Michel Kazatchkine

I was in Brussels earlier this week delivering a speech at the European AIDS Conference and coming on top of the visit to Romania last week, it’s given me some valuable time to reflect on the HIV/AIDS epidemic in the region a year or so into the job as the UN Special Envoy for the region.

I tried to get across five key points in Wednesday’s speech.

In the first instance I wanted to emphasize that the EECA is still home to the fastest growing HIV/AIDS epidemic in the world and that it has been and still is to a large degree primarily linked with injecting drug use.

Over 35 percent of case reports in the EECA are associated with drug use. The prevalence rates among PWID ranges from 25 percent in Ukraine to over 55 percent in Estonia. The countries with the highest levels of reported diagnosed cases among PWID are Ukraine, the Russian Federation and Kazakhstan.

This is also a region where the risks of acquiring MDR-TB are among the highest in the world: 20 percent of new cases and 45 percent of presenting re-treatment cases in the Russian Federation are presenting with resistant. And the prevalence of hepatitis C among people who inject drugs is also particularly high, between 60 and 90 percent.

So, in this region, we cannot just speak of the twin epidemics of HIV and drug use, but rather the quartet of HIV, drug use, TB and hepatitis. We cannot address one without also addressing the other three.

It is alarming that there are nearly 100 000 AIDS deaths each year in the region, a figure that has increased by more than 25 per cent since 2005, compared to stable or decreasing levels in Western Europe and globally.

Equally concerning is that treatment coverage remains unacceptably low, here shown as 23 percent in 2011 and estimated to be now at around 35 percent based on 2010 WHO guidelines, a figure that would drop by half, based on the 2013 guidelines.

Secondly, I wanted to demonstrate that the shape of the regional epidemic is beginning to change. It appears that we will be looking a substantially changed epidemic in the coming years.

In the last five years, there has been a marked increase in reported cases among men who have sex with men. Under-reporting of risk status is however likely in this region where gay men remain highly stigmatized: case reports of “no known exposure group” are consistently high, reminding us that data are only as robust as the surveillance systems and the social contexts that produce them.

Most countries in the region do not collate risk factor data concerning sex workers, but HIV prevalence among this group is estimated at between 2 percent and 6 percent.

What we see then is a complex picture of intersecting epidemics among drug users and their non-injecting sexual partners; among MSM, a substantial proportion of whom also have sex with women that is increasingly fueled by amphetamine and methamphetamines and hampered by poor prevention, including lack of access to NSE and inconsistent condom availability and use.

Heterosexual transmission is increasing and now accounts for 30 percent of reported cases. There is potential for the epidemic to generalize beyond the key populations of PWID, MSM and sex workers.

Heterosexual transmission now accounts for around 30 percent of reported cases in Eastern Europe, largely among women with high-risk sex partners.

Thirdly, the role of harm reduction remains pivotal in overcoming the epidemic in the region.

Access to prevention for PWID and to harm reduction remains unacceptably, scandalously low. On average, only 2 percent or so of PWID in the region have access to Opioid Substitution Therapy (OST). A disproportionally low number of PWID in need of ART actually access it, something that is true both in this region but also globally.

All this despite the evidence showing that high – but quite achievable – coverage levels of NSE can result in large decreases in HIV incidence and prevalence in settings with high prevalence among PWID if it is effectively associated with OST and with significant access to antiretroviral treatment.

My fourth point was why, in the face of a looming human tragedy but at the same time armed with proven scientific evidence of what we know works, why don’t we just do it?

Very few services are tailored to the particular needs of key affected populations, in large part because of widespread political and moral opposition to drug use, sex work and homosexuality.

In most countries of the region, inadequate legal and human rights frameworks, brutal law enforcement and policing practices, and a sheer lack of political will to implement evidence-based HIV prevention, are all seriously hindering progress. Let’s not forget either that undermining access to interventions, even where they are available, increases risk.

An overwhelming proportion of incarceration in the region, between 40 and 70 percent, is for drug offences, such as use and possession. And because prisons themselves constitute a risk environment for the acquisition of HIV, we see a vicious circle of frequently minor drug use, incarceration and HIV infection.

The response is grievously underfunded. Funding for prevention is particularly vulnerable, having been overwhelmingly dependent on international donors so far.

Lastly, the future.

While this is a region that faces many challenges, I have always had strong confidence in what the people of this region can achieve.

We must continue to work at the political level in all these respects by the long and steady process of advocacy and relationship-building. We need to maintain the international leverage and dialogue, wherever possible, by pointing to successes among PWID in other parts of the world and by using entry points such as the various global fora on drug policy of which the region is a part. We must do everything we can to ensure that our language and our actions within the region and outside it do not contribute to further isolating the region and worsening its epidemic.

It is vital that we remain positive, even in the face of daunting challenges. This means recognizing progress where it is happening, having faith in the wonderful people of the region, and remaining confident that, if they do what needs to be done, their fight against AIDS can ultimately be won.

Last week I went on a short visit to Bucharest to understand the origin of the recent outbreak of HIV among people who use drugs in the city. I am disheartened to say that the fears of many of us working in global health held about the potential negative impact on the HIV/AIDS epidemic caused by the withdrawal of the Global Fund to Fight AIDS, Tuberculosis and Malaria from a number of countries, including Romania, have been realized.

Romania’s “middle income” country status has ruled it ineligible to receive Global Fund money and since 2011, the gap in service provision, especially to people who inject drugs (PWID) cannot be met by a civil society sector that receives no State funding whatsoever.

After meetings with the Ministry of Health and the country’s National anti-Drug Agency I spent time one evening with an NGO called ARAS, as they conducted their outreach service in the area in and around the North Station of Bucharest.

On a cold and windy evening at around 10 pm, ARAS parked its bus across the street from the station. Two small buses (actually, more of a van) were bought five years ago on Global Fund money. One remains parked in the courtyard of a hospital, since no funding is available for the repairs that it needs. The other still operates and undertakes outreach five to six evenings a week.

Within minutes, people rushed from a neighboring park and seemingly from nowhere and over the next two hours queued for clean syringes provided by a doctor and a social worker. Each night the ARAS bus supplies between 5000-15 000 needles; the needles are of a type preferred by injectors as opposed to an inferior cheaper type purchased last year by the government which most users subsequently returned unused.

Extreme poverty is exacting human devastation upon a group of people who are injecting legal highs up, many up to 10 times per day. It is estimated that some 50 per cent of injectors use legal highs, originating, from what users told me, from China, with
the remaining half use poor quality heroin.

I saw two boys of fifteen years of age, one of whom have been living on the street since he was born; a wandering/drifting pregnant woman, who was “high” that night; a man nearing his 40s who was raised in a children’s institution in the years of the Ceausescu regime, saw his mother only once in his entire life and subsequently kicked out of the institution for using glue. He’d been living on the streets for 25 years.

Many clients also asked for condoms but ARAS no longer has the funds to provide them as they used to do up until two years ago.

These tragic Bucharest stories are being or will be repeated in other countries where the Global Fund is leaving and it is no coincidence that increases in HIV amongst PWID have begun to surface in Romania. The struggles facing NGOs trying their best to contain a both fragile and volatile situation there under extremely trying circumstances are being exacerbated at the same time by an explosion in the supply and use of legal highs which has in turn fuelled injecting and so increased the risk of needle sharing.

And the evidence is already in.

At the end of 2012 the Anti Drug Agency reported a 20 fold increase in the number of new infections diagnosed amongst people who inject drugs. Around the same time a separate survey of 480 people who inject drugs was published indicating an astonishingly high and sudden prevalence of HIV of 53 percent.

Eastern Europe nations and other economies in transition are facing dramatic HIV/AIDS emergencies amongst PWID. Decision makers within those countries remain blind to this reality.

After my meetings with government officials I’m of the view that the HIV/AIDS scenario in Romania and countries that find themselves in a similar funding situation will not change in the coming months or indeed, years.

And it is the people in the region like those I met on the streets of Bucharest who are ultimately paying a high human price for such inaction and neglect.

I was in London this week attending a meeting on the impact of treatment as prevention (TasP) on Key Affected Populations (KAPS), a gathering of minds, I think, that has the potential to be a pivotal moment in the way we decide to respond to HIV/AIDS in those global “hotspots” where sex workers, men who have sex with men (MSM), people who inject drugs (PWID) and transgender people are en masse being denied access to treatment, care and prevention. The end result is that HIV infection rates amongst these groups is in some countries clearly running at rates that we could consider out of control when compared to the rest of the population. As the Millennium Development Goals come to fruition in 2015 we are being faced with a terrible and daunting reality: that these key affected populations are in fact being left behind.

The meeting this week in London forms part of an International AIDS Society led initiative to identify strategies that will maximize the treatment and prevention benefits of antiretroviral therapy (ART) for Key Affected Populations. The meeting in London is a joint consultation of the IAS Advisory Groups on Treatment as Prevention and Key Affected Populations along with other key stakeholders and the hope is that the discussions will kick start the development of a finalized “White Paper” containing recommendations to international organizations and the AIDS community to be presented at the AIDS 2014 conference in Melbourne, Australia next July.

I believe the starting point that has brought me and my colleagues to these discussions is the powerful evidence provided by the HPTN 052 trial of 2011 demonstrating that treatment is preventative, that is, that, by decreasing viral load it decreases strongly the “ability” of the treated HIV-positive person to transmit.

Recent cohort studies further suggest that increasing antiretroviral treatment coverage is important to decrease the risk of HIV acquisition at the population level. These results have mobilized the global HIV/AIDS community to accelerate the scale-up of antiretroviral therapy (ART) as both a treatment and a prevention strategy.

I believe that currently the evidence of an effect at the population level is mostly conceptual and based on modelling. The strongest “real world” evidence we can presently refer to is the decrease in incidence in the PWID population in Vancouver, Canada. There is also some suggestive evidence that TasP has been successful in Kwazulu-Natal, South Africa.

Against this backdrop however, we do need to be cognisant of one important fact: there is no precedent for a disease of which the transmission at the population level could be stopped by generalized access to treatment.

The fact that treatment is preventative does not mean that it will and should replace prevention. Prevention interventions remains essential. Treatment is preventative but cannot be the only strategy for prevention. We need to be wary, I believe, of the concept being misinterpreted or even being “hijacked” if you will and avoid playing off one form of prevention against another (e.g. “if treatment is prevention why should we embark into difficult to implement prevention programs such as harm reduction”).

The way forward is not an easy one precisely because the issue is one where science, policy and human rights all collide. How we manage that intersect will ultimately determine what kind of solutions will be thrown up. And while we should always acknowledge that the response needs to be thought through and measured (this meeting is a case in point) we’d also do well to acknowledge that the situation facing key affected populations is of the utmost urgency.

For MSM, the fact is that paradoxically the epidemic in this population continues to expand in countries with generalized access to treatment. For the PWID community , there is no doubt that treating as many people as possible is the strategy to move ahead with but in no way should that impact negatively on the need for harm reduction and other proven prevention strategies.. For sex workers, yes, treating them for their own medical needs is absolutely necessary but that does not translate into decreasing their risk at a population level which is mainly dependent on the frequency of infected transmitters among their clients.

I look forward to participating in similar conversations like the one we have had in London this week, elsewhere over the coming year.

This is an important communication and I am pleased and honored to be part of it. Thank you for the invitation.

The Alliance in Ukraine is reporting today that for the first time in ten years, there has been a decrease in the number of new HIV infections in Ukraine (-2%), with  a significant reduction in the number of new infections registered among people who use drugs.

This is in contrast with the trends in the region where the number of new HIV infections, the number of AIDS cases and mortality from AIDS have been increasing dramatically since the early 2000’s.

The decrease in incidence reported today in Ukraine among people who use drugs is of significance.

Forty to sixty percent of the HIV infections in the region are occurring in people who use drugs. People who use drugs are socially marginalized, discriminated, criminalized, have poor access to services and to treatment, worldwide and particularly in the EECA, an important theme of this conference.

The results released today by the Alliance have not been confirmed yet, to my knowledge, by the Ukrainian authorities, but I can say they are acknowledged by the international community. Convergent epidemiological evidence such as the fact that newly diagnosed people are of older and with an longer history of infection before diagnosis actually strengthens the robustness of these results.

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As I see these results, I would like to make three points:

1. My first point is that there are lessons to be learned, particularly for the region, in reflecting on the combined factors that have allowed here for success:

Among those factors: first, a strong advocacy, remarkably conducted by the civil society, based on epidemiological evidence, based on human rights, sensitizing decision makers and the public opinion on the human impact of the disease and the poor access to services of people in need.

Second, resources. For obvious reasons, I am pleased and proud to acknowledge the investments that the Global Fund has made in the fight against HIV/AIDS and TB in Ukraine for now ten years.

Third, political commitment. With ups and downs, there is an overall recognition by the government of the threats of the epidemic  and of the need to act. I have clearly perceived that in my meeting with Prime Minister Azarov last year and when meeting recently with the minister of Health, Mme Bogaterova.

Fourth, and most importantly, this is the result of a joint effort between the public sector and the non-governmental sector. NGOs such as the Alliance or the network of people living with HIV in Ukraine have over the years and under the pressure of the crisis, moved from advocacy to acquiring the technical knowledge and to implementation of programs. They have been an example of efficiency and accountability in delivering on the Global Fund grants.

And last, programs are beginning, but only beginning, to be at scale, allowing for impact. This is far from being the case in the region.

2. My second point is that success is not linked to treatment alone or to prevention alone, but to the combination of the two. Expanding access to testing and to antiretroviral treatment but, at the same time, expanding significantly on access to peer education and support, needle exchange programs, and opioid substitution therapy.

A lesson for many countries in the region that hardly invest in prevention.

3. My third and last point is that, as we celebrate these results, we should also realize how fragile the situation is.

Fragile when it comes to funding in difficult time s in a region where 90 % or so of the financing of AIDS programs, particularly preventative programs is relying on international funding.

Fragile when it comes to acknowledgment of the problem by the public opinion and to  political commitment.

Fragile because discriminatory laws and policies are still there preventing prevention work and access to services of the most vulnerable people.

Fragile because of the risk of spread of the epidemic beyond the key populations at high risk, as we are now clearly seeing it happen in the Russian Federation.

Fragile also because AIDS is not the only threat in the region and when it comes to the most vulnerable such as people who use drugs in the region: TB and multi resistant TB which is under-diagnosed and far from being treated at the needed scale is a huge threat, and so is hepatitis C (over two thirds of people who inject drugs in Ukraine are infected with hepatitis C).

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We know what it is that we should do. If we do it and expand further on our efforts, the battle can be won.

Congratulations to the Alliance and to everyone who is fighting AIDS, TB and hepatitis in Ukraine.

Welcome, thank you, panelists, audience.
I believe this to be a very important session, and to some extent, a new debate for a harm reduction conference.

No doubt: we need to scale up every intervention that is part of the package of “harm reduction”, and in our region, that expansion has to be at a scale that is not comparable with the efforts that are currently going on (even in the “best” cases).

But we also need to advocate, debate, provide evidence, put pressure for changes in drug policies, everywhere and, in particular in this region.

Discriminatory drug laws and policies and hostile law enforcement policies have been fueling the HIV, hepatitis and TB epidemics in the region for twenty years. They have led to millions of unnecessary incarcerations,that often, have placed the health of people who use drugs at even higher risk.

Here, it is not only about lobbying ministers of health and public health programs. It is about opening and supporting a public debate on drug policy reform. It is about opening the debate with the leadership, the government, the parliament, the drug authorities, the press and the public opinion.

In the region, we know that political leaders will invariably respond with calls for continuing and amplifying the fight against the ‘scourge’ of drugs. Actually, it is hard to think of another area of social policy where such a clear lack of progress over the years and all over the world, maintains such widespread political support.

We need to ask ourselves why this is so and I expect today’s session to discuss it.

The main political attraction of “war on drugs” and “be tough on drugs” rhetoric, and of the policies that follow, is that they allow the government to look strong and active on a problem that the public opinion cares about.

The political alternative – that of questioning the ‘tough on drugs’ orthodoxy, of promoting policies that are more tolerant of drug use, or that reduce enforcement or punishment – represents a high risk strategy for any politician.

A political leader considering alternative approaches will be criticized for taking great risks with a ‘leap into the unknown’

In fact, there are lessons we have learnt regarding the impact of more tolerant policies on the level and nature of drug use and markets. Broadly, in countries and states where laws or enforcement practices have been liberalized, there seems to have been a minimal impact on overall levels of use, and positive impacts on drug-related health and social problems, and costs to the state.

But we should also acknowledge that these political dynamics are underpinned by some real conceptual and intellectual problems regarding the case for drug policy reform. One of them is how to address the contention – often stated, and currently the position of the UNODC – that, although enforcement based policies have not reduced the scale of the drug problem, they have at least contained what otherwise would be an ‘epidemic’ or ‘flood’ of increased drug markets and use, with all the related problems increasing accordingly.

The other problem facing the reform-minded policy maker is that the issue is so complex, that trying to replace a simple and seductive political message with one that acknowledges complexity, and recognizes that the government cannot in fact ‘solve’ the drug problem entirely, is a high-risk political strategy. Most policy-makers who have tried this approach, have been criticized as giving in to the drug traffickers and cartels, or for not being tough enough in the fight.

Therefore, considering these political dynamics, it is perhaps not so surprising that so few policy makers have openly questioned the status quo, or pushed for reform.

However, these political realities seem to be changing in some parts of the world, including in the Americas. The harm from drug and from drug policies is different however on the American continent from what it is in Europe and in our region.

So, how to open the debate and the political dialogue in the geopolitical, cultural, social, religious, context of the region? Where are the opportunities ?

I look forward very much to our discussion