Nikolay Lunchenkov is the Health Projects Coordinator at ECOM – the Eurasian Coalition for Health, Rights, Gender and Sexual Diversity – and a doctoral candidate in global health at the TUM School of Social Sciences and Technology in Germany. We spoke to Nikolay about LGBT health in eastern Europe and central Asia (EECA) and the organisations working in this area.
What do we know about LGBT health in EECA?
The information we have on LGBT health in the region shows that it varies widely from one country to another. There are three key areas I would highlight.
The first and most obvious is HIV. The most recent report from UNAIDS, In danger, showed that the number of new cases of HIV continues to rise in the EECA region.
UNAIDS targets for 2025 aim for 95% of those living with HIV to know their status, 95% of those who know they have HIV to be on treatment, and 95% of those on treatment to have achieved viral suppression (undetectable viral load). The 95-95-95 target is being missed across the board in this region.
The centre of the HIV epidemic for EECA is the Russian Federation. The HIV situation in Russia is very bad, and the problem is with HIV prevention. There are no state-supported, evidence-based HIV prevention programmes. Also, since the invasion of Ukraine last year, the legal system has been changing dramatically. We see more oppressive laws regarding the LGBT population and regarding ‘foreign agents’ (e.g. funders from other countries supporting services within Russia) and this prevents people from having access to services.
Why is the Russian Federation the main problem for the whole region? Because a lot of people migrate to Russia for work, particularly from countries in central Asia. People who travel from Kyrgyzstan, Uzbekistan, Tajikistan – back home, they might be in contact with HIV prevention programmes for men who have sex with men, or for people who use drugs, and so they have some protection against HIV or other sexually transmitted infections. These services may not be ideal, but they function quite well.
But when they go to Russia, they don’t have access to these services. We know that when people travel in this way, to a big city where they can be anonymous, they can allow themselves to be the person they want to be and so their behaviour may change. Quite a lot of people who migrate to Russia for work acquire HIV there. This is also problematic because in Russia they cannot access free HIV treatment, and the law says people living with HIV who don’t have Russian citizenship must be deported.
The second area I would highlight is that we still have a huge problem with access to services for trans people, not only for HIV but in general. Gender-affirming therapy just doesn’t exist in many countries and in some countries, people take oral contraceptives as a source of exogenous hormones. Trans people also face huge discrimination from state institutions. Services for trans people is a key issue that we must give more attention to, because trans people are one of the most vulnerable populations in our region.
The third area I would highlight is mental health. In many countries, being a person who belongs to an LGBT population or identifies as queer is a huge emotional and mental burden. This is especially true if you experience stigma and discrimination from your friends, peers, community and the state. People develop coping strategies, but there are healthy coping strategies and there are unhealthy coping strategies, such as excessive alcohol consumption, substance use and chemsex. Using substances to cope with stress or escape pressure often leads to negative health outcomes. I’m currently working on my doctoral thesis about chemsex in Kazakhstan, so this is a major focus for me, and also something we are working on at ECOM, publishing materials and supporting studies.
These are the three major areas I would highlight, but of course there are others – not least issues around access to vaccinations against HPV and hepatitis A and B. Coverage of vaccines in general is very poor.
What is life like for a gay man in EECA?
In the region, we have countries like Estonia, which legalised same-sex marriage a few weeks ago. In the Baltic countries, the situation for gay rights is very different from the situation in Uzbekistan, where homosexuality is criminalised. Uzbekistan is one of the countries where we know that men undergo involuntary anal check-ups to identify whether they have had sex with men. Based on this torture, and it is clearly torture, they could be arrested and put in prison for several years.
What life is like depends on where you live but, in general, I would say that as a gay man you are very likely to experience discrimination and most countries do not have legal protection such as the so-called ‘hate crimes’ that are commonly recognised in western Europe.
However, the LGBT community itself is very supportive. People tend to help one another and build very close and fantastic communities together. I am a huge fan of the organisations in Kazakhstan and Kyrgyzstan, because they manage to build this very broad, very diverse group of people into a supportive, beautiful community. They stay together, supporting one another, in very challenging settings.
I’ve lived in Russia and in various places in central Asia and one thing people always talk about is finding a ‘friendly’ doctor, in the sense of someone who is friendly towards the community. Wherever you go, there are medical professionals who are not sensitised enough to LGBT health issues.
Communities often see people in medical settings as representatives of the state. If you have repressive state institutions, then you may view a doctor in a public clinic as a potential enemy and not an ally. It is not necessarily the case, but it makes access to services harder than in a trusting environment.
Of course in western Europe, doctors might not be sensitive – it’s a common problem around the world. But you would not expect this from a doctor, and if you faced some kind of discrimination, you would know what to do. You know that you can report this, and you could expect the state to be on your side, to protect your rights, whereas in eastern European countries, this is not the case, and actually it might be quite the opposite.
What are the challenges for organisations working in the region to support LGBT health?
Clearly the biggest challenge is financial. Not every country is willing to outsource services to community-based organisations. At ECOM, we try to explain to governments that community-based organisations know what to do – people who are actually from the community and have a certain amount of lived experience know what to do better than anyone else. We advocate for outsourcing prevention work, at least partially.
Quite a lot of organisations in our region are financed by external donors, for example the Global Fund. An important question is how to maintain the sustainability of services without that funding.
For example, in Kazakhstan, the situation is getting better and better. They have a beautiful project, the Almaty ‘Model City’, which is financed by the Elton John AIDS Foundation. It implements best practices to reach key populations. They collect evidence to communicate results to the government and we have already seen examples where the government has supported services as a result.
On the other hand, we see in the Russian Federation that the government has completely refused to give any resources to organisations for HIV prevention.
Another challenging area is the legal environment. Some countries, such as Ukraine and Moldova, are happy to have new organisations registering and doing work in HIV prevention, and also in human rights and advocacy.
But in other countries, for example Kyrgyzstan, organisations may find they are prevented from officially registering. We heard from a trans initiative that would like to register as an organisation but the government refuses them this opportunity. If you don’t have official status as a legal organisation, you can’t make an application for grant funding, or to provide services.
Russia also attempts to influence countries across the region, in some cases trying to force other countries to adopt similar laws to Russia. In Georgia, people went out on the streets to protest the ‘foreign agents’ law, which would impact organisations receiving funding from abroad, and fortunately it was postponed. But I’m not that positive when it comes to other countries with closer relationships to Russia. If these laws pass, it would make life really hard for organisations, because many receive money from international organisations.
What are some of the success stories in EECA?
There has been a lot of progress implementing HIV PrEP in the region. Since the 2019 PrEP in Europe Summit in Poland, things have significantly improved. At the time, just three countries had PrEP: Ukraine, Moldova and Georgia. Now, only two countries don’t have PrEP: Turkmenistan and Russia.
The undisputed leader is Ukraine. Even with the war there, we have seen an incredible scaling up of PrEP and it shows the strength of the services there, built over decades. This is something I think the world should learn from our region: that under the worst situations, people still manage to do the work successfully.
Another example is in Kazakhstan, where fully state-funded PrEP was introduced just two years ago and they have made significant progress, going from zero to over 2000 people accessing PrEP. It may not be a large number, but if you understand that context, where it’s hard to engage with the communities and impossible to do a promotional campaign in the streets, this is a great success.
As a researcher and a medical doctor, I’m happy to see that we have more research data coming from the region, and amazing research happening in Ukraine. There is the potential for an injectable PrEP project in Ukraine, and right now there is a project on long-acting opioid substitution therapy, which is really new. We definitely see an increase in leadership in the region too.
The EECA region is also doing interesting work around community led monitoring. There is an increase in interest among communities, an increase in the number of projects communities are involved in, and active interest from organisations who want to do this research and make use of the data. We are bringing evidence-based advocacy to the field, which is I think very important, and I find it personally very inspiring.
What are the health projects ECOM is working on currently?
We are working on the new round of the European MSM Internet Survey (EMIS), supported by Robert Koch Institute. ECOM is the regional representative of EMIS and is responsible for data collection in EECA.
We are also part of a big project financed by the Global Fund, called SOS Project 2.0. It is a regional initiative with many partner organisations.
ECOM is involved in three areas of the project. The first is advocacy around PrEP. We work on revising protocols, providing assistance to organisations and working in partnership with the World Health Organization (WHO) Regional Office in Europe. We work side by side with them to convince policymakers that they need to improve the existing PrEP protocols. My personal dream is that we will have community-based PrEP models introduced in our region.
Secondly, we support community-led monitoring under this project and there are activities planned in four countries this year.
We also worked on understanding where we are with the 95-95-95 UNAIDS targets for gay, bisexual and other men who have sex with men. Working on this gave us interesting insights, specifically for gaps we need to fill. The major gap in the region is for testing.
For more information on ECOM, visit: https://ecom.ngo/
This feature first appeared in the July 2023 edition of the Sexual Health and HIV Policy Eurobulletin.