HIV epidemic in Eastern Europe and Central Asia
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Latest UNAIDS estimates of 2.4 million people living with HIV in Europe suggest that the reported cases represent just over half of all people living with HIV in Europe. Of these an estimated 1.5 million are in Eastern Europe and central Asia. This represents a 2.5 fold increase from the 410 000 cases in 2001 and more than 10 times the number in 1991. This presentation at AIDS 2012, the XIX International AIDS Conference in Washington, DC, on 23 July 2012, discusses the reasons behind this increase and what we need to do to halt it.
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HIV epidemic in Eastern Europe and Central Asia
- 1. Why is the HIV epidemic in Eastern Europe and Central Asia the fastest growing in the world and what do we need to do to halt it? XIX International AIDS Conference Regional Session on Eastern Europe and Central Asia Martin C. Donoghoe on behalf of the XIX International AIDS Conference Regional Working Group for Eastern Europe and Central Asia
- 2. HIV epidemic in Europe still not under control Cumulative number of diagnosed cases (in thousands), WHO European Region, 1986–2010 1 600 1 418 absolute numbers, thousands 1 400 1 200 1 000 800 600 400 200 0 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 Sources: ECDC/WHO. HIV/AIDS surveillance in Europe 2010. Stockholm: ECDC; 2011. 2010 UNGASS country progress reports for the Russian Federation and Ukraine.
- 3. Low access to HIV testing and counselling among populations most at risk in eastern Europe and central Asia - respondents who reported receiving an HIV test and learning the results in the preceding 12 months, selected countries 2005, 2007 and 2009 0% 10 20 30 40 50 60% People who inject drugs (11 countries in 2005, 22 countries in 2007, 29 countries in 2009) Sex workers (9 countries in 2005, 20 countries in 2007, 21 countries in 2009) Men who have sex with men (8 countries in 2005, 24 countries in 2007, 29 countries in 2009) 2005 2007 2009 Source: UNAIDS/WHO. HIV/AIDS in Europe and central Asia. Progress Report 2011
- 4. People living with HIV: fast growing numbers in eastern Europe and central Asia Estimated number of people living with HIV in Europe, 1990-2011 3.0 2.8 2.6 Europe (total estimated) Estimated number of people living with HIV (Millions) 2.4 2.4 million [2.1 million – 2.7 million] 2.2 2.0 Eastern Europe and 1.8 central Asia 1.6 1.5 million [1.3 million – 1.8 million] 1.4 1.2 Western and central 1.0 Europe 860 000 0.8 [780 000 – 960 000] 0.6 0.4 0.2 0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Source: UNAIDS. Together we will end AIDS. 2012
- 5. Estimated ART coverage in eastern Europe and central Asia among the worst globally (2011) North Africa and the Middle East 13% ART also reduces risk of HIV transmission – Donnell D et al. Lancet, 2010, 375(9731):2092–2098 Eastern Europe and Central Asia 23% Eastern, Southern and South-East Asia 44% Carribean 67% Latin America 70% Sub-Saharan Africa 56% Global coverage 54% 0% 10% 20% 30% 40% 50% 60% 70% 80% Source: UNAIDS. Together we will end AIDS. 2012
- 6. Proportion of people who inject drugs receiving ART in low- and middle-income countries in the WHO European Region 2002 2005 2006 2010 2011* Number of reporting countries among 17 21 23 19 19 26 low- and middle income countries Diagnosed people infected with HIV 46 000 221 800 250 000 124 200 124 500 through injecting drug use (71%) (77%) (77%) (59%) (59%) (% among cumulative diagnosed HIV infections with a known transmission mode) People infected with HIV through 130 4700 5300 7700 9000 injecting drug use receiving ART (20%) (26%) (26%) (21%) (21%) (% among all people receiving ART with a known transmission mode) * Preliminary ART data and 2010 HIV surveillance (case reporting) data Sources: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2010. ECDC, Stockholm, 2011 EuroHIV. HIV/AIDS Surveillance in Europe. End-year report 2006. Saint-Maurice, Institut de veille sanitaire, 2006 WHO/Europe. Annual surveys on HIV/AIDS and HAART 2002-2006 and WHO/UNAIDS/UNICEF monitoring and reporting on the Health Sector Response to HIV/AIDS, 2010-2012
- 7. Infection increasing faster than treatment Cumulative number of reported cases and deaths (in thousands), WHO European Region, 1986–2010 1 600 1 418 absolute numbers, thousands HIV 1 400 AIDS Deaths among AIDS cases 1 200 People on ART 1 000 800 559 600 397 400 210 200 0 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 Sources: ECDC/WHO. HIV/AIDS surveillance in Europe 2010. 2010 UNGASS country progress reports for the Russian Federation and Ukraine. WHO/UNAIDS/UNICEF monitoring and reporting on the Health Sector response to HIV/AIDS.
- 8. HIV infection 1984–2010: WHO European Region 700000 600000 cumulative totals HIV diagnoses by year 500000 Number of cases 400000 300000 200000 100000 0 Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2010 8
- 9. WHO European Region: geographical areas East West Centre Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2010 9
- 10. HIV infections diagnosed 2010 in WHO European Region: geographic area WHO Characteristics of cases European West* Centre* East Region* Number of HIV cases 118 335 25 659 2 478 90 198 Rate per 100 000 population 13.7 6.6 1.3 31.7 Percentage of cases Age 15–24 years** 11.6% 10.0% 17% 13% Female 38% 27% 19% 42% Transmission mode** Heterosexual 43% 24%*** 24% 48% Men who have sex with men 20% 39% 29% 0.7% Injecting drug use 23% 4% 4% 43% Unknown 13% 16% 41% 7% *No data from the following countries: Austria, Liechtenstein, Monaco. ** Countries with no data on age or transmission mode excluded. *** Excludes individuals originating from countries with generalised epidemics. Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2010 10
- 11. HIV infections diagnosed 2010: WHO European Region cases per 100 000 pop Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2010 11
- 12. HIV infection 2004–10:WHO European Region three geographical areas 20 15 Cases per 100 000 population West West adjusted 10 EU/EEA EU/EEA adjusted Centre East 5 0 2004 2005 2006 2007 2008 2009 2010 Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2010 Data not consistently reported or not available from: Austria, Monaco, Russian Federation.
- 13. HIV infections diagnosed 2010 WHO European Region: transmission mode and geographical area Men who have sex with men Injecting drug use Heterosexual Other and unknown 100% 13% 17% 90% 80% 42% 70% 40% 45% 60% 50% 24% 40% 4% 4% 30% 41% 20% 39% 29% 10% 0% 1% West Centre East Sources: ECDC/WHO. HIV/AIDS surveillance in Europe 2010. Russian Federation Ministry of Health and Social Development
- 14. HIV infections 2004–10: transmission groups in WHO European Region - East 14000 12000 10000 Number of cases 8000 IDU Heterosexual Men who have sex with men 6000 Mother-to-child-transmission Other/undetermined 4000 2000 0 2004 2005 2006 2007 2008 2009 2010 Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2010 Data not consistently reported or not available from: Estonia, Russian Federation. 14
- 15. AIDS diagnoses 2004–10: WHO European Region three geographic areas and EU/EEA 2.5 2 Cases per 100 000 population 1.5 West* EU/EEA Centre East** 1 0.5 0 2004 2005 2006 2007 2008 2009 2010 Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2010 Data not consistently reported or not available from: West: Andorra, Denmark, Monaco, Sweden; Centre: Turkey; East: Russian Federation, Ukraine. 15
- 16. Vulnerability and marginalisation Key laws supporting or blocking universal access in countries in the east of the region, July 2010 Countries Protective laws Punitive laws A B C D E F G H Laws and Non- Laws, regulations HIV-specific Laws that Laws that Laws deeming sex Laws that regulations that discrimination or policies that restrictions on specifically criminalize work ("prostitution") impose protect people laws or present obstacles entry, stay or criminalize HIV same-sex to be illegal compulsory living with HIV regulations that to access to residence transmission or sexual treatment for against specify prevention, treatme exposure activities people who use discrimination protections for nt, care and between drugs and/or vulnerable support for consenting provide for subpopulations vulnerable adults death penalty for subpopulations drug offences Armenia Yes Yes Yes Yes Yes No Yes Yes Azerbaijan Yes Yes Yes No Yes No Yes Yes Belarus Yes Yes Yes Yes Yes Yes Yes Estonia Yes No No No No No No Georgia Yes No Yes No Yes No Yes Kazakhstan Yes Yes No No Yes No No Yes Kyrgyzstan Yes Yes No No Yes No No Latvia Yes No No No No No Lithuania Yes Yes Yes Yes No No Yes Republic of Moldova Yes Yes No Yes Yes No Yes Russian Federation Yes Yes Yes Yes No Yes Tajikistan Yes Yes No Yes No Yes Turkmenistan Yes Yes Yes Yes Ukraine Yes Yes Yes Yes No Yes Uzbekistan Yes Yes No Yes Yes Yes Yes Source: UNAIDS/WHO. HIV/AIDS in Europe and central Asia. Progress Report 2011
- 17. Poor scale up of services
- 18. Reported HIV infections acquired through injecting drug use: eastern Europe and central Asia (2010) 100% 90% 80% 70% % IDUs 60% among cumulative 50% reported HIV 40% infections 30% with known 20% transmission mode 10% 0% Data sources: ECDC/WHO. HIV/AIDS surveillance in Europe 2010. UNGASS country progress report of the Russian Federation 2010
- 19. Number of syringes distributed per IDU per year by needle and syringe programmes: eastern Europe and central Asia (2011) 180 160 140 120 100 Syringes 80 distributed 60 per IDU per year 40 20 0 Data source: WHO/UNAIDS/UNICEF monitoring and reporting on the Health Sector response to HIV/AIDS
- 20. Poor integration of services Reduce Optimize HIV Leverage Build strong vulnerability prevention, broader health and and address diagnosis, outcomes sustainable structural treatment and through HIV systems barriers to care outcomes response accessing services Data source: WHO Regional Office for Europe. European Action Plan for HIV/AIDS 2012-2015
- 21. Percentage of people who inject drugs receiving opioid substitution therapy: eastern Europe and central Asia (2011) 16% 14% 12% 10% % IDUs 8% receiving OST 6% 4% 2% 0% * 2010 data Data source: WHO/UNAIDS/UNICEF monitoring and reporting on the Health Sector response to HIV/AIDS
- 22. TB and hepatitis co infection
- 23. HIV infection among all TB cases tested for HIV in the WHO European Region (2006-2010) % 6 Percentage of TB cases 5.5 tested for HIV who were 5 4.8 diagnosed with HIV infection 4 3.6 3 2.8 2.8 2 1 0 2006 2007 2008 2009 2010 Source: ECDC/WHO. Tuberculosis surveillance and monitoring in Europe, 2012
- 24. TB/HIV co-infection WHO European Region (2010) Timely detection and appropriate treatment is a challenge. Almost 16 000 (80%) TB/HIV cases out of an estimated 20 000 (range 16 000 – 25 000) were detected in 2010 and only 70% were offered antiretroviral treatment. Source: ECDC/WHO. Tuberculosis surveillance and monitoring in Europe, 2012
- 25. HIV programme source of funding in Europe and central Asia, 2008 or 2009 100% 80% 60% 40% 20% 0% ia n n ria n ia ia n us lic ia n ia na ro va ija ta ta ta ta en at an rg tv eg ub do ar vi ga zs hs is is a ro La eo rm om go el n rb ep jik ek ul ol gy ak C te B G A ze ze B M Ta zb R R yr on az er A of ch U K K M H lic ze d ub C an ep a ni R os International Public B Source: UNAIDS/WHO. HIV/AIDS in Europe and central Asia. Progress Report 2011
- 26. Percentage of HIV programme spending on key populations originating from international funding sources, most recent year West and centre: Belgium, Bulgaria, Croatia, Czech Republic, Hungary, Montenegro, Poland, Romania, Switzerland, United Kingdom. East: Armenia, Azerbaijan, Belarus, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation, Ukraine, Uzbekistan. Source: UNAIDS/WHO. HIV/AIDS in Europe and central Asia. Progress Report 2011
- 27. Summary: HIV transmission in Eastern Europe and Central Asia • Grows at alarming rate • Poor access to treatment • Vulnerability and marginalisation • Poor (integration of and scaling up) services • TB (and hepatitis) co infection • Funding 27
- 28. Acknowledgements • Andrew Ball Senior Strategy and Operations Adviser, HIV/AIDS Dept WHO, AIDS 2012 Conference Coordinating Committee • Fabiano Bertini AIDS 2012 International Conference Secretariat, International AIDS Society • Sergii Dvoriak Director of the Ukrainian Institute on Public Health Policy • Bernard Kadasia AIDS 2012 International Conference Secretariat, International AIDS Society • Anna Koshikova Head of the Analytical Team, All-Ukrainian Network of PLWH • Jean-Elie Malkin Senior Adviser to Executive Director/Acting Director of the Regional Support Team for Europe and Central Asia UNAIDS • Mara Nakagawa-Harwood AIDS 2012 International Conference Secretariat, International AIDS Society • Serge Votyagov Executive Director of the Eurasian Harm Reduction Network (EHRN)
- 29. Question 1 to the panellists • How can we scale up access to ART and increase early HIV diagnosis and treatment?
- 30. Question 2 to the panellists • How can we leverage broader health outcomes through the HIV response and build stronger and more sustainable health systems?
- 31. Question 3 to the panellists • How can we respond to reduce vulnerability and marginalisation?
- 32. Question 4 to the panellists • How can we respond to the funding crisis?
Editor's Notes
- It is a both a great honour and a matter of some regret that I am addressing you here today in Washington DC . An honour because my peers asked me to make this presentation, this is the major platform for raising the issues affecting my region and I am in the esteemed company of Ministers, prevention and treatment specialists, donors and activists from the Region.A regret because although globally the number of people newly infected with HIV is decreasing, in Eastern Europe and Central Asia it continues to rise at an alarming rate and while prevention and treatment coverage is increasing globally in my Region it has stagnated at shamefully low rates.I do not regret this opportunity to debate keys issues and solutions relating to poor access to treatment; vulnerability and marginalisation; service integration; co-infection and funding raised in the presentation.
- Because of low access to (and low uptake of) HIV testing and counselling (especially among the populations most at risk of HIV infection and transmission – as demonstrated on this slide [1]) not all HIV cases in Europe are diagnosed and reported. [1] Note: relatively small sample sizes and convenience sampling may bias the results of these studies among key populations.
- LatestUNAIDSestimates of 2.4 million [1] people living with HIV in Europe [2]suggestthat the reported cases represent just over half of all people living with HIV in Europe. Of these an estimated 1.5 million [3] are in eastern Europe and central Asia. A 2.5 foldincrease from the 410 000 [4] cases in 2001and more than 10 times the number in 1991.There are an estimated 860 000 [5] in western and central Europe. A somewhat more steady increase from the630 000 cases [6]in 2001 when the estimates for eastern Europe and central Asia were (for the first time) higher than those for the west.So unlike other Regions – including sub-Saharan Africa, the Caribbean and South and South-East Asia where the epidemic appears to be stabilizing and declining [2] – the eastern European and central Asian HIV epidemic continues to grow at an alarming and accelerating pace.[1] 2.1 million – 2.7 million[2] For 2011 reported in UNAIDS (2012) Together we will end AIDS[3] 1.3–1.8 million[4] 340 000–490 000[5] 780 000–960 000[6]580 000–690 000
- Despite the crude measurement[1], these data reveal clear inequities in access to treatment for people who inject drugs. In 2011 people who inject drugs represented 59% of the cumulative number of reported HIV cases (with a known mode of transmission)but only21% of those receiving antiretroviral therapy – this pattern of inequity is similar to previous years with little or no improvement since we first stated collecting these data in 2002. [1] Data from Russian Federation (the country with the largest number of people diagnosed with HIV) missing in 2002, 2010 and 2011. Missing countries (bold = a substantial numberof people on ART)2002: Azerbaijan, Georgia,Hungary, Latvia, Poland, Romania,Russia, Turkey, Turkmenistan2005: Azerbaijan,Albania, Tajikistan, Turkmenistan, Uzbekistan2006: Albania, Turkmenistan, Uzbekistan2010: Bulgaria, Hungary, Romania, Russia,Turkey, Turkmenistan, Uzbekistan2011: Albania, Montenegro, Romania, Russia,Turkey, Turkmenistan, Uzbekistan
- We can see from case reporting, in the European region as a whole, a large increase in the cumulative number of cases since 1984 and no evidence of the epidemic declining.
- There are important differences with regard to the HIV epidemics in Europe. WHO and ECDC analyse the data according to three geographical areas that have been used since reporting first began in the mid 1980s. WEST,CENTRE and EAST and I will use these areas to describe some regional differences.
- Important regional differences in the HIV epidemic are apparent when we considermode of transmission.Although the main transmission routes vary by geographical area; HIV in all European countries disproportionally affects populations that are socially marginalised (such as migrants) and people whose behaviour is socially stigmatised (such as men who have sex with men shown here in green) or stigmatised and illegal (such as people who inject drugs shown here in red). Data confirms that the HIV epidemic in Europe remains concentrated in these key populations. In eastern Europe and central Asia 41% of cases newly reported in 2010 were people who inject drugs, slightly less than the 45% heterosexual cases. In recent years the east has experienced an increasing proportion of heterosexually transmitted HIV cases likely associated with sexual transmission from drug injectors. The proportion of cases among men who have sex with men in the East is low and likely to be under reported. In the western part of the Region, the epidemic remains concentrated among men who have sex with men (accounting for 39% of newly diagnosed cases in 2010) and migrants from countries with generalized epidemics (accounting for at least one third of heterosexually acquired infections). It is of note that many newly diagnosed cases of HIV are of unknown mode of transmission.
- HIV disproportionately affects populations that are socially marginalized and people whose behaviour is socially stigmatized or criminalised (people who inject drugs and their sexual partners; men who have sex with men; transgender people; sex workers, prisoners and migrants). The European HIV epidemic is concentrated in these key populations at higher risk. In some EE and CA countries over 50% of newly diagnosed infections in 2010 were among people who inject drugs. Repressive laws in the Region prevent people who use drugs from accessing treatment. The association between sex work and injecting drug use is accelerating the spread of HIV in the Region, as is the incarceration of people in these key populations. These problems are exacerbated by lack of political commitment to scaling up interventions for people who inject drugs, particularly needle syringe programmes and opioid substitution therapy.Here we show laws which enable (or act as barriers) to universal access in EECA countries. Protective laws relating to discrimination are – on the books at least – present in the majority of EECA countries, however punitive laws particularly against vulnerable populations are also common.
- Services to prevent diagnose and treat HIV infections are often not accessible to highly vulnerable and marginalised individuals and populations. In Eastern Europe and central Asia only 11% of all investment in HIV prevention is focused on key populations at higher risk. In many countries in the Region effective and evidence based harm reduction services for people who use drugs are not implemented, remain at small scale or in a pilot phase. Up to 60% of people living with HIV in some EE and CA countries are unaware of having been infected because of limited access to HIV testing and counselling services. Where HIV services do exist they are often poorly integrated with other health services, notably TB, drug dependence and hepatitis services.
- Here we show the proportion of HIV infections attributed to injecting drug use for eastern European and central Asian countries in 2010 .These data confirm that IDU related HIV is a significant problem in all eastern European and central Asian countries. In all countries reporting data, between 40% and 70% of all HIV infections reported in 2010 were transmitted through injecting drug use.
- However, although injecting drug use is driving the epidemic in many countries, services to prevent HIV transmission for people who inject drugs have not been scaled up.This slide demonstrates that although some (Estonia, Kazakhstan, Kyrgyzstan and Uzbekistan) countries have reached 100 or more syringes per IDU per year; all eastern European and central Asian countries have failed to reach a recommended coverage of 200 syringes per IDU per year.
- Where HIV services do exist they are often poorly integrated with other health services, notably with TB, drug dependence and hepatitis services.
- Here we show the percentage of people who inject drugs receiving opioid substitution therapy and note that no eastern European or central Asian countries provide coverage approaching the 40% recommended.Many struggle to provide OST to more than 1 or 2% of people who inject drugs and some (including Russia not included on this slide) do not provide any OST.HIV services arepoorly integrated with drug dependence services and do not have access to OST – a vital tool to control HIV epidemics among and deliver services to people who inject drugs.
- Tuberculosis and end stage liver disease caused by viral hepatitis C infection are among the leading causes of death among people living with HIV/AIDS - especially among those who are also drug dependent. People living with HIV are especially vulnerable to the impact of TB and multidrug-resistant TB.
- In 2010, there were an estimated 420 000 incident TB cases in Europe and central Asia - with an average estimated HIV prevalence of 5% (range of 0–25%) and nine countries with8% or greater among people newly diagnosed with TB (including Estonia, Latvia, Lithuania, the Russian Federation and Ukraine – all countries with high rates of MDRTB).12% of all people newly diagnosed with TB in Europe and central Asia had multi drug resistant TB, the highest globally where the average is 3.4%, with peaks of up to 26% in some countries (and 28% in some settings). More than half the countries with a high burden of multidrug-resistant or extremely drug-resistant TB are in eastern Europe and central Asia. Among people being re-treated for TB, the percentage with multidrug-resistant TB is even higher, estimated at 37% across the region and as high as 65% in some countries.HIV is the greatest risk factor for developing TB and TB is responsible for more than a 25% of deaths among people living with HIV. In eastern Europe and central Asia the estimated coverage of ART among people with TB/HIV co infection is lower than that for all those with HIV infection. During the last 5 years cases of TB/HIV co-infection increased, from 5 336 to 15 954 – increasing 20% per year in the last five years
- TB is a leading killer among HIV-infected people.Timely detection and appropriate treatment is still a challenge for the Region. Only 74% of TB cases are tested for HIVOnly80%of all estimated TB/HIV cases were detected in 2010 and only 70% of them were offered antiretroviral treatment.
- I will close my presentation with some funding issuesOver dependence on external and international funding has made countries in the Region vulnerable to changing funding priorities (e.g. global economic crisis; suspension and uncertainties of Global Funding; health priorities shifting from communicable to non communicable disease; donor fatigue and shifting donor priorities) and is unsustainable in the long run. Of 16 EECA countries, seven reported that they relied on international funds to finance 50% or more of their total HIV spending.
- HIV prevention programmes, in particular, have over reliance on international funding and prevention programmes for key populations at higher risk (people who inject drugs and their sexual partners; men who have sex with men; transgender people; sex workers, prisoners and migrants) are seriously under funded in many EE and CA countries. There is increasing concern in the Region that there will be less funding for prevention programmes for key populations. In Eastern Europe and Central Asia 91% of total spending on key populations at higher risk (people who inject drugs; men who have sex with men and sex workers) originated from international funding – compared to just 10% in the West and centre.
- I made this presentation on behalf of the Regional Working Group for eastern Europe and Central Asia and would like to acknowledge their contribution to the difficult task of presenting and prioritising all the challenges we face in eastern Europe and central Asia.I believe our distinguished panel will not help us understand what we need to need to do (and indeed what we are already doing) tp respond what may be the only HIV epidemic globally that remains out of control.
- How can we scale up access to ART and increase early HIV diagnosis and treatment?Model answer Optimising HIV prevention diagnosis, treatment and care; using simpler low cost regimens and effective delivery systems supported by the community – as prioritised in Treatment 2.0 and as demonstrated in countries such as Georgia. Elimination of mother to child transmission is realisable throughout the Region, including in Russia the country with the most cases of HIV in the Region. HIV testing and counselling to reduce the size of the undiagnosed population and the number of late HIV diagnoses is being scaled up – for example in Ukraine. Combination prevention, the use of a range of different approaches to reduce risk of infection, is gaining traction in many counties. Implementing the comprehensive package of interventions for drug injectors (including needle and syringe programmes and opioid substation therapy) is beginning to have an impact on HIV transmission through injecting drug use – for example in Estonia. Access to ART for IDUs in Ukraine as elsewhere in the Region is poor, but better in those also treated with OST (32%) than those who are not (10%).
- Model answer The HIV response can have a positive impact on other health outcomes – for example in reducing the burden of tuberculosis and viral hepatitis. Integrating other health programmes and services can improve HIV outcomes. Integration and linkage between HIV and other health services and programmes have shown encouraging results. For example rapid progress has been made towards the elimination of mother to child transmission of HIV especially by integrating HIV prevention into maternal, newborn, child and adolescent health services and programmes. In 2009 93% of all HIV-positive pregnant women in the Region received ART for prevention of mother to child transmission compared to the global average of 53% for low and middle income countries. Other integration models have been developed for example in Estonia (HIV and drug dependence) and Ukraine (HIV, TB and drug dependence).
- Model answer HIV in EECA disproportionately affects populations that are socially marginalized and people whose behaviour is socially stigmatized or criminalised (people who inject drugs and their sexual partners; men who have sex with men; transgender people; sex workers, prisoners and migrants). Barriers to accessing services are not insurmountable and the marginalisation, stigmatization and criminalisation of populations are neither acceptable nor inevitable. The majority of countries in the Region reflect or address human rights in their national AIDS strategies. Nevertheless implementing these laws remains a considerable challenge. Sexual relations between people of the same sex have been decriminalised in all but two countries in the Region. The European Region has been in the vanguard of forming innovative partnerships between international and other statutory agencies and civil society, including with communities of key populations at higher risk and people living with HIV/AIDS. Pan European networks and organizations have emerged (including ECUO and EHRN) and civil society has become a key actor in the formulation, promotion and delivery of change.
- Model answer The strategic investment frame work for HIV/AIDS developed by WHO, UNAIDS and the Global Fund and other key partners takes a targeted approach most suited to the European epidemiology and context; which prioritises areas of intervention and activities, recognises the synergies between the priority areas and with other programmes (TB, drug dependence etc.), pays particular attention to reducing vulnerability and structural barriers and recognises the efficiency gains in involving civil society. It propose a new investment model intended to support better management of national and international HIV/AIDS responses than exists with the present system and a more targeted and strategic approach to investment in the response to the HIV/AIDS epidemic that addresses key populations and targeted interventions including harm reduction programmes for injecting drug users. In times of economic austerity it will be essential to rapidly apply new science, technologies and approaches to improve the efficiency and effectiveness of HIV programmes in countries. Globally increased access to HIV services resulted in a 15% reduction of new infections over the past decade and a 22% decline in AIDS-related deaths in the last five years. Investment in HIV services could lead to total gains of up to US$ 34 billion by 2020 in increased economic activity and productivity, more than offsetting the costs of ART programmes. Application of the investment framework at the national level and increased use of domestic funding, including national health insurance funds – for example in Estonia and Ukraine, are demonstrating solutions to the funding crisis.