Category Archives: General

Towards a new health diplomacy in eastern Ukraine

March 2017, The Lancet HIV

Conflicts and resulting humanitarian crises in countries with high burdens of infectious disease present political, strategic, and logistic public health challenges for agencies charged with implementing health programmes. One need look no further than the ongoing conflict in eastern Ukraine, to illustrate this.

Access to treatments for HIV and drug-resistant tuberculosis in the separatist Donetsk and Luhansk territories has been an issue of concern from the early days of the conflict. Even before the conflict, these regions had some of the highest incidences and prevalences of HIV and drug-resistant tuberculosis in Ukraine and Europe. Donetsk has an estimated 30 000 cases of HIV and Luhansk 5000—above 1% of the population in both territories. 18 000 patients are enrolled in care in the territories and 8200 patients are on antiretroviral therapy. 2200 cases are newly diagnosed each year, and an estimated 12 500 patients will be in need of treatment at the end of 2017 (on the basis of a CD4 count eligibility threshold of 500 cells per μL).

As of March 1, 2016, there were 650 patients with drug-resistant tuberculosis on treatment in Donetsk and Luhansk. During the period of May 2016 to December 2017, an additional 900 patients with drug-resistant tuberculosis are expected to require treatment in the civil sector and the prison sector. The situation is of particular concern in the penitentiary sector because international programmes focusing on drug-resistant tuberculosis, including that of Médecins sans Frontières, were discontinued by the local authorities at the end of 2015. Medical needs associated with HIV and tuberculosis also include laboratory supplies for testing (including GeneXpert), CD4 cell counts, and plasma viral load measurement, as well as ensuring laboratory quality control.

Finances are needed to sustain the work of non-governmental organisations (NGOs) that support patients in care and prevention programmes, including the distribution of clean injecting materials for people who inject drugs—opioid substitution programmes were discontinued in both Donetsk and Luhansk in 2015. Before the conflict, most antiretroviral drugs were funded by the Ukrainian Ministry of Health. Medicines for drug-resistant tuberculosis were funded by the Global Fund To Fight AIDS, Tuberculosis, and Malaria and channelled to Donetsk and Luhansk through a Ukrainian NGO. However, the funding for medicines was discontinued in both the Donetsk and Luhansk territories by the Kiev authorities at the end of 2014, when these territories (and self-proclaimed Donetsk and Luhansk Peoples’ Republics) were declared by the Ukrainian Government as non-government-controlled areas (NGCAs).

In June 2015, I expressed concern about the pending risk of an abrupt interruption in the availability of antiretroviral drugs for thousands of patients with HIV in the Donbass (the region of which Donetsk and Luhansk are part). The clinics in Donetsk and Luhansk continued to treat patients until July 2015 when the interruption to supply became an urgent public health threat. What followed were intense health diplomacy efforts to alert and then to involve the de facto authorities in the NGCAs, the Ukrainian Government, the European Commission, bilateral donors, the UN and the Global Fund. The primary aim was to frame the critical situation to all stakeholders as a humanitarian emergency that required a special set of responses that were geared to ensuring stakeholder cooperation with the twin goals of securing funding for the essential medicines and providing access on the ground to the affected peoples in the conflict region.

Meetings with self-proclaimed officials in Luhansk in January 2016 and Donetsk in March 2016 resulted in roadmaps to seek temporary solutions to the risks of interruptions to supplies of drugs to treat HIV and drug-resistant tuberculosis until the end of 2017. Health diplomacy facilitated the search for possible funding sources to finance emergency support to the NGCAs, which ultimately brought together the Global Fund, UNICEF, WHO, UNAIDS, the Ukrainian Government, and non-governmental partners to set up the mechanism that enabled the drug supply needs to be met and soon came in the form of an emergency grant of US$3·6 million from the Global Fund to UNICEF, covering the supply needs of antiretroviral medicines and laboratory reagents in both territories for 1 year. The Global Fund is considering an extension to this grant. UNICEF successfully implemented a public health approach in which most treatment naive patients would start ART on an optimised single pill formulation of tenofovir disoproxil fumarate, emtricitabine (or lamivudine), and efavirenz and 60% of patients already on first-line therapy would switch to that regimen, resulting in significant financial savings.

Funding for drug-resistant tuberculosis medicines procurement was consolidated in the Global Fund grant to the Ukrainian NGO recipient until the end of 2017. All in all, a solution was found for over 10 000 HIV patients on antiretroviral treatment in the NGCAs and about 500 cases per year of people living with drug-resistant tuberculosis.

Of equal importance to funding guarantees, the Donetsk and Luhansk de facto authorities agreed on key logistic issues, including facilitating the delivery of antiretroviral drugs to the territories by UNICEF and that drugs to treat drug-resistance tuberculosis were still to be provided under the Global Fund grant and delivered safely and on expected schedule to Luhansk. The medical teams and authorities were also made accountable for delivering care and treatment and provide the needed epidemiological and treatment monitoring and evaluation data to WHO, according to international standards.

This diplomatic intervention was a success in terms of permitting the delivery of essential medicines; however, that is only a short-term solution while uncertainties around drug supply remain. The most realistic solution for the mid-term, beyond 2017, is to have the issue of the funding of HIV and drug-resistant tuberculosis treatments addressed within the frame of the Minsk negotiation process on the future status of the Donetsk and Luhansk separatist territories within Ukraine. Since mid-2016, discussions have been underway with the support of the Chair of the Humanitarian Working Group for the Minsk process, with the governments of France, Germany, the Russian Federation, and Ukraine and with the European Union, to attempt to place the issue of the funding of expensive tuberculosis and HIV medicines on the agenda of the negotiations.

The evolving geopolitics in Ukraine, Europe, the Russian Federation, and the USA brings fragility to the Minsk process. If no solution is found in the coming months, the region may again be at risk of treatment interruptions for HIV and drug-resistant tuberculosis that would lead to a regional public health crisis.

ВИЧ и туберкулез: лечение для всех / HIV and Tuberculosis: Treatment for All


03 ноября 2016


Минское заявление министерств здравоохранения стран Восточной Европы и Центральной Азии “ВИЧ и туберкулез: лечение для всех”

Минск, Республика Беларусь

  1. Мы, представители министерств здравоохранения Республики Армения, Азербайджанской Республики, Республики Беларусь, Грузии, Республики Молдова, Республики Казахстан, Кыргызской Республики, Российской Федерации, Республики Таджикистан, Туркменистана, Республики Узбекистан и Украины собрались 3 ноября 2016 года в г. Минск, Республика Беларусь, для обсуждения и координации совместной позиции по расширению доступа к качественным и недорогим антиретровирусным и противотуберкулезным препаратам в странах региона Восточной Европы и Центральной Азии;
  1. Мы понимаем важность и актуальность проблем, в основе которых лежат вопросы эпидемий ВИЧ/СПИДа и туберкулеза, и затрагивающих регион ВЕЦА;
  1. Мы подтверждаем нашу приверженность:
  • Политической декларации по ВИЧ/СПИДу: поиск подходов к ускорению борьбы против ВИЧ/ СПИДа к 2030 г., принятой 8 июня 2016 г. и включающей задачи ЮНЭЙДС 90-90-90 [1];
  • Глобальной стратегии и плану “Global Plan to End TB” 2016 – 2020 [2];
  • План действий по борьбе с туберкулезом для Европейского региона ВОЗ на 2016–2020 гг. [3];
  • План действий сектора здравоохранения по борьбе с ВИЧ-инфекцией в Европейском регионе ВОЗ [4];
  • Повестке дня в области устойчивого развития до 2030 г., включая резолюцию стран-членов ООН, утверждающую намерение покончить с эпидемией СПИДа и туберкулеза к 2030 г. (ЦУР 3: “Обеспечение здорового образа жизни и содействие благополучию для всех в любом возрасте) и в частности индикатор 3.3. [5];
  1. Мы признаем необходимость долгосрочных государственных программ, направленных на укрепление системы здравоохранения и предоставления доступных, качественных и недорогих услуг по профилактике и борьбе с ВИЧ/СПИДом и туберкулезом в странах региона ВЕЦА;
  1. Мы подтверждаем необходимость наиболее полного охвата пациентов и расширения доступа к антиретровирусному и противотуберкулезному лечению и подтверждаем возможность принять рекомендации ВОЗ по назначению антиретровирусного лечения всем людям, живущим с ВИЧ, в соответствии с действующими нормами законодательства стран-участников совещания;
  1. Мы подчеркиваем важную роль доступности современных лекарственных препаратов в реализации права на здоровье и подтверждаем намерение использовать существующие инструменты для снижения цен, чтобы спасти жизнь в странах нашего региона, с учетом действующих норм законодательства стран-участников совещания, в том числе путем:
  • Рассмотрения возможности использования различных механизмов закупок, включая международные механизмы и механизм объединенных закупок
  • Обсуждения цен с поставщиками антиретровирусных и противотуберкулезных препаратов
  • Поддержки производителей из стран ВЕЦА антиретровирусных и противотуберкулезных препаратов;
  1. Поддерживаем гарантии ТАПИС (торговые аспекты прав интеллектуальной собственности) и подтверждаем приверженность работать совместно и соблюдать условия, определенные в соглашении по ТАПИС и инновациям и интеллектуальной собственности, подписанной в Дохе [6] для ускорения доступа к качественным и недорогим антиретровирусным и противотуберкулезным препаратам;
  1. Подтверждаем приверженность работать на укрепление в течение последующих лет регионального сотрудничества по доступу к качественным и недорогим антиретровирусным и противотуберкулезным препаратам в наших странах для поиска наиболее эффективных и экономичных, устойчивых и отвечающих интересам всех сторон решений наших общих проблем в данной области; а также к стремлению укрепить наши совместные усилия, признавая региональную солидарность, общую ответственность и лидерство в политических вопросах, с учетом внутреннего контекста законодательства и юридических обязанностей стран-участниц совещания;
  1. Подчеркиваем важность и призываем к укреплению международного сотрудничества стран региона ВЕЦА по достижению целей и задач, нацеленных на искоренение эпидемий СПИД и туберкулез к 2030 и предоставлению наиболее полного доступа к антиретровирусным и противотуберкулезным услугам.

03 November 2016


Minsk Statement of the Ministries of Health of Eastern Europe and Central Asia “HIV and Tuberculosis: Treatment for All”

Minsk, the Republic of Belarus

  1. We, Representatives of the ministries of health the Republic of Armenia, the Republic of Azerbaijan, the Republic of Belarus, Georgia, the Republic of Kazakhstan, the Kyrgyz Republic, the Republic of Moldova, the Russian Federation, the Republic of Tajikistan, Turkmenistan, Ukraine and the Republic of Uzbekistan met on 03 November 2016 in Minsk, Belarus to discuss and coordinate positions on common interest in expanding access to affordable and quality assured Antiretroviral (ARV) and Antituberculosis (anti-TB) medicines in countries of the Eastern Europe and Central Asia (EECA) region;
  1. We recognize the gravity of the problems resulted from HIV/AIDS and tuberculosis epidemics affecting countries of the EECA region;
  1. We reaffirm our commitment to:
  • the Political Declaration on HIV and AIDS: On the Fast-Track to Accelerate the Fight against HIV and to End the AIDS Epidemic by 2030 adopted on 08 June 2016, including the UNAIDS 90-90-90 treatment target [1];
  • Global Plan to End TB 2016 – 2020 [2];
  • Tuberculosis Action Plan for the WHO European Region 2016–2020 [3];
  • Action plan for the health sector response to HIV in the WHO European Region [4];
  • 2030 Agenda for Sustainable Development, including the resolution of Member States to end the AIDS and TB epidemics by 2030 (SDG3 Ensure healthy lives and promote well-being for all at all ages) and SDG 3.3 [5];
  1. We acknowledge the need for long term state programs that are aimed at strengthening healthcare systems and providing accessible, affordable and high-quality HIV and TB services in countries of the EECA region;
  1. We reaffirm the urgent need for full coverage of patients and expanding access to HIV and TB treatment and confirm the possibility to adopt the 2015 World Health Organization Guidelines recommending that antiretroviral therapy be initiated for everyone living with HIV in accordance with the legislation of the countries participating in the Regional Consultation;
  1. We underline the importance of accessibility to modern medicines in the realization of the right to health and commit to utilizing all available tools to reduce the prices in order to save lives in the countries of our regions in accordance with the legislation of the countries participating in the Consultation through:
  • Considering the possibility to use different procurement arrangements, including international and pooled procurement;
  • Negotiating prices with ARV and TB suppliers;
  • Supporting manufacturers of ARV and anti-TB medicines from EECA states;
  1. We support the Trade-Related Aspects of Intellectual Property Rights (TRIPS) safeguards and are committed to work together to implement the provisions contained in the Doha Declaration on TRIPS and Innovation and Intellectual Property [6] to facilitate access to affordable and quality-assured ARV and anti-TB medicines;
  1. We commit to strengthen the regional cooperation over the next years in order to advance access to affordable and quality assured ARV and anti-TB medicines in our own countries to deliver more cost-effective, equitable and sustainable solutions for common challenges; and that our efforts are intensified through regional solidarity, shared responsibility and political leadership with consideration of internal legislative context and legal obligations of the countries participating in the Regional Consultation;
  1. We highlight the importance of and call for strengthened international cooperation countries to support the efforts to achieve the target on ending the AIDS and TB epidemic by 2030 and implement universal access to HIV and TB services.

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“HIV: yesterday, today and tomorrow” in Kazakhstan

Speech given at the opening of the National Conference on “HIV: yesterday, today and tomorrow” in Almaty, October 12,  2016

Honorable Minister,

Distinguished colleagues,

I thank you for the invitation to this conference. I am truly pleased to be back in Kazakhstan on this occasion.

I wish to congratulate the Ministry of Healthcare and Social Development of Kazakhstan and colleagues from UNAIDS, UNODC and Global Fund for taking the initiative of organizing the first National HIV Conference in the country: a unique opportunity to pause – to formally and honestly assess the situation of the epidemic, acknowledge the challenges and mobilize all energies of the country to fast track the AIDS response and move towards the goal of ending AIDS.

I also wish to pay tribute to the Honorable Salidat Kairbekova whom I remember well and who contributed so significantly to public health in Kazakhstan.

I congratulate the Republic of Kazakhstan for the progress made in recent years in the fight against HIV. The country has taken a number of key initiatives and each of them is an important step toward achieving the 2020 goals: transiting to a predominantly domestic funding of the AIDS response; initiating work on relevant investment cases; reducing the price of medicines through pooled procurement and opening the way for accessing generic medicines; funding NGOs through social contracting; continuously supporting harm reduction for people who use drugs despite pressure from some groups who refuse scientific evidence of its effectiveness. I welcome the recently announced plans for scaling up harm reduction in the country.

It remains however that vulnerable groups of the population, people who inject drugs, sex workers, men who have sex with men and prisoners continue to be highly and disproportionately affected by HIV. A comprehensive analysis of national epidemiological data is key for prioritizing prevention interventions. Since needle exchange programs, opioid substitutive therapy and antiretroviral treatment are synergistic to prevent HIV among people who use drugs, both OST and access to treatment for people who inject drugs should be significantly further scaled up in the country. Laws, policies and practices should be reviewed and if necessary revised, to allow implementation of healthcare for vulnerable populations. And social contracting of NGOs and communities of peers further expanded, building on programs such as those that the Global Fund has been funding here for many years.

Another challenge faced by the country and by the entire Eastern European and Central Asian region is that of increasing rates of TB-HIV co-infection. Integrated services, early detection and adapted treatment regimens can save lives, prevent more costly MDR TB and avoid disproportionate social burden/impact on communities.

And finally, I would like to call on Kazakhstan, as the primary receiver country of labor migrants in Central Asia, and as a leader in addressing the health needs of migrants in the region, to continue working on bilateral and multi lateral agreements that would allow access to care for HIV and TB of all in need and termination of health-related deportations across the Eastern European and Central Asian region.

Operationalizing the 2016-2019 State program “Densaulyk” will be key to setting the goals, implementing HIV prevention and treatment programs and addressing co-morbidity with TB, MDR-TB and hepatitis.

I truly believe that Kazakhstan is well positioned to achieve the 90-90-90 targets, thanks to political will and successful partnerships. Here I would like to also recognize the work of the UN country team and of bilateral and multilateral partners, including USAID and the Global Fund.

As we enter the Sustainable Development Goals era, the initiative of holding a national conference demonstrates Kazakhstan’s commitment to meet the UNAIDS 2020 targets and the 2030 Sustainable Development Goals. The Sustainable Development Goals are the goals of all people for all people. It is for all of us here today to ensure that the journey is successful and its gains irreversible. This is what this Conference is about.

Thank you very much


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.



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: