February 20, 2018 BMJ
The announcement by UNAIDS that some 21 million people living with HIV are now on treatment uncovers an extraordinary achievement and one of the great global health milestones of this century.
It gives us hope that the other 15 million or so people living with HIV can also soon access antiretroviral treatment, and hope that we can begin to turn around the spiralling rates of HIV infection occurring in Eastern Europe and Central Asia (EECA). Much of the media coverage focused on the intransigence of the government of the Russian Federation to changing its prevention policies around HIV/AIDS, namely via the supply of clean needles and opioid substitution therapy (OST) such as methadone. And with the number of people living with HIV in Russia now officially exceeding 900,000 compared to 250,000 a decade ago, and people using drugs still representing over 40% of newly diagnosed cases, that criticism is fair.
However this focus also obscures the fact that in Eastern Europe and Central Asia, which has been much maligned over the past decade for its slowness in responding to the HIV/AIDS epidemic, we are now beginning to see strong hints that public health initiatives based on scientific evidence are taking on a legitimacy across the region.
On a political level we are seeing increased awareness and leadership, for example the Russian Federation government for the first time adopted a state HIV/AIDS strategy followed by an action plan 2017-2020.
There is growing national dialogue across sectors in Kazakhstan, Kyrgyzstan, and Moldova on the back of national multi-partner AIDS conferences held in both countries in 2016 and 2017. Very significantly, Kazakhstan has now successfully transitioned from external financing from the Global Fund to Fight AIDS, TB and malaria to cover the majority of costs for their AIDS response from domestic sources.
Truly encouraging too has been the decision by the Ukrainian cities of Kiev, Odessa, and Balsi in Moldova and Almaty in Kazakhstan to associate themselves as Fast-Track Cities committed to reaching the 90-90-90 treatment target by 2020, the aim of which is to ensure that, by 2020, at least 90% of people living with HIV know their status, 90% of all people diagnosed with HIV infection will receive sustained antiretroviral therapy, and 90% of all people receiving antiretroviral therapy will have viral suppression.
Finally, and hugely important, we are now seeing significant health system reforms in countries like Ukraine and Kazakhstan that are vital to responding to the AIDS and TB epidemics more effectively and efficiently.
This groundswell of change in the region has been building up for some time now and we are seeing the fruits of it beginning to emerge.
Quite remarkably, nine of the 12 EECA countries now implement national programmes around OST, with Uzbekistan currently considering its uptake. Russia and Turkmenistan are certainly isolated on this front, by not implementing a similar strategy.
Armenia and Belarus have now officially been declared by the WHO as having eliminated the transmission of HIV from mother to child.
Equally encouraging is the increase by 13% in antiretroviral treatment coverage across the region in the last two years. Armenia, Belarus, Kazakhstan, Georgia and Ukraine have already adopted a “Test and Treat” strategy and several more countries in EECA are currently pending approval.
Lastly and perhaps a strong indicator of commitment to respond to the epidemic across the region is the significant headway being made across the region to reduce the high prices of antiretroviral drugs. The positive steps being made in the region on HIV/AIDS provides genuine hope. We will need to build on these growing expectations if we are to successfully overcome the barriers that have come to define the epidemic in the EECA. Despite the progress, new cases and AIDS-related mortality continue to increase as a result of previous neglect and inadequate policies over the past fifteen years. Some 400 000 people do not know their HIV positive status, antiretroviral therapy coverage is still the lowest among any region of the world, and prevention programmes are poorly funded and fail to reach the majority of those vulnerable groups at high risk of contracting HIV, and who also continue to be stigmatizsed, criminalised, and often denied access to services.
The growing signs that we may be seeing perceptible changes in HIV/AIDS responses from governments across the EECA region is cause for hope for those at risk of and living with the disease. Those changes will definitely need to be predicated on respect for the human rights of all people to have access to health care if we are truly to change the trajectory of the HIV epidemic in EECA.