Change in mindset is needed to prevent unnecessary human tragedy

By Michel Kazatchkine

UNAids figures released last week on the global HIV/Aids epidemic confirm the very encouraging trend of the past five years: fewer new infections, fewer deaths and increasing coverage (55 per cent globally) of those in need receiving antiretrovirals.

In many parts of the world we are “getting to zero” HIV and Aids (the slogan for World Aids Day), but the UN figures offer unsettling evidence that achieving this target will require the world’s fastest growing epidemic, in eastern Europe and central Asia, to be overcome.

Only a decade ago some 150,000 people in this region were living with HIV. Today, that figure is 1.4m, with Russia and Ukraine accounting for 90 per cent of infections. Aids-related deaths have almost quadrupled in the past 10 years and the number of people receiving treatment is a lowly 23 per cent.

If urgent and measured action, based on scientific evidence is not taken here, we will be heading for a major human tragedy.

The epidemic is characterised by escalating HIV infection and startling hepatitis C, tuberculosis and multi-drug-resistant TB prevalence.

The region has the highest rate of injecting drug use in the world, accounting for two-thirds of new HIV infections there. It is mainly heroin-based, but increasingly involves the use of cocaine, amphetamine-type stimulants, psychotropic substances and home-made cocktails such as krokodil (desomorphine), a mixture of codeine-based painkillers and other cheap household ingredients.

Drug users in the region are often stigmatised and criminalised. Fear of arrest drives people away from testing and services. There are almost no needle exchange programmes and opioid substitution therapy (OST) with methadone or buprenorphine is illegal in several countries.

There is a high HIV prevalence among prisoners, particularly those with a history of injecting drug use, and women who, in the main, are the sexual partners of injecting drug users.

The scenario is bleak – but not hopeless. We have known that, over the past three decades, four major factors have determined our success in the fight against Aids worldwide: political commitment, adequate resourcing, strong involvement of civil society and affected communities; and the implementation of policies and practice based on evidence and science as opposed to prejudice and criminalisation.

We have known since the 1980s that the simple and cost-effective provision of clean needles and methadone prevents HIV and Aids from spiralling out of control among drug- using communities.

Encouragingly, several countries, including Ukraine, Kyrgyzstan, Moldova, Kazakhstan and Tajikistan, have engaged in harm-reduction programmes around clean needles and OST, leading to a decrease in new HIV infections. In the last five years, the Global Fund to Fight Aids, Tuberculosis and Malaria has played a key role in the region, funding needle exchange programmes, OST and access to Aids treatment.

These programmes may be at risk soon if countries in the region, particularly those that are middle income, faced restrictions in access to international funding. Funding cuts would also reduce civil
society’s important role in promoting advocacy, legislative changes, and programme implementation.

On the whole, however, leaderships in eastern Europe and central Asia remain silent on the epidemic. Civil society organisations and communities face increasing logistical, political and legal challenges. And resources from the international community are decreasing as many countries move to being middle income and therefore ineligible for programmes from organisations such as the Global Fund to Fight Aids, Tuberculosis and Malaria.

National governments have failed to pick up the financial slack and, too often, the investments that do happen, particularly in prevention, fail to reach communities at greatest risk of infection. The result is woefully inadequate coverage of the most vulnerable in terms of treatment and prevention, accompanied by an equally low return on investment.

The treatment of HIV and Aids in eastern Europe and central Asia is at a tipping point. We are barely three years from fulfilling the UN Millennium Development Goals of getting 15m people on treatment globally and reducing new infections among injecting drug users by 50 per cent. Eastern European and central Asian countries recommitted to these targets at the UN in 2011.

Only a change in mindset among the region’s political classes towards a public health policy approach will save the region from a human tragedy.

Originally published on the Financial Times.