The changing nature of the Eastern European and Central Asian HIV epidemics

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.