Десять моментов, касающихся профилактики ВИЧ-инфекции в регионе Восточной Европы и Центральной Азии

  1. Эпидемия ВИЧ/СПИДа продолжает расти странах региона. Эта тенденция развития эпидемии не изменится, если, наряду с увеличением масштабов предоставления антиретровирусной терапии, мы существенно не улучшим работу по профилактике – не расширим ее охват, не укрепим ее нацеленность и содержание.

  2. Право «не стать ВИЧ-инфицированным» является частью права на здоровье. Ответственность человека за свое поведение имеет важное значение. Однако это обязанность и ответственность государства, чтобы предоставлялись услуги по профилактике ВИЧ и осуществлялись научно обоснованные меры по профилактике в соответствии с международными руководящими принципами и рекомендациями. Особое значение это имеет для людей, наиболее уязвимых к ВИЧ.
  3. Концепция «лечение как профилактика» подтверждается научными данными, однако в настоящее время охват антиретровирусной терапией в регионе далек от тех масштабов, которые могли бы иметь существенное профилактическое воздействие на уровне населения. Необходимо значительно ускорить обеспечение доступа к антиретровирусной терапии в регионе. Уязвимые группы населения должны иметь такой же доступ к антиретровирусной терапии, как и другие группы населения.
  1. Приоритетность одних или других мер профилактики должна быть основана на тщательном комплексном анализе региональных и национальных эпидемиологических данных. В настоящее время в нашем регионе весьма ограничены данные о заболеваемости и распространенности инфекции среди групп населения, подверженных высокому риску.
  2. Профилактические меры будут неэффективными, если не устранить правовые и политические препятствия на пути к созданию благоприятных условий для осуществления этих мер. Многочисленные исследования, проведенные в регионе и во всем мире, показывают, что распространению эпидемии ВИЧ способствуют криминализация и стигматизация некоторых основных затронутых групп населения, подверженных высокому риску ВИЧ-инфицирования. Люди, которые подвергаются дискриминации, маргинализации или даже уголовному преследованию, как правило, «уходят в подполье» и имеют ограниченный доступ к профилактике и лечению. Криминализация не служит интересам общественного здравоохранения.
  1. Неправительственные организации (НПО) и сообщества уязвимых групп имеют широкие возможности, чтобы достичь групп населения, подверженных наибольшему риску, донести до них информацию и предоставить профилактические услуги.
  2. Эпидемия ВИЧ-инфекции в Российской Федерации и в регионе в целом распространялась и продолжает распространяться в значительной степени в результате небезопасного употребления инъекционных наркотиков. В регионе необходимо повсеместно осуществлять программы снижение вреда, включая все элементы «пакета» мер, рекомендованных ВОЗ, ЮНЭЙДС и УНП ООН (Управлением ООН по наркотикам и преступности).
  3. Профилактика дает результаты. Последовательное и правильное использование мужских презервативов снижает риск передачи ВИЧ-инфекции половым путем до 94%. Имеющиеся в литературе данные также четко свидетельствуют о том, что снижение вреда, доконтактная и постконтактная антиретровирусная профилактика и антиретровирусная терапия являются эффективными средствами профилактики ВИЧ-инфекции. Эти научные данные должны лечь в основу национальной политики.
  4. Комбинированная профилактика, т.е. комбинированное использование всех существующих научно доказанных профилактических мероприятий, в первую очередь с учетом наиболее острых эпидемиологических потребностей в регионе, является одним из ключевых элементов стратегии активизации борьбы против СПИДа в период с 2016 по 2020 год, согласно призыву ЮНЭЙДС. ЮНЭЙДС также рекомендует использовать 25% национальных бюджетов по борьбе против СПИДа для осуществления мер профилактики.
  1. В этом году мы собрались на пятую Конференцию по ВИЧ/СПИДу в Восточной Европе и Центральной Азии. И в пятый раз на конференции мы отмечаем продолжающийся рост эпидемии в регионе. Расширить масштабы лечения и профилактики нужно сейчас. Сейчас это важно как никогда.

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Ten points on HIV prevention in Eastern Europe and Central Asia

  1. The HIV/AIDS epidemic continues to expand in countries of the region. The epidemic trend will not be reversed unless prevention is significantly scaled up and improved in focus and content, along with scaling up of antiretroviral therapy. The UNAIDS-Lancet Commission stated it very clearly: “Get serious about HIV prevention and continue the expansion of access to treatment, while also working to address structural determinants of health that put people at risk »
  1. The right “to not be infected by HIV” should be clearly understood as part of the right to health. Whereas responsible individual behavior is essential, it is the duty and the responsibility of the State and of public health and social services to deliver HIV prevention services and evidence-proven preventative interventions, following the international guidelines and recommendations of the WHO. This is of particular relevance for the people who are most vulnerable to HIV.
  1. The concept of “Treatment as Prevention” is strongly supported by scientific evidence, yet the coverage of antiretroviral therapy in the region is currently far from the scale where it could have a significant preventative impact at population level. Access to antiretroviral treatment needs to be significantly accelerated in the region. Vulnerable populations should have the same access to antiretroviral therapy as other populations. WHO recommends that antiretroviral therapy should be initiated in everyone living with HIV at any CD4 cell count.
  1. Prioritization of prevention interventions should be based on a comprehensive and thorough analysis of regional and national epidemiological data. Currently available data on incidence and prevalence among high-risk groups including people who inject drugs, men having sex with men or sex workers, is very limited in the region.
  1. Preventative interventions will not be effective unless legal and policy-related obstacles to an enabling environment for these interventions are removed. Criminalization and stigmatization of some of the key populations at high risk for HIV have been shown in numerous studies in the region and across the world, to fuel the HIV epidemic. People who are discriminated against, marginalized and/or criminalized tend to go underground and have reduced access to prevention and treatment services.   Criminalization clearly does not serve the interests of public health. Laws, policies and practices should be reviewed and, where necessary, revised to allow the implementation of healthcare services for key populations.
  1. Non-governmental organizations (NGOs) and peer communities have a strong capacity to reach out to people most at risk, deliver information and implement prevention services. Social contracting mechanisms with NGOs should urgently be established, building on existing programs such as those funded in the region by the Global Fund. As we have seen in every country, government alone will never stop HIV. Working with [and empowering] affected communities is an essential element of the fight against HIV.
  1. The HIV epidemic in the Russian Federation and in the region has been and remains largely driven by unsafe drug injection. Harm reduction including all of the elements of the “package” of interventions recommended by WHO, UNAIDS and UNODC, should be implemented everywhere in the region. Methadone and buprenorphine are on the Essential Medicines List of WHO.
  1. Prevention works. Consistent and correct use of male condoms reduces sexual transmission of HIV by up to 94%. The literature has also unambiguously documented that harm reduction, pre-exposure antiretroviral prophylaxis, and post-exposure prophylaxis and antiretroviral treatment are effective in preventing HIV infection. National policies are to be based on this scientific evidence.
  1. Combination prevention, i.e the combined use of all available evidence-proven preventative interventions prioritizing those with the most acute epidemiological needs in a region, is a key element of the strategy of intensification of the AIDS response that UNAIDS is calling for, for the period 2016-2020. UNAIDS also recommends that 25% of national AIDS budgets are dedicated to prevention. Current budgets for prevention are far below these figures in most countries of the region.
  1. This year is the fifth consecutive Eastern Europe and Central Asia AIDS Conference (EECAAC) that sees a continuing growth of the epidemic in the region. The time for scaling up treatment and prevention is now. The need is more urgent than ever.

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Public statement by the Global Commission on Drug Policy on UNGASS 2016

The Global Commission on Drug Policy is profoundly disappointed with the adopted outcome document agreed at the UN General Assembly Special Session (UNGASS) on “the world drug problem”. The document does not acknowledge the comprehensive failure of the current drug control regime to reduce drug supply and demand.

Nor does the outcome document account for the damaging effects of outdated policies on violence and corruption as well as on population health, human rights and wellbeing. By reaffirming that the three international conventions are the “cornerstone of global drug policy”, the document sustains an unacceptable and outdated legal status quo.

UNGASS has not seriously addressed the critical flaws of international drug policy. It does not call for an end to the criminalization and incarceration of drug users. It does not urge states to abolish capital punishment for drug-related offences. It does not call on the World Health Organization (WHO) to revisit the scheduling system of drugs. It does not advocate for harm reduction and treatment strategies that have demonstrated effectiveness. Finally it does not offer proposals to regulate drugs and put governments – rather than criminals – in control.

Equally important, the outcome document fails to recognize the considerable support for change demonstrated by many governments and civil society groups during UNGASS. It also excludes any mention of the many positive drug policy reforms already underway around the world. In fact many federal, state and city governments are adopting progressive legislation and testing new approaches.

In order to achieve meaningful reforms to global drug policy the UN and member states must address the contradiction between the restrictions imposed by the international narcotics conventions and the necessity of governments and societies to regulate drugs. Several countries and some U.S. states are exploring regulation in a more humane and evidence-based manner. These approaches should be encouraged despite the restrictive language of the UN drug conventions.

It is vital that the tensions between the letter of the conventions and ongoing initiatives on the ground are resolved. There will be another international opportunity to do so in 2019 when the UN Plan of Action that calls for a “drug free world” will be reviewed. The Global Commission urges governments and civil societies to continue moving forward and adopting drug policy reforms that are tailored to people’s needs and rights. We encourage and support them in their efforts to fundamentally realign drug policy so that health, citizen safety and human rights are paramount.

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CHRONICLE OF AN (AVOIDABLE) TRAGEDY FORETOLD

March 21, 2016, BRITISH MEDICAL JOURNAL (BMJ)

The road to Donetsk from Kramatorsk, the last city in mainland Ukraine before the internal border, is beautifully lined with frosted trees. But its beauty belies the harsh reality of actually reaching Donetsk.

It is not a simple journey, as I discovered on a recent trip in January. Only one road crosses the so called “contact line” between government-controlled and non-controlled parts of the Donetsk province. That very road is also the only way to travel to Luhansk, which has no open road communication with mainland Ukraine anymore. Several Ukrainian army and Donetsk forces checkpoints need to be crossed along the way. People wait for hours to cross this internal border, with restricted access available only between 10 am to 5 pm. On top of it all, the environment conspires to make it an uncomfortable ride in the ceasefire zone: temperatures of -20C, destroyed high tension cables, no-go minefields, and the occasional bombed building.

Small mercy then that weapons have been laid down after 20 months of a war that has caused over 9000 deaths, driven over a million refugees to Russia and Belarus and beyond, and resulted in nearly 1.5 million people becoming displaced within mainland Ukraine.

East Ukraine remains split from the mainland and it is hard to predict just how long that situation will last. Equally uncertain is the future of organised free elections in the region, as stipulated in the Minsk Agreement.

An estimated five million people and most of the infrastructures of the region have stayed on in the now “self-proclaimed” People’s Republics of Donetsk and Luhansk. For over a year now, these territories have been declared “non-government controlled areas” by the Kiev authorities, meaning that financing for public infrastructure, government salaries, and pensions have been withdrawn by mainland Ukraine.

It is hardly surprising then that the health situation in Donetsk and Luhansk is particularly fragile.

Prior to the conflict, Donetsk and Luhansk both had some of the highest incidence and prevalence rates of both HIV/AIDS and multidrug resistant tuberculosis (MDR-TB) in Ukraine and Europe. The past year has seen a series of disruptions to the region’s healthcare—including interrupted supplies of medicines and diagnostic tools, physicians and social workers leaving the territories, and a reduced presence of non-governmental organisations dedicated to HIV prevention and treatment—which has left it teetering precariously.

The conflict’s ongoing dismantling of the health system threatened to lead to a virtual stockout of antiretroviral (ARV) drugs last October—a situation that was averted at the 11th hour after the drugs were procured by UNICEF through an emergency grant from the Global Fund and finally delivered to people living with HIV.

However, it must be said, the system has adapted to a degree: social workers continue to deliver services (some on a voluntary basis), laboratory reagents and some medicines are smuggled across the contact line, and some international (including Russian) humanitarian help has reached the territory. But it’s not enough.

Last year’s emergency procurement of ARV drugs threatens to repeat itself with 10 000 people living with HIV/AIDS in the region soon facing the risk of treatment interruption. Current ARV supplies are only funded until August 2016. In addition, the amount of procured ARV drugs has been calculated based on the number of patients on treatment a year ago, and does not include some 2000 newly diagnosed patients who will need to start treatment this year. This situation is compounded by a lack of some basic HIV and TB diagnostic tools.

There are no longer any reagents to perform CD4 cell counts in Luhansk and it also lacks the infrastructure to diagnose MDR-TB. Patients with MDR-TB in the Donetsk prison system are currently without treatment.

The time has well and truly come for the Minsk negotiators to prioritise HIV/AIDS, TB, and MDR-TB as urgent issues on the regional agenda that the world must address in these territories. But it is also long overdue for the authorities in Kiev, Donetsk, and Luhansk to accept that HIV/AIDS, TB and MDR-TB are regional and global concerns. The UN must also continue to play its part in fostering health and humanitarian diplomacy to avoid a European tragedy this year.

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The unknown: will we defeat global epidemics ?

Remarks given at the conference ‘The unknown, 100 years from now: A voyage of discovery’ , Lisbon, Portugal, 4-5 December 2015

Dear colleagues, Ladies and gentlemen,

Thank you. I feel truly honored by your invitation to speak today.

My remarks will focus on the question of whether the world can bring an end to epidemics a hundred years from now. I see at least two issues to be considered under this broader question.

The first is: will the world end the current major epidemics that it is facing, namely, HIV/AIDS, TB, malaria?

And the other: will the world, a hundred years from now, end the risk of emergence or re emergence of epidemics?

To the first question, my answer would be a cautious yes.

Yes, because the progress made in the fight against these epidemics in the last fifteen years has been just remarkable – with no precedent in the history of public health – and undoubtedly, a source of major hope for the future. The “end” of AIDS and TB that was unthinkable just fifteen years ago, has now not only entered the language of scientists but has been endorsed as an objective that the world set to itself for 2030 under the new Sustainable Development Agenda adopted by the UN last September.

Progress has been amazing and amazingly fast.

The number of people accessing antiretroviral treatment has increased from 200 000 in 2000 to 16 million by now. The number of new HIV infections has decreased by 40% and AIDS-related deaths have decreased by 35 % globally in the last five years. New effective medicines with fewer adverse effects and/or that are capable of overcoming emerging viral resistance are becoming available every year. The life expectancy of an HIV-infected person on effective AIDS treatment is now similar to that of an HIV-negative person.

We have witnessed a 50% fall in mortality from tuberculosis since 1990, with most of that improvement taking place since 2000. Effective diagnosis and treatment of TB will have saved an estimated 43 million lives between 2000 and 2014.

We have learned about the ingredients of success: political commitment, community mobilization and involvement, resources, innovative approaches to delivery of care, to the international intellectual property framework, to development assistance, and to the global governance of health.

Importantly, science has been vital in advancing control and treatment of the diseases: new scientific evidence, products and approaches have rapidly been incorporated into programs; and the scientific community has been intimately involved in strategy development, implementation and assessment of the response to the epidemics.

I am confident that science will further generate efficacious new medicines, possibly leading to eradication of the virus from infected individuals – that is a cure for AIDS -, and also, most likely, effective vaccines to prevent infection with HIV and transmission of TB.

If my “yes” to the question of whether we will end today’s major pandemics is cautious, it is not because of limitations that I would foresee to progress in science. It is because ending AIDS and TB is not just about fully understanding transmissibility, pathogenicity and immune responses, and generating new medicines and vaccines. It is about our ability in the future to address the social, structural and political determinants that underlie the emergence and expansion of these diseases.

Despite the progress, two million people still become infected with HIV every year and TB now ranks along with HIV as a leading cause of death with a worldwide death toll of 1.2 million.

Epidemics have always been powerful indicators of social and economic inequities, structural weaknesses of health and social systems, and of failures to address the transnational nature of health.

In contrast with the progress made globally, only minor and sometimes little progress has been made with the so-called “concentrated” epidemics of HIV among vulnerable groups of the population. Of the 500 000 new cases of multi-drug resistant TB that primarily affect vulnerable populations, only a quarter are detected and reported.

By vulnerability I refer to young women in sub-Saharan Africa that have no control over their sexual life, men having sex with men, people who inject drugs, sex workers and incarcerated people, in most parts of the world. HIV remains highly prevalent in these communities in both developed and developing countries, and access to prevention and treatment for vulnerable and marginalized groups remains disproportionally low. A strong emphasis – if not an over-reliance – on biomedical approaches has led to an inadequate public health focus on fighting stigma, discrimination, and inappropriate legal and policy environments, as well as an insufficient focus on social and political determinants of health: just think of the major negative impact on the prevention of the transmission of HIV that the denial of the viral origin of AIDS by a former South African president had in a country that is still paying for this absurdity with one of the highest HIV sero-prevalence rates in the world. Together with Fernando Henrique Cardoso, Jorge Sampaio and our fellow members of the Global Commission on Drug Policy, we are denouncing the focus on repressive drug policies that emphasize prohibition and law enforcement rather than public health, approaches that continue to fuel the HIV and hepatitis epidemics among people who inject drugs.

Another source of caution about the prospect of ending these epidemics is the development of resistance, now a major challenge for the prevention and treatment of TB. Resistance may arise from improper treatment regimens and TB programs failing to ensure that patients complete the whole course of treatment. Globally, MDR TB represents 3.3 % of new TB cases and 20 % of previously treated patients that come for re-treatment, but these figures reach 30 and 70 % in some countries of Eastern Europe. Of the few patients with MDR TB who access treatment, only 50% have a successful outcome.

The recent Ebola outbreak probably best illustrates how much health systems and access to basic care are essential in the control of epidemics and cannot be compensated by measures such as confinement and border closure. In the absence of an effective treatment against the Ebola virus, recovery relies on access to rehydration and basic care measures. Whereas the mortality from Ebola has been over 50% in affected countries in West Africa, it is estimated that it would have been less than 10% under the conditions of functioning health systems in developed countries. Similar considerations would apply to cholera or dengue outbreaks.

At the time of the Ebola outbreak, Liberia had less than 50 doctors for a population of more than 4 million. International development assistance has too long neglected structural factors and investing in building sustainable health systems because of a dominant technical vision of international health programs centered on medicines and vertical interventions that neglect social and structural contexts.

Answering the question of whether we will end AIDS and TB by 2030 or even 2115 also involves asking whether the world will be able to reduce social and economic inequities. The question is legitimate as we see increasing gaps between the rich and the poor within countries and across the world, and particularly in the many countries that are now transitioning from low income to a middle-income status, and in the large emerging economies.

Let us hope that – just as in XIX century Europe – political and societal changes will help to accelerate sanitary and social reforms and economic growth that will allow us to end HIV/ AIDS, TB and Ebola at the global level.

Even with these qualifications, my answer is yes. I do foresee an end to AIDS and TB, at least as global public health threats well before of a hundred yeas from now, and consider this as an attainable objective for 2030. It is much harder however to foresee complete elimination of the diseases (that is, zero incidence) or eradication, which means disappearance of both the disease and its causal agent.   So will need to remain vigilant for many years once control has been achieved.

To the second question of whether the next hundred years will see a world free of emerging or re-emerging epidemics, answer must be no.

Bacteria, viruses and parasites that may cause transmissible diseases co-exist with humans and will obviously continue to do so. The microbial world is capable of remarkable mutation, evolution, and adaptation to the environment. Microbes are in the environment and in animals but humans themselves are also a reservoir of bacteria, some being beneficial and some potentially pathogenic.

Eradication of infectious diseases and a world free of epidemics has long been an idealistic goal. From the XIVth century, ports have set quarantine measures. Constantinople, Tangiers and Alexandria put together sanitary councils to protect the population from cholera arriving from the Indies?, and the first international sanitary regulations were developed as early as the 1860s.

However, infectious diseases will never disappear, as first predicted by Charles Nicolle, Director of the Pasteur Institute in Tunis and Nobel laureate in medicine in 1928, in his book “Naissance, vie et mort des maladies infectieuses”.

Moreover global warming, the growth of transport and communications, the increase in the world population, the intensification of livestock farming, increasing contacts between humans and wild fauna, the thoughtless use of antibiotics in human and veterinary medicine, all point to the future emergence and re-emergence of epidemics.

The close interaction between people and pigs, and chicken and ducks led to the recent flu epidemics in Asia. Intense cultivation of fruit trees for pork farming has led to the proliferation of fruit bats, vectors of the Nipah virus, the agent of the respiratory syndrome outbreaks in Asia in 2011.

Eradication of small pox in 1978 will likely remain as the only example of eradication of an infectious disease through vaccination. There are several reasons for this: humans are the only reservoir of the disease and the disease is always symptomatic, with no silent carriers of the infection.

In the other diseases for which we have effective vaccines, the goal is elimination rather than eradication: diphteria, tetanus, poliomyelitis, whooping cough. Any loosening in vaccine coverage is immediately followed by re-emergence of the disease, as recently seen for measles in Europe and in the US.

In the case of new epidemics and diseases for which no vaccine is yet available, the emerging strategic model for control consists of a combination of several interventions: an early diagnosis using rapid bedside diagnostic tests; mathematical modelling of the early stages of the development of the epidemic, sensible public health measures including well thought-out confinement, and treatment interventions even if imperfect, to decrease transmission and disrupt the epidemic chain.

In addition, good governance, education, training of health care personnel and communities, economic growth that reduces social and economic inequities, will all be essential in controlling infectious risks.

Thus, epidemics in the future will persist, as predicted by Charles Nicolle. But epidemics will be better anticipated, detected and contained.

This will especially be true if we apply the lesson from HIV and TB: that epidemics can be reversed when we address them not only with the tools of public health, but also with human rights and efforts to achieve social and economic justice.

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Всемирный день борьбы со СПИДом

1 декабря 2015 г.

Эпидемия СПИДа в регионе Восточной Европы и Центральной Азии (ВЕЦА) находится на критическом этапе. 2016 год будет решающим годом в отношении того, какое будущее ожидает эпидемии на региональном и на международном уровне.

В 2016 году пройдет несколько важных событий: в марте состоится наша Конференция по ВИЧ/СПИДу в Восточной Европе и Центральной Азии (EECAAC), за ней последуют Специальная сессия Генеральной Ассамблеи ООН по наркотикам (ССГАООН) в апреле и совещание высокого уровня по ВИЧ/СПИДу в ООН в июне, а в июле состоится Международная конференция по СПИДу в Дурбане.

2016 год станет первым годом реализации недавно принятых Целей в области устойчивого развития. В рамках этих Целей мы взяли на себя обязательства достичь того, чтобы к 2030 году СПИД перестал быть угрозой общественному здоровью, и объединить все сектора общества под целью устойчивого развития в области здравоохранения.

Я глубоко верю в способность нашего региона значительно ускорить и усилить ответ на СПИД путем расширения доступа к лечению и решительно занимаясь профилактикой ВИЧ-инфекции. Важным шагом в этом направлении стало недавнее заявление Российской Федерации об удвоении своего бюджета на борьбу с ВИЧ/СПИДом начиная с 2016 года.

Нельзя также забывать, что в регионе ВЕЦА наблюдается высокое бремя туберкулеза, один из самых высоких уровней в мире туберкулеза с множественной лекарственной устойчивостью, а уровень сочетанной инфекция ТБ и ВИЧ-инфекции нарастает. Кроме того, регион живет с высоким бременем гепатита С и с большой долью сочетанной инфекции ВИЧ и вирусного гепатита С, особенно среди людей, употребляющих инъекционные наркотики.

Во всех частях планеты Всемирный день борьбы со СПИДом является днем ​​памяти и днем мобилизации. Мое пожелание всем нам — чтобы в нашем регионе правительства, гражданское общество, сообщества и международные доноры работали в более тесном партнерстве для ускорения ответа на эпидемии ВИЧ, туберкулеза, лекарственно-устойчивой формы ТБ и гепатитов.

Приверженность целям ЮНЭЙДС “90-90-90” и целям 2030 года означает срочное наращивание усилий против СПИДа через профилактику ВИЧ-инфекции; обеспечение доступа к тестированию и доступа к лечению; мобилизацию дополнительных ресурсов и усиление подотчетности и прозрачности; защиту прав человека, борьбу со стигмой, дискриминацией и криминализацией уязвимых групп населения; ответ на социальные и структурные детерминанты заболевания; и обеспечение приоритетности вопросов индивидуального и общественного здоровья в страновой политике.

Система ООН, Европейское региональное бюро ВОЗ, ЮНЭЙДС, ПРООН, ЮНИСЕФ, Фонд ООН в области народонаселения (ЮНФПА) и Управление ООН по наркотикам и преступности (УПН ООН) подтверждают свою приверженность оказанию помощи региону в борьбе с ВИЧ-инфекцией и в обеспечении справедливости и достоинства для каждого.

Послание Мишеля Казачкина, Специального посланника Генерального секретаря ООН по ВИЧ/СПИДу в Восточной Европе и Центральной Азии.

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World AIDS Day

1 December 2015

The AIDS epidemic in Eastern Europe and Central Asia (EECA) is at a critical juncture and 2016 will be a decisive year for the future of the epidemic at both regional and international levels.

2016 will see our regional conference, the Eastern Europe and Central Asia AIDS Conference (EECAAC) take place in March, followed by the UN General Assembly Special Session (UNGASS) on drugs in April, the High Level Meeting on HIV/AIDS at the UN in June, the Slovakian Ministerial Conference on TB in Europe, and the International AIDS Conference in Durban in July.

2016 will be the first year of implementation of the recently adopted Sustainable Development Goals, calling for ending AIDS as a public health threat by 2030 and for strengthening the integration of all sectors of society under the Health goal of the SDG Agenda.

I believe in the capacity of the region to significantly accelerate its response to AIDS, scaling up access to treatment and engaging with determination in HIV prevention. In a significant move, the Russian Federation has recently committed to double its budget for the HIV/AIDS response from 2016.

Let us also not forget that EECA is a high burden region for tuberculosis, with some of the highest levels of multidrug-resistant TB globally, and increasing rates of HIV/TB co-infection. The region is also a high burden region for hepatitis C with high rates of HIV/HCV co-infection, particularly among people who inject drugs.

World AIDS Day is a day of remembrance and a day of mobilization across the world. My deep wish is to see governments, civil society, communities, and international donors work together in the region as a stronger partnership to drive accelerated efforts against HIV/AIDS, TB, drug-resistant TB and hepatitis.

I hope that the next months will see a solution to the tragic situation and unnecessary suffering of people in the conflict areas in the region.

Committing to the UNAIDS 90-90-90 targets and to the 2030 goals means urgently escalating AIDS efforts through HIV prevention, access to testing and access to treatment; mobilizing more resources while increasing accountability and transparency; upholding human rights, fighting stigma, discrimination and criminalization of vulnerable groups; addressing social and structural determinants of disease and prioritizing individual and public health in policies.

The UN, WHO EURO, UNAIDS, UNDP, UNICEF, UNFPA and UNODC are strongly committed to support the region in its fight against HIV and in ensuring justice and dignity for all.

 

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

 

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65th Session of the WHO Regional Committee for Europe

Speech given on the opening of the 65th session of the WHO Regional Committee for Europe in Vilnius, Lithuania, 14–17 September 2015

Distinguished Chair and Delegates,

I am making this statement in my capacity as the UN Secretary General’s Special Envoy on HIV/AIDS in Eastern Europe and Central Asia.

I would like to thank the Regional Director for her report and commend her and the WHO Europe staff in Copenhagen and in country offices for steadfast commitment to having people in need in the region access prevention and treatment for HIV/AIDS, TB/MDR TB and viral hepatitis.

I could witness this commitment in the last few months as we deal with the acute risk of disruption of antiretroviral drugs in the non-government controlled areas of the Donbass in Eastern Ukraine; a part of Ukraine where patients are now facing to choose between fleeing their home and stopping life-saving treatment. Together with the Regional Director, we called on the Ukrainian authorities and the Minsk contact Group to urgently act to facilitate and restore medicine supply in the Donbass.

Eastern Europe and Central Asia continue to witness an expanding HIV/AIDS epidemic – in contrast with the significant decrease in incidence and AIDS-related mortality that has been seen globally in the last five years. Last year 2014, 136 000 new infections were reported in the EURO Region – the highest annual number of new HIV infections since reporting began thirty years ago and an 80% increase since 2004. Much of this increase is in the Eastern part of the region that reported over 75% of all new cases.

Some countries have stabilized or even reversed their HIV epidemics, however in twenty-one countries in the Region, newly diagnosed infections have increased by 20% or more in five years. Undiagnosed HIV is a major problem. Typically less than 50% of people living with HIV are tested and diagnosed and almost 50% of those diagnosed present at a late stage of disease. Access to treatment in the Eastern part of the region remains one of the lowest globally, and access to prevention, particularly for the most vulnerable groups – people who inject drugs, men having sex with men, sex workers, people in detention – far below the level where it should be.

The incidence and the prevalence of HIV/AIDS among vulnerable groups is also associated with a high risk of acquiring TB, MDR TB and being infected with the hepatitis C virus.

Distinguished Chair and delegates,

We are at times of opportunity and risk. Advances in science, including in the science of using antiretroviral drugs, provide us now with the tools to stabilize and, one day, end the AIDS epidemic.

For our region, and specifically the Eastern part of it, this opportunity has to be urgently met with strong political commitment, adequate financial resources, implementation of much higher scale evidence-based preventative and treatment programs, and building effective partnerships with civil society and community organizations.

Given the rate of growth of the epidemic, the risk of not acting now, is that of continuing to see the number of new infections far exceed that of people accessing therapy, and an ever increasing human and social cost of the epidemic in the region.

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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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