Category Archives: Articles

The Shifting Diplomacy around Migration, HIV/AIDS and Tuberculosis in Central Asia

March 23, 2017, The Huffington Post 

Central Asia and the Russian Federation face a major intra-regional migration flow, home, as it is, to one of the largest labor migration corridors in the world, with hundreds of thousands of migrant workers moving from Central Asian countries to the Russian Federation and to Kazakhstan each year.[1] This migration flow of further concern given migrants’ increased vulnerability and poor access to HIV and TB prevention and care in host countries.

The Eastern Europe and Central Asia region is home to the fastest growing HIV epidemic in the world. Over the last five years, the number of new HIV diagnoses has more than doubled in Eastern Europe. In Russia alone, it is estimated that over a million people are living with HIV compared to around 250 000 a decade ago.[2] Nine Eastern European and Central Asian countries are also among WHO`s global list of Multidrug Resistant Tuberculosis (MDR-TB) high burden countries.[3]

In Kyrgyzstan, Tajikistan, Uzbekistan and also Armenia, substantial parts of the population are migrating to neighboring Kazakhstan and the Russian Federation for work purposes. Migration is clearly recognized as a risk factor for TB, MDR-TB[4] and HIV[5]. High mobility and seasonal migration patterns associated with poor living and working conditions, are contributing factors towards increasing migrants’ vulnerability and exposure to HIV and TB in the host country where they often experience significant barriers in accessing healthcare services.

For instance, over sixty percent of people who have been detected as HIV-positive in the last three years in Armenia, have, at one point, migrated to the Russian Federation for work. Non-governmental organizations in Kyrgyzstan and Tajikistan report evidence of a growing number of HIV infections among spouses of men who return from labor migration.

A recent report from the Central Tuberculosis Research Institute of the Russian Academy of Medical Sciences indicated that the proportion of TB and MDR-TB among migrants is 2.5 higher than in the general population.[6] Reduced access to health services and the fear of deportation if diagnosed with TB and HIV means that many diagnoses are being hidden or delayed.

Today, only a minority of HIV-positive migrants in the Russian Federation is accessing antiretroviral therapy (ART), while about 10 per cent of migrants are being tested for HIV and TB.[7] Despite pre-departure screening practices in the region for those requesting work authorization, many labor migrants are entering Kazakhstan and the Russian Federation without proper documentation in as much as there are visa-free travel agreements between countries. Scarce data on migrants’ health is an additional barrier to understanding how this group is affected by these diseases.

Notwithstanding, despite the barriers, there are also signs of cautious progress.

In the last few years, Kazakhstan has changed its policies, now ensuring access to full TB treatment for migrants irrespective of their legal status – and to MDR-TB treatment until the point that patients become sputum-negative. Although these clearly are progressive policies, many problems remain, including the conditions under which patients returning to their country of origin have to continue treatment to the end and the complexities of the patient referral system.

Under the auspices of the Kazakh Ministry of Health, with the support of the Global Fund to Fight AIDS, Tuberculosis and Malaria, bilateral agreements are being negotiated between Kazakhstan-Kyrgyzstan and Kazakhstan-Tajikistan on the access of migrant workers to TB care and treatment.

There is also progress in the Russian Federation around policies of both screening and requiring health insurance for migrants prior to entry on its territory. These policies allow for access to care of documented migrants at the site where they have registered for work. The downside to this measure however, is that many people are, however, emigrating for short period of times outside the registration system.

To reverse the rising HIV and MDR TB epidemics, the region will need to move forward on a number of fronts:

Firstly, there must be a halt to the deportation of migrants based on health status in the countries where it is still in practice. Currently, in too many instances in the region, a diagnosis of TB, MDR-TB or HIV means deportation, a practice that is widely known to be ineffective to public health, violate human rights, and may lead to drug resistant forms of infection.

Secondly, the region needs to ensure migrants’ have access to HIV services, including ART, and to full course TB/MDR-TB treatment in the host country. It will be vital that a funding mechanism be established to cover HIV and TB treatment costs for migrants who choose to stay in the host country to be treated.

Lastly, national and regional responses around infectious diseases like HIV and TB urgently need to be reviewed to include migrants as a vulnerable group.

It is no exaggeration to say that unless we see collective movement around the above fronts, all the ingredients of a brewing regional public health crisis will continue to bubble away.

—————————————

[1] IOM (2015) Mapping on Irregular Migration in Central Asia 2014, Astana, 2015.

[2] Unaids (2016) Prevention Gap Report.

[3] WHO (2016) Global Tuberculosis Report 2015.

[4] Dara M et al. (2012). Minimum package for cross-border TB control and care in the WHO European region: a Wolfheze consensus statement. The European Respiratory Journal, 40(5):1081-90. Published online 2012 May 31. Available at:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3485571/

[5] Unaids (2014) The Gap Report.

[6]Demikhova O, Nechaeva O (2016) Access of Migrant to Services on Early Detection, Diagnosis, Prevention and Treatment of Tuberculosis and Tuberculosis Associated with HIV Infection, Moscow, (In Russian : Вопросы доступа мигрантов к мероприятиям по раннему выявлению, диагностике, профилактике и лечению туберкулеза и туберкулеза, сочетанного с ВИЧ-инфекцией в странах СНГ) Available at : http://mednet.ru/images/stories/files/CMT/migranty.pdf

[7] Demikhova O, Nechaeva O (2016) Access of Migrant to Services on Early Detection, Diagnosis, Prevention and Treatment of Tuberculosis and Tuberculosis Associated with HIV Infection, Moscow, (In Russian : Вопросы доступа мигрантов к мероприятиям по раннему выявлению, диагностике, профилактике и лечению туберкулеза и туберкулеза, сочетанного с ВИЧ-инфекцией в странах СНГ) Available at : http://mednet.ru/images/stories/files/CMT/migranty.pdf

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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.

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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

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CHRONICLE OF AN (AVOIDABLE) TRAGEDY FORETOLD

March 21, 2016, BRITISH MEDICAL JOURNAL (BMJ)

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

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

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

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

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

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

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

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

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

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

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

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

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