With Tuberculosis, it is Important to Take Medicine and Believe in Yourself

Sultanmurat from Kazakhstan wanted to get cured of tuberculosis no matter what but the treatment was difficult

Sanat Alemi is one of the civil society organizations (CSOs) supported by the Improved TB/HIV prevention & care – Building models for the future project which gives support to TB patients and their relatives. Founded in 2016 in Almaty, Kazakhstan by a group of ex multidrug-resistant or extensively drug-resistant TB patients, they quickly showed successes through their established self-support groups as well as one-to-one TB patient support. Sanat Alemi is also implementing several community-based activities such as social mobilization, advocacy, and communication to improve TB literacy among people affected by TB, TB/HIV, AIDS and other socially significant diseases (drug abuse, alcoholism, etc), aiming at reducing stigma, discrimination.

Success is possible with trust and professionals

“The social support for TB patients plays a key role in increasing adherence to the treatment. The success in treatment is possible with the combination of trust, human relationships and the support of professionals, such as a psychologist and social worker,” the current director of Sanat Alemi Roza Idrisova is saying.

A TB patient and client of Sanat Alemi Sultanmurat did not know anything about tuberculosis, except that it was a dangerous disease.

“I was horrified when I heard I had TB. I could not even imagine how I got it. I started coughing blood which was so scary, but I did not suspect that it could be TB,” he says. “I thought that the pain was caused by my liver or another internal organ. I told about this to my mother, as she is my closest relative. The other relatives reacted with understanding and this helped me a lot.”

What does not kill us makes us stronger

Sultanmurat wanted to get cured no matter what but the treatment was difficult. In the beginning, he could not tolerate the drugs, and he developed allergies.

“I struggled and tried not to miss a single day of medications and injections. I heard about Sanat Alemi from other patients and started to attend their self-support groups. Receiving support from other patients and social workers during treatment is of great help and being able to join trainings and meetings with different specialists is very useful and gives a lot of interesting information. I had the opportunity to ask questions that I had for a long time. I believe that in the future Sanat Alemi will keep the same spirit and will support many other TB patients,” Sultanmurat says. “TB completely changed my life. I started to appreciate life and learned to tolerate the sickness. I started to appreciate and love my relatives even more as they proved once again that they are there for me and that they would never give up on me during difficult times.”

Sultanmurat would like to say to other TB patients that this disease is curable like many other diseases. The most important thing is to follow the treatment, take pills without interruption, eat well and do sports. It is also important to be friendly, always and everywhere provide support and assistance to other people with TB. The most important thing is to believe in the best, in your recovery and do not forget that what does not kill us makes us stronger.

Donbass: the HIV Epidemic Growing on Both Sides of the Border

Member of the Donbass battalion Aleksey with his wife. When he was taken captive, his wife secretly brought him medications. Photo: Mikhail Fridman

Author: Yana Kazmirenko, Ukraine

HIV is rapidly spreading in the east of Ukraine, which for over three years remains the area of military actions. For two years, pregnant women have not been tested for HIV, and medications could only be delivered illegally.

The armed conflict between Russia and Ukraine divided Donbass into two parts: areas controlled by the central Ukrainian government and the so-called Donetsk and Lugansk People’s Republics (DPR and LPR). The latter are controlled by pro-Russian separatists.

This Russian-Ukrainian conflict demonstrated the differences in the approaches of the two countries to HIV/AIDS treatment and prevention. Thus, in Russia opioid substitution treatment (OST) for people who inject drugs is banned. After Ukraine no longer supplied OST drugs to Donetsk and Lugansk, relevant programmes were also terminated in the areas not controlled by the Ukrainian government. According to experts, the war brought the region back to the 90s in terms of the spread of HIV.

Only half of those in need take the therapy

Sergey Dmitriyev, member of the Coordination Council of the All-Ukrainian Network of People Living with HIV says that there are 16 thousand HIV-positive people living in the areas of Donetsk region not controlled by the Ukrainian government. Only half of them take the therapy. In the Lugansk region, the situation is similar: 2.7 thousand people living with HIV registered, 1.4 thousand – taking the therapy.

On the territory controlled by the Ukrainian government, 13.6 thousand people with HIV positive status are registered, and over seven thousand receive the therapy. It is not surprising that the level of HIV prevalence here is 676.9 per 100 thousand people, which is 2.2 times higher than the average indicator in Ukraine. The highest rates are recorded in Dobropole (1,459.6 per 100 thousand people) and Mariupol (1,154.5).

Apart from the official statistics, the number of undetected HIV cases is at least the same as the number of cases registered as the epidemic in Donbass has long gone beyond the vulnerable populations.

AIDS centres across the border

Natalia Bezeleva, Head of the NGO “Club Svitanok”

Natalia Bezeleva, Head of the NGO “Club Svitanok,” thinks that during the three years of armed conflict only services and deliveries of medications have been re-established in the region. Currently, in the Ukraine-controlled areas , here are 22 sites to prescribe antiretroviral therapy. She remembers the deficit of antiretroviral drugs as a bad dream – her organization had to smuggle the drugs for over a year. Since 2016, the Global Fund has also joined the delivery of supplies, providing the necessary drugs, while UNICEF – the United Nations Children’s Fund – has been bringing the supplies to the “LPR” and the “DPR”.

Ms. Bezeleva illustrates failure of the established HIV/AIDS diagnostics and treatment system with the following fact: in 2014, the Donetsk regional AIDS centre remained on the territory not controlled by the Ukrainian government. Polymerase chain reaction (PCR) tests have not been transported through the newly created border, so for two years, no HIV diagnostics was done for children. Another big challenge was the deficit of doctors – most health professionals left the area of the armed conflict.

According to Ms. Bezeleva, the situation improved in 2016, when the Donetsk regional AIDS centre was opened in Slavyansk. Today, thanks to the support of the Global Fund PCR tests of adult patients are taken to Kharkiv and children’s PCR tests are delivered to Kyiv. There are also first achievements in diagnostics: in 2016, over 113 thousand people or 5.8% of the total population of the region were tested for HIV, and in the nine months of this year 84 thousand people have already been tested.

The military: testing for the contracted soldiers

A social worker visits an HIV-positive TB patient in the TB treatment clinic in Donetsk. Photo: Mikhail Fridman

Even in the peacetime, the military face the risk of infections, in particular HIV, tuberculosis and hepatitis, which is 2-5 times higher than in the general population. At war, this risk grows 50-fold.

In the area of armed conflict, there are 60 thousand of Ukrainian soldiers. According to the result of the research study conducted by the Alliance for Public Health, about 4% of the military enter the conflict area with an HIV positive status, while the percentage of HIV-positive soldiers leaving the area is doubled and reaches 8-8.5%.

Activists of civil society organizations say that the military should be covered with prevention programmes and convinced that they need to be tested. Another important issue is equipping the military first aid kits with condoms.

Tuberculosis is Finally Getting on the Agenda of the Heads of State

22 November 2017, Geneva, Switzerland – Last week, 75 ministers agreed to take urgent action to end TB by 2030 at the conclusion of the WHO Global Ministerial Conference on ‘Ending TB in the Sustainable Development Era: A Multisectoral Response’ in Moscow, Russia. President Vladimir Putin of the Russian Federation gave the keynote speech on the first day of the Conference on 16 November. The first high-level plenary started with the welcome address of Amina J Mohammed, UN Deputy Secretary. The Conference was opened by Veronika Skvortsova, Minister of Health, Russian Federation, Dr Tedros Adhanom Ghebreyesus, WHO Director-General, Zsuzanna Jakab, WHO Regional Director for Europe, Dr Aaron Motsoaledi, Minister of Health of South Africa and Chair of the Stop TB Partnership, and Timpiyan Leseni, TB survivor from Kenya. The meeting was attended by ministers and country delegations, as well as representatives of civil society and international organizations, scientists, and researchers. More than 1000 participants took part in the two-day conference which resulted in collective commitment to ramp up action to end TB.

“In order to achieve a radical change in the fight against this disease, new approaches are needed, both at the national and international level, as well as the joint work of governmental agencies, public and professional organizations. Only coordinated and consistent actions will help us achieve a final victory over TB. We expect these steps to be supported at the highest level – by the General Assembly of the United Nations, whose meeting next year will focus on the problems of TB,” said the President of Russia Vladimir Putin.

“The UN HLM on TB is the moment we have all been waiting for, and we will we seize the moment. No more calls for action, we need commitment. Together I know we can do it, it will not be easy but we must believe it is possible. This house is full, the attendance of so many ministers shows the commitment but we need to prepare for real commitment,” said Dr Tedros, WHO Director-General.

Speaking at the opening of the Global Ministerial Conference on TB, Minister of Health of South Africa and Chair of Stop TB Partnership, Dr Aaron Motsoaledi emphasized the need to elevate the discussions and engagement to end TB at the level of heads of state and government and UN leaders. “Tuberculosis kills more than 4500 people every day and it is time to be seriously addressed with the support and engagement of the heads of governments. We need to ensure that going towards the UNHLM in New York in September 2018, we have a very strong participation, a very strong Political Declaration and a very strong accountability framework.  If we want this, we need  to have good quality data on TB and for it to be user friendly that heads of state, ministers of finance and even ministers of health can rapidly see the status of their epidemic and targets,” said Dr Motsoaledi.

On this occasion, the Minister launched the Stop TB Partnership interactive country dashboards site that presents country-based TB essential information in a manner that is simple and user friendly in easy-to-use graphs – including TB burden, TB care and service delivery, finances and selected determinants/comorbidity.

No new data is collected, rather that data is derived from the Global Fund, Institute of Health Metrics and Evaluation, the Stop TB Partnership, WHO and the World Bank – as indicated in the dashboards.*

Petition signed by more than 35,000 people from 120 countries presented to  Dr. Tedros, head of WHO and Ministers of Health.

In Moscow, the Stop TB Partnership and MSF released the report ‘Out of Step in Eastern Europe and Central Asia’ (EECA), presenting the results of an eight-country survey of national TB policies and practices. Among the countries surveyed, 75% have adopted the policy to use rapid molecular testing instead of older, slower testing methods, yet only half of those countries are actually using the test widely.

“In TB, we fight not only with mycobacterium tuberculosis, but also with the time. When we look at policies and guidelines and if country programmes need to update them, this is not an easy task, and it will take a lot of time to make it happen. If you add the time to have it approved and start the roll out, we are speaking here of years, not months. This is why it is important to keep up with the new recommendations and be able to adjust and adapt to the country context rapidly,” said Dr Lucica Ditiu, Executive Director of the Stop TB Partnership.

At the Global Ministerial Conference, Mariam Avanesova, who was treated for MDR-TB in Armenia in 2010-2012 and represents TBpeople, the Eurasian network of people with TB experience, handed over a petition to WHO’s Director-General, Dr. Tedros Ghebreyesus. The #StepUpforTB petition is an urgent call for health ministers in key TB-affected countries to get their TB policies and practices in line with international standards, as defined by WHO, including testing and treatment of TB and its drug-resistant forms. Initiated by MSF and the Stop TB Partnership, the petition has been signed by more than 35,000 people from 120 countries united with people affected by TB.

Source: Stop TB Partnership

HIV Test: the Work of Mobile Clinic in Kyiv

Tatiana shows a card of the recipient of services from Eney

Author: Yana Kazmyrenko, Ukraine

We have spent one day with the mobile clinic in Kyiv, Ukraine, that provides HIV testing for people who inject drugs. The social worker Tatiana quit using drugs and has now been diagnosing five HIV cases monthly.

Tatiana Martynyuk (54 years old) visits up to 10 apartments every day, and at least five of her clients each month turn out to be HIV positive. She works at a mobile clinic of the Eney Club in Kyiv, where she anonymously detects HIV and hepatitis C. The project has been supported by ICF Public Health Alliance for more than ten years. There are five mobile teams from the organization in Kyiv and one team always works night shifts in order to cover the sex workers’ testing.

Eney has a large base of volunteers. These people actively use drugs. They offer their friends and acquaintances to pass HIV testing which only takes 15 minutes. If the test is positive, they persuade a person to go to the City AIDS Centre and register there. Not everybody agrees, half of them reject saying that nothing is hurting, and they will not go anywhere.

We have the meeting on Shevchenko Square, the northern outskirts of Kyiv. Our first clients live not so far away. Tatiana brings them HIV tests, alcohol wipes and condoms.

Boiling shirka

Irina shows a drop of blood during testing

Sergey and Irina are meeting us in their one bedroom apartment, where everything is filled up with their belongings. The owners have been planning to renew the closet for several years already, but they have no money and energy for that. Irina, 43 years old, takes the test first. She is already receiving services from Eney.

“I tried drugs two years ago and I liked it,” she is saying, hiding her cracked hands. Ira has been working as a dishwasher, but currently she has no income as the restaurant is being closed.

The woman is getting nervous and takes a cigarette from Tania. The social worker asks Ira to do the test on her own so that she can do the test without any help in case of emergency. A drop of blood, four drops of the special liquid, and a long ten-minute waiting during which Tatiana has the time to ask what Ira knows about HIV.

“The most important thing: HIV can be in shirka (the popular name for one of the most commonly injected opiate derivates,) where a syringe was put for just a second. If in doubt – boil shirka,” Tatiana is instructing, asking other people to leave the kitchen. The HIV test result is strictly confidential.

Ira is satisfied with the test results, and she is going to wash the dishes. The 33-year-old Sergey is sitting at the table. It was he who “tricked” his female partner into trying drugs. He has been using drugs for 10 years.

Our client is not interested in getting the information about HIV: he is arguing, and saying that you can get HIV while visiting a dentist. Tatiana changes the subject and asks him to invite his friends for the check. Initially, three more people were willing to take the test, but at the end, only 28-year-old Artem came in. He has a rich biography, which includes a 10-year record of drug usage and imprisonment.

“If I want – I will take the drug. If I decide to quit it – I will quit it. I am not in the system. I earn 18,000 hryvnia (about 600 euros) on repairs and construction sites. I can do everything,” he boasts while lighting up a cigarette.

Receiving assistance from their peers

Vladimir’s wife, Inna, waiting for test results

While we are driving, Tatyana keeps telling her story: she has been injecting drugs for 25 years, and then she quit. She was tired and wanted to change her life. Her husband died, her son was drinking alcohol, and her mother is sick. At first, she found work as a street sweeper, but then she settled in Eney Club.

“I get more tired at this job than when I was sweeping the streets. Everyone needs to talk and to be heard, I need to organize things. I am not judging anyone. These people will only accept a help from a person like they are,” she shares.

It seems that with each visit to the next apartment, Tatiana challenges her willpower. She could possibly get her dose of drugs in any such place. Nevertheless, she is holding on. In her situation, one needs to have a special talent in order not to lose the spirit and to do the work with all your heart.

Needle veteran

Vladimir is having a holiday in his apartment in Obolonsky Lipky, the elite district in Kyiv. His prison sentence for the distribution and transportation of drugs has been changed into the conditional one. This was the fourth prison sentence for the 54-year old Kyiv citizen.

Tatiana helps Vladimir with a test

“I have been injecting drugs for 35 years now. I wonder how I survived. Everybody with who I started, is already dead. I prepare everything myself as I know all the recipes. I have studied the 1938 medical military handbook,” Vladimir is saying.

“Vova, you are such a fine fellow,” admires Tanya. The toothless Vova smiles and invites us to see his bathroom, where he has recently changed the tiles.

Vladimir takes the test and tells that he is going to get tooth implants and will start taking care of his health.

“I would not survive without drugs. I got all possible strains of hepatitis and in this way, I keep myself in shape,” he explains.

Vladimir’s elder brother is 59. He has been trying to quit drugs after a stroke. He smells of alcohol – he has been drinking vodka.

“That is how life used to be. In the 90s you would make a whole basin of shirka and you treat the whole district, but times changed and shirka is not the same anymore. We had loads of heroin,” he recalls with nostalgia.

The wives of the two brothers, Inna and Irina, also use drugs. During the test, Inna tells Tatiana to hurry up. She did not have time for injecting the dose, and now she cannot wait to get it.

Improving personal life

“Can you imagine this? I woke up in the morning and noticed that I lost my tooth and ate it in my sleep,” Marta is saying. She works as a hairdresser and has colorful hair.

Marta has been using drugs since she was 12. She says that drugs in Kyiv in the 80s were an element of prestige like a cherry VAZ 2109 (car model.) There was a seven-year break in her history. She started using drugs all over again when she had found out that her first love was HIV positive.

“He died, and I went crazy. In general, I cannot live without injecting. It is an addiction,” she explains.

Marta tries to take the test once a year, and she is going to improve her personal life.

“Tania, please, give me more condoms. My friends have been searching for a fiancée for me. I imagine him taking drugs, but not being a goner; I want him to have an apartment, as I would like to give birth to a child,” she continues.

Tania asks Marta to take her friend for the testing next time. A woman with a dark hair bandage is nervously waiting for her friend. She has recently become a widow, her husband died because of an overdose.

The social base of drug users is expanding

After the test, Tatyana immediately agrees to meet with the next client

After three visits, the social worker is tired, but there are still some addresses from the other side of the city.

“Our program helps them to be safe and control their health. I would also like to add some food arrangements – some of them do not have any food for weeks,” Tania is saying.

The harm reduction program among people who inject drugs in Eney Club started in 2001. The annual coverage was more than 6000 people in 2016. Out of these number, 80% of people have been tested for HIV. Now, the average level of HIV detection among clients is 3.5%, where 80% of people have been placed on dispensary records. The level of drug usage has been growing in Kyiv. There appeared separate subgroups among the people who use drugs. Veterans of the Donbas conflict and immigrants from the Eastern Ukraine form such subgroups.

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

Author: Anke van Dam, AFEW International

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

Co-infection in the EECA region

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

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

Plan was prolonged

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

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

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

Response is developed

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

Actions within the plan

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

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

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

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

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

AFEW advocates for the plan

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

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

Tuberculosis and HIV are the “Imported” Diseases of Migrants

Author: Nargis Hamrabayeva, Tajikistan

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

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

The fear of deportation – reason for tuberculosis

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

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

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

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

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

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

HIV is “brought” due to the migration

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

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

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

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

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

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

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

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

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

Drug-Resistant Tuberculosis on the Rise in Eastern Europe

Author: Ingrid Hein

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

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

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

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

Eastern Europe Is a “Perfect Storm” for TB

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

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

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

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

More Likely to Die From TB in Eastern Europe

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

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

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

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

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

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

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

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

Prisons and Drugs Contribute

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

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

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

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

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

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

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

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

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

Drs Podlekareva and Lange have disclosed no relevant financial relationships.

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

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.”

Central Asian NGOs Built a Network for Cross-Border Control of Tuberculosis

Author: Marina Maximova, Kazakhstan

During the regional seminar-meeting held on 6-7 June in Almaty, Central Asian nongovernmental organizations established a network of partner organizations to address issues of labour migration and tuberculosis. The participants accepted draft Memorandum of cooperation between non-profit organizations to reduce the prevalence and incidence of tuberculosis among migrant workers in the countries of the region.

“This document was created in response to the need of NGOs consolidation to educate migrant workers about TB symptoms and the opportunities of free treatment and diagnostics in the framework of the project, to promote treatment compliance, to exchange information and to disseminate best practices in the countries of Central Asian region,” says a project manager of the Global Fund, a representative of Project HOPE in the Republic of Kazakhstan Bakhtiyar Babamuratov.

The event was organized by the Project HOPE in the framework of the grant from Global Fund to fight AIDS, tuberculosis and malaria. Representatives of non-governmental organizations from Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan attended the seminar .

Migrants do not want to be treated

From all the countries in the Central Asian region, Kazakhstan is accommodating the main stream of migrant workers from neighbouring countries. Migration flow continues to grow. Those who come to find a job often agree to any work, they often live in poor housing conditions and do not eat well. This results in tuberculosis development. In 2016, 753 external migrants addressed the organizations of primary health care and TB facilities of Kazakhstan and were tested for tuberculosis. In 2015, there were only 157 visits. Most migrant workers prefer not to attend medical institutions and refuse to be treated in the TB clinics or to be examined by a doctor. They consider it to be a wasting of working time, i.e. money. They have to support families left at home, therefore money is the main reason to come to a foreign country. For the same reason people do not want to spend money on health, even though a Comprehensive plan to combat tuberculosis in Kazakhstan for 2014-2020 involves activities to improve TB services for migrant workers.

Particularly alarming are the cases when a migrant worker is diagnosed with HIV/TB co-infection, and when such patient needs a serious treatment and social support. This important topic will be discussed in 2018 in the framework of the 22nd international AIDS conference – AIDS 2018 – in Amsterdam. This conference will be very special as for AFEW International and the whole region where the organization works — Eastern Europe and Central Asia.

Work at construction sites and markets

In the situation mentioned above, the participation of the NGOs in addressing of this issue has become very important. Outreach workers and volunteers – people, whom the target group trusts, – are searching for migrant workers on construction sites, at the farms, markets, in the restaurants or cafes. They tell migrants about the disease and the free treatment, convince to pass the examination and to provide social support. The results of such work are impressive.

“Within the project, implemented by Project HOPE in 2016, staff and volunteers of our public Fund helped 898 migrant workers to be tested for tuberculosis. For 25 of them the diagnosis was confirmed, and with our assistance people were able to receive free treatment. Besides, we provided migrant workers with motivational food packages. 8,312 labour migrants received information about the symptoms of tuberculosis, and now they know where to go if they are sick,” says the Director of the Public Fund Taldykorgan regional Foundation of employment promotion Svetlana Saduakasova.

These are the results of the activity of only one non-governmental organization in Kazakhstan. Nowadays, social activists are effectively working in eight regions of the country. Such results are possible to achieve only thanks to active collaboration with the non-governmental organizations from those countries where work migrants come from. The community members actively communicate with each other and exchange useful information to be aware of whether the diagnosed person came back to his home city, got registered in the TB clinic, continued to receive treatment, and so on. Only under these conditions we can achieve a complete recovery from TB for each individual and finally stop the growth of morbidity in the region.

EECA Organisations Supported Michel Kazatchkine

Michel Kazatchkine, United Nations Secretary-General’s Special Envoy for AIDS in Eastern Europe and Central Asia

AFEW International has reached out to organizations and networks in Eastern Europe and Central Asia with the request to sign the support letter for re-appointment of Michel Kazatchkine as United Nations Special Envoy for HIV/AIDS in Eastern Europe and Central Asia.

His contract/mandate as UN special envoy on HIV/AIDS for Eastern Europe and Central Asia ends on 30 June. His role in addressing three epidemics in the region (HIV/AIDS, tuberculosis, hepatitis) and to raise awareness at political and scientific level of the concerns regarding HIV, TB and viral hepatitis in the EECA region is crucial and very important, especially now as we have the opportunity to highlight the challenges and successes of the region at AIDS2018 Conference. Therefore, there is a dire need for a continuation of his support.

The letter, signed by more than 70 signatories has been sent to United Nations Secretary General António Guterres. You can read the letter here.