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Rapid Responses: Rapid Responses published:
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How low can you go?
- Woody Caan (23 July 2005)
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Strengthening the response to the HIV epidemic in Ukraine: positive sides of economic transition
- Slava Kushakov (15 August 2005)
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Woody Caan, Professor of public health APU, Chelmsford, Essex CM1 1SQ.
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DeBell and Carter's excellent education piece about the Ukraine illustrates the vital importance of coherent public health planning, based on reliable evidence [1]. These factors are not just relevant to Eastern Europe: if the pessimistic Foresight projections of 1 million British 'problem' drug users in 2025 [2] are not prevented here, then similar levels of 10,000 cases of HIV infection will be seen in this UK population, to the Ukrainian infections reported in 2003 [1]. Hepatitis C is more readily spread than HIV, and the Foresight projection gives 350 - 400,000 drug users infected with HCV by 2025. Today, Britain is much more prosperous than Ukraine, but imagine the impact on our economy of £36 billion per annum illicit drug costs, in 2025 [2]. Even in Cool Britannia, 'corruption', a 'cash economy' and low investment with a low tax revenue [1] would flow from this massive distortion of the economy. Let us step back and consider the nature of heroin dependence. In small UK communities making difficult transitions, for example with the collapse of fisheries [3], opiate use in young men rises. Even transient poverty and poor prospects rapidly fuel drug use. As the new Foresight Overview puts it, 'low social status increases vulnerability to addiction' [4]. In family systems we are used to the concept of Circular Causality, e.g. a social transition downwards drives drug use that increases social exclusion that increases economic inequalities that drive drug use that accelerates downwards transition.... The blood-borne viruses lop off young branches of the family tree, making the system even more constrained to spiral down. The answer is to disconnect at least one stage of the loop, for example to reduce social exclusion of people with drug problems. The UK Treasury initiative on "Vocational Rehabilitation" offers a golden opportunity to improve the employment prospects of drug users (and people with HIV). A similar opportunity, during the present British moral panic about "Hoodies" and anti-social youth, is not to demonise teenagers but instead to celebrate the potential of young people at every occasion. 1 DeBell D, Carter R. Impact of transition on public health in Ukraine: case study of the HIV/AIDS epidemic. BMJ 2005; 331: 216-219. 2 McKeganey N, Neale J, Lloyd C. Sociology and substance use. State of Science Review, for Drugs Futures 2025?. London: Department of Trade and Industry, 2005. 3 Caan W. The nature of heroin and cocaine dependence. In: W Caan, J de Belleroche (eds) Drink, Drugs and Dependence. From science to clinical practice. London: Routledge, 2002. 4 Foresight. Factors affecting vulnerability to addiction. In: Drugs Futures 2025? Executive Summary and Overview. London: Department of Trade and Industry, 2005. Competing interests: Briefed the Ukraine team on young people's drug use in 2003. |
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Slava Kushakov, Senior Programme Officer: Ukraine, Eastern Europe and Central Asia International HIV/AIDS Alliance, Queensberry House, 104-106 Queens Road, Brighton, BN1 3XF, UK
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We would like to respond to the recent article by DeBell and Carter [1], based on the International HIV/AIDS Alliance’s five years of experience working in Ukraine on HIV/AIDS prevention and, more recently, acting as a steward for the implementation of the grant awarded to Ukraine by the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM). The authors’ main argument appears to be that transition has undermined public health systems and that this is evidenced by Ukraine’s failure to respond effectively to the HIV/AIDS epidemic. Although the transition did affect the health system enormously, one might question whether the old unreformed systems would have had more success in controlling the epidemic. The Soviet system’s capacity to reach the most vulnerable communities was perhaps even less appropriate – the current growing access these populations have to prevention and care services is largely being achieved through the development of the non-governmental sector stimulated by the process of transition. While the Ukrainian response to the HIV epidemic is not free from challenges, neither is it non-existent nor completely inappropriate. Ukraine has made significant achievements in its HIV/AIDS programming and these should be acknowledged and used as a basis for future scale-up and development. It may be argued that although public health systems in transitional countries are facing multiple challenges and still perform some of their functions less effectively than during the Soviet era, these states are beginning to respond effectively to HIV/AIDS and demonstrate achievements that would be highly unlikely within the old unreformed settings. In the case of Ukraine this is particularly evident in the following three areas: 1. Greater openness to recognise factors driving the epidemic. Since the mid-1990s international organisations as well as government bodies and departments (most importantly the system of AIDS Centres) have acknowledged that unsafe injecting drug use is the key driving force of the HIV epidemic in Ukraine. Efforts of enthusiastic activists from international organisations, local non-governmental organisations (NGOs) and governmental agencies have influenced the development of several consecutive National AIDS programmes. These have been fairly progressive documents outlining complex packages of prevention and (later) care measures – including activities aimed at reducing drug-related harm. Ukrainian AIDS-related legislation includes favourable provisions for activities which aim to reduce drug-related harm. On the other hand the acute contradictions between Ukrainian AIDS- related legislation and drug policies have been pointed out by many. The negative implications of these on HIV/AIDS-related interventions are further complicated by the relatively insignificant influence of HIV policies compared to drug policies. Commitment is needed to promote policies conducive to effective responses to AIDS at a higher political level. This commitment is difficult to get from a new government which is seeking to boost its popularity. Liberal drug policies don’t have sufficient support among the general public – despite the fact that they have shown in many countries to facilitate effective responses to the HIV epidemic [2]. However this lack of political commitment and resistance to international good practice with proven effectiveness is not an exclusive feature of transitional countries and can be found in the developed world. Unsubstantiated claims that the epidemic is entering a generalised phase with sexual transmission becoming a predominant factor have long been part of official rhetoric at national and international levels, despite recent research indicating that the overwhelming majority of transmission cases classified as heterosexual or perinatal were directly linked to unsafe injecting drug use by partners and parents of those living with HIV. The generalisation rhetoric supports inappropriate distribution of AIDS funding within the state budget [2], as well as some of the external funding sources. It should be stressed that unsafe injecting drug use remains the predominant and the most significant mode of transmission in Ukraine and is likely to remain such in the near future. There is also enough research data (including patchy but still available sentinel surveillance studies) demonstrating extremely high prevalence of HIV in injecting drug users, sex workers and prison populations. Lack of political will and resources rather than a lack of surveillance data is the main obstacle to scaling up focused prevention activities. 2. Starting effective programmes of ARV treatment, HIV prevention among drug users, and surveillance methodologies. Undoubtedly, HIV prevention measures among injecting drug users, while in existence, need to be significantly scaled up to reach sufficient numbers of drug users with quality prevention and care services. But a good base for this kind of scaling-up does already exist in Ukraine. The first project aimed at reducing drug-related harm in Ukraine was introduced as early as 1996, with one new project added the following year and 12 more projects launched the year after. Today there are over 40 projects working on HIV prevention among injecting drug users with most of the financial support coming through the ‘Overcoming the HIV epidemic in Ukraine programme’, supported by the Global Fund to fight AIDS, Tuberculosis and Malaria. Nearly 50,000 injecting drug users and about 5,000 sex workers are reported to be accessing the prevention and care services provided by the projects. Most of these projects are being implemented by local NGOs and are considered to be of a relatively high quality for the Eastern Europe and Central Asia region. The projects operate in a more challenging environment than in most developed countries where there is a complex infrastructure and variety of services available to drug users. Underdevelopment of such services in Ukraine puts additional pressure on HIV prevention projects which are expected to fill the gaps in all the service areas while experiencing serious funding constraints. Nevertheless the projects are constantly developing the range and scale of their services [4]. Another developing area in Ukraine is access to anti-retroviral treatment for people living with HIV. This was first introduced in the late 1990s and was significantly scaled up through the Global Fund supported programme. 1,452 people are currently receiving anti-retroviral treatment, with treatment available at clinical facilities in the 15 most affected regions of Ukraine. It is planned to expand this to several additional sites, making treatment available to at least 5,000 people by the end of 2008. One of the challenges here is the lack of programmes to facilitate treatment adherence in HIV positive injecting drug users, who are the overwhelming majority of people in need of anti-retroviral treatment. Again the development of such services is hindered by conservative political forces, most notably law enforcement agencies. 3. Recognition of the roles of different organisations in building an effective response which goes beyond the public health sector and involves donors, international organisations, government agencies and NGOs. The National AIDS Programmes now acknowledge the contribution of other sectors of society and are rightly perceived as not solely state implemented or state funded endeavours. A good example of this approach – and unprecedented in Ukraine – has been the inclusive and transparent process of multi-sectoral collaboration of stakeholders during the development of the request for continued funding from GFATM for further implementation of ‘Overcoming the HIV/AIDS Epidemic in Ukraine’. This programme relies on the partnership of over 100 implementing institutions representing a variety of sectors and technical directions of HIV/AIDS prevention and care work. Cooperation between public health care facilities, non-governmental organisations working on AIDS and communities of positive people at the national as well as local level were among the key factors that allowed for the continuing scale-up of anti-retroviral treatment. Ukraine is also one of the leading countries of the region in terms of the level of involvement of the community of people living with HIV/AIDS in the development and implementation of the national response to the epidemic. This involvement includes active participation of positive people as members of the variety of regional as well as national coordinating bodies including the recently reconstituted national coordinating council on HIV/AIDS, as well as the growing network of community level care and support initiatives throughout the country. Ukraine’s PLHA groups also provide appreciated technical support to their counterparts in other countries of the former Soviet Union. REFERENCES: [1] DeBell D, Carter R. Impact of transition on public health in Ukraine: case study of the HIV/AIDS epidemic. BMJ 2005; 331: 216-219. [2] Recent debates around the introduction of substitution maintenance treatment as a key factor in ensuring access to anti- retroviral treatment for HIV positive injecting drug users demonstrate ambiguities around the government’s support of international good practice in the area of HIV prevention and care. This is particularly the case with politically sensitive issues, such as those related to drug policies. There is even some risk of regression to counterproductive policies in the new government’s search for public popularity. Supporting conservative drug policies is more likely to win votes and strengthen the government at the upcoming parliamentary elections next year. National drug policies may also be influenced by Ukraine’s foreign relations. At the initial stages of the Ukrainian HIV epidemic most injecting drug use involved home made opiate concoctions. International black market imports were, and remain, a relatively insignificant source of illicit injectable substances. Another significant group of substances has been ephedrine-based stimulants. More recent anecdotally evidence is the growing trend among younger substance users of preparing injectable solutions from over the counter pharmaceutical products. All of these patterns involve the use of locally available ingredients and home production of the drug, often in small quantities for personal or small group consumption. These patterns present extra challenges for drug policies in Ukraine and increase the temptation to enforce repressive drug policies affecting individual drug users rather than large scale drug traffickers. [3] One important feature of the Ukrainian response (which can also be found in most of the countries of the former Soviet Union) is the acute lack of investment in HIV/AIDS-related public health interventions. Thus the activities aimed at preventing HIV among injecting drug users have traditionally been funded from international sources, with the share of government funding slowly increasing but from a very low base. The structure of the state budget allocations for HIV/AIDS work is also influenced by the prevailing understanding of priorities which are built on moralistic arguments and public perceptions rather than on the evidence, international good practice, and the nature of the Ukrainian HIV epidemic. Most of the state funding is allocated to epidemiological surveillance, blood safety measures, and modest contributions towards anti -retroviral and other related treatment – with an almost complete lack of investment in focused prevention activities among the vulnerable communities that are key to the epidemic dynamics in the country. [4] Among the most recent developments is a conscious strategy to integrate prevention and care services recognising the significant overlap between the drug user population and the community of people living with HIV/AIDS in Ukraine. Competing interests: None declared |
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