The Global HIV/AIDS Epidemic and Eastern Europe
DEVELOPMENTS
Recent statements by the Pope have revived the controversy surrounding the Catholic Church’s stance on condom provision, underscoring the role of this type of intervention in global efforts to combat HIV/AIDS. While condoms represent an effective and inexpensive prevention tool within the context of many epidemics, condoms might not be as effective in countries where the spread of HIV/AIDS is fueled by non-sexual transmission.
There is a growing HIV/AIDS epidemic in Eastern Europe with distinctive characteristics of its own – notably the non-sexual transmission of the virus.The spread of HIV/AIDS in this region is driven primarily by intravenous drug use. In Eastern European and Central Asian countries, the populations most at risk are injecting drug users, commercial sex workers, men having sex with men (MSM), and each group's various sexual partners. The challenge is to develop national HIV/AIDS strategies that address the unique qualities of the epidemic in their respective countries.
BACKGROUND
The efficacy of any national HIV/AIDS response depends on its ability to apply data on at-risk populations, modes of transmission, and epidemiological drivers to plan programs and allocate resources that specifically combat those factors.
Epidemiology
Europe is not typically regarded as a region with high HIV/AIDS prevalence, but among at-risk populations in certain countries, HIV prevalence now ranges upwards of 1% (the threshold for an epidemic). According to UNAIDS, the estimated number of people living with HIV in Eastern Europe and Central Asia rose to 1.5 million in 2007, and almost 90% of those infected live in either the Russian Federation (69%) or Ukraine (29%). Annual numbers of newly reported HIV diagnoses are also rising in Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, Tajikistan, Ukraine, and Uzbekistan (which now has the largest Central Asian epidemic). In Western and Central Europe, 800,000 people were living with HIV/AIDS in 2007.
National Responses
Worldwide, a plethora of uncoordinated HIV/AIDS donors, groups and activities led to the 2004 statement by UNAIDS on “Three Ones,” intended to harmonize and align all actors. The goal of "Three Ones"is that each country has one HIV/AIDS Action Framework (national strategy) that provides the basis for coordinating the work of all partners, one National AIDS Coordinating Authority, with a multisectoral mandate, and one agreed country-level monitoring and evaluation system. The national HIV/AIDS strategy is meant to be the guiding document to coordinate all components of and actors within the national response. Ideally, it connects recent epidemiological evidence, such as data on the mode of transmission for the last 1000 infections, with targeted prevention interventions designed to reduce HIV incidence rates and also manages resources for treatment and care for existing prevalent cases.
Financing
National strategies in middle-income and low-income countries, of which there are several in Eastern Europe and Central Asia, are generally funded via a combination of domestic resources and international donations. Major international donors include The Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank, the U.N. and its agencies, the U.S. government’s PEPFAR (The President’s Emergency Plan For AIDS Relief), and various national governments. These donors increasingly seek accountability on the part of recipient nations, and the tracking of HIV/AIDS expenditures is one important metric for assessing the impact and relationship between program planning and actual delivery. Tracking expenditures towards certain program areas and specific populations (such as sex workers, drug users and men who have sex with men) allows countries to gauge whether or not funds are reaching at-risk populations. UNAIDS expenditure data reveals varying degrees of tracked or reported expenditure data, and the gaps in data are reason for alarm. For example, Russia doesn’t report prevention expenditures disaggregated across the program areas for most at-risk populations, and Uzbekistan does not report any HIV/AIDS expenditure in the 2008 UNAIDS global report on the epidemic.
ANALYSIS
There are myriad financial, epidemiological and political implications to European countries’ national HIV/AIDS responses. Uncontrolled incidence rates in high-prevalence countries will affect neighboring countries, and the related increase in the cost of responding to these epidemics will reshape the percentage of funding from international sources. At present, the region is comprised of both donor countries and recipient countries, but the dynamics of the donor community will evolve. Economic growth in coming years may move certain countries (most likely Russia) from the category of recipient country into that of a donor country.
Resource allocation is key in light of increased competition for financial resources in the current global economy. Given the range of epidemiological drivers of HIV/AIDS in this region, it is important to fund what works: proven, cost-effective interventions (particularly among populations most at-risk of infection) should receive priority. Each country should conduct a frank assessment of the role of intravenous drug users, commercial sex workers and men who have sex with men within its epidemic and should tailor programming and funding accordingly.
A few key practices are applicable regardless of the epidemiological profile in each country. Knowledge of the mode of transmission of the most recent 1000 infections is essential for program planning and resource allocation. Accurate financial tracking systems and epidemiological data are essential for evaluating the impact of the response to date as well as setting targets for future interventions. Full expenditure data that is disaggregated by source and program area are critical to ensure accountability and to monitor the costs of the national response.
Policies related to penalization of commercial sex work, human trafficking, needle exchange, and homosexuality, as well as sensitization programs in these areas will play important roles in defining the social and political context of the public health response to HIV/AIDS. As integration, communication and transportation improve, each country’s national HIV/AIDS response will increasingly affect its neighbors and the greater region. In the long run, HIV/AIDS will pose a significant financial challenge as well as a potential threat to prosperity and security in Eastern Europe.
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Vaughn Hester is Outreach Director at FORGE, an international NGO working to empower African refugees as agents of peace and development. She was formerly a consultant with the Costs and Financing Working Group of the aids 2031 project at Results for Development Institute and acknowledges conceptual influence for this note from her colleagues there.