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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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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