Joint Call Regarding Health Crisis in Donbas, East Ukraine

Joint call

On behalf of the 100 health leaders, professionals and activists from 60 government institutions, technical partners, donors, civil society and affected communities committed to ending the tuberculosis and AIDS epidemics in Eastern Europe and Central Asia who gathered at Global Plan to Stop TB & Eastern Europe and Central Asia Consultation on Sustainable Impact, on 23-24 July 2015 in Istanbul, the Stop TB Partnership and the Global Fund to Fight AIDS, Tuberculosis and Malaria express grave concerns over challenges in providing access to essential treatments for HIV, tuberculosis and opioid dependence in areas of Donbas in East Ukraine, where:

  • Nearly 8,000 HIV patients, including children and prisoners, are in danger of running out of life-saving antiretroviral medicines by mid-August. The Global Fund has approved an emergency fund grant to UNICEF in the amount of US$3.7 million for the duration of 12 months to prevent disruptions in the delivery of HIV treatment to the areas of Donbas affected by the military conflict.
  • Stocks of medicines for drug-resistant tuberculosis are insufficient, and further shortages – leading to more tuberculosis and more drug resistance – are expected.
  • More than 800 patients that had been receiving opioid substitution therapy can no longer access their treatment, and another 250 patients receive only a fraction of their regular dosages due to a complete lack of medicines.

Patients should not be forced to pay for the conflict with their lives and their health. All parties involved should find solutions to solve this humanitarian crisis.

  • We call upon the Government of Ukraine and the local authorities in areas of Donbas to ensure unhindered passage of humanitarian convoy of internationally-funded vital medicines for HIV, tuberculosis and opioid dependence.
  • The parties involved in the conflict should find long-term solutions for protecting the right to health for all in need in Donbas, independently of status of territory where people live.
  • We call upon international organizations, the UN system, donors, humanitarian aid groups, media and the international community to join forces to resolve this health crisis in Donbas.

Svitlana Moroz
Chair of the Board
Eurasian Women Network on AIDS

Aida Kurtovic
Vice Chair of the Board
The Global Fund to Fight AIDS, Tuberculosis and Malaria

Michel Kazatchkine
UN Secretary-General’s Special Envoy on HIV/AIDS in Eastern Europe and Central Asia

Lucica Ditiu
Executive Secretary
STOP TB Partnership

Mark Dybul
Executive Director
The Global Fund to Fight AIDS, Tuberculosis and Malaria

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An AIDS Crisis in Ukraine

More than 6,500 deaths have been reported in the Donbass region, where Ukrainian forces have battled Russian-supported separatist fighters for control since April 2014. The political violence has led to a humanitarian crisis. More than 8,000 patients being treated for H.I.V. or drug dependence have had life-saving medicines cut off, or will soon be without them, unless action is taken right now to allow a humanitarian convoy through.

Health care was an early casualty of the conflict in the Donbass. The Ukrainian government, saying it wished to ensure that national resources did not fall into the hands of armed groups, cut off funding in November to all facilities in the region, including hospitals, and told patients who remained in the conflict zone that they could travel to government-controlled territory to receive medicines. Unsurprisingly, this has proved impractical for many people who are sick, poor or simply frightened. Mechanisms to monitor and respond to disease outbreaks are no longer functional in the territory; immunization coverage is low, and health experts now fear possible outbreaks of polio and for the safety of blood supplies.

People at risk for, or living with, H.I.V. are already suffering. Ukraine has one of the highest rates of H.I.V. infection in Europe; the majority of patients were infected with the virus through contaminated drug injections. Before the conflict, Ukrainian programs helped control H.I.V. infections in the Donbass by providing sterile needles and syringes and methadone, a medicine the World Health Organization recommends to reduce use of and craving for heroin. Ukraine successfully reduced H.I.V. infections, particularly among young people who inject drugs, for whom infection rates decreased more than fivefold between 2007 and 2013.

Unfortunately, the Donbass conflict now jeopardizes that progress. According to the International H.I.V./AIDS Alliance in Ukraine, a nongovernmental organization based in Kiev, more than 1,000 patients in the Donbass have either had their methadone stopped or reduced to substandard doses, forcing men and women to undergo painful withdrawal or return to street drugs. Requests to the Ukrainian government to replenish methadone supplies, accompanied by an offer by Doctors Without Borders to oversee distribution, were met with the response that the medicine — distributed routinely to hundreds of thousands of patients across Western Europe — could be transported, under Ukrainian law, only by armed convoys. In June, a number of patients sent a video appeal to government officials, saying they feared for their lives because their treatment had been interrupted. It is not known how many people have succumbed to overdose or suicides after methadone treatments were ended, though the video reported nine deaths.

People living with H.I.V. in the Donbass now face a similar interruption in life-saving antiretroviral treatment. The W.H.O. estimates that supplies of H.I.V. medicines will last only until mid-August in some parts of the Donbass. The Global Fund to Fight AIDS, Tuberculosis and Malaria has offered to pay for more antiretroviral treatments, and Unicef is willing to procure them. However, no humanitarian convoy has delivered medicines into the territory since February. Thousands of men and women, many of whom overcame discrimination and financial barriers to secure access to H.I.V. medicines, are now watching their antiretroviral pill supplies vanish, and with them, their hopes for survival. The W.H.O. reports that medicines for multidrug-resistant tuberculosis, diagnosed at high levels in the region, are also running low.

For their part, those in control of the self-proclaimed Luhansk and Donetsk People’s Republics in the Donbass have shown little interest in protecting the lives of people with H.I.V. A number of reports have documented violence against people who use drugs and other marginalized groups. The People’s Republic of Luhansk has indicated that it does not want to continue opioid-replacement therapy (consistent with Russian policy), and has announced that United Nations agencies must register with them prior to provision of any humanitarian aid. The Ukrainian Parliament has exempted itself from culpability for the Donbass, passing a resolution in May that the rights of those remaining are the responsibility of the “occupier.” At the same time, the authorities in Luhansk or Donetsk have not moved to fill the H.I.V. treatment gap, leaving patients in a desperate limbo.

No one should be forced to choose between fleeing their home and stopping life-saving treatment.

This is a humanitarian crisis that can be easily solved. The Ukrainian government, even if reluctant to commit resources in the “temporarily occupied” region, should permit passage of a United Nations convoy with medicines funded by international donors. Those controlling the Donbass could also give the green light for the convoy. The government of Ukraine should work on an interim procedure to provide assistance to the population in these territories and facilitate the passage of humanitarian aid.

The Minsk Group, which is led by France, Russia and the United States and tasked with finding a peaceful resolution to the conflict, should urge immediate action to restore the medicine supply in the Donbass.

Silence and inaction will only bring more suffering. Nothing is gained by making patients hostage to geopolitical disputes. Both the Ukrainian government and the leaders of the separatist Donbass region should ensure that, as a matter of medical ethics and human decency, innocent and vulnerable medical patients do not join the list of casualties in this conflict.

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Is Armenia close to ending AIDS?

As it is the case throughout the East European and Central Asian region, unsafe drug injection has been a driver of the HIV epidemic in Armenia over the last 15 years, though far less today than, say, a decade ago. 40 percent of people who inject drugs are estimated to be infected with HIV in Armenia, and close to 100 percent are infected with the hepatitis C virus. Heterosexual intercourse has been the main route of HIV transmission reported in the last three years among men and increasing numbers of women.

I was in Armenia very recently to learn about the country’s response to its epidemic and came away undoubtedly pleased with progress on a number of fronts but concerned on others.

For people who have been diagnosed with HIV, treatment is now accessible to all those eligible for it, with most people on therapy having viral loads below the threshold of detection. By any measure, that certainly stands as a remarkable success story in the region.

Armenia is also one of the few countries in the Eastern Europe and central Asian region proactively implementing Opioid Substitution Therapy (OST). The Program has the clear support of the Government.

I visited one such program at the Armenian Republican Drug Centre located in a typically Soviet-era austere social service building on the outskirts of Erevan, 30 minutes by bus from the centre of town.

2015-04-30-1430373118-2824559-IMG_4606.jpg

(Centre staff member preparing the rose garden for Spring)

Dr Petros Semerjian’s office runs off an unlit corridor in the Narcological Centre, which is supervised by uniformed guards. Semerjian has directed the since Centre since its creation and opened the first OST clinic in Erevan with the support of the Open Society Foundation more than 10 years ago. OST, he says, is “one of the treatment options” for opiate-dependent people, half way somehow between the Russian and the Western European positions.

Patients in Armenia may access substitutive treatment following approval by an internal advisory committee, usually, after two failed attempts of medically-assisted weaning. 260 patients currently receive methadone on a daily or three times a week basis, assisted by several nurses and doctors. NGOs claim that the program is not attractive to users because the committee that decides on admissions in the program includes a representative from the police. Dr Semerjian argues that associating police with the work of the clinic, as he has done since the early days of the Centre, prevents law enforcement from being confrontational with the Centre and from harassing the clients.

However, with the big picture in mind, what is worth considering here is the fact that Armenia, a country that is almost entirely economically and politically dependent on its partnership with Russia, has a Government that strongly backs its OST and AIDS programs.

The scale of the OST remains however at a very small scale, thus much below that at which it could demonstrate a public health impact on HIV prevention. This is common across the region, providing ammunition for the regional anti-methadone proponents to claim that it is not effective. Dr Semerjian, with much experience in dealing with the system, together with his own strong convictions, stands strong on his assertion that these numbers reflect the right proportion of clients that should access substitutive treatment but my sense is that small numbers of patients are enrolled in the program for reasons that seem to me reflect more the doctor’s personal views than a real assessment of what the program should achieve from a public health perspective.

Of concern to me too are the current dynamics of HIV infection in Armenia.

Most of the men diagnosed with HIV have a history of migration and have worked for some time in the Russian Federation. Together with their female partners in Armenia, they represent 73 percent of all reported cases diagnosed in the last three years. Additionally, an estimated 60 percent of the estimated number of HIV-infected people in the country do not know their status.

While migration is also a risk factor for Central Asian countries and Russia itself, the magnitude of the epidemic which reflects the absolute need for Armenians to migrate to find work, make it a unique phenomenon in the region.

The future of the epidemic in Armenia remains uncertain, despite its small size: some 2,000 infections diagnosed would reach around 90 percent of all infections diagnosed. On the one hand one might be tempted to think that Armenia may be close to ending its epidemic, yet the uncertainty remains on who the undiagnosed are and how to reach them (is it about migrants as some experts believe, or also about vulnerable populations who are largely marginalised from national AIDS programs?). Exacerbating the issue is the decrease in international funding — something which is similarly occurring in other countries in the region — at a time when the country cannot afford (and is not politically ready to afford) to assume the funding gap left from the progressive departure of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

On paper though, it’s certainly something well worth contemplating: if the political will, more expertise and the funding were all there, Armenia could well be the first country in the EECA region to end AIDS.

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Всемирный день борьбы со СПИДом: инфекции в Туркменистане нет?

Мой первый визит в Туркменистан на прошлой неделе был удивителен во многих отношениях. Я приехал туда, чтобы выступить на международном семинаре «Здравоохранение и дипломатия», в котором участвовали представители министерств здравоохранения и иностранных дел из всех пяти стран Центральной Азии — Казахстана, Кыргызтана, Таджикистана, Туркменистана, Узбекистана, — а также Грузии, Беларуси и Армении.

Ярко запомнилась лекция и последующие вопросы студентов в Институте по гуманитарным вопросам и развитию, где учебная программа в настоящее время преподается исключительно на английском языке. Это было интересная неделя — тепло и гостеприимство народа Туркменистана ощущалось постоянно.

Таинственный и непонятный Туркменистан.

Пронизанный пустынным зимним солнцем в один момент, через мгновение он покрыт снегом и обернут в густой непроницаемый туман.

Стремление страны к модернизации и открытости заметно везде: в ее инфраструктуре, в количестве студентов, обучающихся за границей, в постоянно модернизирующемся образе жизни, в строительстве железной дороги Китай — Турция и трубопроводов, благодаря которым страна станет экспортером природного газа в Европу. Модернизационный проект страны тверд, но в то же время осторожен. А как же иначе? Туркменистан в течение долгого времени был закрыт для внешнего мира; авторитарное руководство правило страной в условиях культа личности.

Туркменистан является одной из пятнадцати (из 27 в мире) стран с высоким бременем туберкулеза с множественной лекарственной устойчивостью (МЛУ-ТБ) в Восточной Европе и Центральной Азии. Офис грамотно и энергично проводимой национальной противотуберкулезной программы расположен на северной окраине города в красивом здании, облицованном белым мрамором и оснащенном самым современным оборудованием. Благодаря грантам Глобального фонда центр в столице Ашхабаде и центры в каждой из пяти провинций страны укомплектованы машинами GeneExpertTM, благодаря которым теперь возможны экспресс-диагностика и определение лекарственной устойчивости в образцах, направляемых в эти референс-центры из учреждений первичной медицинской помощи по всей стране.

По официальным данным, МЛУ-ТБ составляет не менее 15% от новых и 34% от ранее леченных случаев туберкулеза в Туркменистане, что уже вызывает большую тревогу. Но, вероятно, и это не полная картина — это лишь имеющиеся цифры, которые далеки от совершенства: прозрачность данных остается огромной проблемой в Туркменистане.

Все большее число пациентов с диагнозом МЛУ-ТБ получают лечение согласно новым стандартным международным схемам, однако 80% финансирования на них по-прежнему обеспечивается из международных источников. Финансовая устойчивость противодействия эпидемиям ВИЧ/СПИДа и туберкулеза в странах со средним уровнем доходов по-прежнему вызывает озабоченность, поскольку международное финансирование сокращается и способность таких стран как Туркменистан к принятию адекватных мер в кратко- и среднесрочной перспективе будет поставлена под вопрос, если государственное финансирование здравоохранения останется на текущем уровне (2% ВВП).

Как только речь заходит о ВИЧ/СПИДе, перед нами вновь старый загадочный Туркменистан. За последние пятнадцать лет не было зарегистрировано ни одного случая ВИЧ-инфекции. В последних ежегодных отчетах ЮНЭЙДС/ВОЗ невозможно найти статистику из страны. Опять встает вопрос о непрозрачности данных.

Рядом с противотуберкулезным центром в Ашхабаде находится Национальный центр по профилактике ВИЧ/СПИДа. Центр издает буклеты, проводит мероприятия в школах и других учреждениях, организует мероприятия, приуроченные к 1 декабря (на прошлой неделе там было очень оживленно). Ежедневно в центре проводится около ста тестов, подавляющее большинство из которых являются обязательными: предоперационная подготовка, беременные женщины, иностранцы, приезжающие в страну, граждане Туркменистана, собирающиеся покинуть страну для работы, получающие сертификат с подтверждением ВИЧ-отрицательного статуса (Туркменистан входит в число стран, где действуют ограничения на въезд ВИЧ-положительных людей).

Я чувствовал замешательство медицинского персонала, когда в разговорах я ставил под сомнение актуальность этих мер и их соответствие правам человека. В ответ я слышал: да, пора пересмотреть их. Вопрос лишь в том, будет ли это принято на политическом уровне, так как руководство страны пытается балансировать между традициями и современностью.

Несмотря на великолепное диагностическое оборудование, подготовленность к измерению CD4 и вирусной нагрузки, знания и приверженность специалистов, для меня ясно, что страна не готова дать ответ ВИЧ/СПИДу, когда рано или поздно он придет сюда, по мере того как страна становится более открытой и прозрачной.

Туркменистан не готов к борьбе с ВИЧ/СПИДом как минимум по трем причинам:

Во-первых, высокий уровень стигмы легко ощутим на всех уровнях, в том, с какой неловкостью и рядовые медицинские сотрудники, и руководители сферы здравоохранения говорят об «этой проблеме».

Во-вторых, сфера здравоохранения в лице врачей и специалистов отдалена от населения, которое они обслуживают. Практически отсутствующий сектор гражданского общества не участвует в диалоге с профессиональной системой здравоохранения, за единственным заметным исключением в виде уважаемого и активно действующего национального общества Красного Полумесяца. Во встречах с руководством и сотрудниками этой организации я узнал больше о вполне ожидаемых мной реалиях секс-бизнеса и наркопотребления, чем из разговоров со специалистами здравоохранения.

Третья причина заключается в том, что в стране царит ощущение ложной безопасности, поддерживаемое нынешней репрессивной правоохранительной политикой в отношении пограничного контроля и наркопотребления. Эти подходы, вместе с официальной политикой пропаганды здорового образа жизни и массовой профилактики, которые не доходят до наиболее уязвимых групп, в конечном счете приведут к нежелательным последствиям, включая нарушения прав человека. Если все-таки окажется, что началась эпидемия ВИЧ/СПИДа, связанная с волной наркопотребления во второй половине девяностых годов и/или расширением международной торговли и передвижений людей по мере открытия страны, то Туркменистан будет плохо подготовлен к ответным мерам.

Перед дипломатией здравоохранения в Туркменистане, как и во многих странах региона, стоит сложная задача помочь начать конструктивный и постоянный диалог между правительством и органами здравоохранения, который укрепит доверие населения к системе здравоохранения — системе, основанной на научных данных и уважении прав человека, целенаправленно сотрудничающей с представителями гражданского общества и широкой общественностью.

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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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Tagged , ,

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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