Less than 10% of East European prevention spending is for vulnerable groups

In the countries of Eastern Europe and Central Asia, 89% of national government funding for HIV prevention goes on programmes for the general population, although most countries’ epidemics are dominated by injecting drug use, Shona Schonning of the Eurasian Harm Reduction Network told the Eighteenth International AIDS Conference in Vienna last week.

She was one of a number of speakers who called on the Global Fund to Fight AIDS, Tuberculosis and Malaria to change its eligibility criteria so that prevention programmes in Russia and other countries in the region can continue to receive Global Fund support.

They believe that the Russian government is unwilling or incapable of responding to the country’s HIV epidemic. Without international support, the prevention needs of vulnerable groups will be ignored and antiretroviral treatment stock-outs will become more frequent.

Speakers and activists frequently said that Eastern Europe and Central Asia now has the fastest growing HIV epidemic in the world. The number of people living with HIV increased from 900,000 in 2001 to 1,500,000 in 2008, the biggest jump of any world region. (The region is primarily made up of the countries of the former Soviet Union, and excludes countries such as Hungary and Poland.)

“While HIV epidemics in Western Europe are, with some exceptions, generally stabilising, in many countries in Eastern Europe, they rage out of control,” Andrew Ball of the World Health Organization said.

The epidemics in Russia and Ukraine are especially severe and rapidly growing. These two countries account for more than 90% of the region’s total infections. HIV prevalence is above 1% in the general population of both countries. But it is exceptionally high in injecting drug users: an estimated 37% in Russia, and between 38 and 50% in Ukraine.

Other vulnerable populations in the region include sex workers and prisoners (partly due to drug use in these groups, but also because of sexual transmission). Prevalence surveys with men who have sex with men suggest that rates of HIV infection are significantly higher than in the general population.

Senior Russian health officials have said that they oppose harm-reduction policies (such as supporting needle and syringe exchange), but instead support ‘supply reduction’. The provision of opioid substitution treatment (methadone, buprenorphine) is illegal in Russia although these are classified as essential medicines by the World Health Organization.

Moreover, only 23% of people who need antiretroviral therapy receive it. Access is therefore poorer than in sub-Saharan Africa (44%) and any other world region except North Africa & the Middle East (14%).

Shona Schonning showed differences in the way in which national governments and international donors spend their money on HIV in the region. Whereas approximately half of government spending goes on treatment and care, only around 20% is spent on prevention activities.

The situation is reversed for international donors – 20% goes to treatment and care and 50% to prevention.

Moreover, when government spending on prevention is analysed, only 8% goes to work with injecting drug users, 2% to work with sex workers and their clients, and 1% to programmes with men who have sex with men. The vast majority (89%) goes to general population prevention programmes.

She also noted that countries in the region were paying high prices to pharmaceutical companies and so not making best use of available resources.

The principal international funding mechanism for countries in the region has been the Global Fund. In Russia, both prevention and treatment programmes in Russia were supported between 2004 and 2009.

Prevention programmes were delivered by civil society and non-government organisations, and concentrated on injecting drug users (outreach services, needle exchange, condoms, and voluntary counselling and testing were provided), as well as men who have sex with men, street children, sex workers, migrants and prisoners.

However, under its current eligibility criteria, programmes there are no longer eligible for Global Fund support. Russia is now an upper middle-income country, and as such is considered capable of responding to its own HIV epidemic.

Shona Schonning (and several people who spoke from the floor at this session) called on the Global Fund to revise its eligibility criteria. They say that a country’s income level does not by itself determine a country’s ability to respond effectively to its epidemic. For example, the Russian government’s approach has been driven by an ideological belief in abstinence-based approaches rather than scientific evidence. The government has persistently neglected the needs of its most vulnerable populations.

Global Fund financing for prevention programmes has in fact been extended for two years “in recognition of the emergency situation that would have arisen if funding had been discontinued”. Nonetheless, unless either the criteria of the Global Fund or the health policies of the Russian government change dramatically, the future of prevention work in Russia in 2012 and beyond looks bleak.

The treatment component of the Global Fund grant has been taken over by the Russian government. Since then, activists have reported shortages of drug supply in many regions and forced treatment interruptions in five regions. Moreover, it is generally difficult for migrants and for prisoners to gain access to treatment.

Schonning S Is there enough political commitment and funding? Eighteenth International AIDS Conference, Vienna, presentation THSY0104, 2010.

View the abstract and slides of this presentation on the official conference website. An audio recording is also available in Russian.