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The analysis and policy recommendations of the Report do not necessarily representthe views of the United Nations Development Programme; its Executive Board or itsMember States.
Cover Designed by KOLOVRATOK, Slovak RepublicPrinted by RENESANS, Slovak RepublicBratislava, 2004
This report contains a simple message: without an immediate, accelerated and signifi-cantly scaled up response by governments and other actors, HIV/AIDS risks undermi-ning and even reversing human development gains across the countries of EasternEurope and the Commonwealth of Independent States. Mounting such a response willbe difficult, but far from impossible. By drawing on experience and knowledge fromother parts of the world, and by using new financing mechanisms such as the GlobalFund to fight HIV/AIDS, TB and Malaria, there is every chance we will succeed in stem-ming the spread of the epidemic and containing its impact in the region. But that willonly happen if the countries of the region first take direct action themselves, focusingtheir own social and economic policies and resources more clearly and explicitly on thisgrowing problem.
In practice that means several things. It means policy makers must put in place new andextensive networks of information: investing in public awareness by educating the pub-lic, especially vulnerable groups. It means that governments need to approach the issuein a way that allows all stakeholders - including people living with HIV/AIDS - to partici-pate in decision-making. And above all it means real leadership in confronting the issue.
Leadership at all levels and in all structures of society - not just at the central govern-ment level, but also with local authorities, in business organisations, civil societies, scho-ols, religious organisations, and in families.
This report does not simply analyse the problems: it offers concrete solutions. Drawingon best practices and on the proven experience of countries and communities whereHIV/AIDS prevention and care have produced results, it sets out a series of recommen-dations for policy makers, government institutions, business and civil society actors onexactly how that can be done. A product of the joint efforts of a team of researchersdrawn from UN agencies, civil society organisations and other partners, it is a powerfulcall to action.
This report is a product of extensive collaboration by many individuals and institutionsactively involved in HIV prevention and care in Eastern Europe and the CIS. Its publicati-on would not have been possible without the joint work of representatives of many dif-ferent UN agencies and programmes who contributed their expertise, time and staff towork in the team of authors and editors of this report. In particular, special thanks aredue to the WHO Euro office in Copenhagen, the World Bank, and the UNAIDS Secretari-at in Geneva.
The report was researched and edited by Tony Barnett, David Barr, Andrey Ivanov, andBen Slay. The introduction was written by David Barr and Ben Slay. Chapters I and II area contribution of WHO, drafted by Martin Donoghoe, Srdan Matic and George Schmid.
Chapter III is a result of joint effort of the World Bank and UNDP: it was prepared by Olu-soji Adeyi, Tony Barnett, Sarbani Cherkaborty, Shombi Sharp, and Ben Slay. Chapter IVwas drafted by Jeff Hoover and Anna Alexandrova, and benefited from valuable contri-butions by Marcia Kran and Stefan Preisner. Chapter VI was written by David Barr andAnna Alexandrova, Chapter V was written by David Barr and Ben Slay. Policy recommen-dations were formulated in a consultative process between UNDP, the UNAIDS Secreta-riat, and national stakeholders. Special contributions were also made by Vadim Pokrov-sky, Mamasabyr Burhanov, Kasia Malinowska-Sempruch and Vladimr Frolov.
The report benefited from extensive comments and contributions made by many nati-onal experts, institutions, and non-governmental organisations in the region. Specialthanks go to AIDS Info Share in Moscow and organisations of people living with HIV.
They also go to the Ukrainian experts and NGOs who commented on the report’ssecond draft.
Editors of the report and the UNDP Regional Bureau for Europe and the CIS express theirgratitude to the many colleagues and experts who offered their knowledge, time andadvice to make the report a strong advocacy tool. Special thanks go to Andrew Ball,Hakan Bjorkman, Sarah Burd-Sharps, Desmond Cohen, Ivan Krastev, Steve Kraus, KasiaMalinowska-Sempruch, Henning Mikkelsen, Monica Sharma, and Nadia Rasheed. Speci-al thanks also go to UNDP and UNAIDS staff working in UN offices throughout the regi-on, especially Natalia Gordienko, Alexander Kashkarev, Elena Malanova, Jelena Marjano-vic, Eduard Petrescu, Helen Petrozzola, Tatiana Shoumilina, and all HIV/AIDS focal pointsand UNAIDS Theme Group members.
Production of this report was made possible by UNDP’s Regional Centre in Bratislava.
Critical support in editing, production and launching the publication was provided byAndrey Ivanov and Sandra Pralong.
Leaders of this initiative—Kalman Mizsei, Soknan Han Jung, Bruce Harland and JoannaKazana—are very grateful for everyone’s help and cooperation in making this publicati-on a strong advocacy tool.
Introduction: HIV/AIDS and Human Development in Central
and Eastern Europe and the Commonwealth of Independent States
Chapter I: HIV/AIDS Epidemiological Trends in Central
Regional overview of epidemiological trends
Western CIS: The Russian Federation, Ukraine, Belarus, and Moldova
Chapter II: Drivers of the Epidemic: Major Risk Factors,
High Risk Behaviours and Environmental Factors
Vulnerability, Susceptibility, and Impact
Macroeconomic Impact of HIV/AIDS on Growth and Development
HIV/AIDS and the Millennium Development Goals
Chapter IV: Human Rights and HIV/AIDS in Central
National, Regional, and International Legal Protection of Human Rights
International Guidelines on HIV/AIDS and Human Rights
Chapter V: Developing an Effective Response to HIV/AIDS
Multisectoral national programming and responses
Treatment to prevent mother-to-child HIV transmission
Access to quality generic HIV-related drugs in CIS countries
Diagnostic Testing, Treatment, and Prevention of Opportunistic Infections
Annex 1: Modelling the Macroeconomic Implications of a Generalised
Annex 2: The National Security Implications of the HIV/AIDS
Annex 3: The ’Leadership for Results Programme’—
UNDP’s Role in the UN System Response to HIV/AIDS
Sample studies of HIV prevalence among injecting drug users
in selected cities in the Russian Federation 2000-2002
Results of HIV sentinel surveillance in Ukraine in 2002
Estimated size of core population groups at high risk of HIV by country
Prisoner population and diagnostic HIV screening
in the penitentiary system of the Russian Federation, 1995-2002
Understanding economic and social impact by level, time and degree
Effects of declining life expectancy on the HDI in selected countries
The Human Development Index and life expectancy in CIS countries
Table 10: Human Rights of Vulnerable Populations
Table 11: Global Fund Allocations for East European and CIS Countries
Why have the numbers of newly registered HIV cases
Modelling the macroeconomic impact of HIV/AIDS
Security implications of HIV/AIDS: The case of Russia
Restrictive policies: Well intended but ill-performing
Unintended Consequences: Punitive Drug Policies Fuel
Methadone substitution therapy in the Kyrgyz Republic
Dialogue with producers increases access to antiretroviral drugs
Improving access to generic antiretrovirals: The case of Ukraine
Figure 1: Estimated HIV prevalence rates and number of people living
Figure 2: Newly reported HIV cases with known transmission route,
entire region, excluding Turkey. Source: EuroHIV (2003)
Figure 3: Newly reported HIV infections in Belarus, Moldova, Ukraine
Figure 4: Number of newly reported HIV cases in the Baltic
Figure 5: Newly reported HIV infections in the Caucasus
Figure 6: Newly reported HIV infections in four Central Asian Republics,
Figure 7: Newly reported HIV, AIDS and AIDS death cases,
Figure 8: Reported HIV cases by transmission group, Central
Figure 9: Reported syphilis cases per 100,000 population, 2000-2001
Figure 10:Rates of reported syphilis cases per 100,000 population, NIS
Figure 11: Newly reported HIV infections through mother-to-child transmission
in Western, Central, and Eastern Europe, 1997-2002
Figure 12:Russia population impact of AIDS by scenario
Figure 13:Russia Dependency Ratios by Age Structure
Figure 15: Prices decreases Fluconazole due to generic imports (Ukraine)
Figure 16: Russia, Cumulative Impact of AIDS on GDP levels
REVERSING THE EPIDEMICFACTS AND POLICY OPTIONSExecutive Summary
One out of every hundred adults walking down the streets of a city in Eastern Europe orthe Commonwealth of Independent States (CIS) countries carries the HIV virus that cau-ses AIDS. Most have contracted HIV from injecting drug use. But the region’s prisonersare increasingly functioning as incubators for HIV, and the numbers of infections attri-butable to commercial sex work and mother-to-child transmission are growing.
Official estimates of the numbers of people living with HIV/AIDS in this region at the endof 2003 ran as high as 1.8 million. Last year, the number of new infections rose sharply inUkraine, Estonia, Latvia, Belarus, and Moldova. The incidence of new infections is alsorising (albeit from very low levels) in some of the region’s poorest countries—in CentralAsia and the Caucasus—whose impoverished and overburdened health care systemswill face grave difficulties in meeting this challenge.
This report details the available data on HIV/AIDS in Central and Eastern Europe and theCIS. It explains the causes of the epidemic in this region and offers policy options to haltthe spread of the disease. While former communist countries harbour the fastest gro-wing rates of infection in the world, paradoxically the region also has the most potenti-al to reverse the trend with relative ease. This report explains why, and what policy cho-ices are needed to stop the epidemic from becoming even more devastating and costly.
AIDS threatens the fabric of society and pushes governance and health care systems tolimits they have not yet faced. Addressing the behavioural and socio-economic factorsthat determine vulnerability requires coordinated actions by many individuals andorganisations, directed toward a common goal. AIDS cannot be conquered through thesort of ‘command and control’ approaches that have traditionally shaped public policyin the region. Instead, the creation of open, democratic, inclusive environments wherecomprehensive, multisectoral policies and innovative partnerships build trust and redu-ce stigma is essential to turning back the epidemic.
Policy makers, academics, civil society leaders, government officials, civil servants, busi-ness and community leaders, and, in general, all those involved in combating the AIDSepidemic, or those who are just curious about what can be done about it, will find thisreport of interest. This is not a report exclusively targeted at health care professionals orpublic health officials. It is instead intended to increase awareness among policy makersand publics in general about this growing threat to human development in the post-communist region.
The United Nations Development Programme (UNDP) views HIV/AIDS as a human deve-lopment issue rather than as primarily a health care concern. The concept of humandevelopment, as used by UNDP, emphasises economic development as a framework forexpanding people’s choices and thereby serving the broader objectives of human wel-fare. To have real choices, individuals need decent levels of education, health and inco-me—the three components of human development. By investigating how the AIDS epi-demic affects human development in the former communist world, this report seeks tocontribute to the debate about improving human welfare in the countries of EasternEurope and the CIS. It is not only those infected who suffer from AIDS, but, rather, theentire community is affected when one of its members becomes infected.
Well conceived public policy can make a difference in halting the spread of HIV andreducing the consequences of AIDS. The report which follows identifies the ways inwhich these challenges can be met to offer a comprehensive response to HIV/AIDS in
HIV/AIDS in Central and Eastern Europe and the CIS
the region. While differences in socio-economic and demographic conditions acrosscountries necessitate an individual approach, the common historical legacy and policyenvironments—particularly in the CIS countries—provide a strong basis for analysis andrecommendations at the regional level. Throughout the region, communities have littlechoice but to face these challenges.
In order to help halt and eventually roll the epidemic back, this report identifies threespecific categories of challenges in the areas of information, leadership, and inclusion.
HIV/AIDS is relatively new in the region, particularly in CIS countries. Like all new infecti-ous diseases it is met with suspicion and ignorance. Ignorance is anathema to good poli-cy. Inadequate awareness and insufficient evidence-based information breeds ineffecti-ve, even harmful responses to HIV/AIDS. This pertains in particular to mechanisms forgathering data on epidemiological trends and risk factors.
Suggested responses to this challenge include:
• Prioritise large scale media, information, and education campaigns, tailored specifically tovulnerable groups, especially injecting drug users and their sexual partners.
• Build the capacity needed to provide universal, affordable access to voluntary counsellingand HIV testing.
• Improve sex education, AIDS awareness, and drug prevention programmes in school curricula.
• Invest in second-generation monitoring systems to better identify the drivers of the epide-mic. Study the behavioural patterns of specific at risk groups, and adjust prevention and carepolicies based on knowledge generated by these studies.
AIDS threatens human development on a broad scale. As such it requires a concertedresponse from leaders of all walks of life—including people living with HIV and AIDS. Aneffective response requires the ability and willingness of diverse social groups to worktogether in the face of this common challenge.
Non-governmental organisations (NGOs) and other grass-roots institutions play keyroles in delivering harm-reduction services, empowering individuals to change theirbehaviour, and connecting people at risk with public health institutions. However, thecommunist institutions that dominated political life in most of this region until the1990s prevented the development of these much needed representatives of civil socie-ty. Their absence—particularly in CIS countries—constitutes a major institutional gap inthe fight against the epidemic.
Suggested responses to this challenge include:
• Build real partnerships and cooperation with the private sector (especially media, pharma-ceutical companies, and employers’ organisations), NGOs, and people living with HIV/AIDS.
Make use of their experience and advice in formulating and implementing prevention andcare policies.
• Invest in the infrastructure and policies needed for universal access to treatment, especial-ly antiretroviral therapies. Promote cooperation between local and multinational pharma-ceutical companies to increase the production and affordability of generic retroviral drugs.
• Remove legal and other barriers that are preventing the rapid development of the NGOswishing to work in the HIV/AIDS area. Help NGOs to become better partners for state agen-cies dealing with the epidemic, particularly those who represent people living with HIV/AIDS.
• Identify those activities that have a proven record for fostering leadership in NGOs and con-necting them with leaders in other sectors.
Including all stakeholders, especially people living with HIV/AIDS, in designing and imple-menting appropriate policy responses is critical to better policy outcomes. In addition,while information is critical for prevention, it is more effective when combined with acomprehensive range of prevention activities. Marginalising people living with HIV/AIDSand members of at risk communities is not only unfair and violates international humanrights agreements that have been signed by all the governments of the region. Margina-lisation is also an ineffective—even harmful—public policy approach to the epidemic.
Adopting inclusive responses to HIV/AIDS means rebalancing criminalisation and puni-tive approaches to the epidemic, in favour of practical, evidence-based, harm reductionapproaches. This means:
• De facto decriminalisation of injecting drug use and sex work, in favour of measures thatprovide health services and address social intolerance.
• Integrating harm reduction programmes, voluntary testing, and staff training into correcti-onal systems.
• Dramatically scaling up needle exchanges, methadone replacement therapy, condomdistribution, and outreach programs for injecting drug users. Focus on projects that preventthe sexual transmission of HIV from drug users to their sexual partners.
A comprehensive response to HIV/AIDS is required for impact, because the effects of theepidemic manifest themselves in a multitude of ways. HIV/AIDS is not solely a matter forthe health sector. By limiting people’s abilities to live with freedom and dignity, the epi-demic threatens prospects for sustainable human development for entire communities.
HIV/AIDS is therefore:
• A social issue: HIV/AIDS feeds on and exacerbates social marginalisation, poverty, stig-ma, and intolerance.
• An economic issue: HIV/AIDS consumes scarce resources and attacks the human capi-tal of workers who would otherwise provide the lion’s share of national labour forces,thereby reducing household, enterprise, and macroeconomic potential.
• A health issue: a cofactor of other diseases, HIV/AIDS attacks the body’s immune sys-tem with fatal consequences if untreated, reducing life expectancies and quality of lifewhile straining public health systems.
• A human rights issue: HIV/AIDS can generate responses that emphasise criminal jus-tice solutions to what is essentially a public health problem. In addition to disregardinginternationally accepted human rights principles, such responses can harm those mostaffected and be counter productive.
• A policy coordination issue: while public health systems must be at the core of anyresponse to HIV/AIDS, effective responses require coordinated engagement by manycentral and local government bodies.
• A security issue: HIV/AIDS breeds insecurity at all levels, from individuals to house-holds to countries. It also reduces the capacity of security organisations such as the mili-tary and police.
• A policy horizon issue: because its consequences are delayed by its ‘slow-onset’ natu-re, AIDS blurs the distinction between today and tomorrow. Policy making must be sha-ken out of short term time horizons in order to respond effectively to the epidemic.
Building the conditions for change requires information, leadership, and inclusion. Itrequires action across all sectors: government, civil society, businesses, and religiousorganisations. The United Nations Development Programme believes this report canserve as a valuable tool in understanding and responding to this complex developmentchallenge, in demystifying an often sensitive and awkward topic, through the presenta-tion of straightforward analysis and practical responses.
Perspectives: A View of Family Medicine in New Jersey Fibromyalgia: Practical Treatments for the Family Physician Richard N. Podell, MD Source: Perspectives: A View of Family Medicine in New Jersey (Written for Perspectives (4Q05), a journal of the New Jersey Academy of Family Physicians, and reprinted with permission.) Richard N. Podell, MD, Clinical Professor in the Department
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