Analytical Report
Based on the Results of the Qualitative Study:
Access of Members of the Risk Groups (Youth, Injection Drug Users, Commercial Sex Workers, Men Who Have Sex with Men, Prisoners) to Prevention, Treatment, Care and Support Related to the HIV/AIDS Epidemic in Ukraine
The report is prepared by the Association of Substitution Treatment Advocates in Ukraine
within the framework of the project of the Eurasian Harm Reduction Network (EHRN)
"Achieving Universal Access: Supporting Community Sector Involvement and Advocacy"
This project is supported by the International Council of AIDS Service Organizations (ICASO) within the framework of the global process of Universal Access.
Ukraine, 2010
Table of Content
Acknowledgements ...... 3
List of Acronyms ...... 4
Overview of the Study ...... 5
Summary ...... 6
Section 1: General Information on the Situation in Ukraine . . . . . 10
______Treatment ...... 12
______Prevention...... 13
______Human Rights...... 14
Section 2: Community Sector Involvement ...... 16
Section 3: Universal Access. Agreed Target Indicators ...... 18
Section 4: Achievement of the Universal Access Targets...... 22
Resume ...... 25
Annex 1: Methodology...... 26
AUTHORS AND ACKNOWLEDGEMENTS
Association of Substitution Treatment Advocates of Ukraine(ASTAU) © is an organization of the IDU/SMT community, the mission of which is to preserve, improve and implement humane, evidence-based medical and social programs using harm reduction approaches in order to improve the quality of life and protect human rights./
Eurasian Harm Reduction Network (EHRN) is a non-governmental organization, the mission of which is to reduce harm from the drug use with the aim of health preservation and support and protection of human rights at the individual, community and general population level /
International Council of AIDS Service Organizations (ICASO) is a council, the mission of which is to mobilize and support various non-governmental organizations in order to create the effective global response to HIV/AIDS /
Coordinator of the working group in Ukraine–Olga Belyaeva.
Desk research and interviewing – Vadym Aftandilyants, Professor of Economics inKyiv National University of Technology and Design, sociologist at Mediatraining.
Consultant – Valentina Ruchkina, patent attorney of Ukraine (license #158), representative for intellectual property issues.
The qualitative study was assisted by national experts and representatives of communities working in the area of Universal Access provision to the key populations.
We appreciate the valuable advices on the report structure and the assistance in choosing the respondents selection criteria, provided by Irina Borushek, Oleg Galaktyonov, Zorian Kys', Irina Mishyna, Yelena Polukhinskikh, Sergey Stratulat, Igor Spinul.
We deeply appreciate the complicated questions and help in finding the answers provided by the participants of the consultative meetings, namely: Lidiya Andrushchak, Sergey Votiagov, Alexandra Gurinova, Konstantin Dumchev, Denis Poltavets, Mirzakhid Sultanov, Liudmila Shurpach, Raminta Shtuikyte.
Association of Substitution Treatment Advocates of Ukraine (ASTAU) would like to thank Eurasian Harm Reduction Network (EHRN) for inspiration as well as for the technical and financial assistance in creation of this publication, provided within the framework of the project "Achieving Universal Access: Supporting Community Sector Involvement and Advocacy".
Text of the report may be found in Ukrainian, Russian and English on the web-site
Recommended citing format:
© АSTAU (2010). "Access of Members of the Risk Groups to Prevention, Treatment, Care and Support Related to the HIV/AIDS Epidemic in Ukraine." Authors: O. Belyaeva, V.Aftandilyants. ASTAU: Dnepropetrovsk/Kyiv, Ukraine.
Views and opinions presented in the report may differ from the views and opinions of the EHRN or ICASO.
List of Acronyms
ICASO — International Council of AIDS Service Organizations
ARV treatment — antiretroviral treatment
AUCO — All-Ukrainian Charitable Organization
HIV — human immunodeficiency virus
WHO — World Health Organization
GFATM (GF) – Global Fund to Fight AIDS, Tuberculosis and Malaria
MARPs – most-at-risk populations
VCT — voluntary counseling and testing
EU — European Union
FSWs — female sex workers
SMT — substitution maintenance treatment
STIs — sexually transmitted infections
PCC — programs coordination council
LGBT-community — lesbian, gay, bisexual and transgender community
PLWHA — people living with HIV/AIDS
PLWH — people living with HIV
ICF — international charitable foundation
MIA — Ministry of Internal Affairs
MH — Ministry of Health
MES — Ministry of Education and Science
MSM — men who have sex with men
NGOs — non-governmental organizations
NOP – national operational plan
UN – United Nations
IDUs — injection drug users
IDU-PLWH — injection drug users - people living with HIV
PMTCT — prevention of mother-to-child transmission of HIV
PIS – patrol and inspection service of law-enforcement agencies
CSWs — commercial sex workers
ROP – regional operational plan
MM — mass media
AIDS — acquired immune deficiency syndrome
UNGASS – United Nations General Assembly Special Session
SSFCY — social services for family, children and youth
CD4 – defining immune status of HIV-positive person
TB — tuberculosis
UNGASS report – National Report on Monitoring Progress Towards the UNGASS Declaration of Commitment on HIV/AIDS in 2008 -2009,ICF “International HIV/AIDS Alliance in Ukraine”, MH, UNAIDS
UNAIDS — Joint United Nations Program on HIV/AIDS
Overview of the Study
The commitments made by the countries at the 2005 World Summit and the Gleneagles G8 Summit on the universal access created momentum to scale up comprehensive prevention, treatment, care and support within the intersectoral national response to HIV/AIDS.
On June 2, 2006 at the 87th plenary session of the United Nations General Assembly the Member States adopted a Political Declaration on HIV/AIDS where countries committed, among other things, to set ambitious targets by end of 2006 to scale up the response toward the goal of achieving universal access by 2010. This process of setting targets was to be transparent and inclusive of civil society and other stakeholders.
In 2010-2011 UNAIDS will be organizing anintersectoral review of the Universal Access to evaluate progress of the countries in achieving the national targets, identify challenges and obstacles and agree on what has to be done to achieve Universal Access and the Millennium Development Goals. Similarly, in June 2011 it is likely that governments will be required to report on progress in their AIDS responses, particularly in line with universal access commitments.
The project "Achieving Universal Access: Supporting Community Sector Involvement and Advocacy" is implemented by the International Council of AIDS Service Organizations (ICASO) together with its Regional Secretariats and partners.
The goal of the project is to strengthen the leadership and involvement of key populations into monitoring and making decisions related to national HIV responses and to influence national target setting and review of progressin achieving Universal Access, particularly in the context of prevention among key populations.
The project stipulates 3 levels of activities:
- Preparing national reports and conducting advocacy activities in participant countries.
- Preparing regional reports and conducting advocacy activities (taking into account the contribution and project activities at the national level).
- Preparing global report and conducting advocacy activities (taking into account the contribution and project activities at the national and regional levels).
Eurasian Harm Reduction Network (EHRN) is a regional partner of the ICASO coordinating the activities concerning the project in Eurasian region. In Ukraine the partner of the project is the Association of Substitution Treatment Advocates of Ukraine. Active participants are members of such communities as IDUs, CSWs, MSM, prisoners, PLWH, and youth.
The objectives of the study in Ukraine were:
to assess the involvement of MARPs into the Universal Access provision process;
to review the data and the results of analysis of the epidemic and related needs (particularly regarding the key populations and prevention);
to identify gaps in the targets set and in the relevant achievements;
to monitor and document the progress in achieving the target indicators.
The following questions were to be answered in order to meet the objectives of the study:
- Has the public sector (including key populations) been involved into the Universal Access provision processes?
•Are the Universal Access target indicators (and the process of their review) realistic, comprehensive and ambitious, and have they been developed taking into account all the aspects of Universal Access provision and the interests of key populations?
•Where is the country in reaching the Universal Access targets (with a particular focus on targets for prevention and key populations)?
•What needs to happen next for the Universal Access to be achieved?
In the course of the study the following tasks have been completed:
Review and analysis of literature, which helped forming a better understanding of the HIV/AIDS epidemiological situation in Ukraine.
Interviewing methodology was adapted (see the Annex).
Seven in-depth interviews with national experts were conducted, which helped improve understanding of various aspects and local specifics of the Universal Access. Quotations are included into the Report.
24 interviews were conducted with members of the key populations who provided information on the accessibility of HIV/AIDS prevention, treatment, care and support. Quotations are included into the Report. The respondent selection criteria are listed in the Annex.
Analysis of the received information was conducted and the Report was prepared.
The Report does not aim to exhaustively analyze all the issues related to the Universal Access or to come up with all the solutions. Only two areas were chosen for the study: HIV prevention and access to services for key populations.
Summary
- Background of the AIDS epidemic in Ukraine and analysis of the response.
Since the first case of HIV infection was registered in Ukraine in 1987 and up to the 01.07.2010 there were 171,661 cases of HIV registered among Ukrainian citizens, including 33,937 cases of AIDS and 19,389 deaths caused by AIDS-related illnesses. During the first six months of 2010 the incidence of HIV has increased by 6.0% as compared to the previous (2009) year[1].
During the whole period of epidemiological surveillance of HIV in Ukraine the numbers of persons dying from AIDS-related illnesses have been increasing – from 2,188 in 2005 to 2,710 in2008. In 2009 for the first time there was a decrease of the AIDS-related deaths as compared to the previous year – from 2,710 to 2,591[2].
In 2009 19,840 new cases of HIV were registered in the country (43.2 per 100 thousand population). And though starting from 1999 the number of registered cases of HIV increases annually, the increment of this number gets lower: 16.8%, 10.5%, 7.6% and 5.7% respectively.
Estimated data on the size of the risk groups and PLWH, confirmed by the National Council on TB and HIV/AIDS as of 10.09.2009[3]: IDUs– 290,000; CSWs – 78,000 (it is important to notice that the number does not take into account female IDUs); clients ofCSWs (men) – 234,000; MSM – 95,000; prisoners – 145,000 people.
During the last four years (2006-2009) the number of the registered new cases of HIV among IDUs remained virtually unchanged and amounted, on the average, to 7,088 people annually.
Ukraine does not register cases of HIV among CSWs because it is difficult to detach this group from all the cases of sexually transmitted HIV infection. However, the data received via sentinel epidemiological surveillance indicate the wide-spread and increasing prevalence in this population.
In 2009, sexual transmission accounted for 44% of cases, while parenteral transmission – 36%. In the first six months of 2010 the percentage of persons infected through injection drug use kept on decreasing and amounted to 34%[4].
The increase of heterosexual transmission rate and the number of HIV-infected women of fertile age has induced gradual increase in the number of children born by HIV-infected mothers. For example, in 2007 the rate of mother-to-child transmission of HIV was 6.2%. Despite certain progress achieved in prevention of mother-to-child transmission, the total number of children with confirmed HIV-positive status keeps increasing[5].
Due to the absence of reliable evidence indicating sexual transmission among the general population being the main driving factor of HIV transmission, Ukraine is at the moment one of those countries where epidemic is concentrated (512.7-223.7 per 100 thousand population) in risk groups[6].
Response:
- in 2009, the services of harm reduction programs reached: 150,000 IDUs (52% of the estimated number); more than 25,000 of CSW (36.2% of the estimated number); more than 28,000 of prisoners (12.31% of the estimated number) and more than 13,000 of street children;
- coverage of HIV antibody test grows every year: in 2009, the quantity of screening tests has increased by 136,000 (4.2%) in comparison with 2008, partially funded from local budgets;
- the coverage of adults and children with advanced HIV with ART is growing: 2006 – 27%, 2007 - 35%, 2008 – 40% (10,629 persons), 2009 - 48% (15,871 persons);
- evidence of equal access to the ART: in 2008, 52% of women received it, in 2009 – 60%. For men, the rate was 33% and 41% respectively.
- percentage of ART coverage for children: 2008 – 90%, 2009 – 100%.
- in February 2009, for the first time in Ukraine the Verkhovna Rada of Ukraine adopted the National Program on HIV Prevention, Treatment, Care and Support of HIV-Infected Persons and AIDS Patients for 2009-2013, providing government funding[7].
2. Description of the process used to design and agree on the target indicators of the Universal Access.
In April 2006, the ‘Road Map on Scaling-up Towards Universal Access to HIV/AIDS Prevention, Treatment, Care and Support in Ukraine by 2010" was created with support from UNAIDS. This Report presents the results of three national consultations held in Ukraine from December 2005 to February 2006. They were dedicated to the issues of the national access to HIV/AIDS prevention, treatment, care and support by 2010. These meetings were attended by over 300 representatives of government organizations (both national and regional), NGOs and international organizations, including over 100 PLWH. The Report was prepared by multidisciplinary working group created under the order of the Cabinet of Ministers of Ukraine and headed by a representative of the MH of Ukraine[8].
There are national indicators for monitoring and performance evaluation of HIV/AIDS epidemic control (MH Order # 870 dated 28.12.2007; indicators listed in the Order conform to UNGASS indicators[9]). The Order lists indicators, responsible offices and reporting deadlines. However, we were unable to find any information on the target indicators (i.e. specific quantitative/qualitative indicators) used for monitoring.
On February 19, 2009 the Law of Ukraine "On Ratification of the National Program on HIV Prevention, Treatment, Care and Support of HIV-Infected Persons and AIDS Patients for 2009-2013" was adopted. The law contains detailed description of the targets, tasks and measures, responsible persons and funding sources.
The target indicators agreed reflect comprehensive nature of the measures taken by different sectors of Ukrainian society in order to overcome the concentrated HIV/AIDS epidemic. The targets imply measures aimed at the key populations.
On July 1, 2010 the National Council on TB and HIV/AIDS approved the National Operational Plan (NOP) for 2011-2013 based on the "National Program on HIV Prevention, Treatment, Care and Support of HIV-Infected Persons and AIDS Patients for 2009-2013."
Over 100 partners, 50 of thembeing regional partners, took part in designing the NOP[10]. The NOP was created on the basis of 27 regional operational plans (ROPs). Based on the regional targets, new quantitative targets for the NOP were set for 2011-2013.[11] For example, key indicators in prevention (number of people covered annually) are as follows:
Target group / 2011 / 2012 / 2013IDUs / 154,413 / 179,944 / 204,634
CSWs / 28,990 / 36,478 / 43,400
MSM / 28,680 / 34,270 / 38,590
Prisoners / 46,941 / 53,393 / 57,045
PLWH / 69,524 / 78,431 / 88,769
In the National Program[12], the figures of groups IDUs, CSWs, MSM, and prisoners are represented in percentage: 2011 – 40% covered, 2012 – 50%, 2013 – 60%. The estimated number for IDUs group in 2005-2008 – 324,000, starting from 2009 – 290,000 is the recommended figure[13].
The research showed some inconsistency in official documents defining targets and the level of their achievement. The detailed results of the analysis are described in section 4.
3. Analysis of the main obstacles and challenges to reach the targets by 2010.
Community members have noted a variety of problems hindering comprehensive and quality achievement of the goals set.
- In 2010, the level of criminalization of the users of illicit opiates grew 20 times, which increases vulnerability to rights violation and restricts the access to medical and social programs.
- Significant level of stigmatization and discrimination of MARPs is still in place.
- In the country's regulatory documents, the data on HIV/AIDS program implementation are partially inconsistent with the targets set; the exact amount of people needing services is not definedmaking it difficult to evaluate the progress in achieving the targets.
- Members of MARPs (IDUs, CSWs, prisoners, MSM) are insufficiently involved in planning, implementation and monitoring of programs.
- While information is widely accessible, it is noted that young people do not fully understand the threat of HIV infection.
- Lower accessibility and quality of medical and social services is notable in small towns and villages of Ukraine in comparison to oblast (regional) centers.
4. Development of strategies and recommendations to address those obstacles and reach Universal Access by 2015.
After the working meeting held on December 22, 2010, MARPs representative discussed the need of bringing in technical and financial aid to create and implement an advocacy program aimed at:
- Increasing of the level and effectiveness of MARPs involvement into Universal Access provision processes in Ukraine.
- Significant involvement into organization of transparent and integratedregular monitoring and reporting process for achieving existing and/or revised Universal Access targets by 2015.
- Better interaction with the UN and other stakeholders at the country (and global) level.
- Attracting more resources to support MARPsmembers’ involvement in programming, monitoring, policy- and decision-making.
SECTION 1:
General Information On The Situation In Ukraine
Overview of the AIDS epidemic in the country
The revised HIV/AIDS estimates show that as of the beginning of 2010, there were 360 thousand HIV-infected people aged 15 and older, living in Ukraine[14].