Concept

ofUkraine’s Country ApplicationtoGlobalFundtoFightAIDS, TuberculosisandMalariaforRound10, the “HIV/AIDS” Component

This document is a brief review of strategic activity areas proposed to be included into the Ukraine’s Applicationto Global Fund to Fight AIDS, Tuberculosis and Malaria for Round 10 , the “HIV/AIDS” component. Taking into consideration tendencies in epidemic development and according to the Global Fund requirements it is proposed to have the main focus of the Application on building sustainable system of providing comprehensive HIV/AIDS prevention, treatment, care and support services to MARPs in Ukraine.

The document has three main sections:

  1. The state of HIV / AIDS epidemic in Ukraine (epidemiological data, trends);
  2. Review of the national response to the epidemic;
  3. Strategy of request for Round 10.

1.The state of HIV / AIDS epidemic in Ukraine

As of April 1, 2010 more than 167883 HIV-infected citizens are registered in Ukraine, including 33003 AIDS cases and 18819 of AIDS[1].

However, these data do not reflect the real scale of HIV / AIDS epidemic in Ukraine, but only provide information about persons who were tested for antibodies to HIV and were included into the official register of HIV infections. Significantly greater number of citizens might be infected, who are not aware of their status. Updated estimates on HIV / AIDS in Ukraine show that in about 360000 people aged 15 years and older are living with HIV. This figure is one of the highest in the European region and at the beginning of 2010 makes up 1.33% of the adult population.In other words, only every third person living with HIV in Ukraine knows of his / her HIV positive status[2].

Unfortunately, there is a growing number of registered new cases of HIV infection in the country[3].

Number of AIDS cases increased each year in Ukraine up to a record limit - 4723 cases in 2006. As a result of widespread introduction of antiretroviral therapy starting since2007 a slight decrease in the number of AIDS cases has been marked (to 4437 cases in 2009). Since the beginning of the epidemic in Ukraine increase in the number of persons who died of disease caused by AIDS is observed. In 2009 for the first time compared to the previous year, the number of deaths from AIDS reduced from 2710 to 2591 (from 5.8 to 5.6 per 100 thousand people), which may be the first proof of the positive impact of the introduced antiretroviral therapy (ART) in Ukraine. At the same time, access to antiretroviral therapy in Ukraine does not meet the needs of patients. By 1 April 2010, 17122 HIV + patients receivedART, while another 7031 were in the waiting list for treatment.

Tuberculosis remains to be one of main causes of death among AIDS patients. In 2009, 1979 HIV-infected patients died of tuberculosis, more than 76% of all deaths of AIDS-associated diseases.

According to the criteria of the Joint UN Programme on HIV / AIDS and World Health Organization, the prevalence of HIV / AIDS situation in Ukraine is classified as a concentrated epidemic in certain most at risk populations. They are:injection drug users (IDUs), female sex workers (CSW), men who have sex with men (MSM), prisoners, partially street children and street adolescents. The epidemiological data indicate the following prevalence of HIV among these groups:

  • injection drug users – 22,9% (c.i. 21,9%–23,9%)
  • commercial sex workers – 13,2% (c.i. 12,0%–14,4%);
  • men who have sex with men – 8.6%(c.i. 7,4%–9,8%);
  • prisoners –15.0 %(c.i. 13%–17%);
  • “street children” - from 10 to 27%[4].

At the end of March 2009, the survey of estimated number of key most at risk groups in Ukraine was completed;its results are approved by the National Council on counteraction to TB and AIDS for the calculation of key indicators:

Key most at risk group / Recommendedestimatednumber / Scope
IDUs
- opiateuseramongthem / 290 000
200000 (70%) / 230 000 – 360000
CSW / 70000 / 65 000 – 93000
MSM / 95000 / 95 000 – 213000[5]
Prisoners / 145 000

The main cause of HIV prevalence remains unsafe injection drug using, to whichunprotected sex has joint in the past two years. Since 2008 cases of sexual transmission of infections have reached and started increase the level ofparentheraltransmission: in 2008. - 7945 compared to 7009 cases, in 2009 - 8635 compared to 7105. However, this does not mean reducing the role of IDUs in the epidemic spread, but shows increasing number of cases of sexual transmission of HIV.

The main arguments for focusing on IDUs are the facts:

  • There is a significant overlap among IDU and CSW as far as the majority of CSWs are using drugs, which is confirmed by data of sentinel surveillance;
  • A significant part of cases of sexual transmission of HIV is among sexual partners of IDUs.

It should be noted that the access to the treatment of active injection drug users remains limited. As of April 1, 2010 only 1208 HIV + patients with status "active IDUs" were receiving ART, and 776 - were in the waiting list.

Increase in sexual transmission of HIV has led to intensification of the epidemic process. In four out of 27 territorial units of Ukraine (Kiev, Mykolayiv, Dnipropetrovsk and Kirovohrad regions) there were signs of generalization of the epidemic, i.e. HIV prevalence among pregnant women upon the results of initial testing result had exceeded 1% (1.59%, 1.28%, 1.12%,and 1.03% accordingly, with an average indicator in the country – 0,55%)[6].Meanwhile,20, 5 % of pregnant women reported an IDU as current and previous experience.43 % of IDU women or those with an IDU history received no ARV prophylaxis for PMTCT are nearly 50% more likely to be diagnosed late due to continued late access to prevention services. This contributes to the rate of mother-to-child transmission, which is still 6, 2%(the MTCT rate for this group is 22.9%)[7].

2. Overview of the national response to the epidemic

2.1Programmes and policies underpinning the national response to the epidemic

The key document, on which the national response to HIV / AIDS is based is the Law of Ukraine“On National Program of HIV Prevention, Treatment, Care and Support for HIV Positive People and AIDS Patients for 2009-2013», # 1026-VI, dated February 19, 2009. The aim of the Program is stabilization of epidemic situation, reduction of HIV / AIDS related morbidity and mortality through the implementation of state policy on ensuring access of population to large-scale prevention, treatment, care and support for HIV-infected and AIDS patients.

National Operational Plan for 2011-2013 (NOP) in support of “National Program of HIV Prevention, Treatment, Care and Support for HIV Positive People and AIDS Patients for 2009-2013”, approved by the Law of Ukraine # 1026 on February 19, 2009 (hereinafter - the National Programme) was developed through numerous consultations which took place from May 2009 to April 2010 among different sectors, national and international partners, as well as local, regional and central authorities.

Activities, their scale and scope specified in NOP for 2011-2013 were developed based on needs identified at the regional / district level, and funding needs identified at the regional level. Requirements for the introduction of software and technical support have been properly calculated for each region, and for the national level as well as for each year of the plan (2011, 2012, 2013).

In the process of NOP development the following national targets were determined:

Table1Key targets of NOP in the area of prevention (the number of people covered annually)

Target Group / 2011 / 2012 / 2013
Most at Risk Groups
IDU / 154 413 / 179 944 / 204 634
CSW / 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
Prevention of Mother to Child Transmission
The number of examined pregnant women / 619,010 / 629,370 / 648,553
HIV+ pregnant women / 4,863 / 5,367 / 5,887
Children expected to be born by HIV+ mother / 5,106 / 5,635 / 6,181
pregnant womenwith unknown HIV status / 24,304 / 24,477 / 25,153
Blood Donors (number of tests) / 685,752 / 698,014 / 711,459

Table2. TargetindicatorsofNOPintheareaoftreatment, careandsupport

Target Group / 2011 / 2012 / 2013
ART Patients, in total / 25,033 / 30,687 / 36,401
1-st line / 16,470 / 20,190 / 23,950
2-nd line / 8,563 / 10,497 / 12,451
Among the whole population / 24,598 / 30,078 / 35,607
Prisoners / 435 / 609 / 794
Clinical Group / 108,026 / 133,776 / 157,259
Persons covered by the psycho-social support / 18,557 / 22,920 / 28,175

Target indicators of ROP are relatively lower compared to indicators of “The State National Program”. They reflect local realities, as they take into account the existing problems / obstacles in the health sector that hinder achievement of higher targets in the regions. Lack of trained specialists, the weak intersectional cooperation in the regions, rigid government control (in the health sector as well as in other sectors) are obstacles that are difficult to overcome and to provide a larger number of more quality preventive and treatment services to patients / clients.

Due to planning at the regional level these systemic obstacles were determined. Regions have carried out a thorough evaluation of their needs in training and technical assistance (see Annex to NOP) and planned accordingly with their budgets the necessary investments in training and strengthening at the local level. The funding plan was taken into account during the development of NOP, and the targets and budgets are reflected in the relevant activities (see table NOP).

Financial need of NOP

1. The evaluation of general needs for funding (in constant prices of 2009) of appropriate measures for counteraction to HIV / AIDS at the national level was conducted. Based on the evaluation conducted at the regional and national levels, these needs are as follows:

  1. 1,406,588,129 UAH in 2011
  2. 1,518,130,514 UAH in 2012
  3. 1,773,942,338 UAHin 2013

2.Taking into account the inflation that is expected in 2010-2013[8], funding needs for NOP will change as follows:

  1. 1,664,837,709 UAH in 2011
  2. 1,897,483,396 UAH in 2012
  3. 2,328,078,781 UAH in 2013

The general structure of the budget shows the following: 11% of financial resources for three years is planned for organizational activities, 27% - on preventive activities, 9% - on care and support, and the largest part of financial resources - 52% - is aimed at treatment[9].

2.2Financing of the response to the epidemic

Financing of activities on counteraction to HIV / AIDS epidemic increases annually.

With regard to the funds from the local budget, the Global Fund grant, the World Bank loan the financing of program made up 532,019.3 thousand UAH in 2009.For the first time in the history of government programs on AIDS the state funding began to prevail over the other funding sources and in general made up 57.9% of the total program budget for 2009.

However it is important to not that under-funding from the state budget in 2009 was 52,93%.

2.3Results and recommendations of external evaluations

Below are incorporated the key recommendations of the Integrated external evaluation of national measures against AIDS in Ukraine (January 2009), International external evaluation of HIV prevention among risk groups for GFATM funding, provided by APMG (October 2009), research on experience of mobilizing and development of potential communities vulnerable to HIV, the SUNRISE project (2006-2007), the mission of WHO, USAID and the European Commission to assess the public procurement system and evaluation in the context of USAID PEPFAR.

1. Intensify programs and strategies of HIV prophylaxis so that they have an impact on the epidemic by:

  • Rapid expansion of coverage and quality of combined prevention programs (harm reduction, substitution therapy, diagnosis and treatment of STIs, condom distribution), including the penitentiary system to solve significant problems at the "entrance" and "exit" to / from system;
  • increasing the focus on behaviour change among high risk groups and their sexual partners; special attention to drug-stimulants, female drug users, ‘street children and teenagers’;
  • reducing the vulnerability of the highest risk groups to eliminate the driving factors of the epidemic, removal of barriers to access and support to safer behaviour models, especially from the part of law enforcement agencies;
  • reflecting gender and age needs;
  • increasing the number of access points to HIV prophylaxis by integration of the prevention programs into other services not directly related to HIV, which will be achieved through cooperation with local institutions of primary health care, social services for youth, representatives of the Red Cross and others;
  • mobilization and development of thecommunities vulnerable to HIV;
  • expanding the coverage and quality of counselling and testing for the highest risk groups, especially the rapid HIV testing and ensuring timely delivery of centralized test systems for high-risk groups.

2. Massive expansion of treatment and care for the patients with advanced HIV infection (treatment as prevention - increasing interdependence of prevention and treatment) by:

  • strengthening cooperation and coordination between specialized treatment facilities to treat HIV / AIDS and TB institutions, drug dispensary, particularly in regard to treatment of co-infected patients;
  • decentralization of routine medical care for patients with HIV outside AIDS centres at district level.

3. Introducing a national system of procurement and supply of goods and services in the context of HIV / AIDS to meet the needs and savings through:

  • bringing the national procurement law in line with international best practice and the requirements of WHO;
  • procurement of ARV drugs and diagnostic systems through IRA, IKVS and other international sources of preferential pricing for commodities related to HIV.
  1. Implement human resources development plan in connection with HIV to ensuremeeting existing and future demands for services by:
  • providing in-depth training on HIV for involved health care professionals;
  • providing basic training on HIV transmission, stigma and discrimination for all medical and nonmedical personnel working with the highest risk groups.

5. Enforce the laws of Ukraine, which protected the human rights of representatives of the highest risk groups and people living with HIV to reduce stigma and discrimination and ensure that services are accessible, user-friendly and trustworthy by:

  • strengthening enforcement of laws and norms on protection of the human rights;
  • implementing policies and programs of zero tolerance to discrimination and violations of confidentiality among the general population, employees of the educational, health and law enforcement sectors.

6. Strengthening the overall control and management systems in the government sector and inter-sectoral coordination for effective governance and strategic leadership by:

  • training on planning and management oriented for results;
  • cooperation with other sectors;
  • work planning with definition of the roles and responsibilities, especially regarding high-risk groups;
  • allocating sufficient resources to achieve planned results.
  • Main achievements and challenges

During last few years national response to HIV/AIDS epidemic in Ukraine was characterized byboth extending access of HIV-positive people to prevention, treatment, care and support services in general and increasing coverage of representatives of target populations. First of all this is the result of a greater contribution of the state (financial and political)and attraction of international donor funding, mainly GFATM grants (rounds 1 and 6).

During the last couple of years Ministry of Health of Ukraine and its HIV-TB Committee demonstrated their leadership position enabling to ensure clear coordination of activities of all partners working to counteract epidemics. National Council of Ukraine to counteract TB and HIV/AIDS started to effectively work as the Country Coordination Mechanism, the work of which is supported by the MoH HIV-TB Committee in the function of its Secretariat.It also enable to set up and activate the work of the regional councils to counteract TB, HIV/AIDFS and drug abuse, through which we are planning to strengthen the regional responses to the epidemic they have.

The National HIV/AIDS Monitoring and Evaluation system was launched through establishment of national and regional centres for M&E of implementation of the interventions of the “The National Program of HIV Prevention, Treatment, Care and Support for HIV Positive People and AIDS Patients for 2009-2013”

Annually the number of HIV tests is increasing (in 2009 3349515 people were tested for HIV). Meanwhile access to testing and counseling for representatives of vulnerable groups remains insufficient.

Prevention programs are expanding mainly due to GF Round 6 Program. Up to 1.04.2010 coverage of most-at-risk populations was as follows:

-IDU - 158350 14482 or 54.6% from the estimated number;

-Commercial sex workers – 25912 or 37%;

-MSM – 14482 or 15, 2%;

-Prisoners – 29525 or 21.1%[10].

Results of prevention interventions among IDUs could be considered as the most tangible as percentage of this group coverage comes very near to the ambitious target of 60% in comparison with the overall estimate number. Against the background of increase of Harm Reduction services’ coverage and quality, both the official statistics and special epid research indicated to the tendency of decreasing of HIV prevalence among IDUs. The routine epid surveillance data of the Ukrainian State AIDS Centre showed that HIV prevalence among IDUs has been steadily decreasing since 2007: from 15,3 % in 2007 to 13,9 % in 2008 and 13,3% in 2009. This positive tendency has been corroborated by the data of sentinel surveillance, and is most tangible in the towns with high coverage of IDUs with prevention services. Thus, HIV prevalence among Kyiv IDUs over the last year decreased by 7,6% (from 30,8 to 23,2%), вin Dnipropetrovsk - by 17,6% (from 40,3 to 22,7%), in Cherkassy - by 6,1% (from 18,2 to 12,1%).

Every year access to antiretroviral therapy is increasing which has a positive impact on epidemiological situation in terms of HIV spreading as ART is a powerful tool of secondary HIV prevention. Compared to 2008 in 2009 volume of ART increased by 43%. As of01.04.2010 there were 17122 HIV+ people receiving ART, 15468 of them at the cost of the state budget, 1654 – at the cost of GF program. In the framework of GF program access to ART in prisons is ensured, as of 1.04.2010376 prisoners were receiving ART.

2009 Data of the Ukrainian State AIDS Centrefor the 1st time in comparison with the previous period showed that the absolute number of deaths from AIDS reduced: from 2710 to 2591 cases ( by 100,000 population – from 5,8 to 5,6%). This is the first significant evidence of the positive impact of ART introduction and scale up in Ukraine.

Progress is observed in extending programs of substitution therapy. As of 01.01.20105194 IDUs were receiving OST, 43,9% of them were HIV-positive. There are 115 treatment facilities already involved to providing OST services.

Due to the wide scale up of harm reduction programmes, including substitution maintenance therapy, the number of newly registered HIV cases among the IDUs has stabilized over the 2006-2009, and their volume among the new registered cases decreased from 55,6% to 35,8% respectively.

At the cost of the World Bank credit and GF grant volumes of opportunistic infections prevention and treatment among HIV+ significantly increased, which allowed decreasing mortality among patients from these diseases (31302 OI treatment cases in 2009). During 2009 the volumes of STI treatment among MARPs were tripled (10345 STI treatment cases during 2009).