Tuberculosis: A Crisis in Eastern Europe and Central Asia That the West Cannot Ignore

Few young doctors in my own country France would currently wish to specialize in phtisiology. Actually, and for over 30 years, the word “phtisiology” had disappeared from the letterheads of lung diseases divisions in hospitals. The focus of pneumology these days is on chronic lung disease and cancer much more than on tuberculosis (TB).

So it came as a surprise to me to hear medical students in Tashkent, Uzbekistan’s capital city, claiming in a unanimous voice that they see “phtisiology” as the most exciting professional future they wish to consider at the end of their studies.

Earlier this year I visited the Republican Scientific and Practical Centre of Phtisiology and Pulmonology in Tashkent as part of a broader mission devoted to HIV/AIDS, TB and Multi- Drug Resistant Tuberculosis (MDR-TB) in the country.

The Institute is a large campus with an adult in-patient facility of 800 beds or so, ambulatory sections, a pediatric section, remarkable laboratory and imaging facilities, and access to most of the latest technologies and structural hospital requirements for TB and MDR-TB. Professor Tillyashaikhov Nigmatovich, the Head of the Institute, can rightly be proud of this institution, the reference point for TB in the country.

On the other hand it is at the same time somewhat unsettling to discover why Uzbekistan has built an institution such as the Centre of Phtisiology and Pulmonology and why young doctors perceive TB care as an attractive and contemporary field of medicine.

Uzbekistan is one of the high burden countries for TB globally and one of the 27 high burden countries for MDR-TB in the world. The number of new MDR-TB cases annually is close to 9000 cases, with 15 per cent of newly diagnosed TB cases being resistant to at least two conventional TB drugs.

And that is the case in almost all countries in Eastern Europe and Central Asia. The World Health Organization’s Euro Bureau reports that fifteen countries in the region are among the high burden countries for MDR-TB in the world, which leaves only very few of the countries out of that list.

Although new technologies are now available to diagnose TB and test for TB drug susceptibility / resistance, the reality is that less than 50 per cent of the estimated new cases of MDR-TB are diagnosed across the region. And only half or less of those patients in need of treatment are actually treated and cured. Those who are not treated remain contagious and they also die. This nothing short of a crisis, one we have to stop neglecting.

One other episode struck me at that hospital in Tashkent. As I entered the room where doctors and students were examining X-Ray and CT scans of patients in the ward, I saw an X-Ray of a diffuse form of pulmonary TB and asked about the physician in charge about the patient’s story. He was a young man in his late twenties who had traveled to Saint Petersburg seeking a job as waiter in one of the growing number of fashionable restaurants in the city. The TB was diagnosed on systematic X-Ray screening and he was immediately sent back to Uzbekistan for treatment. The CT scan from another patient showed a nodular form of pulmonary TB. This was another young man of similar age who was diagnosed upon systematic screening as he was enrolling in a University program in Almaty, Kazakhstan. He also returned shortly after the diagnosis to Tashkent for care.

Migration is a major issue in this region that sees so many students and sees millions of workers move every year in between countries in the region, with a lot of movement to Russia. Migration is a key issue in terms of public health but one that demands asensitive response given it touches on a fragile intersection of the economic, human rights and political arenas in a region where no transborder agreement on the provision of treatment for AIDS and TB currently exist. Tuberculosis is at a crisis point in Eastern Europe and Central Asia and it is a crisis that the West can no longer afford to ignore and it is my hope that the issue begins to receive the attention it deserves at international forums such as the upcoming 45th Union World Conference on Lung Health in Barcelona.

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Postcard From New York: Taking Control of Drug Policy

I am writing this from New York where I am spending the week advocating for reform of the international drug control régime with the Global Commission on Drug Policy and participating in the media launch of its latest report Taking control: pathways to drug policies that work, at the MoMA today, Tuesday. My esteemed Commission colleagues and I are hoping that this week´s meetings with the UN Secretary General and the UN diplomatic missions to New York will also serve as an unofficial launch pad for the ensuing debate that will take place in the lead in to the UN Special Session of the General Assembly on drugs scheduled for the first half of 2016.

Reflecting on the past three years, we have certainly come a long way: In 2011 the Commission denounced the failure of “the war on drugs” and of drug policies based on a strictly prohibitionist and repressive paradigm. It called on the world to “open the debate” and move from the ineffective and harmful enforcement-led approaches to policies prioritizing public health and safety. The Commission further elaborated on how aggressive repressive policies have fueled the AIDS and hepatitis epidemics among people who inject drugs and their communities, one of the main themes of my advocacy in my role as Envoy on AIDS in Eastern Europe where policies prioritizing repression are having major negative effects on public health.

The new report of the Commission comes with strong recommendations to shift policies and improve the international drug regime. They cover extensive ground and include:

• Re-orienting policy priorities from punitive enforcement to health and social interventions of proven efficiency;
• Ensuring access of opiate-based medications for the treatment of pain to all those in need;
• Stop criminalizing people for drug use and possession; and rely on alternatives to incarceration for non-violent and low level participants in illicit drug markets such as farmers and others involved in the production, transport and sale of drugs;
• Moving to legally regulated markets, to put governments back in control. Move to regulation may begin with cannabis, but should NOT be limited to it, also considering coca leaf and certain psychoactive substances (ATS), as it has recently been done inNew Zealand for ATS;
• Calling on the world leadership to use the opportunity of the 2016 Special Session on drugs of the UN General assembly (UNGASS) to intensify the debate, inform the public opinion, objectively analyze what the current international regime has achieved or — rather — failed to achieve; understand the health, social and human rights-related harms and the waste of public resources that it has generated.

This final point is not merely a rhetorical statement.

It is, I believe, where the tipping point lies: resources that otherwise could have gone to prevent people from using drugs in the first place or to prevent people occasionally using drugs from becoming addicted users, or help addicted people to access treatment and care to protect their health and that of their communities, has otherwise been spent to build more and bigger prisons, create bigger police forces and funded government law and order campaigns.

We who work in the field have known and railed against this unfair scenario for many years but what is different now are the incremental changes we are seeing in government attitudes that I believe are partly being driven by a growing change in attitude in the general community — that drug use ought to be seen as a health issue — not one that guarantees deprivation, sometimes for life.

There is a long way to go but some of the right noises are being made on the road to the much-awaited public debate in 2016. I have no doubt that the Commission´s latest report will help stir that debate and ultimately help re-orient drug policies to towards the noble goals of improving health outcomes, respecting human rights and guaranteeing the well-being of people.

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Stepping Up the Pace Means Leaving Nobody Behind

Huffington Post – published on July 17th 2014

Ahead of the 20th International AIDS Conference which I will be attending in Melbourne, Australia, next week, I wanted to reflect on the event’s timely focus on those — “key affected” populations — sex workers, men who have sex with men (MSM), people who inject drugs (PWID) transgender people and incarcerated people that are most vulnerable to HIV.

Despite the remarkable progress achieved globally, the prevalence and incidence of HIV among these groups remains far higher than in the general population in almost all regions of the world due to restricted access to information, prevention and treatment.

And while we have long recognized the “concentrated” character of the HIV epidemic in low-prevalence countries outside Sub-Saharan Africa, we have overlooked the epidemic among key affected populations in the “generalized” epidemics in Africa where it is now also emerging. We have failed to address the structural, legal, cultural, societal, economic and political obstacles that prevent vulnerable and underserved groups from accessing services. We have also been unable to coherently address the interlinked epidemics of HIV, HCV and TB/MDR-TB among key populations. It is time when we are gathered in Melbourne to reflect on these failures.

In the early days of the epidemic, Australia was successful in containing epidemics among its key affected populations, particularly among MSM and PWID. Australia did so by recognizing early the role of community in delivering information and outreach services, by breaking down some of the taboos in the way society addressed the disease and by implementing a rapid expansion of harm reduction services.

It is only by building broad partnerships between the health sector, other relevant public sectors and the communities themselves, that the unmanaged structural and societal challenges posed by the HIV, HCV and TB epidemics in key populations, can be addressed. And building such partnerships is precisely what — for 20 years now what the International AIDS Conferences have been aiming for — bringing together scientists, health professionals, affected people, civil society, the private and philanthropic sectors and government decision makers within and outside the health sector — the unique mix that has allowed so much progress in the fight against HIV/AIDS in the last 15 years.

This is why I will look forward next week to events such as the launch with my colleague and IAS President-Elect Dr Chris Beyrer, of the International AIDS Society White Paper on “Maximizing the benefits of antiretroviral therapy for key populations,” some further discussions of the consolidated WHO guidelines for key affected populations released last week, the pre-conference MSM event, the launch of the special Lancet issue on sex work, the many sessions on HIV and drug use, including the Global Commission on Drug policy event featuring Sir Richard Branson and the Honorable Michael Kirby.

I hope to take away many lessons learned on the issue of key affected populations from the Melbourne conference — lessons I can apply in my work on the epidemic in the Eastern European and Central Asian region where I now focus much of my attention.

The stakes are high: The absence of a much strengthened response to HIV among key affected populations, will mean AIDS will remain a major cause of avoidable suffering, illness and premature deaths in the region and worldwide.

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A Life of Dignity for All

Speech given on the opening day of the 4th Conference on HIV/AIDS in Eastern Europe and Central Asia.

As we open this conference, I would like to salute the physicians, scientists, healthcare and social workers, representatives of civil society and of the community who tirelessly work in the region to fight AIDS, TB and MDR-TB. A number of them are here today; others have decided not to come. Everywhere I travel in the region, I meet extraordinary, dedicated people working in hugely challenging contexts.

Despite the many challenges that we face, I have always had strong confidence in what the people of this region can achieve by focusing together on our shared goal of ending these epidemics.

Since I attended the first of these conferences in 2006, the numbers of new HIV infections, new AIDS cases and AIDS-related deaths have continued to increase in this region. Of the 130,000 new infections reported in the WHO European region in 2012, three-quarters occurred in countries in the East. While reported AIDS cases declined by 54 percent in Western Europe, the number of people newly diagnosed with AIDS increased by 113 percent in the East between 2006 and 2012. [According to UNAIDS and WHO, the numbers of estimated deaths were 91,000 in Eastern Europe and central Asia compared to 7,600 in Western and central Europe in 2012].

These figures are in sharp contrast with the decreasing numbers of new infections and AIDS-related deaths in other regions and globally. Coverage of antiretroviral treatment in this region also remains well below the global level of 60 percent.

The epidemic pattern is also evolving, with heterosexual infections now representing a significant proportion of newly diagnosed cases in addition to the “concentrated” epidemics, particularly among people who inject drugs and gay men that continue to expand, undefeated, and inadequately addressed.

Significant investments have been made in this region, but very little of it has been for effective prevention. The epidemic remains largely uncontrolled. This must be of major concern to all of us, and to anyone who cares about global public health. We need a common understanding of why this is the case and what our strategies should be, so that we can make more substantial progress.

I expect that this conference will focus clearly on this question. “Business as usual” is not enough, and we need a frank and solution-oriented debate on what needs to change. I am not talking about a polarizing or simplistic debate, such as whether treatment or prevention is the right approach. I mean a real debate about both the evidence, and its implications.

For example, there is strong evidence that antiretroviral treatment decreases transmissibility of HIV. But the implication is not that we should abandon prevention in general, and harm reduction efforts among vulnerable groups and people in vulnerable settings, such as prisons, in particular. I strongly believe that an open debate based on evidence will show that, of course, we must do both these things together.

The same is true for harm reduction. Harm reduction for people who use drugs is a set of interventions, including OST and NSP, that is recommended by WHO, UNAIDS and UNODC, and for which there is comprehensive and compelling evidence that, together with ART: it averts HIV infections, reduces HIV transmission, decreases mortality, reduces drug dependency, improves quality of life and reduces crime and public disorder.A health-based approach to drug policies starts with the implementation and scaling up of harm reduction. If there is any evidence to the contrary, let it be debated, in the spirit of scientific enquiry, and the conflicts resolved, so that we can finally move forward with one voice and a common strategy for action.

In this context, as a scientist, physician and in my role as UN Envoy, I must clearly say that the recent statements made on the lack of effectiveness of OST in Crimea and the decision by the Crimean authorities to discontinue these programs, are to me unjustified by the evidence, inconsistent with human rights standards, and a source of unnecessary suffering.

I want to take this opportunity to call on the Russian and regional medical and scientific community to engage in the open and evidence-based debate on preventing HIV/AIDS that for too long has not been a real confrontation between evidence and evidence, but an issue where science has taken a back seat to politics and ideology. This conference provides a critical venue for such debates, but more are likely to be needed, and the UN is ready to support the region in organizing them in the coming weeks or months.

We cannot avoid this debate any longer. Too many lives have been lost to HIV, TB and hepatitis in Eastern Europe and Central Asia. Too many people have become resigned to this region not making progress, because of ideological differences, and to the grim inevitability of even more disease and death. It is past time to change this paradigm. But whether we do so ultimately depends on us. It is within our power alone to make different choices than have been made in the past, and to shape a more hopeful future.

In the words of the Secretary General: Let us “continue to listen to and involve the people… We must continue to build a future of justice and hope, and a life of dignity for all”.

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Russia’s ban on methadone for drug users in Crimea will worsen the HIV/AIDS epidemic and risk public health

BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g3118 (Published 8 May 2014)

Ten years ago 170 000 people in the Russian Federation had HIV.1 The estimated number is now 1.2 million.2 More than 2% of men aged 30-35 are infected, says Vadim Pokrovsky, the head of the Russian Federal AIDS Centre. Russia now accounts for over 55% of all new HIV infections reported in the European region.3

This epidemic was mainly caused by injecting drug use, but it is now spreading to the general community. And it could have been avoided if Russia had implemented large scale harm reduction programmes including opioid substitution therapy (OST).

Treatment with methadone or buprenorphine and the provision of clean needles have saved the lives of millions of injecting drug users worldwide in the past 30 years of the HIV/AIDS epidemic.4

Drug injectors in Ukraine have had access to harm reduction, including OST, for 10 years, and nearly 9000 clients were reported as of March 2014.5 Such programmes had begun to reverse Ukraine’s growing HIV/AIDS epidemic.6

The Ukrainian Center for Disease Control said that in 2013 some 8000 people in Crimea were infected with HIV. OST has helped to manage the epidemic in Crimea, but after Russia’s recent annexation of the peninsula it announced a ban on the supply of such drugs to the region. This will bring unnecessary suffering to the people of Crimea and is a blatant example of health policy being hijacked for political ends rather than being led by evidence.

Russia’s federal law on narcotic and psychotropic substances, introduced in 1997, prevents the medical use of methadone, and buprenorphine is prohibited for treating drug dependence.7

Key Russian specialists in the treatment of drug dependence and officials in law enforcement have openly opposed OST, and the director of the Federal Drug Control Service has repeatedly claimed that it has not been scientifically shown to work.8

The International HIV/AIDS Alliance in Ukraine, the civil society organisation that leads action in the country, said that since mid-March the dosages of substitution drugs had been gradually reduced by half, with the aim of detoxification.

Patients received methadone and buprenorphine until the end of April, and OST provision officially stopped on 1 May. The alliance said that preliminary information from most of the surveyed sites in Crimea that offered OST showed that about 80 patients wished to leave Crimea to continue treatment. Of these patients, 32 were taking antiretroviral drugs and seven had tuberculosis. They all needed financial support for housing, food, and transportation.

The legality of Russia’s move has been questioned because its constitutional law on the incorporation of Crimea included a transition period until 1 January 2015. During this period Crimean law may continue to apply; but Russia’s new law also derecognises Crimean laws that conflict with the Russian constitution. Recent pronouncements by the peninsula’s deputy prime minister and deputy minister of health—namely, that OST is illegal and that treatment approved by Russia should be used—seem to have sealed OST’s fate (see box).

But OST works, and it is recommended by the World Health Organization, the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the United Nations Office on Drugs and Crime as part of a comprehensive range of services for people who inject drugs.9

The United Nations recommends OST coverage for at least 40% of people with opioid dependence.10 Methadone and buprenorphine are designated as essential medicines by WHO, and their value in managing drug dependence, preventing HIV, supporting treatment adherence for HIV and tuberculosis, and reducing crime and public disorder related to drugs, is well established.11 In the European Union about half of heroin users receive OST, the European Monitoring Centre for Drugs and Drug Addiction has said.

The Western world and Australia embraced harm reduction as a public health measure in the early 1980s, and governments of all political and cultural persuasions worldwide have since incorporated such policies in their responses to their own national HIV epidemics.

Eastern Europe is home to the fastest growing HIV/AIDS epidemic in the world. In 2013 the Russian Federation and Ukraine accounted for about 90% of newly reported HIV infections in the region.2

OST programmes are provided through Ukraine’s state health service. The Global Fund to Fight AIDS, Tuberculosis and Malaria—the major donor for harm reduction worldwide—pays for these programmes. But in Crimea, amid a tense environment of suspended bank accounts and tight border control, the future of this support is unclear. Now in the second month of the crisis in Crimea, non-governmental organisations say that they are operating without funding.

Crimea’s HIV prevention programmes include needle exchanges, covering 14 000 people, and OST for people who inject drugs, as well as programmes aimed at sex workers and at men who have sex with men. Many of these services are limited, however, if available at all in Russia.

In Crimea treatment with methadone and buprenorphine started in 2006, and as of March this year 800 clients were receiving OST.5 The multisectoral approach to harm reduction reflects different patient needs including drug dependence, HIV, and tuberculosis.12

The Canadian HIV/AIDS Legal Network said that Russia could pilot OST because the law may permit the use of narcotic drugs and psychotropic substances for scientific research. And at least two cases concerning the lack of access to OST in Russia are pending with the European Court of Human Rights13 14; Russia has been under the jurisdiction of this court since 1998.15

But we already know that OST works. Politics has won out over science—and doctors, scientists, and humanitarians are right to feel abhorrence that a new human tragedy has been imposed on Crimea.

The end of opioid substitution therapy (OST) in Crimea:
16 March. Crimea held a referendum
18 March. The Russian president, Vladimir Putin, signed an agreement to annex Crimea and the city of Sevastopol to the Russian Federation
20 March. Viktor Ivanov, head of the Russian Federal Drug Control Service, announced his intention to end OST as his first priority, focusing on methadone16
22 March. Crimea adopted Russia’s constitutional federal law that incorporates it into the Russian Federation
24 March. The Crimean de facto Ministry of Health asked the Ukrainian health minister to provide drugs so that treatment could continue. UNAIDS suggested that the UN transport the drugs to the Crimean border
25 March. Civil society organisations and experts including the Nobel laureate, Françoise Barré-Sinoussi, who discovered HIV, asked the heads of UN agencies to intervene
1 April. The Ukrainian cabinet asked the State Service on HIV/AIDS, Tuberculosis, and Socially Dangerous Diseases to look for ways to continue to provide OST to Crimea’s 800 patients
2 April. While visiting Crimea Viktor Ivanov confirmed Russia’s urgent intention to end OST in Crimea.17 An emergency meeting in Crimea resolved to “find a solution for the care of 803 Crimean inhabitants who are methadone clients”18
7 April. Moscow city council discussed the “dangers of using methadone” and agreed to write to President Putin to express concern over possibly prolonging methadone use in Crimea, said the website of Lyudmila Stebenkova, the head of the council’s health committee. The Russian chief drug specialist, Dr Brun, is quoted to have said that methadone was a medicine for the poor and that the Russian approach of rehabilitation resulted in remission rates of 48% in one year. Moscow council proposed “methodological and other support” to Crimean drug users19
7-8 April. Protests about banning OST were held in front of Ukrainian and Russian embassies in Crimea, Ukraine, Russia, Moldova, Lithuania, and Georgia
9 April. Crimea’s deputy prime minister, Rustam Temirgaliev, said that the peninsula would need help from Moscow’s experts to replace methadone with Russian drug treatment standards20
10 April. The Crimean deputy minister of health sent a response to the Ukrainian State Service on HIV that OST was illegal in Russia and that no support was needed, the International HIV/AIDS Alliance Ukraine reported
15 April. The UN, monitoring the situation closely and continuing to communicate with Russian and Ukrainian authorities to find solutions, sent a letter by the special envoy in the region to the Crimean deputy prime minister, asking him for an urgent meeting to seek solutions to the crisis
24 April. The Ukraine Anti-Narcotics Agency drew the issue to the attention of the Council of Europe
1 May. Crimea stopped OST provision

References
↵UNAIDS. 2004 report on the global AIDS epidemic. June 2004. www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2004/GAR2004_en.pdf.
↵UNAIDS. Report on the global AIDS epidemic 2013. www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2013/gr2013/UNAIDS_Global_Report_2013_en.pdf.
↵European Centre for Disease Prevention and Control. HIV/AIDS surveillance in Europe 2012. November 2013. www.ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=971.
↵Degenhardt L, Mathers B, Vickerman P, Rhodes T, Latkin C, Hickman M. Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed. Lancet2010;376:285-301. www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60742-8/abstract.CrossRefMedlineWeb of Science
↵Ukrainian Center for Socially Dangerous Disease Control of the Ministry of Health. Information on quantitative and qualitative characteristics of non-personalised data of substitution maintenance treatment as of 1 March 2014 [Ukrainian].
↵ICF International HIV/AIDS Alliance in Ukraine. Harm reduction wins the battle against HIV/AIDS in Ukraine. News release. 7 March 2013. www.aidsalliance.org.ua/ru/tenders/pdf/01q2013/03/Harm_reduction_wins_the_battle_in_Ukraine.pdf.
↵Russian Federation. Federal law: drugs and psychotropic substances. http://base.consultant.ru/cons/cgi/online.cgi?req=doc;base=LAW;n=147329.
↵Drug Reporter. The same old Russian lies against methadone. 2 April 2014. http://drogriporter.hu/en/sameold.
↵World Health Organization. Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. 2009. www.who.int/substance_abuse/publications/opioid_dependence_guidelines.pdf.
↵World Health Organization, United Nations Office on Drugs and Crime, UNAIDS. WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users (2012 revision). www.who.int/hiv/pub/idu/targets_universal_access/en/.
↵Consensus statement of the reference group to the United Nations on HIV and injecting drug use 2010. www.unodc.org/documents/hiv-aids/publications/2010_UN_IDU_Ref_Group_Statement.pdf.
↵Subata E. Opioid substitution treatment in Ukraine. 31 December 2013. Commissioned by the ICF International HIV/AIDS Alliance in Ukraine (available on request).
↵Andrey Rylkov Foundation for Health and Social Justice. Ivan Anoshkin’s complaint to the UN special rapporteur on the right to health regarding the lack of evidence based drug treatment in Russia. 3 January 2012. http://en.rylkov-fond.org/blog/ost/rost/anoshkin-complaint/.
↵Andrey Rylkov Foundation for Health and Social Justice. Activist Irina Teplinskaya, who recently filed a complaint against Russia to UN, was planted with drugs. 23 August 2011. http://en.rylkov-fond.org/blog/drug-policy-and-russia/drug-policy-in-russia/teplinskaya/.
↵Federal Law of 30 March 1998 N 54-FZ: On ratification of the Convention for the Protection of Human Rights and Fundamental Freedoms and its Protocols [Russian]. http://base.consultant.ru/cons/cgi/online.cgi?req=doc;base=LAW;n=18263.
↵24 World. FDCS in Crimea intends to deal with methadone therapy [television interview in Russian]. 20 March 2014. http://mir24.tv/news/society/10105992.
↵Federal Service of the Russian Federation for Narcotics Control. On the organization of anti-drug activities in the Crimean Federal District [Russian]. 2 April 2014. http://fskn.gov.ru/includes/periodics/speeches_fskn/2014/0402/104829810/detail.shtml.
↵Federal Service of the Russian Federation for Narcotics Control. Decree signed on the establishment of a regional anti-drug commission in Crimea [Russian]. 3 April 2014. http://fskn.gov.ru/includes/periodics/news_all/2014/0403/210129871/detail.shtml.
↵Lyudmila Stebenkova. Members of Moscow City Duma/Council are against methadone [Russian]. 7 April 2014. www.stebenkova.com/Депутаты-Мосгордумы-против-метадона/.
↵Highlights in Russia. Moscow will abandon Crimea methadone [television interview in Russian]. 9 April 2014. www.69rus.org/more/7023/.

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Season’s greetings! С новым годом!

I am looking forward to a year of strong progress in the fight against HIV in Eastern Europe and Central Asia !

C нетерпением жду от нового года значимых продвижений в борьбе с ВИЧ в странах Восточной Европы и Центральной Азии !

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The changing nature of the Eastern European and Central Asian HIV epidemics

I was in Brussels earlier this week delivering a speech at the European AIDS Conference and coming on top of the visit to Romania last week, it’s given me some valuable time to reflect on the HIV/AIDS epidemic in the region a year or so into the job as the UN Special Envoy for the region.

I tried to get across five key points in Wednesday’s speech.

In the first instance I wanted to emphasize that the EECA is still home to the fastest growing HIV/AIDS epidemic in the world and that it has been and still is to a large degree primarily linked with injecting drug use.

Over 35 percent of case reports in the EECA are associated with drug use. The prevalence rates among PWID ranges from 25 percent in Ukraine to over 55 percent in Estonia. The countries with the highest levels of reported diagnosed cases among PWID are Ukraine, the Russian Federation and Kazakhstan.

This is also a region where the risks of acquiring MDR-TB are among the highest in the world: 20 percent of new cases and 45 percent of presenting re-treatment cases in the Russian Federation are presenting with resistant. And the prevalence of hepatitis C among people who inject drugs is also particularly high, between 60 and 90 percent.

So, in this region, we cannot just speak of the twin epidemics of HIV and drug use, but rather the quartet of HIV, drug use, TB and hepatitis. We cannot address one without also addressing the other three.

It is alarming that there are nearly 100 000 AIDS deaths each year in the region, a figure that has increased by more than 25 per cent since 2005, compared to stable or decreasing levels in Western Europe and globally.

Equally concerning is that treatment coverage remains unacceptably low, here shown as 23 percent in 2011 and estimated to be now at around 35 percent based on 2010 WHO guidelines, a figure that would drop by half, based on the 2013 guidelines.

Secondly, I wanted to demonstrate that the shape of the regional epidemic is beginning to change. It appears that we will be looking a substantially changed epidemic in the coming years.

In the last five years, there has been a marked increase in reported cases among men who have sex with men. Under-reporting of risk status is however likely in this region where gay men remain highly stigmatized: case reports of “no known exposure group” are consistently high, reminding us that data are only as robust as the surveillance systems and the social contexts that produce them.

Most countries in the region do not collate risk factor data concerning sex workers, but HIV prevalence among this group is estimated at between 2 percent and 6 percent.

What we see then is a complex picture of intersecting epidemics among drug users and their non-injecting sexual partners; among MSM, a substantial proportion of whom also have sex with women that is increasingly fueled by amphetamine and methamphetamines and hampered by poor prevention, including lack of access to NSE and inconsistent condom availability and use.

Heterosexual transmission is increasing and now accounts for 30 percent of reported cases. There is potential for the epidemic to generalize beyond the key populations of PWID, MSM and sex workers.

Heterosexual transmission now accounts for around 30 percent of reported cases in Eastern Europe, largely among women with high-risk sex partners.

Thirdly, the role of harm reduction remains pivotal in overcoming the epidemic in the region.

Access to prevention for PWID and to harm reduction remains unacceptably, scandalously low. On average, only 2 percent or so of PWID in the region have access to Opioid Substitution Therapy (OST). A disproportionally low number of PWID in need of ART actually access it, something that is true both in this region but also globally.

All this despite the evidence showing that high – but quite achievable – coverage levels of NSE can result in large decreases in HIV incidence and prevalence in settings with high prevalence among PWID if it is effectively associated with OST and with significant access to antiretroviral treatment.

My fourth point was why, in the face of a looming human tragedy but at the same time armed with proven scientific evidence of what we know works, why don’t we just do it?

Very few services are tailored to the particular needs of key affected populations, in large part because of widespread political and moral opposition to drug use, sex work and homosexuality.

In most countries of the region, inadequate legal and human rights frameworks, brutal law enforcement and policing practices, and a sheer lack of political will to implement evidence-based HIV prevention, are all seriously hindering progress. Let’s not forget either that undermining access to interventions, even where they are available, increases risk.

An overwhelming proportion of incarceration in the region, between 40 and 70 percent, is for drug offences, such as use and possession. And because prisons themselves constitute a risk environment for the acquisition of HIV, we see a vicious circle of frequently minor drug use, incarceration and HIV infection.

The response is grievously underfunded. Funding for prevention is particularly vulnerable, having been overwhelmingly dependent on international donors so far.

Lastly, the future.

While this is a region that faces many challenges, I have always had strong confidence in what the people of this region can achieve.

We must continue to work at the political level in all these respects by the long and steady process of advocacy and relationship-building. We need to maintain the international leverage and dialogue, wherever possible, by pointing to successes among PWID in other parts of the world and by using entry points such as the various global fora on drug policy of which the region is a part. We must do everything we can to ensure that our language and our actions within the region and outside it do not contribute to further isolating the region and worsening its epidemic.

It is vital that we remain positive, even in the face of daunting challenges. This means recognizing progress where it is happening, having faith in the wonderful people of the region, and remaining confident that, if they do what needs to be done, their fight against AIDS can ultimately be won.

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24 hours in Bucharest

Last week I went on a short visit to Bucharest to understand the origin of the recent outbreak of HIV among people who use drugs in the city. I am disheartened to say that the fears of many of us working in global health held about the potential negative impact on the HIV/AIDS epidemic caused by the withdrawal of the Global Fund to Fight AIDS, Tuberculosis and Malaria from a number of countries, including Romania, have been realized.

Romania’s “middle income” country status has ruled it ineligible to receive Global Fund money and since 2011, the gap in service provision, especially to people who inject drugs (PWID) cannot be met by a civil society sector that receives no State funding whatsoever.

After meetings with the Ministry of Health and the country’s National anti-Drug Agency I spent time one evening with an NGO called ARAS, as they conducted their outreach service in the area in and around the North Station of Bucharest.

On a cold and windy evening at around 10 pm, ARAS parked its bus across the street from the station. Two small buses (actually, more of a van) were bought five years ago on Global Fund money. One remains parked in the courtyard of a hospital, since no funding is available for the repairs that it needs. The other still operates and undertakes outreach five to six evenings a week.

Within minutes, people rushed from a neighboring park and seemingly from nowhere and over the next two hours queued for clean syringes provided by a doctor and a social worker. Each night the ARAS bus supplies between 5000-15 000 needles; the needles are of a type preferred by injectors as opposed to an inferior cheaper type purchased last year by the government which most users subsequently returned unused.

Extreme poverty is exacting human devastation upon a group of people who are injecting legal highs up, many up to 10 times per day. It is estimated that some 50 per cent of injectors use legal highs, originating, from what users told me, from China, with
the remaining half use poor quality heroin.

I saw two boys of fifteen years of age, one of whom have been living on the street since he was born; a wandering/drifting pregnant woman, who was “high” that night; a man nearing his 40s who was raised in a children’s institution in the years of the Ceausescu regime, saw his mother only once in his entire life and subsequently kicked out of the institution for using glue. He’d been living on the streets for 25 years.

Many clients also asked for condoms but ARAS no longer has the funds to provide them as they used to do up until two years ago.

These tragic Bucharest stories are being or will be repeated in other countries where the Global Fund is leaving and it is no coincidence that increases in HIV amongst PWID have begun to surface in Romania. The struggles facing NGOs trying their best to contain a both fragile and volatile situation there under extremely trying circumstances are being exacerbated at the same time by an explosion in the supply and use of legal highs which has in turn fuelled injecting and so increased the risk of needle sharing.

And the evidence is already in.

At the end of 2012 the Anti Drug Agency reported a 20 fold increase in the number of new infections diagnosed amongst people who inject drugs. Around the same time a separate survey of 480 people who inject drugs was published indicating an astonishingly high and sudden prevalence of HIV of 53 percent.

Eastern Europe nations and other economies in transition are facing dramatic HIV/AIDS emergencies amongst PWID. Decision makers within those countries remain blind to this reality.

After my meetings with government officials I’m of the view that the HIV/AIDS scenario in Romania and countries that find themselves in a similar funding situation will not change in the coming months or indeed, years.

And it is the people in the region like those I met on the streets of Bucharest who are ultimately paying a high human price for such inaction and neglect.

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Nobody left behind

I was in London this week attending a meeting on the impact of treatment as prevention (TasP) on Key Affected Populations (KAPS), a gathering of minds, I think, that has the potential to be a pivotal moment in the way we decide to respond to HIV/AIDS in those global “hotspots” where sex workers, men who have sex with men (MSM), people who inject drugs (PWID) and transgender people are en masse being denied access to treatment, care and prevention. The end result is that HIV infection rates amongst these groups is in some countries clearly running at rates that we could consider out of control when compared to the rest of the population. As the Millennium Development Goals come to fruition in 2015 we are being faced with a terrible and daunting reality: that these key affected populations are in fact being left behind.

The meeting this week in London forms part of an International AIDS Society led initiative to identify strategies that will maximize the treatment and prevention benefits of antiretroviral therapy (ART) for Key Affected Populations. The meeting in London is a joint consultation of the IAS Advisory Groups on Treatment as Prevention and Key Affected Populations along with other key stakeholders and the hope is that the discussions will kick start the development of a finalized “White Paper” containing recommendations to international organizations and the AIDS community to be presented at the AIDS 2014 conference in Melbourne, Australia next July.

I believe the starting point that has brought me and my colleagues to these discussions is the powerful evidence provided by the HPTN 052 trial of 2011 demonstrating that treatment is preventative, that is, that, by decreasing viral load it decreases strongly the “ability” of the treated HIV-positive person to transmit.

Recent cohort studies further suggest that increasing antiretroviral treatment coverage is important to decrease the risk of HIV acquisition at the population level. These results have mobilized the global HIV/AIDS community to accelerate the scale-up of antiretroviral therapy (ART) as both a treatment and a prevention strategy.

I believe that currently the evidence of an effect at the population level is mostly conceptual and based on modelling. The strongest “real world” evidence we can presently refer to is the decrease in incidence in the PWID population in Vancouver, Canada. There is also some suggestive evidence that TasP has been successful in Kwazulu-Natal, South Africa.

Against this backdrop however, we do need to be cognisant of one important fact: there is no precedent for a disease of which the transmission at the population level could be stopped by generalized access to treatment.

The fact that treatment is preventative does not mean that it will and should replace prevention. Prevention interventions remains essential. Treatment is preventative but cannot be the only strategy for prevention. We need to be wary, I believe, of the concept being misinterpreted or even being “hijacked” if you will and avoid playing off one form of prevention against another (e.g. “if treatment is prevention why should we embark into difficult to implement prevention programs such as harm reduction”).

The way forward is not an easy one precisely because the issue is one where science, policy and human rights all collide. How we manage that intersect will ultimately determine what kind of solutions will be thrown up. And while we should always acknowledge that the response needs to be thought through and measured (this meeting is a case in point) we’d also do well to acknowledge that the situation facing key affected populations is of the utmost urgency.

For MSM, the fact is that paradoxically the epidemic in this population continues to expand in countries with generalized access to treatment. For the PWID community , there is no doubt that treating as many people as possible is the strategy to move ahead with but in no way should that impact negatively on the need for harm reduction and other proven prevention strategies.. For sex workers, yes, treating them for their own medical needs is absolutely necessary but that does not translate into decreasing their risk at a population level which is mainly dependent on the frequency of infected transmitters among their clients.

I look forward to participating in similar conversations like the one we have had in London this week, elsewhere over the coming year.

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Remarks, Ukraine press conference, IHRC, Vilnius, June 10th 2013

This is an important communication and I am pleased and honored to be part of it. Thank you for the invitation.

The Alliance in Ukraine is reporting today that for the first time in ten years, there has been a decrease in the number of new HIV infections in Ukraine (-2%), with  a significant reduction in the number of new infections registered among people who use drugs.

This is in contrast with the trends in the region where the number of new HIV infections, the number of AIDS cases and mortality from AIDS have been increasing dramatically since the early 2000’s.

The decrease in incidence reported today in Ukraine among people who use drugs is of significance.

Forty to sixty percent of the HIV infections in the region are occurring in people who use drugs. People who use drugs are socially marginalized, discriminated, criminalized, have poor access to services and to treatment, worldwide and particularly in the EECA, an important theme of this conference.

The results released today by the Alliance have not been confirmed yet, to my knowledge, by the Ukrainian authorities, but I can say they are acknowledged by the international community. Convergent epidemiological evidence such as the fact that newly diagnosed people are of older and with an longer history of infection before diagnosis actually strengthens the robustness of these results.

***

As I see these results, I would like to make three points:

1. My first point is that there are lessons to be learned, particularly for the region, in reflecting on the combined factors that have allowed here for success:

Among those factors: first, a strong advocacy, remarkably conducted by the civil society, based on epidemiological evidence, based on human rights, sensitizing decision makers and the public opinion on the human impact of the disease and the poor access to services of people in need.

Second, resources. For obvious reasons, I am pleased and proud to acknowledge the investments that the Global Fund has made in the fight against HIV/AIDS and TB in Ukraine for now ten years.

Third, political commitment. With ups and downs, there is an overall recognition by the government of the threats of the epidemic  and of the need to act. I have clearly perceived that in my meeting with Prime Minister Azarov last year and when meeting recently with the minister of Health, Mme Bogaterova.

Fourth, and most importantly, this is the result of a joint effort between the public sector and the non-governmental sector. NGOs such as the Alliance or the network of people living with HIV in Ukraine have over the years and under the pressure of the crisis, moved from advocacy to acquiring the technical knowledge and to implementation of programs. They have been an example of efficiency and accountability in delivering on the Global Fund grants.

And last, programs are beginning, but only beginning, to be at scale, allowing for impact. This is far from being the case in the region.

2. My second point is that success is not linked to treatment alone or to prevention alone, but to the combination of the two. Expanding access to testing and to antiretroviral treatment but, at the same time, expanding significantly on access to peer education and support, needle exchange programs, and opioid substitution therapy.

A lesson for many countries in the region that hardly invest in prevention.

3. My third and last point is that, as we celebrate these results, we should also realize how fragile the situation is.

Fragile when it comes to funding in difficult time s in a region where 90 % or so of the financing of AIDS programs, particularly preventative programs is relying on international funding.

Fragile when it comes to acknowledgment of the problem by the public opinion and to  political commitment.

Fragile because discriminatory laws and policies are still there preventing prevention work and access to services of the most vulnerable people.

Fragile because of the risk of spread of the epidemic beyond the key populations at high risk, as we are now clearly seeing it happen in the Russian Federation.

Fragile also because AIDS is not the only threat in the region and when it comes to the most vulnerable such as people who use drugs in the region: TB and multi resistant TB which is under-diagnosed and far from being treated at the needed scale is a huge threat, and so is hepatitis C (over two thirds of people who inject drugs in Ukraine are infected with hepatitis C).

***

We know what it is that we should do. If we do it and expand further on our efforts, the battle can be won.

Congratulations to the Alliance and to everyone who is fighting AIDS, TB and hepatitis in Ukraine.

 

 

 

 

 

 

 

 

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