Yearly Archives: 2014

Всемирный день борьбы со СПИДом: инфекции в Туркменистане нет?

Мой первый визит в Туркменистан на прошлой неделе был удивителен во многих отношениях. Я приехал туда, чтобы выступить на международном семинаре «Здравоохранение и дипломатия», в котором участвовали представители министерств здравоохранения и иностранных дел из всех пяти стран Центральной Азии — Казахстана, Кыргызтана, Таджикистана, Туркменистана, Узбекистана, — а также Грузии, Беларуси и Армении.

Ярко запомнилась лекция и последующие вопросы студентов в Институте по гуманитарным вопросам и развитию, где учебная программа в настоящее время преподается исключительно на английском языке. Это было интересная неделя — тепло и гостеприимство народа Туркменистана ощущалось постоянно.

Таинственный и непонятный Туркменистан.

Пронизанный пустынным зимним солнцем в один момент, через мгновение он покрыт снегом и обернут в густой непроницаемый туман.

Стремление страны к модернизации и открытости заметно везде: в ее инфраструктуре, в количестве студентов, обучающихся за границей, в постоянно модернизирующемся образе жизни, в строительстве железной дороги Китай — Турция и трубопроводов, благодаря которым страна станет экспортером природного газа в Европу. Модернизационный проект страны тверд, но в то же время осторожен. А как же иначе? Туркменистан в течение долгого времени был закрыт для внешнего мира; авторитарное руководство правило страной в условиях культа личности.

Туркменистан является одной из пятнадцати (из 27 в мире) стран с высоким бременем туберкулеза с множественной лекарственной устойчивостью (МЛУ-ТБ) в Восточной Европе и Центральной Азии. Офис грамотно и энергично проводимой национальной противотуберкулезной программы расположен на северной окраине города в красивом здании, облицованном белым мрамором и оснащенном самым современным оборудованием. Благодаря грантам Глобального фонда центр в столице Ашхабаде и центры в каждой из пяти провинций страны укомплектованы машинами GeneExpertTM, благодаря которым теперь возможны экспресс-диагностика и определение лекарственной устойчивости в образцах, направляемых в эти референс-центры из учреждений первичной медицинской помощи по всей стране.

По официальным данным, МЛУ-ТБ составляет не менее 15% от новых и 34% от ранее леченных случаев туберкулеза в Туркменистане, что уже вызывает большую тревогу. Но, вероятно, и это не полная картина — это лишь имеющиеся цифры, которые далеки от совершенства: прозрачность данных остается огромной проблемой в Туркменистане.

Все большее число пациентов с диагнозом МЛУ-ТБ получают лечение согласно новым стандартным международным схемам, однако 80% финансирования на них по-прежнему обеспечивается из международных источников. Финансовая устойчивость противодействия эпидемиям ВИЧ/СПИДа и туберкулеза в странах со средним уровнем доходов по-прежнему вызывает озабоченность, поскольку международное финансирование сокращается и способность таких стран как Туркменистан к принятию адекватных мер в кратко- и среднесрочной перспективе будет поставлена под вопрос, если государственное финансирование здравоохранения останется на текущем уровне (2% ВВП).

Как только речь заходит о ВИЧ/СПИДе, перед нами вновь старый загадочный Туркменистан. За последние пятнадцать лет не было зарегистрировано ни одного случая ВИЧ-инфекции. В последних ежегодных отчетах ЮНЭЙДС/ВОЗ невозможно найти статистику из страны. Опять встает вопрос о непрозрачности данных.

Рядом с противотуберкулезным центром в Ашхабаде находится Национальный центр по профилактике ВИЧ/СПИДа. Центр издает буклеты, проводит мероприятия в школах и других учреждениях, организует мероприятия, приуроченные к 1 декабря (на прошлой неделе там было очень оживленно). Ежедневно в центре проводится около ста тестов, подавляющее большинство из которых являются обязательными: предоперационная подготовка, беременные женщины, иностранцы, приезжающие в страну, граждане Туркменистана, собирающиеся покинуть страну для работы, получающие сертификат с подтверждением ВИЧ-отрицательного статуса (Туркменистан входит в число стран, где действуют ограничения на въезд ВИЧ-положительных людей).

Я чувствовал замешательство медицинского персонала, когда в разговорах я ставил под сомнение актуальность этих мер и их соответствие правам человека. В ответ я слышал: да, пора пересмотреть их. Вопрос лишь в том, будет ли это принято на политическом уровне, так как руководство страны пытается балансировать между традициями и современностью.

Несмотря на великолепное диагностическое оборудование, подготовленность к измерению CD4 и вирусной нагрузки, знания и приверженность специалистов, для меня ясно, что страна не готова дать ответ ВИЧ/СПИДу, когда рано или поздно он придет сюда, по мере того как страна становится более открытой и прозрачной.

Туркменистан не готов к борьбе с ВИЧ/СПИДом как минимум по трем причинам:

Во-первых, высокий уровень стигмы легко ощутим на всех уровнях, в том, с какой неловкостью и рядовые медицинские сотрудники, и руководители сферы здравоохранения говорят об «этой проблеме».

Во-вторых, сфера здравоохранения в лице врачей и специалистов отдалена от населения, которое они обслуживают. Практически отсутствующий сектор гражданского общества не участвует в диалоге с профессиональной системой здравоохранения, за единственным заметным исключением в виде уважаемого и активно действующего национального общества Красного Полумесяца. Во встречах с руководством и сотрудниками этой организации я узнал больше о вполне ожидаемых мной реалиях секс-бизнеса и наркопотребления, чем из разговоров со специалистами здравоохранения.

Третья причина заключается в том, что в стране царит ощущение ложной безопасности, поддерживаемое нынешней репрессивной правоохранительной политикой в отношении пограничного контроля и наркопотребления. Эти подходы, вместе с официальной политикой пропаганды здорового образа жизни и массовой профилактики, которые не доходят до наиболее уязвимых групп, в конечном счете приведут к нежелательным последствиям, включая нарушения прав человека. Если все-таки окажется, что началась эпидемия ВИЧ/СПИДа, связанная с волной наркопотребления во второй половине девяностых годов и/или расширением международной торговли и передвижений людей по мере открытия страны, то Туркменистан будет плохо подготовлен к ответным мерам.

Перед дипломатией здравоохранения в Туркменистане, как и во многих странах региона, стоит сложная задача помочь начать конструктивный и постоянный диалог между правительством и органами здравоохранения, который укрепит доверие населения к системе здравоохранения — системе, основанной на научных данных и уважении прав человека, целенаправленно сотрудничающей с представителями гражданского общества и широкой общественностью.

Share and Enjoy

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

Tuberculosis: A Crisis in Eastern Europe and Central Asia That the West Cannot Ignore

Few young doctors in my own country France would currently wish to specialize in phtisiology. Actually, and for over 30 years, the word “phtisiology” had disappeared from the letterheads of lung diseases divisions in hospitals. The focus of pneumology these days is on chronic lung disease and cancer much more than on tuberculosis (TB).

So it came as a surprise to me to hear medical students in Tashkent, Uzbekistan’s capital city, claiming in a unanimous voice that they see “phtisiology” as the most exciting professional future they wish to consider at the end of their studies.

Earlier this year I visited the Republican Scientific and Practical Centre of Phtisiology and Pulmonology in Tashkent as part of a broader mission devoted to HIV/AIDS, TB and Multi- Drug Resistant Tuberculosis (MDR-TB) in the country.

The Institute is a large campus with an adult in-patient facility of 800 beds or so, ambulatory sections, a pediatric section, remarkable laboratory and imaging facilities, and access to most of the latest technologies and structural hospital requirements for TB and MDR-TB. Professor Tillyashaikhov Nigmatovich, the Head of the Institute, can rightly be proud of this institution, the reference point for TB in the country.

On the other hand it is at the same time somewhat unsettling to discover why Uzbekistan has built an institution such as the Centre of Phtisiology and Pulmonology and why young doctors perceive TB care as an attractive and contemporary field of medicine.

Uzbekistan is one of the high burden countries for TB globally and one of the 27 high burden countries for MDR-TB in the world. The number of new MDR-TB cases annually is close to 9000 cases, with 15 per cent of newly diagnosed TB cases being resistant to at least two conventional TB drugs.

And that is the case in almost all countries in Eastern Europe and Central Asia. The World Health Organization’s Euro Bureau reports that fifteen countries in the region are among the high burden countries for MDR-TB in the world, which leaves only very few of the countries out of that list.

Although new technologies are now available to diagnose TB and test for TB drug susceptibility / resistance, the reality is that less than 50 per cent of the estimated new cases of MDR-TB are diagnosed across the region. And only half or less of those patients in need of treatment are actually treated and cured. Those who are not treated remain contagious and they also die. This nothing short of a crisis, one we have to stop neglecting.

One other episode struck me at that hospital in Tashkent. As I entered the room where doctors and students were examining X-Ray and CT scans of patients in the ward, I saw an X-Ray of a diffuse form of pulmonary TB and asked about the physician in charge about the patient’s story. He was a young man in his late twenties who had traveled to Saint Petersburg seeking a job as waiter in one of the growing number of fashionable restaurants in the city. The TB was diagnosed on systematic X-Ray screening and he was immediately sent back to Uzbekistan for treatment. The CT scan from another patient showed a nodular form of pulmonary TB. This was another young man of similar age who was diagnosed upon systematic screening as he was enrolling in a University program in Almaty, Kazakhstan. He also returned shortly after the diagnosis to Tashkent for care.

Migration is a major issue in this region that sees so many students and sees millions of workers move every year in between countries in the region, with a lot of movement to Russia. Migration is a key issue in terms of public health but one that demands asensitive response given it touches on a fragile intersection of the economic, human rights and political arenas in a region where no transborder agreement on the provision of treatment for AIDS and TB currently exist. Tuberculosis is at a crisis point in Eastern Europe and Central Asia and it is a crisis that the West can no longer afford to ignore and it is my hope that the issue begins to receive the attention it deserves at international forums such as the upcoming 45th Union World Conference on Lung Health in Barcelona.

Share and Enjoy

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

Postcard From New York: Taking Control of Drug Policy

I am writing this from New York where I am spending the week advocating for reform of the international drug control régime with the Global Commission on Drug Policy and participating in the media launch of its latest report Taking control: pathways to drug policies that work, at the MoMA today, Tuesday. My esteemed Commission colleagues and I are hoping that this week´s meetings with the UN Secretary General and the UN diplomatic missions to New York will also serve as an unofficial launch pad for the ensuing debate that will take place in the lead in to the UN Special Session of the General Assembly on drugs scheduled for the first half of 2016.

Reflecting on the past three years, we have certainly come a long way: In 2011 the Commission denounced the failure of “the war on drugs” and of drug policies based on a strictly prohibitionist and repressive paradigm. It called on the world to “open the debate” and move from the ineffective and harmful enforcement-led approaches to policies prioritizing public health and safety. The Commission further elaborated on how aggressive repressive policies have fueled the AIDS and hepatitis epidemics among people who inject drugs and their communities, one of the main themes of my advocacy in my role as Envoy on AIDS in Eastern Europe where policies prioritizing repression are having major negative effects on public health.

The new report of the Commission comes with strong recommendations to shift policies and improve the international drug regime. They cover extensive ground and include:

• Re-orienting policy priorities from punitive enforcement to health and social interventions of proven efficiency;
• Ensuring access of opiate-based medications for the treatment of pain to all those in need;
• Stop criminalizing people for drug use and possession; and rely on alternatives to incarceration for non-violent and low level participants in illicit drug markets such as farmers and others involved in the production, transport and sale of drugs;
• Moving to legally regulated markets, to put governments back in control. Move to regulation may begin with cannabis, but should NOT be limited to it, also considering coca leaf and certain psychoactive substances (ATS), as it has recently been done inNew Zealand for ATS;
• Calling on the world leadership to use the opportunity of the 2016 Special Session on drugs of the UN General assembly (UNGASS) to intensify the debate, inform the public opinion, objectively analyze what the current international regime has achieved or — rather — failed to achieve; understand the health, social and human rights-related harms and the waste of public resources that it has generated.

This final point is not merely a rhetorical statement.

It is, I believe, where the tipping point lies: resources that otherwise could have gone to prevent people from using drugs in the first place or to prevent people occasionally using drugs from becoming addicted users, or help addicted people to access treatment and care to protect their health and that of their communities, has otherwise been spent to build more and bigger prisons, create bigger police forces and funded government law and order campaigns.

We who work in the field have known and railed against this unfair scenario for many years but what is different now are the incremental changes we are seeing in government attitudes that I believe are partly being driven by a growing change in attitude in the general community — that drug use ought to be seen as a health issue — not one that guarantees deprivation, sometimes for life.

There is a long way to go but some of the right noises are being made on the road to the much-awaited public debate in 2016. I have no doubt that the Commission´s latest report will help stir that debate and ultimately help re-orient drug policies to towards the noble goals of improving health outcomes, respecting human rights and guaranteeing the well-being of people.

Share and Enjoy

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

Stepping Up the Pace Means Leaving Nobody Behind

Huffington Post – published on July 17th 2014

Ahead of the 20th International AIDS Conference which I will be attending in Melbourne, Australia, next week, I wanted to reflect on the event’s timely focus on those — “key affected” populations — sex workers, men who have sex with men (MSM), people who inject drugs (PWID) transgender people and incarcerated people that are most vulnerable to HIV.

Despite the remarkable progress achieved globally, the prevalence and incidence of HIV among these groups remains far higher than in the general population in almost all regions of the world due to restricted access to information, prevention and treatment.

And while we have long recognized the “concentrated” character of the HIV epidemic in low-prevalence countries outside Sub-Saharan Africa, we have overlooked the epidemic among key affected populations in the “generalized” epidemics in Africa where it is now also emerging. We have failed to address the structural, legal, cultural, societal, economic and political obstacles that prevent vulnerable and underserved groups from accessing services. We have also been unable to coherently address the interlinked epidemics of HIV, HCV and TB/MDR-TB among key populations. It is time when we are gathered in Melbourne to reflect on these failures.

In the early days of the epidemic, Australia was successful in containing epidemics among its key affected populations, particularly among MSM and PWID. Australia did so by recognizing early the role of community in delivering information and outreach services, by breaking down some of the taboos in the way society addressed the disease and by implementing a rapid expansion of harm reduction services.

It is only by building broad partnerships between the health sector, other relevant public sectors and the communities themselves, that the unmanaged structural and societal challenges posed by the HIV, HCV and TB epidemics in key populations, can be addressed. And building such partnerships is precisely what — for 20 years now what the International AIDS Conferences have been aiming for — bringing together scientists, health professionals, affected people, civil society, the private and philanthropic sectors and government decision makers within and outside the health sector — the unique mix that has allowed so much progress in the fight against HIV/AIDS in the last 15 years.

This is why I will look forward next week to events such as the launch with my colleague and IAS President-Elect Dr Chris Beyrer, of the International AIDS Society White Paper on “Maximizing the benefits of antiretroviral therapy for key populations,” some further discussions of the consolidated WHO guidelines for key affected populations released last week, the pre-conference MSM event, the launch of the special Lancet issue on sex work, the many sessions on HIV and drug use, including the Global Commission on Drug policy event featuring Sir Richard Branson and the Honorable Michael Kirby.

I hope to take away many lessons learned on the issue of key affected populations from the Melbourne conference — lessons I can apply in my work on the epidemic in the Eastern European and Central Asian region where I now focus much of my attention.

The stakes are high: The absence of a much strengthened response to HIV among key affected populations, will mean AIDS will remain a major cause of avoidable suffering, illness and premature deaths in the region and worldwide.

Share and Enjoy

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

A Life of Dignity for All

Speech given on the opening day of the 4th Conference on HIV/AIDS in Eastern Europe and Central Asia.

As we open this conference, I would like to salute the physicians, scientists, healthcare and social workers, representatives of civil society and of the community who tirelessly work in the region to fight AIDS, TB and MDR-TB. A number of them are here today; others have decided not to come. Everywhere I travel in the region, I meet extraordinary, dedicated people working in hugely challenging contexts.

Despite the many challenges that we face, I have always had strong confidence in what the people of this region can achieve by focusing together on our shared goal of ending these epidemics.

Since I attended the first of these conferences in 2006, the numbers of new HIV infections, new AIDS cases and AIDS-related deaths have continued to increase in this region. Of the 130,000 new infections reported in the WHO European region in 2012, three-quarters occurred in countries in the East. While reported AIDS cases declined by 54 percent in Western Europe, the number of people newly diagnosed with AIDS increased by 113 percent in the East between 2006 and 2012. [According to UNAIDS and WHO, the numbers of estimated deaths were 91,000 in Eastern Europe and central Asia compared to 7,600 in Western and central Europe in 2012].

These figures are in sharp contrast with the decreasing numbers of new infections and AIDS-related deaths in other regions and globally. Coverage of antiretroviral treatment in this region also remains well below the global level of 60 percent.

The epidemic pattern is also evolving, with heterosexual infections now representing a significant proportion of newly diagnosed cases in addition to the “concentrated” epidemics, particularly among people who inject drugs and gay men that continue to expand, undefeated, and inadequately addressed.

Significant investments have been made in this region, but very little of it has been for effective prevention. The epidemic remains largely uncontrolled. This must be of major concern to all of us, and to anyone who cares about global public health. We need a common understanding of why this is the case and what our strategies should be, so that we can make more substantial progress.

I expect that this conference will focus clearly on this question. “Business as usual” is not enough, and we need a frank and solution-oriented debate on what needs to change. I am not talking about a polarizing or simplistic debate, such as whether treatment or prevention is the right approach. I mean a real debate about both the evidence, and its implications.

For example, there is strong evidence that antiretroviral treatment decreases transmissibility of HIV. But the implication is not that we should abandon prevention in general, and harm reduction efforts among vulnerable groups and people in vulnerable settings, such as prisons, in particular. I strongly believe that an open debate based on evidence will show that, of course, we must do both these things together.

The same is true for harm reduction. Harm reduction for people who use drugs is a set of interventions, including OST and NSP, that is recommended by WHO, UNAIDS and UNODC, and for which there is comprehensive and compelling evidence that, together with ART: it averts HIV infections, reduces HIV transmission, decreases mortality, reduces drug dependency, improves quality of life and reduces crime and public disorder.A health-based approach to drug policies starts with the implementation and scaling up of harm reduction. If there is any evidence to the contrary, let it be debated, in the spirit of scientific enquiry, and the conflicts resolved, so that we can finally move forward with one voice and a common strategy for action.

In this context, as a scientist, physician and in my role as UN Envoy, I must clearly say that the recent statements made on the lack of effectiveness of OST in Crimea and the decision by the Crimean authorities to discontinue these programs, are to me unjustified by the evidence, inconsistent with human rights standards, and a source of unnecessary suffering.

I want to take this opportunity to call on the Russian and regional medical and scientific community to engage in the open and evidence-based debate on preventing HIV/AIDS that for too long has not been a real confrontation between evidence and evidence, but an issue where science has taken a back seat to politics and ideology. This conference provides a critical venue for such debates, but more are likely to be needed, and the UN is ready to support the region in organizing them in the coming weeks or months.

We cannot avoid this debate any longer. Too many lives have been lost to HIV, TB and hepatitis in Eastern Europe and Central Asia. Too many people have become resigned to this region not making progress, because of ideological differences, and to the grim inevitability of even more disease and death. It is past time to change this paradigm. But whether we do so ultimately depends on us. It is within our power alone to make different choices than have been made in the past, and to shape a more hopeful future.

In the words of the Secretary General: Let us “continue to listen to and involve the people… We must continue to build a future of justice and hope, and a life of dignity for all”.

Share and Enjoy

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