Eastern Europe and Central Asia is one of the three regions in the world where new HIV infections are increasing, with a persisting trend over the last eight years.

On the eve of World AIDS Day, we spoke to Rosemary Kumwenda, who works with UNDP on HIV/AIDS programming.

What has changed in the landscape of HIV and AIDS in the Eurasia region?

The rate of new HIV infections is decreasing globally, however in this region, the HIV epidemic has grown by 29 percent since 2010.  Our region is one of only two in the world (the Middle East and North Africa being the other) where the annual number of AIDS-related deaths has increased: 38,000 estimated AIDS-related deaths in 2018 compared to 36,000 in 2010 - although that trend appears to be reversing.

As of 2017, about one fifth of all people living with HIV in the entire European region were unaware of their infection, and half of those who were aware were diagnosed late. This resulted in delayed treatment, an excess of AIDS-related morbidity and mortality, and drove further HIV transmissions.

Antiretroviral treatment (ART) coverage is improving but is still very low, only covering approximately 38 percent of all people living with HIV.  Many countries are not on track to reach key global targets by the end of next year, 2020.

Why are the prevalence rates so high?

I think the high figures reflect insufficient political commitment and domestic investment in national AIDS responses. Most new infections are among at-risk populations: men who have sex with men, sex workers and their clients, transgender persons, people who inject drugs and prisoners. These populations must often contend with punitive legal environments and discrimination.

In addition, our region is experiencing high rates of "co-infections", with tuberculosis cases linked to HIV infection and drug use, while hepatitis C infection is approaching 80 percent prevalence amongst people who use drugs. Nine of the world’s 30 countries with a high burden of multidrug-resistant TB and extensively drug-resistant TB (Azerbaijan, Belarus, Kazakhstan, Kyrgyzstan, the Republic of Moldova, the Russian Federation, Tajikistan, Ukraine and Uzbekistan) are in this region and unfortunately less than 50 percent of cases have been detected and successfully treated.

While the overall number of annual HIV tests in the region continues to increase, the proportion of tests among key populations—including people who use drugs, gay men and other men who have sex with men, and patients with sexually transmitted infections is declined from 4.5 per cent of all HIV tests conducted annually in 2010 to 3.2 per cent in 2016.

Are people aware of their HIV status?

We’re seeing slight improvements here. Among the 1.4 million people living with HIV in the region at the end of 2017, 73 percent  were aware of their HIV status, an four percent increase from 2016. Late HIV diagnosis also remains a major challenge in the region: in the Russian Federation, almost 69 percent of patients who started treatment in 2016 already had very low CD4 cell counts.

Even when people know their status, treatment are slow to scale up. Coverage remains among the lowest in the world. Only about 36 percent  of all people living with HIV in the region are accessing ARVs. The region needs to test and treat 635,000 people living with HIV by 2020.

Which countries are doing better, which countries worse?

The Russian Federation accounts for the highest HIV infection rates at 71 percent, followed by Ukraine.

Several countries—Belarus, Kazakhstan, the Republic of Moldova, the Russian Federation and Ukraine—have successfully reduced the cost of first-line treatment regimens in recent years, in some cases to as little as US$78 per person per year.

Score cards for this region on laws and policies show that Turkmenistan and Uzbekistan criminalize same sex sexual acts. Russian Federation, Ukraine, Serbia, Moldova, Bosnia and Herzegovina, Tajikistan punish sex work. Belarus, Kazakhstan, Kyrgyzstan, Moldova, Russia, Tajikistan and Uzbekistan criminalize drug use or consumption or possession of drugs for personal use. Azerbaijan, the Russian Federation and Turkmenistan restrict entry, stay and residence of people living with HIV.

This legal and societal stigmatization and criminalization hinders safe behaviours, rates of HIV testing and proper treatments.

What are the most encouraging trends?

In the region, cities are proving to be dynamic. At the end of 2017, harm reduction programmes were still operating in 17 cities in the Russian Federation. The city of Saint Petersburg, for example, has achieved a consistent decrease in new HIV infections thanks to city authorities collaborating with CSOs. But there are limited options to sustain these types of projects in the future.

Several countries have maintained and scaled up harm reduction programmes with government resources, leading to reductions in new HIV infections among people who inject drugs. The coverage of opioid substitution therapy has proven to be efficacious and cost-effective, but still remains suboptimal throughout the region.

What needs to change? What is UNDP doing?

Civil society organizations (CSOs) should be engaged by governments to increase programmes to reach the marginalized populations heavily affected by the epidemic to be provided HIV- related services.

UNDP produced guidance for NGO social contracting so that countries transitioning from foreign aid to domestic financing can ensure sustainability of their HIV response, which requires more than just a sufficient HIV budget allocation. This also contributes to addressing the critical issue of an overall shrinking thematic and fiscal space for CSOs as HIV-related service providers.

A series of HIV and TB Legal Environment Assessments identified critical barriers for effective HIV-related responses, proposing relevant changes to regulatory, policy and legislative frameworks on topics such of criminalization of HIV and TB transmission, non-disclosure  and exposure, same-sex relations, sex work and drug use including possession for personal use.

UNDP also supports countries to improve the legal frameworks and policies, effectiveness and transparency.

Together with UNAIDS, WHO, UNFPA, UNODC, IOM and CSOs, we are collaborating to further protect the rights of key populations at higher risk of HIV, people living with HIV, and other vulnerable and marginalized populations.

This year, the first ever Eastern Europe and Central Asia judges’ forum offered affected key population communities space to share their personal stories on how the legal environment inhibits the fight against HIV. We will continue to support the Judges Forum platform expansion to enable virtual discussions on HIV, sexual and reproductive health and rights, TB, and law and human rights issues affecting the region. When we re-convene face to face in Tajikistan in 2020 to discuss HIV, health and human rights issues of priority concerns, we hope that we will see better progress in tackling this epidemic.