On 22 November, at a meeting held in Minsk, Belarus, countries from across eastern Europe and central Asia signed the Statement on Expanding Access to Affordable and Quality Assured Medicines and Diagnostic Technologies for HIV, Tuberculosis and Viral Hepatitis (Minsk 2).

In Minsk 2, countries in eastern Europe and central Asia commit to make urgent use of the best global practices and available tools to ensure the quality, safety and efficacy of health products and reduce the prices of essential HIV, tuberculosis and hepatitis C medicines and diagnostics in the region. The statement, among other things, envisages the revision of procurement mechanisms, the use of international and joint procurement and consultations and negotiations on price policy with medicine suppliers.

“In Minsk, the countries of eastern European and central Asia adopted a set of new, tangible, urgent actions. The countries will learn and share many lessons while implementing the Minsk 2 statement, which will help to lower prices, improve quality and save lives,” said Tim Martineau, UNAIDS Deputy Executive Director, Programme, a.i.

During the meeting, the Mayor of Minsk signed the Paris Declaration to end the AIDS epidemic in cities, becoming the fourth city in eastern Europe and central Asia to join the network of more than 300 cities and regions worldwide that are committed to Fast-Track their local HIV responses and to reach the 90–90–90 targets by 2020.

“The signing of the Paris Declaration by Minsk gives a boost to our capital’s goal to stop the spread of HIV by mobilizing officials, the workforce and public associations,” said Valery Malashko, Minister of Health, Belarus.

Belarus continues to make progress in its AIDS response. In 2016, Belarus was validated by the World Health Organization as having eliminated mother-to-child transmission of HIV and congenital syphilis. Belarus implements a full range of HIV policies and programmes with government support and funding, including harm reduction programmes for injecting drug users and antiretroviral therapy for people living with HIV. In 2017, Belarus rolled out HIV self-testing, selling self-testing kits in pharmacies.

“As civil society we believe that the simplest universal solution to ensure access to resources is to change political principles and priorities. People’s lives must be a priority,” said Dmitry Sherembey, from the All-Ukrainian Network of People Living with HIV.

Also during the meeting, eight international organizations signed an agreement to establish a regional interagency group to support the coordinated efforts and implementation of Minsk 2, focusing on results and impact at the country and regional levels.

“Closing the gap to cost-effective, equitable and sustainable access to quality medicines and diagnostic technologies requires further effective collaboration and political leadership in eastern European and central Asian,” said Zsuzsanna Jakab, Regional Director for Europe, World Health Organization.

The Mayor of Yekaterinburg, Alexander Vysokinsky, has announced that Yekaterinburg will become the first city in the Russian Federation to sign the Paris Declaration to end the AIDS epidemic.

In signing the Paris Declaration, Yekaterinburg will commit to putting the city on the Fast-Track to ending the AIDS epidemic through reaching the 90–90–90 targets, whereby, by 2020, 90% of people living with HIV will know their HIV status, 90% of people who know their HIV-positive status will be accessing treatment and 90% of people on treatment will have suppressed viral loads.

According to government statistics, more than 22 000 people are living with HIV in Yekaterinburg.

In announcing the decision to sign the Paris Declaration, Mr Vysokinsky noted that the initiative will encourage innovations and cutting-edge treatment programmes to address HIV and other health challenges and will contribute to a better life for future generations.

Since the launch of the Fast-Track cities initiative on 1 December 2014, about 300 cities and municipalities around the world have signed the Paris Declaration. Leaders in those cities have recognized that their strategies for responding to the AIDS epidemic also offer them a platform to address the need for social inclusion, public services, primary health care and community mobilization.

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Countries reaffirmed the fundamental right of every human being to the enjoyment of the highest attainable standard of health and committed to strengthen primary health-care services at the Global Conference on Primary Health Care. The Declaration of Astana, unanimously endorsed at the conference by all World Health Organization Member States, makes pledges in four key areas: making bold political choices for health across all sectors; building sustainable primary health care; empowering individuals and communities; and aligning stakeholder support to national policies, strategies and plans.

HIV disproportionately affects populations that are in many countries marginalized, stigmatized, discriminated against and criminalized. The new commitment to primary health care presents a timely and unique opportunity to step up efforts to address the many barriers that those populations face in accessing HIV and primary health-care services. Addressing such barriers requires having the courage to respond to issues that are often considered sensitive or taboo—around gender, sexuality, identity, exclusion and power.

“UNAIDS is proud to be leading on community and civil society engagement, as part of our contribution to the Global Action Plan for Healthy Lives and Well-Being for All. Only by taking AIDS out of isolation can we can save lives holistically, not disease by disease, issue by issue,” said Vinay P. Saldanha, Director of the UNAIDS Regional Support Team for Eastern Europe and Central Asia.

UNAIDS’ contribution to the event, The AIDS response and primary health care: linkages and opportunities, sets out examples of how to integrate HIV services into primary health care and, conversely, how to use the AIDS response to further leverage primary health care. It calls for urgent attention to be given to the structural and root causes of ill health and for sexual and reproductive health and rights to be central to primary health care.

The Global Conference on Primary Health Care took place in Astana, Kazakhstan, on 25 and 26 October.

Stigma and discrimination among health-care workers is among the most severe barriers that people living with HIV experience in accessing life-saving health services. In order to encourage a new generation of health-care workers in the Russian Federation to provide medical services in a non-stigmatizing and discrimination-free setting, 20 medical students from across the country are participating in a new week-long course at the Vera HIV Medical School.

“Medical students often only hear second-hand stories about how to treat or care for people living with HIV. But if they receive the right training and practical support, they can be a bridge between people at risk of HIV and access to life-saving services,” said Anton Yeremin, the course’s coordinator, who is also an infectious diseases doctor who specializes in HIV treatment and care. “If doctors unknowingly promote stigma or explicitly discriminate against people living with HIV, or people at risk of HIV, it can result in patients being denied access to treatment, or even avoiding contact with medical services," he added.

The course is designed to complement what students learn at university. “We encourage future doctors to develop skills specific to the HIV context, such as relating to patients and understanding some of the social and legal aspects of their diagnosis,” said Mr Yeremin. The course consists of lectures and workshops on non-discriminatory approaches to people living with HIV and meeting people living with HIV, doctors, lawyers, psychologists, HIV activists and representatives of nongovernmental organizations to hear their stories.

According to Dmitry Petrov, a peer counsellor at the Svetlana Izambayeva Charitable Foundation, his clients are often denied admission to hospital. “An ambulance will arrive and the ambulance crew will say we can drive him to a hospital, but they won't admit him,” he said. Not long ago, he was helping a client to be admitted to a hospital; two official referrals from the local AIDS centre made no difference, and the woman was denied admission. Only after formal complaints filed by the patient’s family to the local government did the client get admitted. When asked about the most recent time a client was refused hospital admission, Mr Petrov answered “Yesterday,” without hesitation.

The stories shared by the Svetlana Izambayeva Charitable Foundation’s staff are consistent with the findings published in a recent Human Rights Watch report, which notes that people living with HIV regularly face stigma and discrimination from health-care workers. The situation is said to be worse outside of the major cities.

The course was initiated and organized by the National Union of Medical Students and was featured on a crowdfunding platform called No One Left Behind, a joint project of the Russian AIDS Center Foundation and UNAIDS.

Vera Brezhnevа, UNAIDS Goodwill Ambassador for Eastern Europe and Central Asia, has sponsored the course. “Every doctor must expect to see a person living with HIV at some point. We want medical students to understand that people living with HIV are a large and diverse group of people and their diagnosis is not a reason to hold negative attitudes towards them,” said Ms Brezhnevа. "I hope these first graduates of the Vera HIV Medical School will be the beginning of the end of HIV-related discrimination in health-care settings,” she added.

To defend her access to life-saving opioid substitution therapy, Marzhan Zhunusova overcame her fear of flying and, for the first time, took a flight to Astana, the capital of Kazakhstan. She was visiting the city to take part in a country-wide mobilization of people accessing the country’s harm reduction pilot programme, with people from all over Kazakhstan publicly showing the importance of opioid substitution therapy.

After injecting drugs for more than 25 years, Ms Zhunusova had lost hope for a better life. “When I first heard about opioid substitution therapy, I thought that it may be the way out and that it could help me. Drugs, my HIV-positive status, I thought my life was over. I’m 45 years old and only now thanks to methadone have I started to live life fully.”

The campaigners marched in Astana on 27 June and were joined by activists from other groups, including people living with HIV and gay men and other men who have sex with men.

The people who mobilized for the event share similar backgrounds. Their use of drugs may have deprived them of their health and their dreams. Some do not have jobs or have served time in prison. Many are isolated from society and the majority are living with HIV.

Ibrahim Dolgiev tried drugs for the first time in the 1970s, when he was 22 years old. “After many years of trying to stop using drugs, for the past year I’ve been in the opioid substitution therapy programme. It has been a salvation for me. My life has changed dramatically for the better, and for the first time in many years I can get through the day without heroin,” he said.

The people taking part in the mobilization came together to express their hope that the opioid substitution therapy programme will remain and that it will be further expanded.

In partnership with international and national partners, UNAIDS provided the Government of Kazakhstan with evidence-informed arguments on the effectiveness of opioid substitution therapy in controlling the HIV epidemic among people who use drugs.

“Access to opioid substitution therapy is one of the main factors enhancing adherence to antiretroviral therapy among people who use drugs,” said Alexander Goliusov, the UNAIDS Country Coordinator in Kazakhstan.  

“Over the past three years, people who use drugs in the opioid substitution therapy pilot project in Pavlodar demonstrated 100% adherence to antiretroviral therapy,” said Zhannat Musaevich Tentekpayev, Chief Doctor of the Pavlodar AIDS Centre.

Unfortunately, however, the future of the programme in Kazakhstan remains uncertain, and no one has been enrolled in the programme since December 2017.

At the end of June 2018, a government commission announced that the pilot programme would continue, but that it would not be expanded to other regions of the country. An investigation into the cost-effectiveness of the programme is under way and the results will be presented by November. The Kazakhstan Union of People Living with HIV has appealed to the President of Kazakhstan not to close down the programme, noting that support for effective national responses to HIV is critical to making progress towards the 90–90–90 targets.

"While the law enforcement agencies are deciding whether the opioid substitution therapy programme is appropriate or not, the number of people accessing the programme remains very limited. The programme has to be not only maintained, it must exit its pilot status and be available and accessible everywhere in Kazakhstan for people who inject drugs,” said Oksana Ibrahimova, the coordinator of the Kazakhstan Union of People Living with HIV.

Today, there are 13 opioid substitution therapy centres in Kazakhstan, in nine of the 16 regions of the country. Since the beginning of the programme in 2008, more than 1000 people have been enrolled. Currently, 322 people are enrolled in the programme, the majority of whom have stopped using drugs, become employed and are enjoying a family life.

The Russian Minister of Health, Veronika Skvortsova, has reiterated the commitment to reach the targets agreed at the 2016 United Nations General Assembly High-Level Meeting on Ending AIDS.

“We have to provide every person living with HIV with quick access to the correct treatment. The Ministry of Health plans to increase the coverage of people living with HIV who know their status on antiretroviral therapy to 75% by 2019, and by 2020 the figure should reach 90%,” said Ms Skvortsova at the 28th meeting of the Health Council of the Commonwealth of Independent States, held in Saransk, Russian Federation, on 4 September 2018.

In 2018, the Russian Federation reported for the first time on national progress towards the 90–90–90 targets—in 2017, 81% of people living with HIV in the Russian Federation knew their status, 45% who knew their status were on treatment and 75% who were on treatment were virally suppressed.

In order to improve strategic information and build evidence for decision-making at the local level, the Russian Ministry of Health recently conducted a workshop on HIV estimates for representatives of 10 Russian regions. Regional experts were trained on modelling HIV estimates, which will help to ensure a more complete picture of the number of people living with HIV and of the 90–90–90 targets at the subnational level.

Eastern Europe and central Asia is the only region in which the numbers of new HIV infections and AIDS-related death are still on the rise. At the end of 2017, the number of new HIV infections in the region reached 130 000. At the end of 2017, it was estimated that the 90–90–90 cascade in the region was 73%, 50% and 72%.

“The Russian Minister of Health’s statement is another important step in a series of consistent actions undertaken by the Government of the Russian Federation to accelerate the country’s Fast-Track approach to reach 90–90–90 by 2020,” said Vinay P. Saldanha, Director of the Regional Support Team for Eastern Europe and Central Asia.

Maria Godlevskaya, a courageous community activist living with HIV from the Eastern Europe and Central Asia region, was the only Russian language speaker at the opening of the 22nd International AIDS Conference, AIDS2018. 

"We all deserve high-quality treatment, regardless of sexual orientation, beliefs and religious preferences. We all deserve a quality life with HIV and without it. For many people, stigma and discrimination remain the main barriers to access support to preserve their health and the health of their loved ones." said Maria Godlevskaya in her opening remarks at AIDS2018. "I believe in the community. As an indestructible link in the chain of resistance, I have defended, defend and will defend the rights of people living with HIV to have full quality of life and a high standard of living. I encourage everyone to support our campaign "Chase the virus, not people!" #chasethevirusnotpeople

Maria has been living with HIV for over 18 years. She openly speaks about her HIV status on television and openly shares her personal story with journalists. Maria leads a team of peer counselors and runs a video blog at E.V.A. - the first Russian network to support women affected by HIV. She shares her personal experience and disseminates the latest HIV news and information with people affected by the epidemic across Russia every day.

"Some people call me and others reach out to me via social media. I try to respond to every request. I think my life has changed dramatically and now I have found my purpose in life. It is priceless to be able to communicate with people around the world.”

Maria was diagnosed with HIV when she was 16 years old. "When you are 16, there is no panic. You are not frightened by horror stories about AIDS and not bound by social rules, so it was not hard for me to accept my HIV diagnosis. I was more worried about my mother. My diagnosis was like litmus paper - people who were afraid of HIV abandoned me, but the most trusted ones have remained forever.”

Maria has been working for different HIV organizations for many years, starting with providing counselling for people who were using drugs and living with HIV. "At that time there were no well developed communities to support people who use drugs. We helped those in remission to start treatment and stay adherent to treatment."

A few years ago, Maria became pregnant and gave a birth to a healthy baby. "When I met the father of my child, I immediately told him about my "peculiarity” and left him to choose to stay with me. And he gave me a beautiful answer: ‘Every person has something special’ he said.  So we stayed together, and he remained HIV negative.”

I stayed on HIV treatment throughout and after my pregnancy, and I was lucky to have a great relationship with my doctor. My pregnancy and birth is now an example for other women living with HIV. Today I get lots of questions from young Russian women about pregnancy, health care, obstetrical care for women with HIV, so I can share with them my positive experience.”

Maria’s organization, E.V.A. implements many projects in Saint Petersburg and across Russia, focused on providing HIV services for women and their families: support groups for women living with HIV and their families; trainings to increase medical literacy among people living with HIV, and help for women to communicate and negotiate with their doctors and care givers.

"Our trainings help women to adhere to treatment, minimize side effects, and manage undesirable consequences. We empower women to enhance their physical condition as they get used to taking ART long-term. We also support peer consellors so they can provide other women with moral and psychological support.”

Maria considers the main challenge of the growing HIV epidemic among women in Russia is that women have received little sexual education, lack a culture of safe and equal sexual relations and experience irregular monitoring of their HIV status. Many women simply do not identify themselves with any key population, and consider that having one regular sexual partner will safeguard their health. 

"Now we are seeing so many new HIV infections among women over the age of 50 - which brings new challenges as how to support these women. When a woman in her thirties learns her HIV positive status, she may understand how she acquired it. But women in their fifties or sixties are often shocked to learn they have HIV and they often think that their lives are over. In such cases, peer counsellors are so important because they can answer practical questions from their own personal experience.”

“I have a clear set of goals: I know why I'm doing what I do, and I have the energy and strength. I try to set real goals and don’t try to save the whole world – I’m just supporting those who really need help.”

Ministers of health and senior policy-makers from 10 countries in eastern Europe and central Asia reaffirmed their political commitment to scale up national HIV responses during a ministerial policy dialogue on HIV, which was held on the eve of the International AIDS Conference in Amsterdam, Netherlands.

The participants exchanged their experiences and the results of their national AIDS responses with a view to adapting them and scaling them up across the region. They discussed the Fast-Track priorities for achieving the 90–90–90 targets, whereby, by 2020, 90% of people living with HIV will know their HIV status, 90% of people who know their HIV-positive status will be accessing treatment and 90% of people on treatment will have suppressed viral loads. The Fast-Track priorities include the scale-up of domestic funding, the continued focus on key populations, strengthening collaboration across sectors and working in partnership with civil society and people living with HIV.

According to the recent UNAIDS report Miles to go, in eastern Europe and central Asia the annual number of new HIV infections has doubled since 2010—one of the only regions of the world in which HIV continues to increase.

Stigma and discrimination discourages HIV testing and treatment uptake. Harm reduction services remain essential in a region where nearly one third of new HIV infections are among people who inject drugs. Harm reduction programmes are in place across the region, but often at a limited scale.

At the end of 2017, among the 1.4 million people living with HIV in eastern Europe and central Asia, 73% were aware of their HIV status, an increase from 69% in 2016. A majority of the countries in the region have officially adopted test and treat, but owing to resource constraints and barriers to treatment among key populations, the pace of treatment scale-up is slow and coverage remains among the lowest in the world. About 520 000 people were accessing antiretroviral therapy in 2017, just 36% of all people living with HIV in the region.

During the dialogue, the Compendium of good practices in the health sector response to HIV in the WHO European region, featuring 52 successful examples from 32 countries, was launched.

The dialogue was organized by the World Health Organization Regional Office for Europe and UNAIDS, in cooperation with the Government of the Netherlands.

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Absamov Mannap Kamilovich works as a peer consultant in a primary health-care clinic in the city of Osh, in southern Kyrgyzstan. Mr Absamov injected drugs for more than 20 years, but, after a period of community-based treatment, stopped injecting and started a new life.

After taking an HIV test in 2013, Mr Absamov was asked to work as a peer consultant for a newly formed multidisciplinary HIV team.

In 2014, the first multidisciplinary HIV teams started work in southern Kyrgyzstan. They include a specialist in infectious diseases or a family doctor, a nurse and a peer consultant. The teams aim to improve the quality of medical and social services for people living with HIV and their families and are based in local health clinics.

The multidisciplinary HIV teams are supported by a grant from the Russian Federation through a regional cooperation programme that is implemented by UNAIDS in partnership with the Araket Plus nongovernmental organization. Ten multidisciplinary HIV teams have now been formed in Kyrgyzstan.

Mr Absamov works with up to seven clients a day, who go to a local clinic where they can access a comprehensive package of medical services.

Mr Absamov says that initially many people were afraid to visit the clinics, as they feared stigma and discrimination from medical personnel. “I had to persuade them, explain that it is possible to get all the medical services they needed at the local clinic.”

Ainagul Osmonova, the project manager, believes that people living with HIV have developed a genuine trust for their peer consultants.

The teams have helped to get people living with HIV on antiretroviral therapy. In 2013, only 285 people newly diagnosed with HIV started antiretroviral therapy. With the support of the multidisciplinary HIV teams, by the end of 2017 that number had increased to 885 people.

The peer consultants help the teams to recruit people living with HIV into the programme and to provide them and their families with access to social support services, which includes a psychological help desk for families and children affected by HIV. The peer consultants are in close contact with family members of people living with HIV and community organizations.

The multidisciplinary HIV teams work in close contact with the AIDS Centre in Osh. By moving many services for people living with HIV to the clinics, the role of the AIDS Centre has changed to focus more on coordination, training and seminars for general practitioners and the clinics’ medical staff.

According to the UNAIDS Country Director in Kyrgyzstan, Meerim Sarybaeva, the transfer of the AIDS Centre’s services to the primary health-care level has increased the overall coverage of clients enrolled in HIV treatment, care and support programmes. “Our experience shows that we should not be afraid of change. All people living with HIV and members of their families need to be able to access services where they live and be able to receive them freely, without experiencing stigma and discrimination,” she said.

Mr Absamov says he enjoys his job. Thanks to him, many people living with HIV have stopped using drugs, have started antiretroviral therapy and adhere to their treatment.