On a recent visit to Belarus, I was thinking about the country's multi-cultural heritage arising from its shared history with Lithuania, Poland and Russia, together with its more recent Soviet past. The geographical reality is however that over two thirds of its borders to the South and to the East are with either Ukraine or the Russian Federation, with the latter continuing to be Belarus' major political and economic partner.
That is highly significant, I believe, from a public health standpoint: The Russian Federation and Ukraine account for a huge swath of the HIV/AIDS epidemic in Eastern Europe, accounting for more than 90 percent of all new HIV infections and of people living with HIV in the region.
Incidence, prevalence and mortality of HIV/AIDS continue to grow at a disturbing pace in the Russian Federation. In Ukraine, major economic difficulties, decreasing international funding for AIDS, conflict in the Donbass, and complex internal politics are raising significant concerns about whether the significant gains achieved in reducing HIV incidence over the last 10 years will be improved upon or at best maintained.
And yet, Belarus has succeeded in maintaining an overall low prevalence (0.4 percent) and incidence rates of HIV, about a third lower than its immediate neighbors.
There are a number of reasons for that. The quality of the country's HIV/AIDS and TB programs is excellent and follows a balanced strategy of prevention and treatment based on international standards.
The strategy starts from a shared understanding of the issues around HIVAIDS across a number of ministries including health, finance and foreign affairs. Belarus was one of the first countries in the region to put together a transition plan from international (Global Fund) to national funding of the HIV and TB responses that will transpire over the next three years. Management of the Global Fund grant is now transitioning from UNDP as a principal recipient to government ownership in a smooth process.
As is the case throughout the Eastern European and Central Asian region, the Belarus epidemic has largely been driven by unsafe injecting drug use. Forty percent of new cases are still detected among people who inject drugs. Belarus has been implementing harm reduction programs for many years, although not at sufficient scale, including needle exchange programs (NSP) and opioid maintenance therapy with methadone (OST). The OST program successfully started by UNDP with Global Fund funding is now to be fully funded by the government. There was no doubt among the AIDS physicians and "narcologists" I met that harm reduction is an accepted component of the standard of care. Additionally, there are a number of experienced NGOs who are active in prevention programs among the most vulnerable groups and in supporting patients in care.
One of the challenges for both the government service providers and the NGOs will be undoubtedly being prepared to respond to the growth of new and cheap injectable psycho-stimulants that are now replacing the street heroin and poppy seed market ("cleaned" up by the authorities.)
Despite the broadly fine response to the epidemic in Belarus, there remain a number of issues to be addressed in what is still a fragile environment, to avoid the risk of a shift in the pattern of the epidemic.
The number one issue is high stigma and legislation and policies that can only divert people who inject drugs, men having sex with men and sex workers from services. A recent decree in the last few months brought even more constraints on people who use drugs. Since May of this year, health workers are obliged to report to the police any person who uses drugs, including those coming to seek treatment. Drug policy remains framed in prohibition and policing to the detriment of public health. This despite the fact the very same decree actually encourages the involvement NGOs in working with vulnerable populations.
Secondly, there exists an urgent need for the implementation of a mechanism that would allow government to directly fund NGOs for its peer outreach work with vulnerable groups -something that is on the drawing board as part of the transitioning to government funding but that needs to happens much sooner than later.
Thirdly, evidence-based interventions such as treatment, NSP and OST are not currently being run at sufficient scale to prevent outbreaks occurring in the country´s epidemic, a measure that would ultimately enhance Belarus´s status as the to be one the leading first countries in the region to fully control its epidemic.
Lastly, the country has not yet acquired effective enough experience in the forecasting and procurement of antiretroviral and other expensive (e.g. MDR-TB) medicines. These medicines, when purchased by the public system, can actually be two and a half times more expensive that when procured internationally by the UN system.
I am confident that all of these challenges can be overcome: Belarus has made spectacular progress in fighting TB. It is containing HIV but could - no doubt - significantly enhance its efforts, reach internationally set targets and seriously consider ending the epidemic. This will require support and encouragement from the international community and a commitment at the highest level of government to address the structural, social and policy issues that contribute to compound risks and increase vulnerability to HIV in the country.
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