HIV and AIDS in Russia, Eastern Europe and Central Asia

Around 1.5 million people in Russia, Eastern Europe and Central Asia were living with HIV in 2008, 110,000 of whom became infected that year, with 87,000 dying of AIDS.¹ It is estimated that over two-thirds of the area’s infected people live in Russia, and combined with Ukraine, these two countries account for 90% of the region’s total infections. Both countries also have some of the highest adult prevalence rates in the region, with 1.6% of Ukrainians and 1.1% of Russians infected. Significant numbers of people with HIV live in Belarus (13,000), Kazakhstan (12,000) and Uzbekistan (16,000) among other countries, with prevalence rates in Latvia (0.8%) and Estonia (1.3%) also being some of the highest in the region.

Since 2001, HIV prevalence in Russia, Eastern Europe and Central Asia has roughly doubled, making the region home to the world’s most rapidly expanding epidemic. In contrast, over the same period, prevalence in sub-Saharan Africa fell from 5.8% to 5.2%, and stabilised in South and Southeast Asia at 0.3%.²
This page focuses on the 15 former Soviet republics that constitute the Caucasus (Georgia, Armenia and Azerbaijan), the Baltic states (Estonia, Latvia and Lithuania), Central Asia (Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan), as well as Ukraine, Belarus, Moldova and Russia.

Affected populations

The regional epidemic is currently concentrated among injecting drug users (IDUs), sex workers and their sexual partners.

Drug users

The rise in HIV in the region is closely linked with increasing rates of injecting drug use that developed in the mid-1990s during the socioeconomic crisis that followed the break-up of the Soviet Union. At this time, nearby Afghanistan became the world’s largest producer of opium, from which heroin is derived, and drug trafficking increased throughout the region. Initial outbreaks were detected in Ukraine, Russia, Belarus and Moldova.³

Injecting drug use paraphernalia in Russia

Sharing of contaminated drug taking equipment is a highly efficient way to transmit HIV, and over 60% of newly reported HIV cases in 2006 were attributed to injecting drug use. In Russia, which has an estimated 1.5 million to 3 million, mostly male, IDUs, this accounts for 83% of all infections among people who know their infection history, though only 65% of new cases in 2007 were caused this way. Nearly 12% of Russian IDUs are HIV positive.⁴ A joint study by UNAIDS, WHO, the International HIV/AIDS Alliance in Ukraine and the Ukrainian Ministry of Health estimated the HIV prevalence among IDUs as somewhere between 17% and 70%.⁵ The infection rate among IDUs in Estonia has been estimated as being as high as 90% with around one-fifth to one-quarter of IDUs being infected in Tajikistan, Azerbaijan and Latvia.⁶ Georgia, Lithuania, Bulgaria and Kazakhstan have lower rates of IDU infection relative to the rest of the region.⁷
While incidences of new HIV infections among IDUs in Russia decreased between 2002 and 2006, many countries in the region experienced rapid increases. Ukraine experienced a 55% increase; Kazakhstan, a 132% rise; with Azerbaijan seeing a 377% increase in the number of new infections among IDUs. On a positive note, significant decreases were seen in Belarus, Estonia, Latvia and Lithuania.⁸

Sex workers

Sex workers are at risk of HIV because of the overlap with injecting drug use as well as unsafe sexual behaviours including low contraception use and multiple sexual partners. Nearly four-in-ten female sex workers in Russia’s Samara region and St Petersburg used injecting drugs.⁹ In Ukraine, HIV prevalence among sex workers ranges from 4% in the capital, Kiev, to 24% in Donetsk and 27% in Mikolayev. Uzbekistan has a 10% infection rate among sex workers, similar to the prevalence in Azerbaijan, and likely explained by low condom use. The infection rate among sex workers in Tajikistan’s capital, Dushanbe, and the second city, Khujand, leapt from 0.7% to 3.7% between 2005 and 2006. Other countries in the region have showed relatively low prevalence rates among sex workers.¹⁰
HIV knowledge among Russian sex workers is low with just 36% rejecting popular misconceptions and correctly identifying how sexual transmission can be prevented. The same proportion answered correctly in Kazakhstan, with fewer than a quarter able to do so in Lithuania.¹¹

Sexual partners of risk groups

Posters promoting condom use in Tallinn, Estonia

Partners of IDUs and sex workers are at risk of becoming infected through sexual transmission. Heterosexual contact, which accounts for nearly two-thirds of infections in women in Russia, accounts for an ever-growing proportion of new infections. In 2000, women comprised 20.6% of new infections; in 2003, this figure was 38.5%; and in 2007, the proportion had grown to 44% or 135,000.¹² In Ukraine, the growth of heterosexual transmission as a proportion of total HIV incidences between 2001 and 2006 (28% to 35%) is largely attributable to unprotected sex with an injecting drug user.¹³ Regionally, half of HIV-positive women became infected by drug using partners, with a further 35% infected directly through needle sharing.¹⁴
Fewer than 1 in 200 (0.46%) pregnant women in Russia in 2006 were HIV positive. The proportion of tested pregnant women being diagnosed HIV-positive, which saw a very steep rise between 2000 and 2001, has levelled off and all pregnant women are advised to take a test.¹⁵
UNAIDS states that it is unlikely the regional epidemic will spread independently of transmission among injecting drug users and sex workers.¹⁶ Similarly, another study states that even in countries that have prevalence rates of 1% or more, “the virus is still concentrated among injecting drug users and their sexual partners, and has not ‘bridged’ into the general population.”¹⁷

Other affected groups

Prisoners

As with sex workers HIV levels are prevalent in prison populations because of the over representation of injecting drug users. Furthermore, IDUs in prison are more likely to have HIV than those who inject among the general population, suggesting that risky injecting behaviour is more frequent inside prison.¹⁸
Precise information on patterns of HIV in prisons is hard to obtain, especially from lower and middle-income countries which dominate the region.¹⁹ In Russia, over 10% of all new HIV diagnoses in Russia during 2006-2007 were registered to prison populations. Overall prevalence in prison is estimated at around 5% with the majority of inmates already infected before entering.²⁰ In Ukraine, 3.5-12% of prisoners are estimated as living with HIV. Once again, this is attributed to high levels of injecting drug use and men who have sex with men.²¹ Estonia, which has one of the highest imprisonment rates in the European Union, has a 14% prevalence rate among prisoners.²² The potential danger that prison conditions pose to drug users is indicated in an HIV outbreak in Lithuania’s Alytus prison in 2002 that infected 263 inmates, almost doubling the nation’s total epidemic.²³ This highlights that although HIV rates in prison are often concentrations of the epidemic among free populations, prison can create fertile breeding grounds for HIV independent of a country’s general trends.

MSM

Official figures show that men who have sex with men (MSM) are a relatively small proportion of total HIV cases in the region in comparison to Western European and North American nations. Unprotected male-to-male sex accounted for less than 1% of newly registered cases in Russia in 2006, where the route of transmission was known.²⁴ Prevalence rates among MSM range from 9% in the large city of Nizhni Novgorod to 4.6% in Yekaterinburg, 3.8% in St Petersburg and under 1% in Moscow.²⁵ An MSM prevalence rate of 11% was reported in Tashkent, Uzbekistan’s capital, and 1% in Kyrgyzstan.²⁶
However, it is believed that the epidemic is thriving among this group but is being kept hidden and underreported due to a reluctance by MSM to reveal the cause of their infection for fear of stigmatisation.²⁷ In Ukraine, for example, estimated HIV prevalence among MSM ranges from 4.4% in Kiev to as high as 23% in Odessa despite just 110 cases having been officially reported since 1987.^28 29 It is believed by some that the underground epidemic among MSM has been allowed to escalate due to very little funds targeting this group:

Governments everywhere are reluctant to spend money on sex workers, on drug users, but MSM comes at the top of the reluctance list. It is probably the last programmes that the governments will start. - Roman Gailevich, UNAIDS Regional Programme adviser³⁰

In a survey of nearly 3,700 MSM in Russia only 31% of those in a monogamous relationship always used condoms, with just 61% of MSM who only have casual sexual partners always using condoms. Just 2.7% had injected drugs – slightly more than the upper estimate of 2% in the general population - highlighting that the spread among MSM is largely, though not completely, separate from injecting drug use.³¹

Prevention

Given that injecting drug use accounts for the overwhelming majority of HIV prevalence and new diagnoses, the availability of needle exchanges and drug substitution therapy is vital if HIV is to be effectively tackled. Additionally, information regarding safer sex is also necessary to ensure the epidemic does not bridge to wider populations. Services to prevent the spread of HIV among IDUs are inadequate and it is estimated that just 9% of injecting drug users at best utilise harm reduction programmes.³²

Russia

There are just 69 needle exchange programmes in Russia to cover as many as 2 million IDUs and UNAIDS estimated in 2005 that just 5% of all IDUs had access to such preventive measures.^{33 34} Despite this, the government cut its funding for needle exchanges from 15 programmes in 2006 to just 3 in 2007. Of the $289m in state funding for HIV just $7.75m was allocated to prevention. The bulk of what little harm reduction measures there are has therefore been left to bodies such as the Global Fund to Fight AIDS, Tuberculosis and Malaria implemented through NGOs including the Russian Harm Reduction Network and the Global Efforts Against AIDS in Russia (GLOBUS) consortium.³⁵ Under its normal funding guidelines, the Global Fund would not provide support for prevention programmes in Russia due to the country having attained a certain degree of economic development. However, due to the government's continued refusal to adequately fund prevention programmes for sex workers and injecting drug users, the Fund felt compelled to extend funding for these programmes until 2011.³⁶

There are few needle exchange programmes in Russia.

Drug users are heavily stigmatised in Russia and often come into contact with the law, driving them away from initiatives that could avert the risk of becoming infected. There are reports that IDUs have been harassed and arrested by police outside needle exchange programmes and pharmacies where they have bought syringes, a practice that further deters other drug users from accessing them.³⁷ One survey of police attitudes in Togliatti, a city with high HIV prevalence - 2.7% among the general population, with over half of IDUs found HIV positive in 2001 – found the pre-emptive, intensive surveillance approach towards drug users, and the belief that they are potential criminals, undermined the city’s harm reduction initiatives.³⁸ Another study of the same city found the odds of needle sharing among IDUs increase if they were last arrested for a drug offence.³⁹
Substitution therapy, which provides IDUs with a legal opiate – methadone or buprenorphine – so users can avoid the risks of injecting, does not exist in Russia. A vigorous debate has occurred over whether this form of harm reduction should be legalised. In 2005, leading figures in the government and scientific community, including the deputy director of the Department of Corrections, the chair of the Russian Society of Psychiatrists and the director of the National Center on Addictions, authored a memorandum entitled “Say No to Methadone Programs in the Russian Federation”. The letter, which presented evidence against the measure, was printed in Russia’s Medical News and Issues in Narcology, and distributed throughout the region. The following year, a rebuttal by over fifty HIV and addiction experts from around the world was sent to the memorandum’s authors highlighting its errors and pointing to the scientific evidence supportive of such treatment:

“Methadone is currently being administered to more than 750,000 patients in more than sixty countries, including all twenty-five members of the European Union. The medication has been proven to reduce illicit opiate injection and criminal activity, and to decrease HIV risk and increase adherence to HIV medication. “The errors in your memorandum are all the more alarming since methadone’s effectiveness as an HIV prevention measure is of particular importance in Russia, where eighty-five percent of cumulative registered HIV cases were among injecting drug users.  Failure to provide a lifesaving means of drug treatment will mean more HIV infections and lives lost.”⁴⁰

Substitution therapy’s illegal status can in part be explained by Russia’s attitude towards drug addiction and drug users. Practices to tackle drug use are defined by ‘narcology’, a subspecialty of psychiatry originally developed in relation to alcohol addiction. One heavy critique of this approach is that treatment for drug addiction in Russia is seen only within the bounds of ‘cure’ or ‘failure to cure’. This ignores the most effective practice of pursuing multiple outcomes, not just abstinence, including reductions in injecting and exposure to HIV and other blood-borne viruses.⁴¹ Instead of relying on the scientific evidence of harm reduction measures to treat drug addiction, Russian policy towards drug users emphasises criminalisation. “[A]s in the US, mass incarceration of drug users in Russia, under brutal conditions, produces a set of predictable adverse results for the individuals affected, and enables the continued spread of HIV throughout the general population.”⁴²

“Conditions within drug treatment facilities in Russia remind more of prisons than hospitals”

Vitaly Djuma, Executive Director, Russian Harm Reduction Network

Detoxification and psychotherapy at state-run narcological dispensaries – health centers focusing on problematic drug and alcohol abuse – are the primary methods of treating drug addiction.⁴³ One study found this to be largely ineffectual with over half returning to drug use after one month, and 96% returning after two years. These poor results are despite the willingness of addicts to quit, with one study showing 91% of IDUs having tried once, and 64% attempting to quit at least five times.⁴⁴
In December 2006, a fire at a Moscow treatment unit killed 44 HIV-positive women and two nurses trapped behind barred doors and windows. This was seen by some as reflective of an inhumane and repressive attitude towards drug users.⁴⁵ One leading Russian harm reduction advocate went so far as to say, “Conditions within drug treatment facilities in Russia remind more of prisons than hospitals.”
Standard addiction therapy also does not offer sexual behaviour counselling to drug users, a vital component as heterosexual transmission occurs largely between IDUs and their partners. One study found sexual practices were likely to be safer when IDUs were offered sexual behaviour counselling at the same time as receiving addiction treatment.⁴⁶

Ukraine

Ukraine appears to have some of the most developed prevention programmes in the region with 46% of IDUs and 69% of female sex workers accessing at least one prevention service in the previous 12 months.⁴⁷
There are an estimated 362 needle exchange sites in Ukraine including fixed, mobile and street-based units. It is also one of only two countries in the region that has both pharmacy-based and non-pharmacy-based needle exchanges. Each year the country distributes 80 sterile needles per IDU, the highest in the region.⁴⁸ The Global Fund is aiming for 65% of IDUs to follow safer injecting and sexual practices by 2012, up from 53% in 2006.⁴⁹

World AIDS Day 2002 activities in the Ukraine

Provision of opiate substitution therapy began in 2004 with IDUs receiving buprenorphine. In 2007, the Ministry of Health made methadone legal, and relaxed the criteria regarding who could receive such treatment. The Global Fund hopes to reach 11,000 IDUs with substitution therapy by 2011.⁵⁰
Despite Ukraine’s generally positive approach to prevention, relative to much of the region, there remain barriers that IDUs face. As in Russia, similar problems exist regarding police harassment and arrests of IDUs trying to access needle exchange services.⁵¹ Furthermore, drug users wishing to receive substitution therapy are placed on an official register that can be used to exclude them from certain professions, and information is often shared between medical and law enforcement institutions.⁵² Such problems could deter other IDUs from using available services.

Central Asia

Little is known about the HIV situation in Turkmenistan, but of the other four countries – Kazakhstan, Tajikistan, Kyrgyzstan and Uzbekistan – all provide needle exchange services, with the latter two providing substitution therapy.
Kyrgyzstan has some of the most developed harm reduction programmes in Eastern Europe and Central Asia with clean needles being provided in prisons and pharmacies.⁵³ This is facilitated by cooperation between primary health care providers and NGOs to improve access and reduce the stigma of needle exchange programmes. Clean needles can be obtained in prisons as well as pharmacies. The Global Fund is promoting methadone substitution therapy, which is available in eight locations, and in three years has provided this to nearly 500 drug users. A pilot programme offering substitution therapy in prisons was scheduled to begin in 2008.⁵⁴
In 2007 over 40% of IDUs in Kazakhstan were reached by HIV prevention programmes, short of the more than 70% of sex workers and nearly half of MSM who were covered.⁵⁵ Around 65 syringes are distributed on average per IDU each year.⁵⁶ There have been moves towards providing substitution therapy, though as of 2009 there were just two small-scale pilot projects covering 50 people.
Harm reduction in Uzbekistan is fairly limited with needle exchange sites, where available, being under resourced and understaffed. Just over 100 IDUs were receiving substitution therapy – 90 on buprenorphine, 37 on methadone – in November 2007. Fewer than one-in-five IDUs were estimated to be reached by harm reduction services in 2006.⁵⁷ Needle exchange is also limited in Tajikistan. Promises to implement needle exchange in prisons, where one-in-five HIV-positive people live, have not been implemented; nor has methadone treatment.

Eastern Europe

Access to harm reduction services is fairly low in the rest of the region with, for example, around 14% of IDUs accessing needle exchanges in Armenia where injecting drug use accounts for half of all HIV infections. Just 10% had access to clean needles in Azerbaijan at the end of 2006. Only 17% of IDUs in Belarus accessed harm reduction services, with a slightly improved picture in Moldova where over a quarter did so.⁵⁸ Some harm reduction programmes, providing methadone maintenance in prisons, have been in place in the Baltic countries (Latvia, Lithuania, Estonia) since 2006 as a result of a United Nations Office on Drugs and Crime (UNODC) project.⁵⁹

Treatment

According to the World Health Organization just 23% of adults and children in need of antiretroviral therapy (ART) in low- and middle-income European and Central Asian countries were receiving it as of December 2008.⁶⁰ In 2007, only a handful of countries including Uzbekistan, Kazakhstan and Moldova provided antiretroviral (ARV) drugs to more than 20% of those in need. Ukraine has a particularly poor coverage rate at just 8%.⁶¹ Only 16% of adults and children with advanced HIV in Russia were receiving antiretroviral therapy in 2007, despite the treatment being free, though this figure increased roughly five percentage points each year since 2005.⁶² In Latvia, the 2009 financial downturn led the government to cut the HIV and health services budget and introduce a cap on the number of people who are provided with free antiretroviral treatment.⁶³
This means most countries in the region lag severely behind the 33% global coverage average in low- and middle-income countries and far below several African countries with severe epidemics including Botswana (79%), Zambia (46%) and South Africa (28%).⁶⁴
Because of stigma and doubts about adherence to therapy IDUs in Russia were only a quarter of those receiving ARV drugs in 2006, despite accounting for the majority of HIV infected people.⁶⁵ It has been projected that a strategy specifically targeting drug users for antiretroviral therapy would actually be a significantly more effective and cheaper method of preventing infection among all people, including non-IDUs.⁶⁶ This further highlights the great extent to which drug users will have to be involved in treatment and prevention efforts if HIV is to be tackled.
As Russia does not produce its own generic versions of antiretroviral drugs, unlike other large transitional countries such as Brazil and India, they can be costly to provide. The World Health Organization warned in 2006 that shortages of drugs and breaks in treatment, blamed also on bureaucracy, could lead to drug resistant strains of HIV developing and spreading.⁶⁷
One expert on Russian health has pointed to official Russian documents showing the number requiring ARVs is likely to multiply to more than 450,000 by the end of 2010, exceeding by as many as eight times the number requiring it in 2009. This is due to the average eight to ten years it takes for HIV infection to develop into AIDS, and taking into account that 2001 saw the highest number of new infections.⁶⁸ The official number of cumulative HIV cases jumped from 31,000 in 1999 to 228,000 in 2002 despite annual testing rates remaining at a fairly constant 15-17% of the population since 1990.⁶⁹
Perhaps insufficient levels of treatment should be considered in the context that the region has the world’s fastest growing HIV epidemic and that mechanisms for the provision of ART have not been able to keep pace with such rapid growth. Providing treatment for an ever-growing number of people is, in effect, like chasing a moving target. However, efforts to treat people need to be significantly stepped up if the situation is to be prevented from getting further out of control.

Attitudes and awareness

As in many regions of the world discrimination exists against people living with HIV. Given that the most at-risk groups in the region – IDUs, sex workers and MSM – are involved in what are viewed as socially unacceptable activities, this stigma is perhaps intensified. Peter Piot, former head of UNAIDS, has said stigma and discrimination against drug users and homosexuality in the region act as deterrents to seeking treatment, and according to the United Nations Development Programme (UNDP), most people living with HIV are more fearful of discrimination than they are of the negative health effects.^{70 71}
In 2004 a survey was conducted in Moscow which found that 7-in-10 people felt ‘fear, anger or disgust towards those living with the virus’.⁷² Similarly, a survey in Samara Oblast region found that ignorance and discrimination were widespread, even among health workers and family members. Many people were afraid that they could acquire HIV through casual contact; some suggested isolating all infected people from the rest of the population.⁷³
A United Nations Development Programme (UNDP) study of people living with HIV in the region examined the difficulties encountered in the areas of healthcare, education and employment. In the health sector, stigma and discrimination were borne out by substandard care, hidden expenses and sometimes denial of treatment. Negative attitudes among health professionals were believed to result from inadequate education, training and hospital resources to treat people with HIV. A lack of universal precautions and procedures in medical settings to guarantee staff safety also contributed to an unwillingness to treat people with HIV.⁷⁴
Adding to negative attitudes of people with HIV is the fact that, in Russia, patients are treated at AIDS centres which are segregated from the rest of the health care system, further marginalising those in need. This separation has also led to a disparity in HIV knowledge between AIDS specialists and nurses and doctors in the general health system, with the latter “shockingly ignorant of basic facts about the disease,” according to an article in The Lancet.⁷⁵

'HIV is NOT transmitted through sport' poster

The UNDP has found that teachers and school officials believe students with HIV would be discriminated against by their peers, and that parents of HIV-negative children would remove their children from the school if an HIV-positive child was enrolled.⁷⁶

“Yes, they are really dangerous. I think that such children [living with HIV] should not attend neither schools nor kindergartens as the other children will not be safe.” - Teacher from Georgia⁷⁷

In the same research, people with HIV said disclosing their status would be a hindrance to finding employment and would result in discrimination at work. Many people had therefore resigned themselves to unemployment or informal employment. Further, people with HIV in low-skilled jobs were considered more vulnerable to discrimination and firing. Adding to the problem is a lack of confidential legal action that could be taken in the event of unfair dismissal or discrimination.⁷⁸

"I know beforehand my status will certainly hinder the chance to get job or to be promoted… I do not search for a job as I think they will have a negative attitude towards me." - Person living with HIV from Georgia⁷⁹

Confronting negative attitudes is vital in order to encourage people to come forward for testing and treatment, and to ensure they do not infect others.

• A Miss HIV Positive beauty pageant was held in 2005 to mark World AIDS Day.
• A poster campaign was launched by UNAIDS and a Russian community group in 2004 featuring famous paintings alongside slogans such as ‘HIV is NOT transmitted through sport’.
• The Russian Media Partnership to Combat HIV/AIDS was launched in 2004, with sponsorship from over 40 media companies, and places public service messages across all Russian media. According to its website, 85% of Russians had seen its StopAIDS brand in 2008, and those who had done so were more likely to take preventive measures and be tested.⁸⁰
• Ukraine launched its own public information campaign in September 2005 with a World Bank-backed advertisement being broadcast daily for three months highlighting the fact that eight Ukrainians die of AIDS every day.⁸¹
• A mass campaign directed towards Ukrainian students in 2008 resulted in 15,000 free and anonymous rapid tests, and 100,000 receiving information on HIV and where they could be tested.⁸²
• Other awareness efforts include that of the UK government’s Central Asia HIV and AIDS Programme (CARHAP) that is providing £5.4 million in Kyrgyzstan, Tajikistan and Uzbekistan. As well as aiming to improve HIV services it is also addressing stigma and discrimination issues to increase access.⁸³
• Three large scale conferences in Moscow addressing HIV and AIDS in Eastern Europe and Central Asia were held in 2006, 2008 and 2009, which could be an indicator the epidemic is receiving more attention.
• A touring photo exhibition, Stars against AIDS, launched in May 2008, featuring 25 famous women from Russia and Ukraine, to raise awareness of HIV and tackle discrimination. A calendar of the exhibition will launch on World AIDS Day.⁸⁴

Former Olympic gymnastics champion, Svetlana Khorkina, participates in the Stars Against AIDS awareness campaign

The extent to which these messages are getting through is debatable. A 2008 audit by the UN, Global Fund and the USA, found shortcomings in Ukraine’s response to the epidemic with many regions of the country being insufficiently supported despite high levels of funding.⁸⁵

Recent funding initiatives

Positive steps made by Russia in addressing HIV have included significantly stepping up funding in recent years, and this could be seen as a positive step towards treating the epidemic with the graveness it deserves. The $140m allocated to HIV and viral hepatitis in 2006 was a 20-fold increase on funding for 2005. This was doubled in 2007. Future expansion of funding has been criticised, however, for directing too small a proportion to prevention, projected to be less than 9% in 2010. The country’s global commitments towards HIV funding include $40m for vaccine research and a $217m pledge to the Global Fund by 2010, a figure equal to the grants it has received.⁸⁶
Prevention, treatment and care initiatives in Ukraine have been greatly boosted by substantial grants from the Global Fund including nearly $100m in 2003 and $151m in 2007.⁸⁷ A bill was passed in September 2008 to greatly expand HIV prevention, treatment and care for the 2009-13 period. The program will require around $730m in funding.⁸⁸

Conclusion

While many areas of the world have kept their HIV epidemics relatively stable, the region encompassing Russia, Eastern Europe and Central Asia is a glaring exception. Although there are signs of a heightened awareness of HIV, demonstrated by funding commitments, conferences and public awareness campaigns, far more needs to be done. Unless, IDUs, the drivers of the regional epidemic, are at the core of HIV prevention and treatment efforts, little headway will be made. Political will to tackle stigma and discrimination directed against people with HIV, injecting drug users and other vulnerable populations is imperative as is the introduction and expansion of universally tried and tested prevention methods.
It has been predicted that Russia will experience the greatest number of AIDS-related deaths between 2009 and 2015, indicating the worst is yet to come.⁸⁹ It will be tragic if thousands more AIDS-related deaths are needed in order to prompt the countries of the region to effectively address their epidemics

References

1. UNAIDS (2009), 'AIDS Epidemic Update'
2. UNAIDS (2009), 'AIDS Epidemic Update'
3. Hamers, F.F., and Downs, A.M. (2003, March), ‘HIV in central and eastern Europe’, The Lancet 362:9362
4. Federal Service for Surveillance of Consumer Rights Protection and Human Well-Being of the Russian Federation and UNAIDS (2008), ‘Country Progress Report of the Russian Federation on the Implementation of the Declaration of Commitment on HIV/AIDS’
5. Kruglov, Y.V. et al (2008, June), ‘The most severe HIV epidemic in Europe: Ukraine’s national HIV prevalence estimates for 2007’, Sexually Transmitted Infections 2008:84 (Supplement 1)
6. International Harm Reduction Development Program, Open Society Institute (2008, March) ‘Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics’
7. Kruglov, Y.V. et al (2008, June), ‘The most severe HIV epidemic in Europe: Ukraine’s national HIV prevalence estimates for 2007’, Sexually Transmitted Infections 2008:84 (Supplement 1)
8. European Centre for the Epidemiological Monitoring of HIV and AIDS (2007, December), ‘HIV/AIDS Surveillance in Europe. Mid-year report 2007’ (PDF)
9. UNAIDS (2008), ‘2008 Report on the global AIDS epidemic’
10. UNAIDS (2008), ‘AIDS epidemic update - Regional Summary’
11. UNAIDS (2008), ‘2008 Report on the global AIDS epidemic’
12. Federal Service for Surveillance of Consumer Rights Protection and Human Well-Being of the Russian Federation and UNAIDS (2008), ‘Country Progress Report of the Russian Federation on the Implementation of the Declaration of Commitment on HIV/AIDS’
13. UNAIDS (2008), ‘AIDS epidemic update - Regional Summary’
14. UNAIDS (2008), ‘AIDS epidemic update - Regional Summary’
15. Federal Service for Surveillance of Consumer Rights Protection and Human Well-Being of the Russian Federation and UNAIDS (2008), ‘Country Progress Report of the Russian Federation on the Implementation of the Declaration of Commitment on HIV/AIDS’
16. UNAIDS (2008), ‘2008 Report on the global AIDS epidemic’
17. Lazarus, J. et al (2006, June), ‘HIV/AIDS In Eastern Europe: More Than a Sexual Health Crisis’, Central European Journal of Public Health 14:2
18. International Harm Reduction Association (2008), 'The Global State of Harm Reduction 2008: Mapping the response to drug-related HIV and hepatitis C epidemics'
19. Dolan, K. et al, ‘HIV in prison in low-income and middle-income countries’
20. Federal Service for Surveillance of Consumer Rights Protection and Human Well-Being of the Russian Federation and UNAIDS (2008), ‘Country Progress Report of the Russian Federation on the Implementation of the Declaration of Commitment on HIV/AIDS’ (PDF)
21. Kruglov, Y.V. et al (2008, June), ‘The most severe HIV epidemic in Europe: Ukraine’s national HIV prevalence estimates for 2007’, Sexually Transmitted Infections 2008:84 (Supplement 1)
22. Drew, R. et al (2008), ‘Evaluation of fighting HIV/AIDS in Estonia’ (PDF), World Health Organization Europe and United Nations Office on Drugs and Crime
23. Dapkus, L. (2002, 21st August), ‘Finding of high number of HIV cases among prison inmates unsettles Lithuania’, Associated Press
24. UNAIDS (2008), ‘AIDS epidemic update - Regional Summary’
25. UNAIDS (2008), ‘AIDS epidemic update - Regional Summary’
26. UNAIDS (2008), ‘AIDS epidemic update - Regional Summary’
27. UNAIDS (2009, January), 'Hidden HIV epidemic amongst MSM in Eastern Europe and Central Asia'
28. Kruglov, Y.V. et al (2008, June), ‘The most severe HIV epidemic in Europe: Ukraine’s national HIV prevalence estimates for 2007’, Sexually Transmitted Infections 2008:84 (Supplement 1)
29. UNAIDS (2008), ‘AIDS epidemic update - Regional Summary’
30. UNAIDS (2009, January), 'Hidden HIV epidemic amongst MSM in Eastern Europe and Central Asia'
31. ‘Russian Federation (2006): HIV/AIDS TRaC Study among Men who have Sex with Men’ Population Services International (2006)
32. International Harm Reduction Development Program, Open Society Institute (2008, March) ‘Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics’
33. International Harm Reduction Association (2008), 'The Global State of Harm Reduction 2008: Mapping the response to drug-related HIV and hepatitis C epidemics'
34. International Harm Reduction Development Program, Open Society Institute (2008, March) ‘Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics’
35. International Harm Reduction Development Program, Open Society Institute (2008, March) ‘Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics’
36. The Global Fund to Fight AIDS, Tuberculosis and Malaria (2009, 13th November), 'Global Fund to provide $24 million of new funding to fight HIV/AIDS in Russia'
37. ‘Lessons Not Learned: Human Rights Abuses and HIV/AIDS in the Russian Federation’ Human Rights Watch (2004)
38. Rhodes, T., et al (2006, July), ‘Street Policing, Injecting Drug Use and Harm Reduction in a Russian City: A Qualitative Study of Police Perspectives’, Journal of Urban Health 83:5
39. Rhodes, T., et al (2004, March) ‘Injecting equipment sharing among injecting drug users in Togliatti City, Russian Federation: maximizing the protective effects of syringe distribution’, Journal of Acquired Immune Deficiency Syndromes 35:3
40. (2006, 11th May) ‘IHRD Joins Drug Treatment and HIV Experts in Criticizing Russian Memorandum Against Methadone Programs’
41. Elovich R. and Drucker E. (2008), ‘On drug treatment and social control: Russian narcology's great leap backwards’, Harm Reduction Journal 2008, 5:23
42. Elovich R. and Drucker E. (2008), ‘On drug treatment and social control: Russian narcology's great leap backwards’, Harm Reduction Journal 2008, 5:23
43. ‘Rehabilitation Required: Russia’s Human Rights Obligation to Provide Evidence-based Drug Dependence Treatment’ Human Rights Watch, 2007 19:7(D)
44. International Harm Reduction Development Program, Open Society Institute (2008, March) ‘Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics’
45. Russian Harm Reduction Network (RHRN) and the International Treatment Preparedness Coalition – Region of Eastern Europe and Central Asia (2006, 11th May), ‘Inhumane conditions in the Russian drug treatment facilities are the roots of Moscow’s tragedy’
46. Samet, J.H. et al (2008, September), ‘Mitigating risky sexual behaviors among Russian narcology hospital patients: the PREVENT (Partnership to Reduce the Epidemic Via Engagement in Narcology Treatment) randomized controlled trial’, Addiction 103:9
47. UNAIDS (2008), ‘AIDS epidemic update - Regional Summary’
48. International Harm Reduction Association (2008), 'The Global State of Harm Reduction 2008: Mapping the response to drug-related HIV and hepatitis C epidemics'
49. International HIV/AIDS Alliance in Ukraine, ‘Two year Programme budget. Main targets and Programme indicators, implemented by the Alliance Ukraine’
50. International Harm Reduction Development Program, Open Society Institute (2008, March) ‘Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics’
51. Human Rights Watch (2006, March), ‘Rhetoric and Risk: Human Rights Abuses Impeding Ukraine’s Fight against HIV/AIDS’, Human Rights Watch 18:2(D)
52. International Harm Reduction Association (2008), 'The Global State of Harm Reduction 2008: Mapping the response to drug-related HIV and hepatitis C epidemics'
53. International Harm Reduction Association (2008), 'The Global State of Harm Reduction 2008: Mapping the response to drug-related HIV and hepatitis C epidemics'
54. The Global Fund – Kyrgyzstan website, accessed 15th October 2008
55. UNAIDS, Latest UNGASS Data, accessed 15th October 2008
56. International Harm Reduction Association (2008), 'The Global State of Harm Reduction 2008: Mapping the response to drug-related HIV and hepatitis C epidemics'
57. International Harm Reduction Development Program, Open Society Institute (2008, March) ‘Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics’
58. International Harm Reduction Development Program, Open Society Institute (2008, March) ‘Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics’
59. International Treatment Preparedness Coalition (2010, April) 'Rationing Funds, Risking Lives: World backtracks on HIV treatment
60. WHO/UNAIDS/UNICEF (2009), 'Towards Universal Access: Scaling up priority HIV/AIDS Interventions in the Health Sector'
61. WHO (2008), ‘Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector’
62. UNAIDS (2008), ‘2008 Report on the global AIDS epidemic’
63. International Treatment Preparedness Coalition (2010, April) 'Rationing Funds, Risking Lives: World backtracks on HIV treatment
64. UNAIDS (2008), ‘2008 Report on the global AIDS epidemic’
65. UNAIDS (2006) ‘AIDS Epidemic Update: December 2006’
66. Long, E.F. et al (2006), ‘Effectiveness and cost-effectiveness of strategies to expand antiretroviral therapy in St. Petersburg, Russia’, AIDS 20:17
67. ‘Antiretroviral Drug Shortages In Parts Of Russia Could Lead To Drug Resistant HIV Strains, Experts Say’, Kaisernetwork.org, June 23, 2006
68. Feshbach, M., (2008, August 13), ‘What’s in a number? A new projection by Pokrovskiy’s Center for HIV prevention and treatment and some consequences for Russia’, Johnson’s Russia List
69. Federal Service for Surveillance of Consumer Rights Protection and Human Well-Being of the Russian Federation and UNAIDS (2008), ‘Country Progress Report of the Russian Federation on the Implementation of the Declaration of Commitment on HIV/AIDS’
70. Macauley, J., ‘HIV/AIDS and UNDP in the Eastern Europe and CIS region’, United Nations Development Programme website, accessed October 16th 2008
71. New Scientist (2008, 11th May), ‘Stigma helps AIDS flourish in Russia’
72. BBC News online (2004, 14th May), ‘Russia campaigns against AIDS fear’
73. Balabanova Y. et al. (2006, October), 'Stigma and HIV infection in Russia', AIDS Care 18(7)
74. UNDP (2008, December), ‘Living with HIV in Eastern Europe and the CIS: The Human Cost of Social Exclusion’
75. Brown, H. (2006, 5th August), ‘Russia's blossoming civil society holds the key to HIV’, The Lancet 368:9534
76. UNDP (2008, December), ‘Living with HIV in Eastern Europe and the CIS: The Human Cost of Social Exclusion’
77. UNDP (2008, December), ‘Living with HIV in Eastern Europe and the CIS: The Human Cost of Social Exclusion’
78. UNDP (2008, December), ‘Living with HIV in Eastern Europe and the CIS: The Human Cost of Social Exclusion’
79. UNDP (2008, December), ‘Living with HIV in Eastern Europe and the CIS: The Human Cost of Social Exclusion’
80. Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria, ‘Russian Media Partnership to Combat HIV/AIDS’, accessed 28th September 2009
81. The World Bank Group (2005, 27th September), 'Ukraine Launches Information Campaign Against AIDS'
82. International HIV/AIDS Alliance in Ukraine (2008, 1st August), 'Press release: On the results of the first large-scale HIV prevention campaign among students'
83. Department for International Development (2007, November 27), ‘Defeating the stigma around HIV and AIDS in Kyrgyzstan’
84. UNAIDS (2008, 19th May), ‘Stars against AIDS’ in Eastern Europe’
85. Kyiv Post (2008, 7th May), ‘Ukraine losing HIV/AIDS fight’
86. Transatlantic Partners Against AIDS,  ‘On Russian Federation State Financing of Measures to Prevent and Fight HIV/AIDS, 2007–2010’, accessed 15th October 2008
87. The Global Fund – Ukraine website, accessed 30th October 2008
88. Kaiser Network (2008, 2nd October), ‘Ukraine Parliament Introduces Bill To Increase HIV Prevention, Treatment Efforts’
89. Feshbach, M., (2008, August 13), ‘What’s in a number? A new projection by Pokrovskiy’s Center for HIV prevention and treatment and some consequences for Russia’, Johnson’s Russia List