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Prevention and Treatment
in Eastern Europe
by Kasia Malinowska-Sempruch,
photography by Ilse Frech
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Those who have worked in the
area of HIV prevention in Eastern Europe and the former Soviet
Union (fSU) have spent well over ten years talking about the
social, economic, and human factors that make these countries
susceptible to HIV. Now, in 2003, we no longer speak of what
may be: HIV and AIDS have arrived and, as everywhere else,
the virus is causing devastation.
For three years in a row
UNAIDS has reported that HIV is growing faster in Eastern
Europe and the fSU than anywhere in the world. Today, there
are 235,000 registered HIV infections in Russia with the total
number of people living with HIV estimated to be much higher—up
to 1.5 one million.[1]
The situation is equally dire in neighboring Ukraine, where
close to 1% of the adult population is estimated to have HIV.[2]
This is startling in a region where countries had few, if
any, HIV/AIDS cases before 1995.
The meteoric rise in HIV/AIDS
cases in this region began with an outbreak of HIV in Ukraine
and Belarus in 1995, followed by outbreaks in Moldova in 1996
and the Russian Federation in 1998. Although case numbers
remain relatively small in other European and fSU countries,
growth rates have increased tremendously during the same time
period. In 1999, Estonia reported 12 cases of HIV, by 2001
this number increased to 1474; in 1997 Latvia reported 25
new infections, in 2001 they reported 807.[3]
Unlike in most other regions,
HIV in Eastern Europe and the fSU is spreading primarily through
injection drug use. Economic despair, social dislocation,
and easy access to heroin and other opiates en route from
Afghanistan have all contributed to an explosion of drug use
in the region. For many of these countries, IDUs comprise
the majority of registered HIV/AIDS cases. In the European
Newly Independent States (Russia, Moldova, Belarus and the
Ukraine) IDUs account for 88% of HIV/AIDS cases, while in
the Baltic States (Estonia, Latvia, and Lithuania) they account
for 80.1% of all cases. Even in countries with a longer history
of HIV/AIDS, drug users continue to be among those most affected.
In Poland, a country with one of the most mature HIV epidemics,
drug users account for 62.5% of all cases.[4]
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Above and left:
Moscow, Russia 2002. Misjakoetis—Children's Department
at Orechovo-Zoejevo.
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Repressive drug policies in
the region fuel the HIV epidemic. Injecting drug users receive
little or no sympathy from the general population and even
less from governments that favor confinement over treatment.
Drug users are sent to overcrowded prisons where needles are
shared and HIV rates are surging at an even faster rate than
among the population at large. In Russia alone, more than
one-sixth of all registered HIV cases are people in prison.[5]
Potential for such pockets of infection among drug users both
in and out of prison are ripe. In Lithuania, a country previously
regarded as having the lowest prevalence of HIV in Europe,
321 cases of HIV were detected between May 1 and August 20,
2002 almost doubling the number of previously recorded cases.[6]
Of these 321 cases, 284 were located in one closed prison
facility.
Halting the spread of HIV
among drug users requires entirely new ways of thinking. Clearly
these pockets of infection must be addressed. National and
local governments must implement flexible and caring health
policies that focus on helping drug users, not punishing them.
In the context of drug users, harm reduction is the most humane
and realistic way to stem the spread of HIV.
One key element of most harm-reduction
programs is needle exchange. Hundreds of studies around the
world have shown that providing injecting drug users with
access to clean needles greatly reduces needle-sharing and
thus HIV infection. The World Health Organization (WHO), the
American Medical Association, UNAIDS and many others consider
provision of clean syringes to be an effective and necessary
method of preventing HIV transmission among injecting drug
users.
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Right and below—
Moscow, Russia 2002.
Children's Home #7.
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Treatment programs that offer
methadone and other substitution therapies are another vital
part of harm reduction efforts. Unfortunately, rigid and repressive
drug policies in many countries mean that such programs are
few and far between. In Russia, for example, substitution
treatment is not available. Ukraine, on the other hand, recently
took a promising step when they registered methadone.
Along with HIV prevention
we must also work with those already infected, including drug
users, to provide treatment options. Treatment options in
this region are scarce. In 2001, less than 1000 of the estimated
1 million people living with AIDS in Eastern Europe and the
fSU were receiving antiretroviral treatment.[7]
The situation is especially bad for HIV-infected drug users,
who are often placed last on the list of those in line for
antiretrovirals, are required to stop methadone in order to
gain access to HIV treatment, or are denied antiretrovirals
altogether.
In this bleak picture there
are signs of hope. In the first two rounds of proposals, grants
from the Global Fund to Fight AIDS, Tuberculosis and Malaria
have approved over US$120 million in funding for the region.
These funds will be used for the prevention, treatment, care
and support of people infected and directly affected by AIDS
and tuberculosis. Projects funded will increase access to
health services; provide critical health products including
antiretroviral drugs; train personnel and community health
workers; conduct outreach and create community-based programs.
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While Global Fund resources
are much needed in the region, these resources are but a very
tiny step in the right direction. Pilot programs are simply
not enough. One methadone program in Bulgaria (where methadone
has been legal for over five years) is not enough to stem
an HIV epidemic. Large-scale interventions must be implemented.
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There are no easy solutions
to the AIDS epidemic in Eastern Europe and the former Soviet
Union—or in any other region of the world. But this does
not mean that people in the region or elsewhere can allow
themselves to shy away from making difficult decisions—financially,
culturally, or morally—about how to address it. Violence
at the hands of police, denial of public services, imprisonment
that destroys health and breaks the spirit, so-called “drug
treatment” that humiliates clients and their families…
all of these human rights abuses experienced by drug users
not only make for a repressive society but also fuel the HIV
epidemic. If the world is unable or unwilling to turn its
attention to this region and offer help in dealing with this
looming disaster, the consequences will be horrific.
Reprinted with permission
from IATEC UPDATE, the magazine of the International
Antiviral Therapy Evaluation Center, located at the University
of Amsterdam, the Netherlands. Visit www.iatec.com.
Malinowska-Sempruch is director of the International Harm
Reduction Development Program for the Open Society Institute,
in New York City.
Photographer Ilse Frech
is from Amsterdam, and has participated in the World Press
Photo’s Joop Swart Masterclass. Frech’s recent work
will be shown on their website, http://www.worldpressphoto.nl,
starting November 2003. Ilse Frech can be contacted via e-mail,
ifrech@xs4all.nl.
References
[1]
CanWest News Service. “HIV-AIDS spreads rapidly
in Russia.” Edmonton Journal 19 April 2003, final ed.:
A11
[2]
UNAIDS. Fact Sheet: HIV/AIDS in Eastern Europe, Central
Asia. 03 July 2002. Available at: http://usinfo.state.gov/topical/global/hiv/02070304.htm
[3]
UNAIDS. Fact Sheet: HIV/AIDS in Eastern Europe, Central Asia.
03 July 2002. Available at: http://usinfo.state.gov/topical/global/hiv/02070304.htm
[4]
Central and Eastern European Harm Reduction Network, Injecting
drug users, HIV/AIDS Treatment and Primary Care. July 2002.
Available at: http://www.ceehrn.lt/EasyCEE/sys/files/CEE-HRN.EN.pdf
[5]
“Russia’s HIV epidemic attributed to jails,”
Corrections Professional 7 (Vol. 7, No. 20, July 26, 2002).
[6]
UNAIDS (2002). Report on Outbreak of HIV Infection
in the Lithuanian Prison System Assessment of the Situation
and the Developing Response. Vienna, UN AIDS Vienna Team.
[7]
UNAIDS (2002). Report on the Global HIV/AIDS Epidemic, 2002.
Geneva, The Joint United Nations Program on AIDS.
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