Natalya Shumskaya: “We Want to Improve Country Health System Coordinating Mechanisms”

shumskayaPublic Foundation “AIDS Foundation East-West in the Kyrgyz Republic” makes a significant contribution to public health of the country in reducing the growth rate of socially significant infections in Kyrgyzstan. The head of AFEW-Kyrgyzstan Natalya Shumskaya is telling what we should expect from the organisation in 2017, and outlines the achievements of the previous year.

 – How was the year of 2016 for AFEW-Kyrgyzstan? What do you think were your greatest successes?

– 2016 was a successful and fruitful for our organization. We managed to keep our activities on HIV prevention in the prison system, including law enforcement, prevention of HIV among women who use drugs. During the last year, 1013 women received an access to health and social services. One of the achievements was that in 2016 our organization supported the Ministry of Health of the Kyrgyz Republic in the development of the clinical protocol “Pregnancy, childbirth and the postnatal period for women who use drugs.” In December of the last year this protocol was adopted. Later, we started a very difficult project with the aim to return the patients with multidrug-resistant tuberculosis (MDR-TB) to the treatment. Since August 2016, AFEW-Kyrgyzstan together with the City Centre for Tuberculosis Control in Bishkek started a project “Joint control of tuberculosis and HIV in Kyrgyz Republic.” During five months of 2016, 17 MDR-TB patients returned for the treatment; three patients co-infected with HIV were connected to antiretroviral treatment, five patients with tuberculosis and extensively drug resistant TB (XDR-TB) had the necessary tests, and their results were given to the council for inclusion in a treatment program under the new scheme. There was organized controlled treatment at home for 28 patients. The delivery of products is done 6 days a week, except Sundays. Additionally, project case managers conduct information sessions with patients with MDR-TB and their inner social circle, monitor the side effects of anti-TB drugs, and, if necessary, deliver drugs to relieve the side effects. They also maintain regular contact with doctors. In January of 2017 we increased project staff. It was done for the full coverage of all MDR-TB patients who need to receive treatment at home and assisting them to diagnosis and friendly services. Two case managers and a social worker were hired.

– How is the work of the research department of your organization that you created two years ago?

– The Department continues to work successfully. Over the past year, the researchers conducted a qualitative study among the inmates of correctional facilities that are getting ready to be released. It was called “Prisons, injecting drugs and the environment of risk of HIV infection.” This is a continuation of the positive experience of effective cooperation of AFEW-Kyrgyzstan with medical school researchers from Yale University and the State Penitentiary Service of the Kyrgyz Republic. This study aims to describe and research the quality of the program of methadone substitution treatment in the penitentiary system of Kyrgyzstan and civil society. The recommendations based on those results will be offered to the country to optimize harm reduction programs.

– One of the main directions of your work is cooperation with the police and the prison systems. Please tell us, how is this cooperation going? What is the role of AFEW in it?

– AFEW cooperates with the Ministry of Internal Affairs for 10 years already. In 2016 our organization has provided technical support to the Ministry in carrying out monitoring visits to all the regions of the country. The aim of the visits was to control how the law enforcement officers perform the instruction on HIV prevention. In addition, we organized and conducted four trainings for the staff responsible for the official trainings and for non-governmental organizations on the reform of law enforcement agencies. It is important that the civil sector supports current reforms, and it is important that law enforcement officers assist the execution of the State Programme on HIV.

AFEW is also working with the penitentiary system of the country for more than 10 years. We work together in three areas: technical assistance and coordination, increasing the capacity of staff and providing direct services to prisoners. In 2016 we worked first in six and then in four institutions to promote the goal 90-90-90. We provided services for people who inject drugs (PIDs), told them about HIV and the ways of transmission, motivated them to pass the test for HIV. We actively worked with people living with HIV at the stages of realising of the diagnosis, preparation for therapy, start of therapy, development of adherence to treatment. One of the achievements, of course, is to extend the work on the colony-settlements. Before, prisoners there fell of HIV prevention services, as there are no medical units there, and they usually have no documents for getting help from the civilian health organizations.

– In October AFEW-Kyrgyzstan helped to sign a memorandum of cooperation of four key groups. Please, tell us what these groups are and why their teamwork is so important? How is this cooperation going now?

– Unfortunately, there is mutual stigma within the key groups. Cooperation can help to overcome barriers and build partnerships. The leaders of key groups started to work closer. They discuss new joint projects, research abstracts for AIDS2018 conference in Amsterdam. Together they will carry out activities to reduce stigma and discrimination in relation to other key groups through the mini-session, for example, PIDs for LGBT and sex workers’ organizations. Since last year, we have been inviting all the participants of memorandum for the event and, of course, they also invite us for their events.

– In February, you will host a training for the members of the Country Coordinating Committee on HIV/AIDS (CCC) project BACK UP-Health. Tell us more about it. What are other areas of your work with the CCC?

– Starting from July 2016, AFEW-Kyrgyzstan will implement the project “Harmonization and consolidation of resources to fight HIV infection and tuberculosis in Kyrgyzstan.” It will be done with the financial support of GIZ, program Back Up-Health. With this project we want to improve the coordination mechanisms in the country’s health care system. We want to involve civil society in the discussion on the reform of CCC, and we also want to increase the capacity of the Committee. In February of 2017 AFEW-Kyrgyzstan plans to host a seminar for members of the CCC to prepare the Country Request for continued funding in the state funding for 2018-2020. The following groups will take part in the seminar: members of the Committee for the preparation of applications for resource mobilization and harmonization of CCC; CCC board; members of the Advisory Working Group, which were included by the Kyrgyz Ministry of Health; national experts who work on the preparation of the request for continued funding who will directly collect information and write application; international consultant; head of the expert working group on writing requests for funding, and also key partners from the public and international sectors which may influence decisions and who expressed their readiness to provide technical assistance in the preparation of high-quality country request to the state financing from Kyrgyzstan. During the workshop, participants will act as experts and will share their knowledge and experience with each another. They will also learn how to fill the forms for the requests, will learn the new priority areas of TB and HIV, which are included in national policies and programs, will discuss and analyse the share of public funding, make mapping of the services, clients and funding. Actually, the main purpose of this seminar is to assist the CCC, experts and other stakeholders in the preparation of high-quality application. We want everyone to have one vision and one structure of the request, so that the process of approval of the CCC members is efficient and fast.

– What are AFEW-Kyrgyzstan plans for the year of 2017?

– AFEW-Kyrgyzstan spent its first three years as a local non-governmental organization. The most important achievement is that we were able to successfully implement its first strategic plan and to develop partnerships with international and donor organizations. In 2017 we will review the strategic plan of the organization. Of course, the priority for the board of the organization has been and continues to be ensuring of the stability of the organization.

Bridging the Gaps in Women’s Hostel in Kyrgyzstan

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Leila and Sofia live in women hostel in Bishkek

Five-year-old Sofia is playing with her mother’s telephone. The girl is sitting on the floor and is listening to the music. She is switching between the songs, watching videos, and trying to find her favourite track. There are four beds in a small room. At some moment, the girl puts the phone away and asks: “Mom, what will Santa bring me?”

“What would you like, dear?” she hears from her mother, and the broad smile appears on her face. “I would like him to bring me a kitten. I will feed it with milk.”

When the girl is smiling, she has cute dimples on her cheeks. She brings a toy – plastic alphabet with the buttons. She presses the letters and repeats them. Sometimes she gets the letters wrong, and then the mother asks her to do it again.

TELLS ABOUT HIV TO NEW FRIENDS

Sofia and her forty-year-old mother Leila live in the hostel that operates in the centre of adaptation and socialization of women – injecting drug users in the public fund Asteria in Bishkek, Kyrgyzstan. Leila was recently released from prison.

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Leila is teaching Sofia an alphabet

“I do not have any relatives; I was raised in the orphanage. I got to prison when I was pregnant, and my daughter was born there,” Leila tells. “Now I work in the kitchen or wash the floors. Recently I went to Turkey, and wanted to find a job there, but I do not know Turkish language, and that is why it did not happen. By education, I am a seamstress and a pastry chef, but it is hard to find a job because I am HIV-positive. I am being asked about my diagnosis all the time, and I always have to go through medical examinations. Now I have found a job as a nursemaid, but I do not have anyone to leave my daughter with. She has to go to kindergarten, but all of them here are not free of charge. I will have to spend almost whole salary to cover the pay for kindergarten… I am currently waiting for the cash advance to pay.”

Leila says that she tells her new friends about her diagnosis, even though she does not always want to do it.

“I think, people with my disease should talk about it, and warn others as well. Now I also bring other people to get tested. I am telling them they have to do it, and that it is free of charge,” Leila says. “Of course, people treat me different when I tell them about my diagnosis. Yes, it is unpleasant, but I am happy that in this way I do something nice to others. Everybody should know such things.”

PRAYING FOR ASTERIA

Leila is worried that the hostel in Asteria can be closed. In that case, the woman can end up on the street. She does not have anywhere to go to.

“I should not be complaining; we have everything here. The main thing is the roof over your head,” the woman smiles and hugs her daughter. “I am very comfortable here. We receive medical treatment, there is a place to sleep, to do laundry. Every Sunday we go to church. In the church I always pray for this house, for people who help us here, and ask God that the organization has donors.”

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The head of Asteria Iren Ermolaeva shows the rules of the hostel

Leila says that she would like to move from the hostel in the future, but she does not have such possibility yet. She dreams of her own home, family, and work. She also wishes that the hostel will never close. People who work in Asteria have the same desire.

“We indeed often have problems with financing. Every year we do not know what to expect in the next one,” the head of the public fund Asteria Iren Ermolaeva says. “Our public fund is working since 2007, and the hostel – since 2009. We would like to have the whole range of services, but there is not enough financing these days. We know how to find the approach to women, we know how to create friendly atmosphere so that a woman would want to change her life for better herself, and we would like to use this knowledge. We feel sorry for our clients, and we would like to help them more.”

DREAMING ABOUT OWN HOUSE

Workers of Asteria also dream about purchasing the house where they will place the centre of adaptation and socialization of women – injecting drug users and the hostel. They have already found funds for the future house renovation, but cannot find money for its purchase.

“Then we would be able to have social entrepreneurship, maybe some little farm. In that way, we could at least not depend on donors in food,” the coordinator of the social services of the fund Tatiana Musagalieva is saying. “Until now, we rented all three houses for our centre.”

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Asteria workers Iren Ermolaeva (on the right) and Tatiana Musagalieva say that their organisation often has problems with financing

Thanks to “Bridging the Gaps: Health and Rights for Key Populations” project from Public Foundation “AIDS Foundation East-West in the Kyrgyz Republic”, in 2016 Asteria could support four beds in the hostel. The project also helped with medicine and warm food.

“People often come to us to eat, to do laundry,” Iren Ermolaeva says. “Around 300 women come through our centre during one year. Leila, for instance, came here after she was released from prison. She has got all the necessary services, clothes, shoes, and got medical examinations. Leila was imprisoned for five years, and, now, due to the conditions that we have, she adapts and integrates into society. In this way, she becomes more confident in herself, can find a job and build her future.”

AFEW: High Standards in Service Delivery

The new social bureau of AIDS Foundation East-West in Tajikistan attracts diverse key populations for respectful attitude, quality services and professional counselling

In 2014, AIDS Foundation East-West (AFEW) officially opened its branch office in the Khatlon region (in the city of Qurghonteppa, formerly Kurgan-Tyube). This branch office aimed to expand prevention, treatment, care and support services for key populations at high risk of acquiring HIV and other infectious diseases.

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Prior to 2014, AFEW had never provided direct healthcare, social, psychological or legal services to key populations. Instead, AFEW supported local community organisations by increasing their capacity and providing them with the skills and knowledge to offer such services. Whilst AFEW plans to continue providing technical assistance to local non-governmental organisations (NGOs), opening its own social bureau will allow AFEW to significantly increase the coverage of quality services aimed at assisting key populations.

THE HIV SITUATION AND LOCAL CONTEXT

High unemployment rates persist in Tajikistan. Official figures indicate that 2.6% of the economically active Tajik population currently have no job, whilst many Tajik migrant labourers returned home following the Russian economic crisis. According to World Bank data from 2014, one-third of Tajikistan’s population lives below the poverty line.

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In Qurghonteppa the major source of income for the locals is bazaar

Tajikistan lies along the primary transit routes of Afghan drugs making their way to Russia and eventually Europe. The Tajik–Afghan border stretches for 15 000 km, a considerable portion of which lies along rugged mountain terrain, ideal for trafficking. According to official data from 2005, officials seized 4676 kg of opiates illicitly trafficked. Since then, the volume of narcotics exported from Afghanistan has continually increased. Between 2010 and 2015, authorities seized 31 696 kg of illicit drugs.

The availability of drugs, and the high rates of poverty and unemployment in Tajikistan, relate to other demographic characteristics and statistics in the country. For example, in 2004, the estimated number of sex workers reached more than 14 000 individuals. As of 2015, unprotected sexual contact accounted for nearly 62% of all newly registered cases of HIV.

Considering these factors, AFEW chose the location of its social bureau deliberately. The Khatlon region stands as the most densely populated area in Tajikistan. According to Republican AIDS Centre data, since 2013, this region is home to the highest number of new HIV cases.

SOCIAL BUREAU STAFF

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Staff meeting at AFEW social bureau

AFEW’s head office in Dushanbe — Tajikistan’s capital — took matters related to human resources for the new social bureau quite seriously. Of primary importance, setting and maintaining high standards for the social bureau received particular focus since the facility would serve as an example for other NGOs. Today, AFEW is genuinely proud of its branch office staff given how well-known and respected they are within Qurghonteppa and the surrounding region.

Until recently, Tursunpulod Norkulov, PhD (on the right) worked as the chief physician at the Regional AIDS Centre. Today, Dr Norkulov serves as a project specialist at AFEW’s social bureau. His nurse at the AIDS Centre, Kurbongul Alimova (middle) — also a trained biologist and virologist — works as a social worker within the bureau. Clients seeking services from AFEW know both Dr Norkulov and Ms. Alimova from their work at the AIDS centre. Clients also confess to experiencing better attitudes towards those seeking services at AFEW compared to elsewhere. Each individual consultation or group meeting traditionally begins with inquiries about the client’s health, exchanging news from one’s private life and a discussion about any successes and problems the client recently experienced.

JurabekJurabek is one of the most active participants of such meetings. In the past, this 48-year-old man used drugs. He now works at AFEW as an outreach worker. Jurabek knows all of the places in town where people who use drugs typically congregate, and many of those who use drugs know him. In 2015, he reached 190 individuals through his work, 14 of whom joined the opioid substitution therapy (OST) programme.

Jurabek: ‘People who use drugs do not believe in substitution therapy, because drug dealers tell them that the state is deliberately handing out methadone in order to get rid of drug users in a year or two. But, of course, this is not true and only serves to keep their clients buying street drugs. Every time I hear this myth, I tell them my own story—that I myself was on methadone, began to feel well and have now stopped taking methadone completely.’

Alisher, another AFEW outreach worker, uses the same approach when working with people living with HIV. Many are afraid to initiate treatment for HIV, or quit soon after they start it because they lack accurate information about antiretroviral treatment.

Alisher: ‘I work with HIV-positive families, and visit them together with my wife. The AIDS centre provides us with information on those who have quit treatment. The most important elements to this work consist of trust and communication. My wife and I explain to them everything that we did not hear ourselves when we needed it: information related to the side effects of treatment, the importance of continuing treatment and so on.’

CLIENTS

Zhanna-42-SW-Kurgan_smallZhanna (42), a sex worker, divorced her husband when he found another woman when working as a migrant labourer in Russia. Finding herself alone with two young children, she became a sex worker to support herself and her family. When the opportunity arises, Zhanna also cleans houses.

She visited the social bureau initially when it opened, and continues to visit it regularly now. Here, she picks up informational brochures, takes part in information sessions and group consultations or simply comes to chat with other clients. Social worker Kurbongul regularly accompanies Zhanna during her consultations for various tests and consultations at the women’s health and infectious disease clinics. Every three months, Zhanna undergoes HIV testing.

‘I love myself and value my health,’ she said. When asked if she always uses condoms, Zhanna said that she doesn’t always with her regular clients.

She said, when she suggests that her clients use condoms, they suspect her of having a sexually transmitted infection.

Zhanna: ‘Then, I explain to them that it is for my own protection, because not all diseases have visible symptoms, including HIV.’

In future, Zhanna hopes to find a permanent job. Now, she is busy gathering the paperwork necessary to work as a kindergarten teacher.

Sharifbek-and-Bobo1Sharifbek Safarov (left) is 54 years old. He is a Master of Sport on the national wrestling team, a six-time Tajik champion and a Candidate for Master of Sport in judo. For many years, he worked as a wrestling coach. The difficult economic situation, as well as the instability resulting from the civil war in Tajikistan between 1992 and 1997 and the flow of drugs from neighbouring Afghanistan contributed to many young people, including Sharifbek, picking up heroin use.

Sharifbek: ‘For a pair of rubber galoshes, dealers doled out a half kilo of opium.’

In June 2014, Sharifbek met an outreach worker from AFEW’s branch office in the Khatlon region. After Sharifbek underwent an HIV test and screening for tuberculosis, he was offered enrolment in an OST programme.

Thanks to OST and support from social workers, Sharifbek returned to his favourite job. Today, his wrestling programme includes around 70 teenagers, for which he receives a salary from the state. In addition, his methadone dosage is gradually decreasing. With a diploma from a sports college, despite his age, Sharifbek also hopes to complete further higher education training and receive a diploma from the Sports Pedagogical Institute.

Together with his friend, Bobokhuja Badridinov (right)—who is also a client of the OST programme—they often visit AFEW’s branch office to take part in the group sessions with active drug users. In doing so, they explain the advantages of OST and the resulting positive changes to their own lives.

‘Methadone has literally saved us. We can work and feed our families. There is no need to look for drugs. It means there are fewer health risks and chances that we will get into trouble with the law.’

Shodi-MSM-Kurgan-dancer-waiter-volunteer-has-boyfriend_smallShodi (24) is a volunteer at AFEW’s social bureau. He conducts thematic mini training sessions for men who have sex with men and accompanies them to the AIDS centre and infectious diseases clinic. Nearly 20 individuals attend training sessions.

With his boyfriend, whom he met on a popular social network, Shodi regularly undergoes HIV testing. Whilst the couple has been together nearly three years, their parents remain ignorant of their relationship—they think that the two are simply good friends.

Shodi: ‘In Tajikistan, every man must marry a woman. Marriage also awaits both of us. However, this won’t be a problem for us—we will continue our relationship as always.’

In addition to his work at AFEW’s social bureau, Shodi also works as a waiter at a local cafe. When asked by his boss, Shodi performs Indian and Tajik national dances.

Whilst AFEW’s social bureau provides services to all key populations, the majority of its clients consist of people who use drugs. None of those who use drugs holds a permanent job and almost all of them served time in prison. Many clients come directly to the social bureau upon release from prison carrying AFEW’s business cards in their hands. Since September 2014, AFEW has regularly conducted training sessions for prisoners in two colonies in the Khatlon region, preparing individuals for release and reintegration into society. These activities fall within the framework of the Start Plus transitional client management programme. Currently, 26 individuals are enrolled in the programme, the main activities of which consist of AFEW informational sessions on the prevention of tuberculosis and HIV, personal hygiene and healthy lifestyles.

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Clients come to AFEW’s social bureau for consultations on HIV and other infectious diseases. Here, they may also receive legal counselling and referrals to health centres. Many individuals visit the social bureau simply to chat with each other whilst drinking tea or playing ping-pong.

safetySoon, clients may undergo HIV testing on the premises of the social bureau. In September 2015, the Tajik Ministry of Health issued an order allowing on-site testing based on an AFEW initiative. To provide HIV testing services, public organisations must offer all of the necessary testing infrastructure (i.e., a separate room, equipment and materials) and the staff must complete a relevant training programme. AFEW has already met all of the requirements, including approval from the Blood Centre to handle blood samples. To begin testing, AFEW needs to amend its statute, which is also underway.

Many clients’ primary challenge centres on their lack of employment. Whilst most clients possess only a secondary education, nearly all have hands-on construction, electrical, welding and carpentry skills and experience. Many clients are willing to work in the garden to grow their own fruit and vegetables to sell, raise poultry or rabbits or initiate small-scale production of paving stones for instance. Clients argue that such opportunities would significantly change their lifestyles, habits and behaviour.

CO-OPERATION WITH STATE AGENCIES

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Training plan with the police

AFEW’s partnership with the Ministry of Justice’s Punishment Implementation Department to increase prisoners’ awareness of HIV prevention stands as one example of successful cooperation with state agencies. In May 2015, Tajikistan’s Interior Ministry turned to AFEW with a request to organise information sessions on HIV prevention for police personnel. Accepting this request resulted in a total of 566 police officers from district stations completing a training session. Analysis of completed pre- and post-training mandatory questionnaires demonstrated a significant improvement in knowledge about HIV and the means of prevention amongst attendees. Police training will continue in 2016.

FUTURE PLANS

We may safely say that AFEW’s branch office in the Khatlon region has hit the ground running. For such a small organisation, its list of accomplishments for just two years is rather impressive. With its multiple achievements, AFEW plans to expand its work amongst and for this region’s key populations.

Abdumadzhid Saitov, AFEW social bureau’s co-ordinator: ‘As we expand, we will try to accommodate as many of the wishes of our clients. For example, we will develop a library for them towards self-education, offering interesting and educational films. Unfortunately, we cannot address all of their wishes in the nearest future—for example, creating a dormitory for our homeless clients remains a bit beyond our reach. To organise such a place, we would need significant financial resources and qualified personnel.’

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Female Activists from Kazakhstan, Tajikistan on Study Tour to Saint Petersburg

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Study tour participants

Four activists representing networks of women living with HIV in Kazakhstan and Tajikistan travelled to Saint Petersburg, Russia to learn about building relationships and cooperation with state authorities and businesses to promote the interests of women with HIV and explore fundraising opportunities. The study tour took place August 24-26 and was organised by AFEW-Kazakhstan in the framework of its UN Women project on building the capacity of women living with HIV.READ MORE