people from Eastern Europe and Central Asia there. Have you participated in previous conferences and do you plan to attend the next one?

– The first AIDS conference I attended was held in Geneva in 1998. Now I plan to attend the conference in Amsterdam. I already have two ideas for the conference abstracts. During the conference, I would like to get new information about the interaction with public organizations.

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.

EU-Russia Civil Society Forum Invites Young Professionals to Poland

The EU-Russia Civil Society Forum invites young professionals aged between 25 and 35 from the EU, Russia, and other European states to apply for the Annual “Europe Lab” Forum.

Forum for Young Professionals “Europe Lab” is a unique communication and exchange platform for change makers from all over Europe working in public administration, business, NGOs, universities, think tanks, and other fields of professional engagement.

Main goals of “Europe Lab” are to enable cross-sector cooperation and promote exchange of ideas, develop partner and professional networks, and encourage common cross-border projects and initiatives all over Europe.

The working language of the Forum is English.

“Europe Lab” will take place on 27–30 July 2017 at the European Solidarity Centre in Gdańsk, Poland.

The programme of “Europe Lab” 2017 includes:

Workshops:

  • Freedom and Captivity – Solidarity in the Present and in the Past
  • Climate Change – Where Are You Going?

Innovative Formats:

  • Gdańsk in the Spot – City Development Hackathon
  • 360° Story – Multimedia Telling

Each format will be curated by a coordinator.

The best common projects, whose ideas were elaborated during the Forum, will be granted. The results will be presented at the 8th General Assembly of the EU-Russia Civil Society Forum in 2018.

Finally, “Europe Lab” alumni are invited to join the young professionals’ platform at the EU-Russia Civil Society Forum, to lead and play a role in a number of future initiatives.

Costs for workshops, accommodation, and meals are covered by organisers. Travel costs are borne by participants themselves.

Please submit your application until 1 May 2017 here.

Should you have any questions, don’t hesitate to contact us via e-mail.

Forum for Young Professionals “Europe Lab” is organised by the EU-Russia Civil Society Forum in cooperation with the European Solidarity Centre as well as supported by the European Commission and the Oak Foundation.

Andrey Rylkov Foundation Presents a Shadow Report to the Review of the Periodic Report of the Russian Federation

logoOn 17th of January, 2017, the Shadow Report in relation to the review of the 6th Periodic Report of the Russian Federation (E/C.12/RUS/6) was submitted on behalf of the Russian Public Mechanism for Monitoring of Drug Policy Reform to the Committee on Economic, Social and Cultural Rights (CESCR).

The report was drafted by the Andrey Rylkov Foundation for Social Justice and Health (ARF) with technical assistance of the Canadian HIV/AIDS Legal Network (CALN).

The report informs the CESCR about the next serious violations of Articles 3 and 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR):

  • The Russian Federation did not fulfill CESCR recommendations given in paragraph 29 of June, 2011 Concluding Observations; Russian authorities retaliated against civil society organization which called upon them to fulfill these recommendations. As a result, HIV epidemic in Russia continues growing. Nearly two-thirds of European HIV cases are now in Russia. Up to 1.8 million of people who inject drugs remain a group of people most vulnerable to HIV, Hepatitis C, Tuberculosis (TB), and lethal drug overdoses. Moreover, Russian authorities obstruct the activities of HIV and harm reduction service providing non-governmental organizations by labeling them “foreign agents”, which bares significant humiliating connotation in Russia.
  • The Government of the Russian Federation does not ensure gender sensitive medical and social care for women who use drugs, including women living with drug dependency and drug dependent women with children.

Particularly the report provides the Committee with the information regarding:

  • The ignoration by Russian authorities of the CESCR recommendation to apply human rights-based approach to drug users;
  • The persecution by Russian state authorities of the civil society activists for promoting CESCR recommendations;
  • The termination of OST program in Crimea;
  • The ongoing litigation challenging the legal ban on OST in the European Court of Human Rights;
  • The lack of access to OST for pregnant women who use drugs and the lack of HIV prevention and social support for women who use drugs;
  • The Russian Government not providing any political, financial, or legal support to needle and syringe, and overdose prevention programs.

Earlier in 2010 ARF with support of CALN have already submitted the report to the CESCR on implementation by the Russian Federation of article 12 of the International Covenant on Economic, Social and Cultural Rights in relation to access of people who inject drugs to drug treatment and HIV prevention, care and treatment programs which led to the inclusion into the Concluding Observations of the Committee on Economic, Social and Cultural Rights on Russian Federation of the recommendation to the State party “to provide clear legal grounds and other support for the internationally recognized measures for HIV prevention among injecting drug users, in particular the opioid substitution therapy (OST) with use of methadone and buprenorphine, as well as needle and syringe programs and overdose prevention programs”.

The Russian Public Mechanism for Monitoring of Drug Policy Reform (Mechanism) is a consortium of more than 70 civil society activists, legal and medical professionals, which are committed to improve drug policy in Russia through legal and policy analysis, information sharing, and strategic litigation. From 2009 the Andrey Rylkov Foundation for Health and Social Justice (ARF) serves as a Secretariat for the Mechanism.

Source: Andrey Rylkov Foundation for Health and Social Justice

Reasons for Drug Policy Reform

Michel_Kazatchkine_2012

Text: Michel Kazatchkine, UN secretary general special envoy on HIV/AIDS in Eastern Europe and Central Asia

Why is eastern Europe the only region in the world that still has a growing HIV epidemic? In one of the region’s countries, Russia, more than two thirds of all HIV infections, and 55% of the near 100 000 new infections reported last year, resulted from drug injection.

Some 3.2 million people in eastern Europe inject drugs, and about 1.5 million of them are in Russia. In 2007 the number of newly reported HIV cases among Russian people who inject drugs (12 538) was similar to the number in the rest of eastern Europe (12 026). But since then the numbers have diverged hugely.

Scaling up of harm reduction programmes in several countries coincided with a stabilising of HIV rates—and fewer than 7000 new cases outside Russia in 2014. In Russia, however, where access to sterile needles and syringes is low and opioid substitutes remain illegal and unavailable, the number of people who inject drugs newly infected with HIV climbed to nearly 22 500 in 2014.

Criminalisation of drug use

The reasons for Russia’s high figures include the prohibition and effective criminalisation of drug use, repressive law enforcement, and stigma around drug use. These factors lead people to inject in unsafe conditions for fear of police and arrests and result in needle sharing and overdose.

In 2015, the United Nations’ secretary general, Ban Ki-Moon, called for “careful rebalancing of the international policy on controlled drugs.”

“We must consider alternatives to criminalisation and incarceration of people who use drugs,” he said. “We should increase the focus on public health, prevention, treatment, and care.”

The World Health Organization, the United Nations Office on Drugs and Crime, and UNAIDS jointly recommend a package of harm reduction interventions as best practice to reduce the risk of acquiring, and improve treatment of, HIV, hepatitis, and tuberculosis among people who inject drugs. Such strategies, which do not require prohibition of harmful behaviours, are key to reducing death and disease because drug dependency is characterised by people’s inability to abstain.

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Nearly two-thirds of European HIV cases are now in Russia

hiv-death-rate-globally

Source: ria.ru

The annual number of new cases of HIV increased by at least 8% in 2015 in the whole of the World Health Organization (WHO) European region, and by 60% in the last decade, according to last month’s annual surveillance report by the European Centre for Disease Control (ECDC) and WHO Europe.

A continued increase in new diagnoses in Russia was responsible for most of the increase. The previous year, as aidsmap.com reported, 60% of European-region new cases were in Russia. In 2015 this increased to 64% of all cases.

The 98,177 diagnoses recorded last year in Russia equate to one HIV diagnosis for every 1493 Russians each year. In comparison, the 55,230 diagnoses recorded in the rest of the WHO region represent one diagnosis for every 13,157 people – one-ninth as many per head.

The number of new HIV diagnoses in Russia has increased 15% in one year, 57% since 2010, and 133% since 2006. Russia admitted this year that more than a million of its citizens have HIV. This is 0.8% of its adult population and is at least the same number as the US in a country with 45% of the US population. At the current rate of increase, this prevalence will double to 1.6% in the next 12 years.

Excluding Russia, 46% of infections in the WHO Europe region were ascribed to heterosexual sex, 26% to sex between men, and 13% to injecting drug use – and less than 1% to mother-to-child transmission. In the last ten years, infections in men who have sex with men (MSM) have increased by 38% and in heterosexuals by 19%, but have fallen in injecting drug users by 38%. In Russia, heterosexual sex is the cause ascribed to half of all recorded cases and a third to injecting drug use.

WESTERN, CENTRAL AND EASTERN EUROPE

In western Europe (which also includes Israel and Greece for WHO’s purposes), and in the European Union (plus Norway, Switzerland and Iceland), the number of new cases of HIV have remained almost static. In western Europe about 30,000 new cases have been reported each year from 2010 to 2014 and in the EU 32,500. An apparent slight decline in 2015 (10% in western Europe and 8% in the EU/EEA) may be due mainly to delays in 2015 reports arriving.

Central Europe – which includes the former communist countries running from Poland down to the Balkans, and also Cyprus and Turkey – remains a low-prevalence area for HIV, but saw a 78% increase in infections from 2010. However, there are signs that a feared acceleration of HIV in these countries may have slowed, with only a 4% increase registered between 2014 and 2015, though this does conceal larger increases in infections in gay men in some countries, including Bulgaria and the Czech Republic. However, many of these countries still have the lowest rate of new infections in Europe, with Macedonia (one infection per 83,000 people last year) and Slovakia (one per 62,500) reporting the lowest rates.

In eastern Europe, which comprises all the former Soviet states (including Lithuania, Latvia and Estonia, which are in the EU) if Russia is excluded, the annual number of new diagnoses has stayed flat or fallen slightly (by 9%) since 2010, though the percentage due to heterosexual sex has more than doubled to 65% of the total and the proportion due to injecting drug use has fallen to 26% of the total. The slight overall fall in eastern Europe conceals big increases in some countries with relatively low HIV prevalence, including Georgia with a 48% increase since 2010, Cyprus with a 95% increase, and Belarus with a 116% increase.

INFECTIONS IN MEN WHO HAVE SEX WITH MEN

In western and central Europe the epidemic is increasingly concentrating in men who have sex with men. In the last ten years, the proportion of infections due to heterosexual sex in western Europe has fallen by 41% and to injecting drugs by 48%, while the proportion due to sex between men has increased by 7%.

The proportion ascribed to sex between men in eastern Europe is still only 4% – but this in fact represents a tenfold increase. In some states such as Belarus and Estonia, infections in MSM were regarded as scarcely existing ten years ago – which means that the 58 cases recorded in Belarus and the 18 in Estonia last year represent proportionally big increases. In Russia sex between men still officially only accounts for a tiny proportion of new HIV cases – 1.5%. However, WHO does not regard Russian data as “consistent” and excludes it from some of its analyses.

The increases in infections in gay men seem to be starting to occur in some countries further east than previously. Georgia, for instance, saw a nearly 50% increase in the annual HIV diagnosis total from 2010 to 2015, a 12-fold increase in gay men, and a threefold increase in MSM from 2014. Belarus saw a 166% increase in HIV cases and a fourfold increase in gay men. Ukraine reports similar increases in gay men against a background of falling diagnoses in other groups. Increases in MSM infections were also reported from the central Asian countries of Kazakhstan and Kyrgyzstan. These increases are from a very low base, though, and may just represent that more men testing HIV-positive are prepared to admit they caught HIV from other men.

OTHER CHANGES IN INDIVIDUAL COUNTRIES

One country that has seen big relative increases in HIV is Turkey. The 2956 cases reported last year represent a 5.5-fold increase over diagnoses in 2010 and a 62% increase in one year. Because Turkey is a populous country (75 million), this still represents a low rate of infection (one per 37,000 head of population per year, less than a third of the UK’s rate), but Turkey may be a country whose HIV epidemic is worth watching.

In the EU, Latvia and Estonia had the highest rates. While Estonia’s formely explosive needle-driven epidemic continues to shrink, new HIV cases have increased by 43% since 2010 in Latvia. Notably, Latvia has been till very recently the only WHO Europe country whose national HIV treatment guidelines still recommended treatment should not start till CD4 counts had fallen below 200 cells/mm3.

Western European countries that saw increases in recent years include Malta, where the new HIV diagnosis figures leaped by more than 50% last year and have risen more than fourfold since 2010, though the absolute number of people with HIV in this small island country is still low, at about 300 people in total.

Another country that has seen significant increases since 2010 is Ireland, with a 47% increase relative to 2010 and a 43% increase from 2014 to 2015 – again, mostly in gay men.

The UK still reported by far the largest number of new cases of HIV of any country in western Europe to ECDC – 6078 reported to ECDC last year, way ahead of France, with the second highest number at 3943. However, the annual diagnosis figure has fallen since 2005, as we reported last September, including for the first time a tiny (1%) decrease in diagnoses in gay men. The diagnosis rate per head of population, one per 10,638 people, was second only to Luxembourg’s in western Europe in 2014, but in 2015 was overtaken by Portugal, Ireland and Malta.

One needs to be cautious about saying HIV cases have fallen in specific countries because there is such variation in the number of delayed reports sent to ECDC. However, since 2010 there have been significant falls in HIV diagnoses, exceeding the falls seen in the UK, in France, Spain and Italy.

In France there appears to have been a significant drop of 30% in diagnoses notified between 2014 and 2015, and a 40% drop in gay men. Fewer than 1000 HIV cases were reported in French gay men last year, a third as many as in the UK. In contrast reported diagnoses have risen by 36% in Germany since 2010 (33% in gay men) and this country reported nearly as many new HIV cases as France last year.

eastern-europe-and-c-asia

Source: UNAIDS

MIGRANTS, LATE DIAGNOSES, AND AIDS

Over a quarter (27%) of new diagnoses in the WHO Europe region were in people not born in the country where they were diagnosed. While two-thirds of this 27% represent people from outside Europe, primarily high-prevalence countries, infections in migrants from outside Europe fell by 29% in the last ten years while infections in intra-European migrants increased by 59%.

Nearly half of all new diagnoses (48%) were in people with CD4 counts below 350 cells/mm3. The proportion of these late diagnoses was 55% in heterosexuals and 37% in gay men. It was also 64% in those over 50 years old. Over a quarter (28%) were diagnosed with CD4 counts below 200 cells/mm3, and 12% had an AIDS-related condition at diagnosis.

Regarding diagnoses of AIDS (in both newly-diagnosed people and the already diagnosed), there were 14,579 reported in the WHO European region last year. Diagnosis of any AIDS-related condition was extremely rare in central and western Europe – only one person per half a million head of population in central Europe, and one person per quarter million in western Europe. In contrast one person per 10,000 head of population had an AIDS diagnosis in eastern Europe, including Russia. This means that AIDS diagnoses in eastern Europe were more common than HIV diagnoses in all western European countries bar Ireland, Luxembourg and Malta.

INTERPRETING THE FIGURES

ECDC’s figures always need to be interpreted with caution. Russia, with its huge preponderance of HIV cases, reports a much more limited and more irregular set of figures to ECDC than most other countries. The efficiency of HIV surveillance and the proportion of late reports vary widely from one country to another.

The proportion of people diagnosed also varies widely. If testing rates increase in a country, then it may look as if new infections are increasing when they are not. Some countries, including large western European ones like the UK and Germany, do not collect centralised, verifiable figures for HIV tests. In those that do, testing rates vary hugely. In Kosovo, for instance, just three HIV cases were reported last year – but that is probably because only 1312 tests were conducted, representing 0.07% of the population. In contrast, Russia performed over 28 million tests – meaning it tested more than 20% of its adult population. Generally, HIV testing rates are higher in eastern Europe than they are in central and western Europe. This tends to mean that higher testing rates compensate for lower reporting rates.

It is in central European countries like Poland (0.62% of the adult population tested) and Serbia (0.71%) that low rates of testing imply low rates of diagnosis – meaning that there may be considerably more people with HIV in these countries than appears to be the case.

REFERENCE

The 2015 ECDC/WHO Europe HIV/AIDS Surveillance Report can be downloaded here.

Source: www.aidsmap.com