INTERVIEW: HIV Prevention in Uzbekistan. A Turning Point.

Worldwide, barriers to reduce the number of new HIV cases still exist. These are insufficient political support and, as a result, a lack of investment; reluctance to address sensitive issues related to the rights and needs of young people with regard to sexual and reproductive health; the lack of systematic prevention among key population groups, even in those regions where the political situation is favorable. The goal of the UN Political Declaration on HIV and AIDS in 2016 is to reduce the number of new infections to 500,000 or less by 2020 (in 2016, more than 1.8 million people contracted HIV).

In the context of HIV prevention, people who inject drugs (PWID) are considered one of the most vulnerable groups of population. Measures aimed at reducing the risk of infection among PWID require additional efforts.

In Uzbekistan, 2018 has become an extremely important time in terms of HIV reduction. In June, the President of the Republic of Uzbekistan signed a Decree aimed at counteracting the spread of diseases caused by the human immunodeficiency virus, and prevention of nosocomial infections (Decree of the President of the Republic of Uzbekistan PP-3800 dated 22.06.2018. "On additional measures to counter the spread of the disease caused by the human immunodeficiency virus and the prevention of nosocomial infections.").

The Decree notes a number of shortcomings in the implementation of measures on prevention of blood-borne infections: insufficient measures for the timely and full provision of medical and preventive institutions, especially primary health care, medical instruments and supplies; problems of equipping the sterilization departments of medical and preventive institutions with the necessary equipment and inventory, a lack of a modern approach to the methods of organizing sterilization measures; inadequate coverage of inpatient treatment of HIV-infected persons in the regions of the republic, weak material and technical base of regional AIDS centres and inter-district laboratories for the diagnosis of HIV infection.

The decree determined the main directions for further improving and expanding the provision of medical and social assistance to the population in terms of prevention, diagnosis and treatment of HIV infection, including establishing that, starting in 2022, state budget will allocate funds to prevent the spread of HIV among vulnerable groups of population.

The Resolution approved a Set of additional measures to improve the effectiveness of measures taken to counteract the spread of HIV infection and prevention of nosocomial infections (hereinafter - Comprehensive Measures).

Inter-agency Expert Council (CCM or IEC) under the Cabinet of Ministers of Uzbekistan, established in 2008, works to ensure close cooperation and coordination with international organizations on HIV, TB and malaria. The IEC launched a M&E (Monitoring and Evaluation) Group in 2013 which is responsible for monitoring of National Programmes on HIV, TB and malaria. UNODC is also a member to the IEC.

UNODC supports the Government of Uzbekistan in promoting international approaches and standards of HIV prevention and treatment, ensuring access for people who use drugs to essential medical care through evidence-based comprehensive programs, as well as respect for human rights, reduction of stigma and discrimination. UNODC provides capacity building opportunities for health and social workers who serve PWID. In 2012, together with WHO and UNAIDS, UNODC released an updated version of the Technical Guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users, and in 2017 - IDUIT (Implementing Comprehensive HIV and HCV Programmes with People Who Inject Drugs).

From May to August 2018, the Monitoring and Evaluation Group of the IEC under the Cabinet of Ministers of Uzbekistan jointly with the UNODC Regional Office for Central Asia conducted its annual visits and observation of HIV related service through all regions of Uzbekistan.

During the monitoring, the Group visited the Trust Points, Regional AIDS Centres, TB clinics, and NGOs supporting people living with HIV (PLHIV) and vulnerable populations. The M&E team aimed to determine the effectiveness and quality of HIV prevention services, including harm reduction programs (exchange of injecting equipment), pre-test and post-test counseling, and antiretroviral therapy.

In 2017, the prevalence of HIV infection among PWID was 5.1% (compared to 0.1% for the general population, according to the Republican AIDS Centre). What is more, the level of awareness of PWID about the ways of transfer is improving 82.6% (in 2007 - 76.9%). Coverage of preventive measures including information and educational materials increased almost threefold and amounted to 68% (2013 - 24%).

However, most people who use injecting drugs do not realize the risk of infection and are not motivated to know their HIV status, despite the fact that the HIV test is anonymous and free. In this regard, there is a need to ensure joint work of NGOs with state institutions aimed at changing the injecting and sexual behavior of PWID into less risky ones, paying special attention to preventive programs, creating acceptable conditions for voluntary testing and counseling for HIV.

Professionals of relevant medical and social institutions of Uzbekistan recognize that among all known method of prevention there is no any that can stop the HIV epidemic in itself. There is a high demand on a comprehensive approach and integration of efforts of various structures and organizations, especially a quality interagency coordination.

Global best practices suggest the following approaches in terms of joining efforts:

• Revision and amendment of legislative acts and practice of their applications,

• Active involvement of communities,

• Reducing stigma,

• Strengthening of advocacy work.

On 17 August 2018, the Inter-Agency Expert Council and the UNODC Regional Office for Central Asia organized a National Forum on HIV Infection with a theme: "Health Care Reform in the Republic of Uzbekistan: HIV Prevention among Vulnerable Populations."

Within the framework of the National Forum, Mr. Botirjon Kurbanov (B.K.), the Deputy Chief Physician on the epidemiological issues of the Republican Centre for State Sanitary and Epidemiological Supervision of the Ministry of Health of the Republic of Uzbekistan shared his observations. Mr. Krubanov is the Chairman of the Monitoring and Evaluation Group at IEC, which discusses the main directions of improving and expanding the provision of medical and social assistance to the population on the prevention, diagnosis and treatment of HIV infection.

DK: As one of the leaders of the State organization that directly participates in counteracting the spread of HIV infection, could you please comment on the new Comprehensive Measures that are reflected in the Presidential Decree PP-3800, which was presented today at the round table?

B.K.: The detailed report on the Presidential Decree PP-3800 was presented by Mr. Kakhramon Yuldashev, Director of the Republican Centre for AIDS Control of the Ministry of Health of the Republic of Uzbekistan. I can only add briefly that the Decree describes the Comprehensive Measures that cover a total of 24 events. The document notes that the achievement of the goals will directly depend on financial support. A distinctive feature of this document is that each event is accompanied by information on financial costs. I think that this approach will ensure complete and timely fulfillment of tasks. In total, more than 103 billion soums and 35 million US dollars will be allocated for 24 events.

The Decree examines the situation with vulnerable groups of population and provision of services in the Trust Points. Friendly Cabinets, as one of the types of Trust Points, are a relatively new practice for national AIDS centres. Since this year, more attention has been paid to the activities of Friendly Cabinets that provide services to vulnerable groups of population. It is extremely important to ensure the smooth operation of the Cabinets, providing timely funds necessary for the implementation of preventive measures.

The Decree envisages that, over the years, the Trust Points and Friendly Cabinets which serve as key elements in HIV control and prevention activities, will be financed and managed by the Government.

Also, the Decree reflects the prevention of nosocomial infections. A separate section emphasizes on the prevention of HIV infection by parenteral transmission, as well as improvement of the technical capacity of AIDS centres and other treatment and prevention institutions.

I would also emphasize that the Decree envisages the improvement of normative legal acts in the field of HIV prevention. It should be noted here that proposals to improve legislative and regulatory documentation have been developed jointly with a number of international organizations. The recommendations and best practices presented by international organizations were taken into account when developing this Decree, and amending other legislative and regulatory documents in order to conduct effective work on HIV prevention and reduce the incidence of the disease in the country.

DK: In your opinion, why exactly now is the moment when the state is ready to take this important step?

B.K.: These days we witness the reforming process in all sectors - in the economy, in the defense system and others. Same situation is in the health care system.

Health care reform, as well as the need for comprehensive approach, led to the fact that we have this Decree today. This document has been through a long process of preparation and development and represents a thoughtful plan for the implementation of the Comprehensive Measures. I consider this document very relevant and timely.

DK: You are the Chairman of the Monitoring and Evaluation Group of the IEC and have been directly involved in monitoring visits for many years now. What is your impression of the last visit?

B.K.: Since 2014, I am the Chairman of the Monitoring and Evaluation Group. All these years we monitor, verify and study the activities and the role of the Trust Points throughout the country, which becomes possible thanks to UNODC and IEC.

After many years, we are able to witness that the Points are well-equipped through funding provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria

When I first began my work as the Chair of the Monitoring and Evaluation Group, the number of HIV cases among vulnerable groups registered in the Trust Points, in particular among injecting drug users, was several times higher than it is today.

The Trust Points aim to reduce the incidence of HIV infection among vulnerable groups of population - PWID. And I would like to say that we are achieving this. How? - Thanks to the right approach - training of assistants of the Trust Points, the work of volunteers, who themselves carry out preventive work and train their clients. Preventive measures are very resultative. Every year, the number of HIV-infected individuals among vulnerable groups of population decreases.

Also, the level of accessibility of the services of the Trust Points is improving, both in cities and in remote regions. All services are free of charge. Moreover, the Trust Points conduct consultations and screening. Fifteen years ago, PWID did not have access to the Trust Points, could not get the services and consult the specialists. Today, all these services are available, even in remote areas. A few years ago, PWID could not get disposable syringes and other services for the prevention of infections. On the one hand, they feared to go somewhere. On the other hand, there was no access to consulting services. To date, there are no prohibitions or obstacles, which could prevent injecting drug users from obtaining the necessary medical advice.

DK: Please, explain, what other favorable changes will the new Decree of the President bring?

B.K.: The new Decree envisages a broad work on raising public awareness through the mass media.

A separate event involves the creation and distribution of social video clips, innovative projects, and their distribution via social media. The population will receive useful information about HIV prevention, treatment. This process will involve all interested ministries and departments, as well as international organizations.

DK: Concluding our conversation, I would like to ask you to comment on the role of cooperation between civil society, the state and international organizations. What is the role of improving the cross-sectoral approach, which was discussed at the National Forum?

B.K.: Reduction of HIV infection requires a comprehensive approach. It is necessary that the Government interacts with civil society and international organizations to make tangible changes. A special role, as noted today at the round table, is assigned to the non-governmental sector, civil society organizations, which provide services to vulnerable groups of population on a peer-to-peer level, along with the Trust Points. It is necessary to recognize that the Government needs the help of non-governmental organizations in the process of providing services to vulnerable groups of population - consultations, training of the population and conducting screening tests. Thus, in order to achieve results in this area, an intersectoral approach and comprehensive preventive measures are extremely important. Separately, the health care system, AIDS centres, or the Republican Centre for State Sanitary and Epidemiological Supervision, will not be able to achieve the goals.

DK: Thank you very much for an interesting conversation. In the finale, what would you wish the participants and partners of today's National Forum?

B.K.: I would like to wish all the partners of the national forum that this meeting creates a space where they can once again emphasize on their role. So that, after this meeting they could ask themselves how to revitalize the intersectoral approach. So that, each participant asks himself: "What can I give? What other approach or solution exists that other partners have not thought about yet? What can be done to contribute to the reduction of AIDS and HIV prevention and influence the situation?"


The interview is conducted by Ms.Daria Kudabaeva (DK), Communications and External Relations Specialist, UNODC Regional Office for Central Asia

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