INTERVENTION ON THE HIV ACTION PLAN RESOLUTION

Remarks given at Sixty-sixth session of the WHO Regional Committee for Europe in Copenhagen, September 14,  2016

 

Madame Chair, Madame Director General,

 

I would like to thank the Regional Office for framing and drafting what I consider a relevant, comprehensive and strong action plan for the health sector response to HIV in the region.

I would also wish to thank you, Mme Regional Director, for your leadership and your call on day 1 of this meeting, for member states to urgently address the AIDS crisis in Europe.

The plan of action that is submitted for approval is fully in line with the approved WHO Global Health sector strategy on HIV, with the UNAIDS strategy and with the ultimate objectives of the political declaration adopted at the High Level Meeting on AIDS in June this year in New York.

We rightly celebrate successes in the region in decreasing and eliminating vertical transmission of HIV. But this cannot and should not take our attention away from the fact that Europe, and primarily the Eastern part of the continent, remains the only region of the world where the HIV epidemic continues to grow.

In Eastern Europe and central Asia, the number of newly HIV cases has increased by 57% in the last five years (more than 70 % since 2005), while incidence and AIDS-related mortality have decreased by 30-40 % globally in the last ten years.

HIV, in addition, is inextricably linked with TB, MDR TB and hepatitis C in the region. And as delegates would know, the wide extent of drug resistance in Eastern Europe represents a critical challenge to TB control, as reflected in low treatment success rates.

 

Dear colleagues delegates, it is essential that we fully recognize that HIV and TB/MDR TB continue to be ongoing epidemic health emergencies in the region.

The European plan of action that is submitted to you is a robust plan that complements the TB plan of action for 2016-2020 approved last year. I urge you to approve it. As the Secretary General’s Special Envoy, I urge you to intensify access to effective prevention and to treatment for the many people in need in the region, with a strong focus on vulnerable populations, to remain committed and refuse complacency. I urge the regional office to strengthen its capacity for HIV and TB at country and regional levels.

Europe cannot persist in being be the epidemic exception in the global fight against HIV/AIDS.

 

 

Share and Enjoy

  • Facebook
  • Twitter
  • Delicious
  • Digg
  • StumbleUpon
  • Add to favorites
  • Email
  • RSS

The Johns Hopkins – Lancet Commission on Drug Policy and Health Report in Russian

A Russian translation of the Johns Hopkins–Lancet Commission on Drug Policy and Health report is available here: JH-Lancet Commission Report vRU

The original version is available here: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00619-X/abstract

Share and Enjoy

  • Facebook
  • Twitter
  • Delicious
  • Digg
  • StumbleUpon
  • Add to favorites
  • Email
  • RSS

Addressing migrants’ access to health, HIV/AIDS and TB services in Eastern Europe and Central Asia

photo side eventRemarks given at the side event “Addressing migrants’ access to health, HIV/AIDS and TB services in Eastern Europe and Central Asia”, held during the Human Rights Council in Geneva, June 17,  2016

 

Honorable Delegates, Ladies and Gentlemen,

Thank you for being present at this side event on HIV and TB among migrants in Eastern Europe and Central Asia.

Thank you to the Permanent Representation of the Kyrgyz Republic, the Permanent Representation of the Republic of Kazakhstan, IOM, UNAIDS, WHO, OFID in Vienna, IFRC and Project Hope for co-organizing this event with us. Thank you to the panelists. And thank you, Honorable Daniiar Mukashev for agreeing to co-Chair the event.

The event is focusing on HIV and TB among migrants in EECA and there are a number of reasons to that.

  1. Some of the world’s largest international labor migration trends are registered among Central Asian countries and with the Russian Federation, be it legal or irregular. A large proportion of migrant workers come from the Kyrgyz Republic, Tajikistan, and Uzbekistan. But other countries are also sources of migration labor in the region, including Ukraine, Moldova, and Armenia.
  1. Eastern Europe and Central Asia (EECA) is the only region of the world that continues to see a growth in the HIV/AIDS epidemic with a 57 % increase in the number of new infections reported in the last five years. The overall coverage with antiretroviral treatment remains low in the region as well as access to prevention, particularly for the most vulnerable groups of the population, including migrants.
  1. EECA is also a region where TB is a major issue of concern for public health. EECA accounts for approximately a quarter of the world’s MDR TB burden in the world. A number of circumstances may contribute to TB among migrants, including conditions of living and work; limited access to diagnosis and treatment; late presentation due to fear of being deported; the complex patterns of migrations including high mobility due to temporary and seasonal migration patterns and high number of undocumented migrants.

 

This event takes place on the sidelines of the Human Rights Council and there are also reasons to that.

In his report during this session of the Human Rights Council, the Special Rapporteur on the human rights of migrants has remembered that under the international law, states have the obligation to ensure and the responsibility to respect and uphold the right to health, in a manner that promotes non-discrimination, dignity and freedom for migrants regardless of legal status.

The inclusion of migration in the 2030 Agenda for Sustainable Development is a call for leaving no one behind.

And of course, respecting the human rights of migrants can bring positive development outcomes, considering that labor migrants contribute to significant economic gains in the host country.

How is it that in 2016, deportations for Health reasons and restrictions on the circulation of people between countries in the region based on HIV status continue to happen?

Countries must work together to facilitate orderly, safe, regular and responsible migration and mobility of people. And countries in the region must recognize that there is a need for a comprehensive response to HIV and TB among migrants in EECA, if we want to fast-track HIV and TB and give priority attention to vulnerable groups, as the world committed to by adopting the 2030 agenda and in the political declaration adopted at the High Level Meeting on AIDS last week in New York.

Civil society and communities have an important role to play in reaching to migrants and countries must be ready to support their work. I am pleased that IFRC and project Hope also participate to our panel.

Human rights are universal. They are also the rights of migrants. The right to health and decent care. The right to freedom from discrimination. The rights to equality before the law, to privacy, to work and education. The right to share in the advances of science.

Thank you.

 

Share and Enjoy

  • Facebook
  • Twitter
  • Delicious
  • Digg
  • StumbleUpon
  • Add to favorites
  • Email
  • RSS

Международная научно-практическая конференция “Актуальные вопросы ВИЧ-инфекции”

Выступление на международной научно-практической конференции “Актуальные вопросы ВИЧ-инфекции”, в Санкт-Петербурге, 30-31/05/2016.

Уважаемые коллеги,

Благодарю Вас за любезное приглашение на конференцию. Для меня это очень приятно вновь встретиться с коллегами и друзьями. И я особенно рад вернуться в Санкт‑Петербург.

Позвольте сперва поприветствовать врачей, ученых, медицинских и социальных работников, представителей гражданского общества и сообществ, всех, кто неустанно борются против СПИДа, туберкулеза и туберкулеза с множественной лекарственной устойчивостью (МЛУ-ТБ).

Во всех местах, которых я посетил, путешествуя по стране за последние две недели – в Иркутске, Екатеринбурге, в Казани и Набережных Членах, в Москве, в Выборге и Санкт-Петербурге, – я встречал исключительных, преданных своему делу людей, работающих нередко в трудных обстоятельствах.

 Я остаюсь твердо убежден в том, что люди этой страны могут добиться любой цели, в том числе и положить конец этим эпидемиям, если они на это направят совместные усилия.

Я чувствую, что сегодня Россия находится во времена повышенной политической приверженности к борьбе с эпидемиями, увеличения усилий и ускорения перемен. Я приветствую цели в области лечения, поставленные в последнем проекте национальной стратегии и  намеченные Министром Скворцовой Вероникой Игоревной, достичь к 2020 году 80 (восьмидесяти) процентов охвата антиретровирусной терапией всех людей на медицинском учете.

Число новых случаев ВИЧ-инфицирования, новых случаев СПИДа и смертей от СПИДа в Российской Федерации продолжает увеличиваться. Общее количество выявленных случаев ВИЧ-инфекции за последние 10 лет увеличилось в три раза. Охват антиретровирусной терапией остается на низком уровне. Эти цифры ясно контрастируют с другими частями мира, где уменьшаются число новых случаев инфицирования и смертность от СПИДа.

Меняется общая картина эпидемии в Российской Федерации. Значительная часть вновь выявленных случаев ВИЧ-инфекции в настоящее время происходит половым путем. Это происходит на ряду с так называемыми «концентрированными» эпидемиями среди лиц, употребляющих инъекционные наркотики, мужчин, имеющих половые отношения с мужчинами, заключенных и секс-работников. Эпидемии среди этих уязвимых групп неуклонно продолжают расти – без адекватного ответа—и непобежденные.

То, что эпидемия в этой стране остается, в значительной степени, не под контролем, должен вызывать серьезную озабоченность у всех нас, кому важна Россия, ее народ и глобальное здравоохранение. Нам необходимо прийти к общему пониманию, почему это происходит и  каким образом мы можем достичь прогресса.

Сегодняшняя конференция должна четко сосредоточится именно над этими вопросами.

Для расширения охвата лечением и достижения целей, которые поставлены ЮНЭЙДС и которые должны быть утверждены на следующей неделе на ООН’овском Заседании в Нью-Йорке, потребуется упростить и стандартизировать алгоритмы диагностики и схемы лечения, значительно уменьшить цены на препараты, а также пересмотреть действующие модели предоставления медицинских услуг, в том числе децентрализовать услуги по лечению, снизить вертикальность специализированной помощи и повысить фокус услуг на потребности тех, кто в них нуждаются.

Больше внимания требуется также уделить быстро растущему бремени коинфекции туберкулеза и ВИЧ и коинфекции ВИЧ и гепатита С.

У нас есть убедительные данные о том, что антиретровирусная терапия снижает передачу ВИЧ-инфекции. Однако это не означает, что мы должны отказаться от профилактики в целом и от усилий по снижению вреда среди уязвимых групп населения и людей, находящихся в уязвимых условиях. Как и в случае со другими заболеваниями, нам нужно работать одновременно и по профилактике, и по лечению. Профилактика ВИЧ‑инфекции по‑прежнему является необходимой, в первую очередь, для поддержания здоровья населения и снижения бремени ВИЧ и СПИДа на систему здравоохранения. Однако, как мне представили в посещенных областях, в настоящее время мало инвестиций идут на программы для обеспечения эффективной профилактики.

Крупные информационные кампании и кампании по тестированию будут способствовать повышению информированности людей и раннему выявлению ВИЧ‑инфекции у тех, кто уже инфицированы. Однако только упрощение доступа к презервативам, снижение вреда и аутрич‑работа на поле совместно с нeкоммерческими организациями предотвратят новые случаи инфицирования.

Снижение вреда для людей, употребляющих наркотики, рекомендовано ВОЗ, ЮНЭЙДС и Управлением ООН по наркотикам и преступности, включает в себя предоставление стерильного инъекционного инструментария и опиоидную заместительную терапию. Имеются убедительные доказательства, что эти меры, совместно с антиретровирусной терапией, предотвращают ВИЧ‑инфицирование, снижают риск передачи ВИЧ и гепатита С, повышают приверженность к антиретровирусной и противотуберкулезной терапии, уменьшает смертность и зависимость от наркотиков, улучшают качество жизни, снижают уровень преступности и вероятность общественных беспорядков.

Я понимаю изменения, происходящие в области наркопотребления здесь в России, то есть расширение гаммы наркотиков от героина до спайсов, солей, стимуляторов амфетаминового ряда, наркотиков домашнего производства и смесей лекарственных веществ, находящихся в свободной продаже. Даже на фоне этих изменений, в целях здравоохранения, политика контроля над наркотиками должна начаться с внедрения и расширения мер по снижению вреда. Я хочу поприветствовать решение, принятое городом Санкт-Петербурга, расширять внедрение программ по обмену шприцев в пунктах профилактики в центре СПИДа и наркологической службе.

Позвольте мне также сказать, что я не вижу никакого противоречия между реализацией, например, широкомасштабной программы обмена по раздаче шприцев в качестве средства снижения риска для общественного здоровья, и продолжением ориентированных на пациента «усилий по реабилитации», если они основаны на данных, подтверждающих их эффективность и на уважении прав и достоинства пациентов.

Слишком много жизней было потеряно из-за ВИЧ, туберкулеза и гепатита здесь и во всей Восточной Европе и Центральной Азии. Слишком много людей потеряли надежду, что существенный прогресс будет достигнут, и живут с мрачной неизбежностью дальнейшего роста заболеваемости и смертности. Настало время это изменить. Я с большим удовлетворением отмечаю укрепление политической воли в этом направлении. Мы переживаем важный момент, когда цена недостаточного действия становится слишком высокой, а возможности для достижения прогресса становятся все более очевидными.

Я убежден, что только открытость к переменам позволит нам воспользоваться этим моментом. Как отметил Генеральный секретарь ООН:

“Борьба со СПИДом по-прежнему является источником инноваций и вдохновения и демонстрирует, что можно сделать на основе объединения достижений науки, активной деятельности на уровне общины и политического руководства.”

От нас зависит, сможем ли мы изменить темпы и масштабы ответа на эпидемии. Только от нас зависит, сделаем ли правильный выбор, каким путем вести лечение и профилактику, будет ли уделено приоритетное внимание уязвимым группам населения и создано более светлое будущее для россиян и для Восточной Европы и Центральной Азии.

Благодарю за внимание.

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

Share and Enjoy

  • Facebook
  • Twitter
  • Delicious
  • Digg
  • StumbleUpon
  • Add to favorites
  • Email
  • RSS

Официальный визит в Российскую Федерацию 16–31 мая 2016 года: Маршрут

Москва: 16, 17 мая

Свердловская область – Екатеринбург: 18 и 19 мая

Иркутская область – Иркутск: 20 и 21 мая

Республика Татарстан – Казань и Набережные Челны: 23, 24 и 25 мая

Ленинградская область – Санкт-Петербург: 26, 27 и 28 мая

30-31 мая : Международная научно-практическая конференция «Актуальные вопросы ВИЧ-инфекции»

Share and Enjoy

  • Facebook
  • Twitter
  • Delicious
  • Digg
  • StumbleUpon
  • Add to favorites
  • Email
  • RSS

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.

Share and Enjoy

  • Facebook
  • Twitter
  • Delicious
  • Digg
  • StumbleUpon
  • Add to favorites
  • Email
  • RSS

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.

Share and Enjoy

  • Facebook
  • Twitter
  • Delicious
  • Digg
  • StumbleUpon
  • Add to favorites
  • Email
  • RSS

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.

Share and Enjoy

  • Facebook
  • Twitter
  • Delicious
  • Digg
  • StumbleUpon
  • Add to favorites
  • Email
  • RSS

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.

Share and Enjoy

  • Facebook
  • Twitter
  • Delicious
  • Digg
  • StumbleUpon
  • Add to favorites
  • Email
  • RSS

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.

Share and Enjoy

  • Facebook
  • Twitter
  • Delicious
  • Digg
  • StumbleUpon
  • Add to favorites
  • Email
  • RSS